The Psychiatrist (2006) 30: 189-191. doi: 10.1192/pb.30.5.189
© 2006 The Royal College of Psychiatrists
Psychiatric Bulletin (2006) 30: 189-191
© 2006 The Royal College of Psychiatrists
Pharmaceutical sponsorship of educational events: what can we learn from healthcare ethics?
Christopher A. Vassilas, Consultant Psychiatrist
Queen Elizabeth Psychiatric Hospital, Edgbaston, Birmingham B15 2QX,
e-mail:
c.a.vassilas{at}bham.ac.uk
Sarah Matthews, General Practitioner and Acting Senior Lecturer
Warwick University, Coventry
Declaration of interest
None.

Introduction
In the UK, postgraduate medical educational events are commonly
sponsored
by pharmaceutical companies, often with the provision
of food and gifts with a
small monetary value (e.g. pens and
torches). The involvement of
pharmaceutical companies with
doctors has been discussed extensively
(
Abbasi & Smith, 2003;
Shooter, 2005). We have chosen
to consider sponsorship of
educational events from an ethical point of view in
order to
see if this approach can provide guidance for a situation that
is the
norm in many hospitals, but of increasing concern to
educationalists. We also
hope to illustrate how the application
of ethical principles can be applied to
a medical education
issue.

Ethical background
The four core principles of medical ethics expounded by the
American
ethicists Beauchamp and Childress
(
2001) are shown
in Box 1. The
four principles are claimed to be culture-free
concepts which can be
universally applied and therefore offer
a framework for tackling any ethical
problem within medicine.
Although this methodology is not unanimously accepted
(
Campbell, 2003),
the four
principles do provide a useful structure and starting
point to look at ethical
issues.
Why should a doctor eating a sandwich given free by the representative of a
company whose products they would regularly prescribe anyway involve any
breach of the ethical principles outlined above? One way to approach this
problem is to look at an extreme example of conflict of interest that most
doctors would agree on, see what ethical principles are involved and then
gradually work down a hierarchy of scenarios where the ethical issues are less
clear.
| Box 1. The four ethical principles of Beauchamp and Childress
(2001)
- Respect for autonomy - we should respect the rights of others to make their
own decisions.
- Beneficence - we should do good for our patients.
- Non-maleficence - we should do no harm.
- Justice - doctors should act fairly.
|

Three scenarios showing conflict of interest
Scenario 1
A doctor accepts direct payments from a pharmaceutical company
to prescribe
a particular drug to his or her patients.
Scenario 2
A related scenario would be that of a doctor receiving £10 000 in
cash from a pharmaceutical representative every year to attend an annual
educational event organised by a drug company with no strings
attached.
Scenario 3
Many doctors are flown abroad by drug companies to attend meetings. Some of
these are sponsored conferences that may launch a new product or present
research about one or more of the companys products. Others are high
profile international conferences not organised by the pharmaceutical firms
but guests will be encouraged to attend sponsored satellite
talks and perhaps visit the companys offices.

