On the Take

Your relationship with your doctor might be more complicated than you ever imagined. Financial conflicts of interest abound among physicians, researchers, insurance companies, professional societies, university medical centers, editorial boards, government agencies and the pharmaceutical industry. Jerome Kassirer, former editor of the venerated New England Journal of Medicine, is quick to point out that conflicts of interest themselves are not immoral or unethical. However, they promote a bias that can affect the type of health care we receive.

Kassirer cites example upon example of financial conflict of interest in his detailed look at the relationship between big business and the medical establishment. Although he often fails to articulate why some of the conflicts he describes are problematic, the ill effects he does cite are sobering.

Kassirer doubts most physicians’ ability to remain unbiased when they receive gifts from pharmaceutical companies. While he acknowledges that the impact of gifts depends on the type of gift given, he asserts that the moral high ground requires elimination of the temptation in the first place—physicians should not take gifts from pharmaceutical companies or be bound financially to them in any way. I was not always convinced that there are problematic conflicts of interest at the same points where he sees them, but it is impossible when reading the book not to be bothered by the extensive advertising of drugs to both physicians and patients. The quality of drugs should speak for itself, as Kassirer points out, and an independent, centralized drug registry for physician access would seem an ideal strategy for reducing or eliminating conflicts of interest.

Kassirer’s illustrations of insurance company policies are often more gripping than the examples from the pharmaceutical industry. Many readers have personally experienced conflict with insurance companies and physicians when services were denied. Physicians often face ethical dilemmas when they must decide whether to confront insurance companies about limits to treatment or to restrict the care options they offer to their patients.

Conflicts of interest emerge from many directions. During the late 1990s many physicians’ real earnings decreased while salaries in every other major job sector in the U.S. were growing. Kassirer points out that pharmaceutical companies pay particular attention to medical residents, who are often underappreciated, underpaid and working long hours at the outset of their careers. As medical professionals mediate their dual loyalties as both healers and wage earners, industry incentives and frustrations with compensation and insurance policies have driven physicians to expose themselves to more conflicts of interest, sometimes at the expense of patient care.

Surprisingly, Kassirer offers little in the way of recommendations for public action in response to these problems. He says that people can advocate policy change and ask their doctors to detail their conflicts of interest. However, our duties lie deeper and our contributions could be greater. Communities of faith have richly woven histories with the medical profession. As patients and health-care professionals, the people of God should revisit the charitable roots of the medical profession and reawaken appreciation for the services of health-care professionals by listening to their concerns and those of patients. Fundamentally we need to preserve and strengthen trust between physicians and their patients, and this can be accomplished better if physicians are unencumbered by competing loyalties.

Kassirer recalls a talk to the American Medical Association in which Cardinal Joseph Bernardin highlighted the moral dimensions of the trust covenant between physicians and patients as the primary underpinnings of medicine. As we hold physicians accountable to Bernardin’s challenge, we must call for a change in the behaviors of the insurance and pharmaceutical industries so they will help physicians better care for their patients rather than sustaining systems that create obstacles to care.

On the Take further confirms my belief that the lofty and largely humanistic ideals for medical care that were shaped by Greek, Jewish and Christian histories are necessary for putting the patient first. This requires that the profession distance itself from the type of free-market capitalism that drives other sectors. As Kassirer writes, “Caveat emptor (let the buyer beware) may be an appropriate slogan for selling used cars or life insurance, but it is not a worthy dictum for health care. In the final analysis, it is not a patient’s responsibility to protect himself against the medical profession, it is the profession’s responsibility to protect the patient.”