On the Take: How America’s Complicity with Big Business Can Endanger Your Health JEROME P. KASSIRER, M.D. OXFORD UNIVERSITY PRESS ONTHE TAKE This page intentionally left blank ONTHE TAKE HOW AMERICA’S COMPLICITY WITH BIG BUSINESS CAN ENDANGER YOUR HEALTH JEROME P. KASSIRER, M.D. 2005 OXFORD NEW YORK AUCKLAND BANGKOK BUENOS AIRES CAPE TOWN CHENNAI DAR ES SALAAM DELHI HONG KONG ISTANBUL KARACHI KOLKATA KUALA LUMPUR MADRID MELBOURNE MEXICO CITY MUMBAI NAIROBI SÃO PAULO SHANGHAI TAIPEI TOKYO TORONTO Copyright © 2005 by Jerome P. Kassirer, M.D. Published by Oxford University Press, Inc. 198 Madison Avenue, New York, New York 10016 www.oup.com Oxford is a registered trademark of Oxford University Press All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Oxford University Press. Library of Congress Cataloging-in-Publication Data Kassirer, Jerome P., 1932– On the take : how medicine’s complicity with big business can endanger your health / by Jerome P. Kassirer. p. ; cm. Includes bibliographical references and index. ISBN 0-19-517684-7 1. Physicians—Professional ethics—United States. 2. Pharmaceutical industry—Corrupt practices—United States. 3. Medical ethics—United States. 4. Conflict of interest. 5. Gifts. [DNLM: 1. Practice Management, Medical—ethics. 2. Conflict of Interest. 3. Physician Incentive Plans—ethics. 4. Physician’s Practice Patterns—ethics. 5. Physician’s Role. 6. Physician-Patient Relations—ethics. W 50 K188o 2004] I. Title: How medicine’s complicity with big business can endanger your health. II. Title. R725.5.K376 2004 174.2’6—dc22 2004012890 1 3 5 7 9 8 6 4 2 Printed in the United States of America on acid-free paper to Sheridan This page intentionally left blank Acknowledgments I am grateful to dozens, scores, and possibly hundreds of physicians. Many contributed their time, knowledge, and wisdom to help me delve into the kind, extent, and consequences of physicians’ collaborations with industry. Many were forthcoming and eager to get the problem exposed. I also inter- viewed many who were defensive, even angry at the inference that financial conflicts might have influenced their medical decisions. I understand their attitude: because financial arrangements with industry create an impossible- to-resolve dilemma between a doctor’s professional role and his or her per- sonal responsibilities, exposure of their conflict is a moral stigmatizer. Interestingly, I also interviewed many others who had no financial conflicts and expressed their moral indignation about the misdeeds of their colleagues who did, yet demurred when I asked to cite their quotes by name. They disappointed me. Financial conflicts of interest invoke strong emotions. Support from the Josiah Macy Jr. Foundation, the Open Society Insti- tute, and the American Board of Internal Medicine Foundation made the project possible. June Osborn at the Macy Foundation, Gara LaMarche and David Rothman at OSI, and Harry Kimball and Christine Cassel at ABIM deserve special mention for their encouragement. The foundation support made it possible to hire three enthusiastic and outstanding research assis- tants, Ethan Eddy and Vu Luu from Tufts University School of Medicine and Lisa Olmos from Baylor College of Medicine. Their contributions were both technical and intellectual. I owe a special debt of gratitude to my bosses who created the academic atmosphere and the flexible teaching schedule that allowed me to devote time to the book. They include John T. Harrington, Nicolaos Madias, Michael Rosenblatt, and Deeb Salem at Tufts vii University School of Medicine, and David Kessler, Ralph Horwitz, and David Coleman at Yale University School of Medicine. Raymond Tye, an old friend and former patient who is silently behind many medical projects in Boston, provided substantial financial support for my position at Tufts. Many people enriched my understanding of the subject, debated the pros and cons of relations with industry, read drafts of chapters, provided information, and made invaluable suggestions. They include Elliott Antman, Robert Bass, William Bennett, David Blumenthal, Sandy Bogucki, Robert Bonow, Dawn Bravata, Troyen Brennan, Susan Chimonas, James Cleeman, Jordan Cohen, Douglas Drossman, Thomas Duffy, Peter Eisenberg, Scott Epstein, Mark Feldman, Thomas Finucane, Marshall Folstein, Joanne Foody, Howard Gardner, Lawrence Gartner, Thomas Glynn, Stephen Goldfinger, William Gouveia, William Grossman, Karen Hein, James Herndon, Cora Ho, Jerry Hoffman, Timothy Johnson, Ingrid Katz, Norman Katz, Paul Katz, Ruth Katz, Vincent Kerr, Harry Kimball, Harlan Krumholz, Neil Kurtzman, Andrew Levey, Peter Libby, David Lowance, Kenneth Ludmerer, Eric Mazur, Donald Moore, Carol Nadelson, James Naughton, Joseph Palca, Brian Pereira, Eric Peterson, Robert Reisman, Ellen Relkin, John Ritchie, Marc Rodwin, David Rothman, Harry Selker, David Shriger, Neil Smelser, Robert Steinbrook, Samuel Thier, Dennis Thompson, Robert Utiger, Shaw Warren, Douglas Waud, John Wennberg, James Weyhemeyer, Stephen Winter, and Alexi Wright. Inevitably, this list will be incomplete. The book covers many aspects of medicine in which I am not an expert, as well as fields such as psychology and sociology. In all these disciplines I relied on the knowledge and advice of many of the above people and oth- ers for accuracy and interpretation of information, but in the final analysis any misinterpretations are my own. I also relied heavily on the outstanding work of several reporters, many of whom have doggedly pursued the well-hidden financial conflicts of phy- sicians for years. They include Liz Kowalczyk at the Boston Globe, Andrew Julien and Matthew Kauffman at the Hartford Courant, David Willman at the Los Angeles Times, Melody Petersen, Kurt Eichenwald, and Gina Kolata at the New York Times, Duff Wilson and David Heath at the Seattle Times, Jenni- fer Washburn and Eyal Press of the Atlantic Monthly, and Dennis Cauchon viii Acknowledgments at USA Today. Melody Petersen deserves special mention because of the ex- tent and excellence of her work. Special credit goes to Larry Tye, former reporter for the Boston Globe. To my delight, Larry