Ethical debate
In Scenario 1, it might be argued that the drug prescribed is
a licensed
treatment for the disorder, that other doctors would
prescribe that drug
anyway and no more harm is likely to happen
to the patient than if other drugs
had been prescribed. However,
the main factor affecting treatment decisions is
the payment
received from the drug company rather than the well-being of
the
patient. A core feature of the relationship between doctors
and patients is
trust (
Green & Bloch,
2001): patients
entrust their well-being to doctors who in turn
are expected
to act for their benefit. It is clear that this latter principle
is being breached and would be recognised as such by both doctors
and patients
as being unethical. Any beneficence that results
for the patients is merely an
incidental effect and there is
a risk of maleficence. This behaviour would be
considered illegal
in most Western countries, including the UK, although it
does
occur (
Burgermeister,
2004).
In Scenario 2, the arguments supporting this behaviour might be that the
doctor is simply accepting money from the drug company to compensate him or
her for their time in going to the educational event. There is no explicit
agreement to prescribe and even if there were, the same arguments in support
of Scenario 1 would apply. However, the sum of money involved is such that the
perception of others would be that fidelity to the patient is compromised in
exactly the same way as in the first scenario.
In Scenario 3, doctors may believe these events benefit them and their
patients because they are educational and that the sponsorship enables them to
attend talks that they would not otherwise be able to hear. Few trusts would
fund doctors to go to international conferences, such as those held by the
American Psychiatric Association (APA). However, as reported by Baird in this
issue (pp. 161162) pharmaceutical companies have sponsored UK
psychiatrists to attend the annual meeting of the APA for many years. Doctors
may believe they are able to come to balanced decisions and that the events
contribute to their continuing medical education.
Relationships between pharmaceutical companies and doctors in the UK are
governed by a code of practice (Association
of the British Pharmaceutical Industry, 2001), which is reflected
in the guideline on the website of our own College
(Royal College of Psychiatrists,
2003). This states that the level of hospitality provided at
meetings must be appropriate and not out of proportion to the
occasion and costs must not exceed that level which the
recipients would normally adopt when paying for themselves. We would
argue that the level of hospitality provided at international meetings in
Scenario 3 does not comply with the spirit of these guidelines.
The association between the receipt of hospitality from a pharmaceutical
company and the prescription of their drugs may not be as direct as in
Scenarios 1 and 2. However, drugs may be prescribed for reasons other than
best clinical indications. Doctors who attend courses sponsored by a
particular company are more likely to preferentially prescribe that
companys product after the event
(Bowman & Pearle, 1988).
Despite physicians believing that attending sponsored conferences has no
effect on their prescribing, this is contradicted by the evidence
(Orlowski & Wateska,
1992).
Doctors are influenced by many sources but they are expected to evaluate
opinions and evidence and arrive at decisions that provide the best care for
their patients. By attending sponsored events they are allowing drug companies
to exert undue influence. Again, a failure of fidelity towards their patients
arises and a breach of the ethical principles.

Hospitality
What harm could there be from the scenario we gave in the introduction
to
this article? Sponsorship of hospital educational events
does not breach
guidelines, the food and token gifts encourage
doctors to attend educational
meetings. The provision of sandwiches
saves time for busy clinicians.
Pharmaceutical companies could
be seen as supporting education in a way that
is not always
done by NHS trusts. As the monetary value of the gifts offered
is small, less than £6 (
Association
of the British Pharmaceutical Industry, 2001),
they may be
perceived as being insufficient to exert any influence.
However, the social
obligations that result from receiving
even small gifts are immensely
powerful. The marketing departments
of pharmaceutical companies take advantage
of these obligations
in selling their products
(
Cialdini, 2001). Similarly,
providing
food seems to have a marked effect on making individuals receptive
to information (
Janis et al,
1965). Pharmaceutical representatives
set up a relationship
encouraging doctors to reciprocate. This
may lead to changes in prescribing
that compromise fidelity
to patients in a way that is analogous to the
situations in
the above scenarios.
Professionals, such as doctors, should agree to moral standards that oblige
them to place the good of those they serve above their own self-interest
(Pellegrino, 1983). We know
that the public has concerns about psychiatrists relationships with
pharmaceutical firms (Shooter,
2005). There is a view that routine acceptance of small gifts and
hospitality will influence prescribing which may not benefit, and may even
harm, patients (Mainous et al,
1995; Gibbons et al,
1998).

What is the way forward?
The majority of physicians see pharmaceutical company representatives
and
attend company sponsored medical education sessions
(
Lexchin, 1993).
Although the
pharmaceutical industry has contributed greatly
to the improvements in health
and life expectancy (
Abbasi & Smith,
2003),
the interests of physicians and pharmaceutical companies do
not always coincide. Involvement of the pharmaceutical industry
with medical
education, even at the very low level of providing
lunch for an educational
programme, may result in a breach
of ethical principles. Our own College has
begun to address
this issue (
Shooter,
2005). Within individual trusts, the starting
point must be to
develop clear guidelines for the relationship
between all staff and commercial
organisations. At least one
medical school in the USA has started a programme
that helps
residents to deal with drug company representatives
(
Watkins & Kimberly,
2004).
Waud (1992) argued that
drug companies should not subsidise education in any form, using as his
guiding ethical principle the Hippocratic oath, In every house where I
come I will enter only for the good of my patients.

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