DOI: https://doi.org/10.20529/IJME.2011.019
Financial arrangements between healthcare providers, or their professional organisations, and industry have long been a matter for ethical concern. Howard Brody, a member of the American Academy of Family Physicians (AAFP) himself, has argued strongly against the controversial financial arrangement between AAFP and the Coca-Cola (CC) Corporation. AAFP accepted funding in the name of developing patient education material on obesity from CC, a major producer of sweetened drinks that are considered to be a significant cause of obesity. The concern is whether the arrangement would create a conflict between the AAFP’s financial interest and its interest in serving public health objectives.
Brody sets out to examine the arguments by AAFP leaders in defence of their arrangement with CC, in order to separate ethical arguments from rationalisations. In the author’s opinion, the leadership of professional medical organisations is such that more such alliances, posing worrisome conflict of interest issues, are likely to take place, and these may not be easy to resolve.
Brody states that medical professional bodies must provide ethical guidelines to their members. Further, for doctors to abide by the guiding principles of their profession, the individuals managing these professional bodies must practise the highest level of professional and ethical conduct. In addition, these organisations are also the “face of the profession, and how they behave will determine to a considerable extent the degree of trust and respect that medicine earns from the general public and societal leaders”. Controversies like the one under discussion can destroy the overall credibility of medical professionals who are committed to patient and public health.
AAFP has provided counter arguments in public statements and communications with its members to justify its position. AAFP suggests that the accusation is premature to begin with. It believes that until the patient-education materials prepared are critically analysed by the public and professionals, it would be wrong to charge the organisation with conflict of interest. Brody refers to the definition of “conflict of interest” in response to this counter argument: a “… reasonable presumption that they will be tempted to put aside the primary interests in favor of a secondary set of interests”. This means that a conflict has occurred once an arrangement in favour of a “secondary interest” is made. Measures need to be taken to resolve the conflict before the public or patients are harmed.
Second, AAFP states that CC, whose “product may contribute to obesity” should not be considered as “evil” just because it is willing to fund a public awareness programme against obesity. Brody’s response is that it is not a matter of being good or evil. The basic difference in the objectives of the medical professional body (the well being of public health) and CC (selling their product) is what indicates that the arrangement has conflicting interests.
Third, AAFP has suggested that relationships like the one between it and CC are “opportunities to change the company’s behavior for the better”. Therefore, it would be wrong to avoid such an alliance, to not engage with them. Brody is sceptical of this argument because of the large amounts of money involved. Arrangements can exist between medical organisations and corporations only if any conflict of interest is eliminated and the end result is primarily “improved public health”.
Finally, AAFP has compared its case with a multimillion dollar scandal involving the American Medical Association (AMA) and Sunbeam and argued that it has taken care of the “traps” that caused AMA embarrassment. Brody rejects this argument and points out that AAFP’s consideration in this respect is to avoid the legal and public relations mistakes that AMA made, rather than “learning the key ethical lesson”.
Finally, Brody states that AAFP has made certain ethical counterarguments that support such alliances. One is based on the definition of “conflict of interest”. In AAFP’s view, proven conflicts of interest are potentially harmful, and “apparent” conflicts are not worrisome. AAFP supports a “management strategy” which calls for disclosure of conflict and managing it by establishing procedures to prevent “ill effects”. He argues that even an apparent conflict affects the public’s trust in the profession. Hence, AAFP’s line of thinking is unacceptable for organisations “that aspire to higher ethical standards of conduct”.
Brody concludes that discussions on conflict of interest must separate rationalisation from ethical arguments. The AAFP president, when announcing CC funding, called the arrangement a “consumer alliance program”. Brody describes it as a “corporate alliance program” because such plans are made primarily to look after the interests of the corporation. He states that medical organisations that enter into corporate deals are benefiting their leaders and office bearers. Such alliances harm the public health and affect public trust in medical professionals. Any organisation that makes an effort to rationalise the loss of public trust and health cannot be functioning ethically.
This issue is not new in our part of the world. Companies dealing in medical consumables and other medical products usually support medical organisations and individuals in arranging educational programmes for doctors and the community. These collaborations are viewed as necessary for making events financially feasible and are generally not considered “unethical” in the public opinion for the simple reason that the conflict of interests is not obvious, even if it exists. Brand endorsements, on the other hand, by medical practitioners, associations and professional bodies, often seen in Pakistan, India, and other countries in this region, are envisioned as a potential threat to the trust that people have in the medical profession. In fact, most ethical guidelines prohibit such activities directly or indirectly (1, 2, 3).
From the cultural point of view, medical professionals in our region are viewed as protectors of public health. Therefore, the main difference between the two arrangements – companies collaborating with medical organisations for educational activities; and brand endorsement by professionals – is in the primary interest. In the former, the benefit goes towards educational programmes for improving public health; in the latter scenario, the brand takes that position, creating a feeling of distrust among the general public. Brody has given the same importance to the trust that “people and leadership” have in medical professionals.
In Pakistan, a recent advertisement had a high ranking office bearer in a national infection control society making the unscientific claim that a particular “anti-bacterial soap” eliminated 99.9 % of bacteria and swine flu virus. He was criticised by medical professionals in the country for endorsing the product and jeopardising public trust in professionals (4). Although the medical society did not directly endorse the company’s product in this venture, when a senior public figure affiliated with a professional body, is seen on television, standing in front of the company’s banner, and describes the product positively, there is no need for a direct endorsement.
The officer released a statement in reply, arguing that since there was no personal (financial) gain for him in this public awareness project, there could not be a conflict of interest or any other ethical concern related to his actions. The advertisement was discussed in different bioethics forums in Karachi. The questions asked included: Is it ethical for an office bearer of an infection control society to appear on television and promote a brand of anti-bacterial soap? Is there any undisclosed financial or other benefit for the Society in this endeavour? The need was felt to make medical professionals realise the potential problems associated with such activities and the ethical unrest that they can create. In our line of work ignorance is not bliss, it is negligence.
There are many such examples of brand endorsements by medical professionals. Soaps, washing liquids, “energy drinks”, cooking oils, toothpastes and mouthwash endorsements by associations and individuals are just a few. Many of them also make unscientific claims, deceiving the consumer and damaging the trust that people have in the healthcare profession. These endorsements may not provide money for the endorsing body upfront; their office bearers may be given perks instead. In any case, the arrangements are not disclosed to “consumers”, who indirectly bear the brunt of the expenses.
The Karachi Bioethics Group, a collaboration of medical professionals in the city, holds that no matter how beneficial a corporate proposal (like funding for educational programmes and symposiums or financing health awareness programmes on television) may look, the primary benefit will be for the company, rather than for patient or public health. This view must be upheld by professional organisations to maintain the highest standards of ethical behaviour.
In a discussion with medical students and young doctors at Pakistan Medical Association House, Karachi, it was suggested that since corporates often argue that their funds are intended to fulfil their responsibility to the community, to be used through medical professional associations, they may be interested in funding awareness programmes that are not directly related to their product. For example, Coca-Cola could finance a public awareness drive for infectious diseases, and Safeguard soap an obesity prevention programme. In such cases, companies could not have a primary agenda of their own and would have to be interested in promoting public health.
One may argue that in a developing country with inadequate infrastructures for hygiene, healthcare and education; public education is a priority even if it is funded by corporate vested interests. Such reasoning amounts to rationalisation, leading to a slippery slope that ends in the depths where physicians and medical societies eventually become no more than marketing tools.
It is the duty of medical professional societies to undertake activities that fulfil their obligation to raise public awareness and continued medical education without creating conflicts of interest and jeopardising the trust that the public has in the medical profession.