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LETTER TO THE BOOKSHELF

A letter from Howard Brody regarding Arthur Caplan's review of three books on the pharmaceutical industry, and a reply from Caplan

To the Editor:

Arthur L. Caplan's spirited and insightful review of three books on the pharmaceutical industry ("Indicting Big Pharma," January-February 2005) ends with the recommendation that "dialogue and redirection, not demonization" is the right way to deal with the serious problems of this industry. His review might be interpreted as hard-hitting in its discussion of pharmaceutical misdeeds, yet he also, it appears, wishes to defend the industry from some of the attacks contained in these books.

I was curious whether American Scientist thought it worthy of disclosure that this reviewer, in the process of doing a study of the ethics of drug company marketing, accepted research support from the industry and defended the ethics of accepting such support when commentators took issue with it.

Results of the study were reported in an article ("All Gifts Large and Small: Toward an Understanding of the Ethics of Pharmaceutical Industry Gift-Giving," by Dana Katz, Caplan and Jon F. Merz) that was published in the Summer 2003 issue of the American Journal of Bioethics [3(3):39-46], along with 15 open peer commentaries, including one written by me. The article, which explored the ethics of pharmaceutical companies giving small gifts such as pens and notepads to physicians and examined evidence from the social sciences showing that behavior can be influenced by gifts of negligible value, was accompanied by an acknowledgment that the research reported in it was partially sponsored by an unrestricted gift from Pfizer, Inc., to the University of Pennsylvania Center for Bioethics.

The article contained a number of conclusions antithetical to the position of the pharmaceutical industry; yet the authors concluded in the end that tighter regulations of physician behavior would be counterproductive. They offered reasons to back up their conclusions. Unfortunately, as I noted in my commentary on the article ("Pens and other pharmaceutical gifts," pages 58-60), a skeptical reader might still wonder: Did they decide against recommending stricter regulations because that was truly their independent, scholarly view? Or might the research support they received from a major pharmaceutical manufacturer somehow have colored their perceptions and interpretations?

There seems to be a parallel between the commentary in the paper by Katz, Caplan and Merz and Dr. Caplan's more recent book review. The authors of the books he reviewed argue that the record of the pharmaceutical industry is not a pretty one. "Demonization" is precisely what at least some of those authors might feel is appropriate. By saying that we should be critical of the industry, but not too critical, might Caplan be reflecting the fact that his center has received funding from the industry? It is precisely for reasons such as this that journal editors have lately decided to err on the side of disclosing authors' conflicts of interest, allowing readers to decide how much weight, if any, should be attributed to such factors.

Asking whether authors of book reviews need to disclose conflicts of interest might appear to be straining at gnats. However, both Dr. Caplan and I work in university centers devoted to the study of bioethics. I believe that we have a special responsibility to ask tough questions about conflicts of interest and the negative effects these might have on academic and scientific judgment, especially our own.

Howard Brody, M.D., Ph.D.
Center for Ethics and Humanities in the Life Sciences
Michigan State University
East Lansing, MI

The Editors respond:

Prompted by Dr. Brody's inquiry, we have added to the March-April issue a note mentioning that pharmaceutical companies are among the sponsors of the work of Dr. Caplan and the Center for Bioethics at the University of Pennsylvania. We think this information, which is posted at http://www.bioethics.upenn.edu/Resources might be of interest to our readers. Decisions about mentioning authors' financial interests or funding sources in the magazine are made on a case-by-case basis; we generally favor transparency.

A Response from Arthur Caplan

To the editor:

Dr. Brody implies that I am pulling punches in my recent book review. He bases this claim on the fact that I and my colleagues did a study three years ago funded by an unrestricted gift from Pfizer to examine what influence small gifts (pens, doughnuts, pizza) have on physician behavior. I will leave it to readers to judge whether that is true about my book review. But let me address the issue of cooptation that Brody raises.

Dr. Brody readily acknowledges that our Pfizer-funded study produced findings that are inimical to Pfizer's commercial interests, although he misinterprets the interpretations that we ourselves drew in that paper. Since the paper has been cited in reviews, on Web sites and in articles about conflicts of interest (most recently in a set of papers on conflicts of interest published in the New England Journal of Medicine), it would seem that his opinion neither carried the day when he wrote his earlier commentary about our study nor does it do so at present. Sour grapes?

The broader issue is what to do about conflicts of interest in writing articles or book reviews or letters to the editor for journals. Our Center has taken money from private organizations in the form of unrestricted gifts to do studies. The bulk of our support comes, however, from foundations, government sources and our own medical school. The same is true at Dr. Brody's institution.

We have long disclosed all our sources of support on our Center Web site, since transparency is crucial to credibility. That said, I did not report any conflict of interest in my review because, contrary to Dr. Brody's insinuations, I do not have any personal conflicts of interest that influenced what I wrote in the review.

Dr. Brody might say, But wait—what about support your Center has gotten over the years from private sources? Is that corroding your willingness to take on the industry?

Well, Dr. Brody works at an academic medical school at Michigan State University. His school held joint patents, which only recently expired, with the pharmaceutical company Bristol-Meyers Squibb on the drugs cisplatin and carboplatin. His medical school received more than 300 million dollars in royalties from these drugs, starting in 1978. Should Dr. Brody have disclosed that fact when he wrote his letter? What about in all of his publications since 1978? Does this massive underwriting of his medical school by a private drug company lead him to think twice in what he has to say about the pharmaceutical industry or about cancer treatments?

I do not know, but I doubt it. The reality is that every faculty member and every school, university and academic medical center has to deal with the real world of grants, contracts, gifts, donors, foundations, corporations and alumni. Each offers a source of revenue, and each brings a set of pressures and values along with that revenue. We in academia have not yet figured out how to manage conflicts of interest when it comes to all of these sources. But if one wants to impugn someone else's integrity, more than suggestiveness is required.

My point in my review was that the critics of the pharmaceutical industry seem to me to have plenty of evidence that it has gone off the ethical rails, but those critics should not be demonizing an industry desperately in need of reform—one that medicine is going to have to live with for the foreseeable future. I think that point stands. The tone and content of Dr. Brody's letter inadvertently reinforces my concern about the dangers of demonization when it comes to playing the conflict of interest card.

Arthur L. Caplan
Center for Bioethics
University of Pennsylvania School of Medicine


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