Modern medical practice depends extensively on the use of drugs and it is the function of the drug industry to supply them. In a way, the two – the medical profession and the drug industry – may be considered partners in health care. However, they differ in their objectives and guiding principles.

Medical practice must be based on scientific principles. Thus, doctors have a duty to improve themselves through continued medical education (CME). At the same time, the medical profession is service-oriented : it puts the patient before self and works for the maximum benefit of the patient (loyalty or fidelity). Beneficence (doing good) or at lease non-maleficience (doing no harm) and confidentiality are other guiding principles. The medical profession also engages in the advocacy for patients : identifying their needs and working for reallocation of time, money and personnel to satisfy them. The movements against child labour, focusing attention on the problems of the girl child, and for promotion of breast feeding are some examples of advocacy by paediatricians.

Profit, not patients
The drug industry, on the other hand, is profit-oriented and aims at giving maximum benefit to share holders. The drug industry is not bothered about consumers / patients – otherwise the market would not be flooded with irrational formulations. Confidentiality is maintained about the production and marketing strategies, and advocacy for justice is rarely considered.

The drug industry’s profits continue to increase despite escalating financial constraints. In the US, it takes $9.4 million to develop a new drug and get it approved. The only way this can be compensated for is by aggressive promotion.

Although there is some drug advertising in the lay media and although many drugs are sold unofficially over the counter, the majority of drug sales comes from doctors’ prescriptions. An estimated 20 percent of pharmaceutical companies’ budgets is spent on marketing; of this money, 20 percent is spent on training and maintaining medical representatives, 30 percent for advertising in the scientific and lay media, and 50 percent for special methods such as stalls at scientific meetings, sponsored dinner meetings for invited doctors, and the publication and distribution of books.

Unscrupulous acts
There can be no objection to the drug industry’s making a reasonable profit. What is objectionable is profiteering by unscrupulous means :

• Product information given by medical representatives may be incomplete and scanty. Yet, for many practitioners they are the only source of information about drugs.

• Help for educational activities can be acceptable if it is without strings and the activity’s organiser is the sole decider of every aspect of the programme: venue, topics, speakers, and so on. Donations should be made to the academic society, and the speaker’s expenses should be reimbursed by the professional body, not by the drug company.

• Grants should be given to professional bodies and institutions and not to individuals. The professional body/institution and the research worker must be decider of every step from project planning to report publication.

• Medical practitioners should be concerned about false advertisements in the lay media for products harmful to the health. The bans on advertisements of alcohol, infant milk substitutes and feeding bottles are examples of this concern. Drug companies advertise their products in scientific journals as well. It is very important to ensure that wrong messages are not given, and irrational products are not promoted, through advertisements in scientific journals.

• The drug industry persuades doctors to prescribe certain brands by giving gifts or providing ‘hospitality’. At times, dinner and cocktail meetings have sponsored speakers. The money does not come from the shareholders’ pockets. In our country, where 40 percent of the people live below the poverty line, the gift relationship violates the ethical principles of fidelity and non-malficience. Drug manufacturers like LOCOST, who do not engage in unethical promotional activities, are able to provide quality drugs under generic names at half the current market price, sometimes even less.

Doctors claim that they are not influenced by ‘gifts’. They forget that no profit-oriented business organisation would spend large sums of money unless there were good returns. The crippling effect of such sponsorship is evident when professional bodies feel convinced that even a one-day CME programme must be sponsored by the drug industry. They claim that delegates want comfort but apparently do not wish to pay for it even though they can certainly afford to so. So patients pay twice : once directly to the doctor and then indirectly through the drug industry.

During their medical education, doctors are never exposed to the socioeconomic aspects of heath care. They lack conviction and fall easy prey to the principle : Incur debt and enjoy your life; there is no return after you are burnt to ashes. But we arehomosapiens.We must act with due consideration to others and not selfishly like animals.

It can be accepted that the drug industry also has a societal interest in having well-educated doctors with improved skills but this should not be used as a excuse for brand promotion and for squeezing money from the poor.