became my mentor. He urged me to apply for foundation support and to hire research assistants to help with the work. He pressed me to go beyond a literature survey, to use the techniques of investigative reporting, and to go after substantial fresh material to supplement all that was already available in journals and newspapers. In lunch meetings in Cam- bridge over many months, he listened patiently to my progress, pushed me hard, and helped me become a fledgling reporter. Theresa Park, my agent, never lost faith in the project, and found it the right home with Oxford University Press, where my superb editor, Timothy Bartlett, improved the book’s organization, style, writing, and especially the logic. The love, support, and unshakable optimism of my children—Amy, Richard, Wendy, Elizabeth, Winston, and Sam—have heightened the many peaks of my career and blunted the occasional valley. I owe them more than they owe me. Nobody deserves more credit than my wife, Sheridan. Within weeks af- ter I left the New England Journal of Medicine in 1999, she began encourag- ing me to write a book, and her support has been unfailing. Despite her own demanding schedule, she never failed to listen patiently to my daily stories and occasional frustrations. In her “copious free time” she un- complainingly read and edited the entire book three times. Her integrity, intelligence, tenacity, and her love continue to be an inspiration. Acknowledgments ix [...]... that their doctors are recommending treatments that benefit them, and that their doctors are involving them in research projects for the right reasons Their doctors must not only be at their sides, but on their sides It is time to expose the complexities and the extent of the complicity between doctors and industry It is time to distill the benefits of these collaborations and to fully explore the risks... of the doctors becomes a walking advertisement At one, a cloth cord imprinted repeatedly with AstraZeneca held the nametag around the doctor’s neck At another, the nametag had two panels, one with the doctor’s name and the other, below, with the company’s name (Aventis Pharma) and in large letters the name of Lovenox, one of the company’s new drugs that is used to prevent and treat blood clots The convenient... Here is the dilemma: where does the line exist between advancing the cause of science and the betterment of patient care on the one hand and the pecuniary interests of the physicians collaborating with industry to produce these advances on the other? There is little doubt that substantial sums of money induce physicians to drift across the line, and as they do, financial conflicts of interest can cause... into ongoing consultations and memberships on drug company advisory boards—positions that command up to six figures a year A massive expansion of the highly profitable drug, device, and biotechnology industries, along with the addition of large sums of money for health care has transformed medicine from a sleepy mom-and-pop operation to one of the most successful businesses in an otherwise dormant economy... failure?” Another simply asked whether the attendee knew the location and time of a Roche-sponsored symposium that was being held separate from the meeting If the doctor didn’t know the answers, he or she didn’t go away empty handed: someone was around to help with the answers or to correct the errors, and the second chance yielded the booty anyway The gifts at this meeting, of course, only seemed free... employees who nominated the doctors to attend the ‘consulting’ programs typically had no discussions with the doctors regarding the consulting services to be provided or that ‘had been provided’ during the course of the weekend event .[This supports] the conclusion that in fact the physicians were not consultants and were merely receiving a benefit from TAP in their attendance at the event.” In-Kind... that pit the physicians’ personal welfare against the welfare of their patients They can exaggerate physicians’ financial expectations, impair their judgment, create deception, inflate medical costs, erode professionalism, and harm patients I will tell the story of physicians’ everyday struggle between their professional responsibilities and their personal financial well-being In the middle of the twentieth... extent of the collaboration may even be undiscoverable Nonetheless, innumerable stories about these conflicts are compelling A sample illustrates how ubiquitous they are, who has the conflicts, and how they are manifested These stories give a broad overview of a profession on the take Freebies at Medical Meetings People outside of medicine would be dazzled to watch some physicians interact with industry... pursuits One only has to wonder what effect the exploitation of faculty ingenuity has on the kind of research the scientists engage in Perverse incentives do not end, however, with individual physicians Many medical professional organizations have also become much too close to industry, and their coziness with drug companies has influenced some of their professional and lay publications Hidden financial conflicts... walked through the exhibit hall The attendees were carrying several different cloth bags advertising one drug or another, one company or another Some bags contained only heavy programs of the meeting, others were brimming with “stuff”: notepads, fans with cute cats on one side and an advertisement on the other, rubber models of red blood cells and kidneys, plastic carrots and pickles, real candy, drug . On the Take: How America’s Complicity with Big Business Can Endanger Your Health JEROME P. KASSIRER, M.D. OXFORD UNIVERSITY PRESS ONTHE TAKE This page intentionally left blank ONTHE TAKE HOW. University Press. Library of Congress Cataloging-in-Publication Data Kassirer, Jerome P., 1932– On the take : how medicine’s complicity with big business can endanger your health / by Jerome P. Kassirer. p advancing the cause of science and the betterment of patient care on the one hand and the pecuniary interests of the physicians collabo- rating with industry to produce these advances on the other? There