The relationship between doctors and the drug industry is complex; both exist to serve people and to improve health. Yet, their interests can often conflict. The authors elaborate on some of the problems and make recommendations for reducing the conflict. From their well referenced article, we learn that the cost of development of a new drug is between US$300 and $600 million, most of which is provided by industry. In the United States, about US$6 billion was spent on clinical research in 2000, of which 70% came directly from industry. Promotion and marketing consumes a quarter to a third of a company’s entire budget, and over $8,000 per physician.
They stress that transparency between doctors and drug companies is essential and recommend that dualities of interest should be publicly declared, acceptance of gifts should be kept to a minimum while non-service-oriented gifts should not be accepted. Further, support for travel should be restricted to those making formal contributions to meetings while research should be guided by scientific and ethical rather than commercial values.
The renowned ethicist at Georgetown University Medical Center, Ed Pellegrino, points out that although the Hippocratic oath has come under fire in recent times from a variety of groups including ethicists, historians, feminists, and patients’ rights activists and has been called outdated, it continues to be in use at commencement exercises in virtually all American and Canadian medical schools, though modified to satisfy today’s mores.
Pellegrino argues that oath taking persists because it unites the medical profession as a de facto moral community and sets it apart as one committed to beyond self interest. It reminds one of the antiquity of the profession and has the seed of hope in it. Forgetting the oath would risk converting medicine into a commercial or industrial enterprise.
The authors describe a study of informed consent in Bangladesh, among 105 pregnant women participating in a community-based study of iron supplementation.
“Although most women were informed about the objectives of the study, many…did not understand that they were free to decline to participate. Even fewer women understood that they might choose to leave the study. About half believed that participation was part of ordinary, routine health care. Eighty-seven percent indicated that they participated because they believed that doing so might carry such great advantages, primarily in terms of medical treatment for themselves or improved health for their babies, that it was difficult to say no.”
Should one use the unsafe but cheaper Semple vaccine for rabies when a safer non human cell culture vaccine exists? The writers argue that smaller intra-dermal doses of the latter vaccine are as effective and medically accepted, require fewer visits to the doctor, and bring costs down to the same as for the Semple vaccine. This makes it unethical to continue Semple vaccine which results in 600 Indians developing Allergic Encephala Myelitis annually.
Despite our flourishing industry in assisted reproductive technologies, there has been little debate, in India, on ethical questions raised by the technique of preimplantation genetic diagnosis (PGD). This has been the subject of heated debate in Japan, where people with genetic disorders face stigma and discrimination. This article describes the development of guidelines before reporting the results of two surveys, of geneticists and of lay people participating in support groups for parents of children with genetic abnormalities. Questions were asked on attitudes towards PGD, amniocentesis, and women’s right to abortion. The results show interesting differences in the opinions of lay people and experts, and between men and women. The discussion and conclusion refer to attitudinal changes evident in more recent studies, and call for more open public debate on the subject. The guidelines are given as an appendix.
It is most amusing to read a letter from a fourth-year medical student suggesting that the St Johns Medical College experiment of teaching medical ethics to their students (Natl Med J India 1997;10: 288-9) be used as a model for teaching medical ethics in British medical schools. At a time when Indian medical schools themselves have yet to introduce ethics in the course, it appears that, once again, the grass is greener on the other side.