Institutions like the Medical Council of India, the Indian Medical Association, the Indian Drug Manufacturers’ Association, the Drug Controller of India and the judiciary should not only have suitable guidelines and laws but also monitor their application. They must have the power to enforce these rules. Unfortunately, they have neither nails to claw, nor teeth to bite, and not even a loud bark to warn.

Steps forward
The sky seems to be full of dark clouds but occasionally there is a silver lining. For example, some time around 1980, the general body of the Indian Academy of Paediatrics (IAP) took a donation for an oration made by an infant milk-substitute producer. In January 1997, the IAP resolved that "The IAP shall not accept the sponsorship in any form from any industry connected directly or indirectly with the products covered by the Infant Milk Substitutes, Feeding Bottles and Infant Food Act, 1992."

The current dependence of the medical profession on commercial sponsorship is a result of the failure of end-organ : the doctor. If doctors are convinced and committed to their ethical responsibility, they will not yield to the unscrupulous pressures of the industry. They must learn to say ‘No’ to gifts, subsidies and hospitality; to aid with strings attached; to brand promotion; and to prescribing irrational drugs and formulations.

Dr Arun Phatak, consultant paediatrician, editor of the Society for Rational Therapy and Chairman for the Committee for the Protection of the Child Consumer of the Indian Academy of Paediatrics.

Based on the presentation made at the International Conference on Ethical Values in Health Care at Panchgani, January 2-4-, 1998.

Neurosurgery and medical ethics

Sunil Pandya
The Ninth convention of Academia Eurasiana Neurochirugica Houthem St. Gerlach, The Netherlands July 29, August 1, 1998.

The Academia Eurasiana Neurochirurgica was founded in 1985 by Professors H.W. Pia (Giessen, Germany) and Keiji Sano (Japan) to foster exchanges between European and Asian neurosurgeons. This year, the theme was medical ethics.

Oriental views on ethics
H. Handa (Japan) reviewed traditional ethical ideas on life and organ transplantation in Japan and explained the Japanese reluctance to embrace the concept of brain death. The belief that the soul resided in every part of the human body disallowed the removal and transplant of a body part. Why, then, do the Japanese accept transplants from live organ donors? "It is difficult to explain," said Dr. Handa. One senses that Japanese society is in the process of coming to terms with the concept. Dr. Thomasz Trojanowski (Poland) commented that Polish law presumes the donor’s willingness; persons not willing to donate organs must register their objection on admission to hospital. While permission for organ removal is sought from the families of brain-dead patients, the law does not require this consent.

Dr. Iftekhar Ali Raja (Pakistan) discussed Islam and medical ethics. Starting off with a quotation from Einstein ("Religion without science is lame; science without religion is blind."), among the issued Dr. Raja discussed was euthanasia. He quoted Prophet Mohammed’s last address : all killing (except that prescribed by the courts as punishment for certain well defined crimes) is prohibited. "There is no mercy in such killing," Dr. Raja said.

Dr. Sunil Pandya (India) showed how the ancient Indian principles of medical ethics were at considerable variance with current realities. Dr. Fahlbusch (Germany) posed an ethical dilemma : what if a person dying on the banks of the Ganges was found to have an eminently treatable illness like a blood clot? Would it be justified to enforce treatment on someone who had prepared to die and gain salvation?

Dr. A Van Bommel, a convert to Islam who held the post of Imam, pointed out that the sanctity of life from the Muslim perspective demands every effort at preserving life. The ventilator would not be switched off as long as the heart was still beating and was evidence of life. Dr. Harry Rappaport (Israel) said cessation of respiration is central to the Jewish diagnosis of death. The rabbinical criteria for death include cessation of respiration and the diagnosis of irreversible brainstem damage. The Jewish doctor may not shorten life in order to improve the quality of survival.

Dr. Graham Teasdale (Glasgow, Ireland) felt that the attempt to solve ethical dilemmas on the basis of traditional religious beliefs implied an excessive reliance on authority, and could be antithetical to a modern, scientific approach to ethics. An ideal distillate of traditional wisdom and modern concepts would be possible through cross-cultural dialogues.

