Published online: March 5, 2019
Doctors in denial: Why Big Pharma and the Canadian Medical Profession are too close for comfort opens with Dr Brian Goldman, an acclaimed Canadian medical journalist and broadcaster, acknowledging the role he unwitting played in influencing the overuse of OxyContin in Canada. Goldman apprises readers that “Drug company money and marketing, coupled with recommendations from people like [him] helped fuel a massive increase in the number of uses of OxyContin . . .” (p 13). Initially unsuspecting, Goldman recounts being “easily swayed by flimsy scientific evidence” (p 13) and entering into a relationship with Purdue Pharma Canada believing he would be providing a balanced message on the safe and responsible prescribing of opioid drugs. Goldman (1). argues the impossibility of education paid for by drug companies being free from commercial bias, is firm in his transformed convictions that drug companies should not be involved in educating physicians, and is clearly disturbed that the medical establishment remains relatively unconcerned.
Doctors in denial is a much-needed chronology of the unabated presence of the pharmaceutical industry in all aspects of organised medicine over more than 60 years. The author’s purpose is to reveal the deeply entrenched relationship that exists between the pharmaceutical industry and Canadian doctors, medical journals, academic institutions, regulatory and professional bodies, and medical associations and societies. Lexchin’s instructive treatise calls upon readers to reflect critically and deeply on what has happened, and continues to happen in organised medicine relative to the influence the pharmaceutical industry brandishes, despite advances made in curtailing that influence over recent years.
In the introduction, readers are welcomed into an ambivalent “comfort zone” that the author argues doctors occupy as evidenced by the research exploring physician attitudes about their relationship with the pharmaceutical industry. Lexchin argues that although a number of medical professionals express significant doubt about the ability of their colleagues to remain unaffected by pharmaceutical industry influence, they themselves believe they are immune from that influence; thus, their “illusion of unique invulnerability” (2). Indeed, Doctors in denial reveals this sense of invulnerability to influence extending to the highest levels of authority in medicine; levels upon which society is reliant for ethical leadership and oversight of the best practice of medicine.
In each chapter of the book, Lexchin carefully chronicles the consequent implications of organised medicine’s denial of its all too comfortable relationship with the powerful pharmaceutical industry. The well-researched critiques Lexchin offers provide cogent substantiation for the less than desirable relationship that has evolved over more than half a century between the pharmaceutical industry and organised medicine; a relationship the author mindfully argues jeopardises the public’s trust. “When the medical profession adopts the values of private industry it is in essence saying that the needs of the private sector take precedence over the health of patients and society in general” (p 283), Lexchin states. Moreover, Lexchin asserts that many of the unacceptable patient outcomes that arise in association with misinformation and questionable prescribing occur as a result of the medical establishment being undeterred by the conflicts of interest that do exist in contexts when “individuals [and] organizations are placed in situation[s] where there is a risk that judgments or actions regarding a primary interest will be unduly influenced by a secondary interest” (p 26).
In the chapter “Medicine and industry: A marriage of convenience,” Lexchin explores the natural affinity between doctors and drug companies, which he attributes to pharmaceuticals as one of the mainstays of modern medicine. He highlights the era following World War II as a transformative time for Big Pharma and presents evidence showing increased collaboration between doctors employed by pharmaceutical companies and organised medicine. By the 1950s, for example, doctors employed by industry were in sufficient numbers to form a Medical Section of the Pharmaceutical Industry Association, a move applauded by the Canadian Medical Association (CMA), which Lexchin firmly believes was economically motivated in terms of the contribution advertising would make to the Canadian Medical Association Journal (CMAJ)
“Government, industry and the medical profession: ménage à trois” explores the role the alliance between the pharmaceutical industry and the medical profession played in how government initiatives rolled out over this past half century. Through a careful review of a number of bills, Bill C-102 as but one example, which ushered in compulsory licensing of generic drugs, Lexchin describes the “wave of protest” (p 46) that ensued with the Bill’s introduction from prominent figures in defense of the pharmaceutical industry. Lexchin recounts how this particular Bill drew the ire of the then director of the Clinical Research Institute of Montreal who praised the courageous Merck Frosst for its financial support of a scientific symposium “despite so unfavourable and so disturbing a climate of current legislation [Bill C-102], and the attitude of ignorance and distrust, if not antagonism, which is found among [certain people] [Lexchin among them]who want socialization of the pharmaceutical industry and state control of drug manufacturing and marketing” (p 47). The provocation of such disparaging remarks about colleagues who present a critical perspective was at that time, and remains today, steeped in fears that such legislation might evoke a downturn in research and development.
