As some of you know, one of my interests is continuing medical education (CME), mainly because I have worked on-and-off in the field for the past several years. One of the main topics that comes up within CME—and medicine generally—is the presence of pharmaceutical influence over physicians' prescribing behavior. Influence, of course, must be bought, and if one visits a typical American hospital or medical center, he/she will soon notice the presence of pharmaceutical paraphernalia (pens and sticky notes), free drug samples, and sales reps peddling their wares directly to physicians, nurses, and anyone else who will listen.
Pens and free samples seem relatively harmless, and the latter actually can benefit low-income patients. However, the stakes climb higher when we hear of sales reps treating physicians (and their spouses) to steak dinners, theater productions, and (at the top of the scale) free trips to resort locales (occassionally disguised as opportunities for "professional development").
When these instances of influence peddling (bribery) make the news, we subsequently encounter the inevitable reactions: Members of Congress promise to hold hearings, professional ethics guidelines are introduced, and Big Pharma goes on the defensive. However, these stories often don't ask the simple, most important question: Are doctors corrupt, and if so, should we care?
If you want to offend any given physician, a good tactic would be to impugn his/her integrity by stating that he/she is in bed with Big Pharma. Perhaps the physician's financial connections come in the form of the goodies mentioned above, or perhaps he/she receives research grants from companies or serves on well-paying speakers' bureaus / "advisory" panels.
In any case, I would hypothesize that implying any sort of improprietary, regardless of the nature of the relationship, would invite an angry retort from the physician. "Just because I receive grant money from ABC Pharmaceuticals doesn't mean that I cannot review medical research objectively!" "Are you saying that I'm prescribing more XYZ medications because the sales rep bought me dinner? Do you think I'm that cheap?"
Of course, whether these financial connections actually influence prescribing behavior is an empirical question. I have heard that they do, but that is not the main question I'm asking here. Rather, for the sake of argument, let's assume that pharmaceutical companies do successfully bribe the medical profession, that their influence peddling does make a material difference in prescribing behavior (i.e., that if they did not engage in such practices, fewer brand-name prescriptions would be written). Should we care?
Public indignation at such practices primarily stem from two emotions: envy and betrayal. Physicians, despite their complaints about being nickel-and-dimed by HMO's, are still well-compensated for their knowledge and expertise. When we hear that these well-heeled professionals are getting extra goodies (steak dinners, ski trips), we feel indignant at yet another example of the haves taking huge chunks of the pie. This is simply envy, and on both theological and philosophical (libertarian) grounds, I do not regard it a legitimate basis of critique. Remember: physicians are well-compensated because they generally know much more about medicine than the average person.
This brings me to betrayal. If a physician writes more prescriptions for XYZ medications because he/she is being bribed by Big Pharma, then we feel as though our trust has been violated. We feel as though the doctor doesn't care about us, the patients, but rather is more interested in the lucre. While the feelings of betrayal are understandable, they stem from three ill-conceived presuppositions about contemporary medicine:
- Trust: While trust in many other professions (e.g., accounting, law) has eroded in the past several years/decades, many still hold onto to the belief that we should "trust" our physician implicitly. Granted, this trust, too, has been eroding recently with greater public access to medical information (e.g., anyone with an Internet connection can surf WebMD and then go to the doctor's office armed with questions and alternative therapies), but I hypothesize that we still trust the profession of medicine more than, say, politics.
- Professionalism: We are under the mistaken impression that professionals are somehow both intellectually and morally superior. Physicians are not supposed to engage in the grubby give-and-take of, say, stock traders or car sales. Rather, they are supposed to rely on their training, examine "all of the evidence," and make judgments based on precise reasoning and sound moral guidance. This, of course, is silly. Professionals are humans, suceptible to the economic pressures and moral conundrums that the rest of us face on a daily basis. When we see a doctor, we should see him/her as a human being — smart and well-educated, for sure, but nevertheless human.
- Body Obsession: Finally, our sense of betrayal stems from our mistaken assumption that the human body is not a mere commodity, that it is something more and thus, should be treated with the utmost gravitas by any health professional. Unfortunately, our bodies are commodified goods, and we treat them as such every day. Do not our bodies carry our minds and our very "selves"? Do we not use them for work and pleasure? Perhaps we are theologically mistaken to give so much moral weight to the body. (The theologian Stanley Hauerwas has remarked that the best and the brightest in our society attend Medical School, rather than Divinity School, because we are more concered with training competent doctors than competent priests/pastors/ministers; in other words, we are more concerned with the health of our bodies, rather than the health of our souls.)
So, are doctors corrupt? I'm sure that most of them are people of integrity, who care about their patients, blah, blah, blah. I'm sure that the most egregious cases of corruption stem from the "few bad apples," etc., etc. That is not the most important question. Rather, should we care? I argue no. If we maintain a healthy skepticism of all professionals, do a little bit of our own research, and eschew body obsession, then the question of corruption fades into irrelevance.