Christian thought
The first session on Christian thought noted that physicians are expected to have compassion – which different from pity – for their patients. Since man has no right to interfere with life, the participant stated that euthanasia and assisted suicide were unacceptable. At the same time, the prolongation of useless life implied refusal to accept God’s tenderness and mercy. Extraordinary means of preserving life which had lost all meaning were forbidden.

Professor W.J. Eijk (Netherlands) pointed out that discussions on medical ethics often concentrate on dramatic issues such as euthanasia and neglect the physician’s positive duties – relieving pain, consoling the individual and generally making the patient comfortable as the end approaches.

Dr. E.O. Backland highlighted some anomalous situations following from current definitions of brain death; dead and living patients are treated side by side whilst formalities for organ donation are completed; the physician diagnosing brain death chooses the tine of the patient’s death – which can have judicial consequences; a baby can be born after the death of its mother.

On death with dignity, Dr. M. Nagai (Japan) felt that all acts that bring the patient closer to natural death are justified. The patient must be helped to die like a human being. Dr. Backlund commented on the perspective which views death as something to be fought tooth and nail. On the other hand, euthanasia is often taking the easy way out when counselling and good palliative care would have been appropriate. Dr. Rappaport expressed doubts on the current trend in which life-and-death decisions are made by committees of hospital managers, lawyers and clergymen. While taking away doctor’s powers to make decisions will society absolve them of their responsibilities?

Dr. Graham Teasdale discussed ethics in research. An important argument made was that the insistence on fully informed consent can cause needless cruelty to patients and their relatives. Explanations of everything that can go wrong is not in the interests of the patient’s peace of mind.

Dr. R. Dillman, Secretary of Medical Affairs, Royal Dutch Medical Association, presented details on the Netherlands experience with euthanasia. Doctors had been divided on the public demand for euthanasia. It was permitted after a national debate, and under specific conditions, to ensure transparency and accountability. The law does not permit euthanasia, but no legal action is taken if the conditions are followed. Six thousand of 9,000 requests for euthanasia were turned down because the suffering was not unbearable, it could be palliated, available treatment had not been completed or there was evidence of treatable depression. The Netherlands Parliament will now consider legal modifications to make euthanasia legal.

The lessons from the Dutch experience : an euthanasia programme should not be embarked upon without an adequate legal framework that ensures transparency and accountability; patients must have free access to high quality medical care before such a step can be considered; there must be a full professional review of each case, and euthanasia is not an alternative to palliative care but a possibility when all else has failed to afford relief.

Dr. E. Schroten (Netherlands) discussed professional integrity in teaching medical ethics. The subject was best introduced with case studies, not ethical theories, with a phased analysis consisting of questions such as : What is the moral question ? What are the options at first sight? What other information must be obtained? Who must be involved? What are relevant arguments?

The meeting was unusual in that it focused on ethics in neurosurgery from a variety of viewpoints and contrasted traditional, religious and historical concepts with those based on modern scientific thought.

Dr. Sunil K Pandya,Flat 11, fifth floor, Shanti Kutir, Marine Drive, Mumbai – 400 020.

Hardships of medical teachers
Increasing pressures on medical teachers
Often talked and addressed among themselves
Due to limitations in their work
Patient care, teaching, administrative and research works
Impedence of their abilities and work
Though asking for expansion and new ones
Finally adjust with available ones
Due to financial constraints
Increasing workload every day
Lead to frustration and despondency
Representations are made on every other day
Hoping for improvement, on one of these days
Examinership, considered as prestigious
Some get it always
Others get it at times
Needs influence and pulls
Internal examinership gets recognition
Also avoids leave and dislocation
But subjects one to local pressures
And to satisfy many people
External examinership too has difficulties
Tedious travel experiences
Followed by reimbursement policies
When money comes, subject to I.T. returns
More responsibilities including legal works
The threat of transfer – for service persons
And out-of-turn promotion – the hanging swords
Also no vacation as in for other teachers

P Thirumalikolundasubramanian
Gizan, Saudi Arabia