Despite being accused of “an over-developed penchant for self-righteously tweaking the noses of pharmaceutical firms” (p 81) in response to criticisms he advanced about the Pharmaceutical Advertising Advisory Board, Lexchin’s message remains steadfast: “industry [is] acting in its own self-interest to preserve its ability to generate the largest possible profit” (p 64). Indeed, Lexchin quite rightly argues that the primary interests of medical doctors and their organisations ought always to be “promoting and protecting the integrity of research, the welfare of patients and the quality of medical education” (p 26).
“Medical journals ‒ advertisements, money, regulation, rebellion and possibly retrenchment” draws the reader’s attention to the authoritative position journals continue to occupy in terms of communication and medical education. In this chapter, Lexchin highlights how Canadian journals have responded to criticisms about their engagement with pharmaceutical companies over the years. Lexchin cites the then (1980) director of publications for the CMA who, when asked about industry advertisements to the tune of “tens of millions of dollars. . .” (p 67), responded: “. . . Were we, as some purists have urged to turn up our editorial noses at advertising, we’d very quickly have them rubbed in red ink” (p 70). Lexchin presents data revealing advertising spending to be above $50 million annually between 1990 and 2005, peaking in 2004 at just under $80 million, and in recent years declining, with only [my emphasis] $13.3 million spent in 2015. In this chapter, Lexchin also documents a history of distasteful and offensive ads, which included seduction, the shaming of children, and the degradation of menopausal women; ads which appeared despite provisions in the Pharmaceutical Industry Association Code stating: “promotion should be in good taste, it should in no way be offensive . . . should give doctors as complete a picture as possible. . . and it should reflect an attitude of caution about using drugs, particularly those that were relatively new” (p 75).
Lexchin concurs with recent critiques of the implications of the commercialisation of universities for scientists, researchers and scholars (3), 4). and links his own critique to the neoliberal organised market as influencing how relationships have continued to evolve between industry and the academy. In “Academic health science centres: research, money, controversies, conflict of interest and independence”, Lexchin reports on the corporate research income universities with medical faculties receive from the pharmaceutical industry for the purpose of bridging a government funding gap and exposes the conflicts of interest this money creates. He recounts the responses of several university leaders who were quick to justify the partnerships as necessary for future research as captured in the words of the then (2009) president of the University of Saskatchewan: “It is well known across the country that so much of the research that is being done now and will be done in the future will be done pursuant to partnerships” (p 108).
In each subsequent chapter of Doctors in denial , Lexchin continues his rigorous approach to the laying out of overwhelming evidence that demonstrates the firmly-rooted relationships and interactions between the pharmaceutical industry and the Canadian medical profession; relationships he asserts have resulted in a “comingling of interests” (p 233). Lexchin is prudent in acknowledging that in some cases “anecdotes are the only evidence for the established relationships between industry and medicine. However, his careful chronology makes visible that the “interactions are real, long standing, and deeply entrenched” (p 233).
In the closing chapter ‘Reforming the comfort zone so that doctors are no longer in denial”, Lexchin narrates the systemic failure on the part of governments, the pharmaceutical industry and organised medicine to “constructively manage the relationship between the medical profession and the pharmaceutical industry (p 252). He outlines the general principles for needed reform, and offers an impressive list of 55 recommendations for federal and provincial governments (12), the medical profession (34), and the general public (9) in terms of how to roust doctors out of their comfortable positions of denial and ambivalence.
Doctors in denial: Why Big Pharma and the Canadian medical profession are too close for comfort is a must read for medical students and residents, practising physicians, medical researchers, scholars, health science professionals, academic administrators, journal editors, and importantly, the medical elite. It is a book that bores deeply in a comprehensive effort to reveal the shrouded conflicts of interests that exist at all levels of established medicine. Lexchin’s in-depth historiography of what can only be described as serious ethical lapses on the part of organised medicine, coupled with his comprehensive list of recommendations, provides a clear path forward towards the “openness, safety and objectivity” (p 283) he argues will affirm the trust that society has placed in the profession of medicine.