A Resurgence of Ethics

By Louis Sportelli, DC

I could hardly believe my eyes when I read the June 19, 2008 news release from the American Association of Medical Colleges (AAMC) urging approval by all medical colleges and teaching hospitals of a new set of guidelines that would prohibit drug-industry gifts and services to physicians, faculty, residents and students, as well as limit industry support of medical education activity. The recommendations were part of a 14-month effort titled, "Industry Funding of Medical Education." AAMC leadership also is urging all members to adopt these guidelines by July 1, 2009.

The report examined the benefits and pitfalls associated with drug-industry funding of medical education, and developed principles, recommendations and guidelines to help medical schools and teaching hospitals better manage their relationships with the drug industry. For a copy of the report, go to www.aamc.org/industryfunding.

The panel was chaired by retired Merck Chairman and CEO Roy Vagelos, MD, and members included institutional leaders, faculty, residents, ethicists, public representatives and the medical-device industry. The AAMC president stated in glowing terms the "interactions between industry and academic medicine are vital to the public health, but they must be principled partnerships effectively managed to sustain public trust." Now I don't want to be cynical, but there will soon be a public revolution if there is not some attempt to restore ethics back to the health care delivery system and remove corporate greed and influence from the process.

The report went on to suggest there is "mounting scientific evidence that indicates gifts, favors and other marketing activities, both explicit and implicit, prejudice independent judgment in unconscious ways." Wow, I hope it didn't take too much money to convene this panel of experts. Their findings are obvious to anyone observing the corrupt system and influence peddling that goes on every day in hospitals and doctors' offices. Nonetheless, the recommendations of the report are as follows:

  • Establish and implement policies prohibiting the acceptance of any gifts from industry by physicians, faculty, students and residents, on- or offsite.
  • Eliminate receiving drug samples or manage their distribution via a centralized process that ensures timely patient access throughout the health care system.
  • Restrict access by pharmaceutical representatives to individual physicians by confining visits to nonpatient areas and holding them by appointment only.
  • Set up a central continuing-medical education office to receive and coordinate the distribution of industry support for CME activities.
  • Strongly discourage participation by faculty in industry-sponsored speakers' bureaus.
  • Prohibit physicians, residents and students from allowing presentations of any kind to be ghostwritten by industry representatives.

The AAMC should be complimented on its effort, albeit long overdue, to attempt to minimize the incredible influence exerted by the pharmaceutical industry over physicians and hospitals. In my opinion, it might be too little too late for the drug industry because the system simply is too entrenched to be overcome or eliminated (not that either party really wants to, but public opinion is getting in the way, and some semblance of reform is almost mandatory).

Amazingly enough, right on the heels of the AAMC's news release, a new survey was released on repairing research integrity that concluded, "The way misconduct is policed and corrected reflects on the integrity of the whole enterprise of science." The National Academy of Science has asserted scientists share an "obligation to act" when suspected research misconduct is observed. Estimates extrapolated from the 2,212 researchers surveyed observed more than 2,300 observations of potential misconduct are made each year. Not all are reported to the universities and fewer are reported to the Office of Research Integrity.

The conclusion of the survey was that no regulatory office can hope to catch all the misconduct. The primary deterrent must be at the institutional level. A culture must be established that promotes safeguards for whistleblowers and establishes zero tolerance, both for those who commit misconduct and for those who turn a blind eye to it. There must be safeguards for whistleblowers, or at least some safe haven for individuals who see misconduct and/or outright illegal activity. They must have some assurances from their colleagues they will be not ostracized as if they were the problem and not individuals with the courage to disclose the misconduct.

Maybe June is ethics month. For whatever reason, there were a host of articles dealing with ethics, integrity and reestablishing a culture of honesty and integrity in government, industry and in our personal lives.

The country has just gone through a series of some of the worst corporate scandals from the most recent impropriety of congressmen getting special benefits from Countrywide, Bear Stearns executives selling backdated stock and American International Group suing their ex-chairman for breach of duty, to the now very old news we know simply as "Enron." The shock and disbelief is wearing off. There are an incredible number of daily scandals involving every aspect of our lives: the judiciary, Congress, corporations, churches, sports figures, police departments. There seems to be despair that there is nothing in which we can believe anymore, and something must be done.

The lesson for doctors of chiropractic, as well as for our chiropractic organizations, is simply this: Public scrutiny, which is driving governmental oversight, will drive the future regulation(s) of all professions and organizations. If chiropractic is proactive in its quest to avoid harsh and unnecessary governmental oversight by rules and regulations, we must impose stronger and more stringent rules upon ourselves. We need only to take a page from the accounting industry.

On the heels of corporate scandals, the accounting profession had to decide to police itself or be subject to greater and greater scrutiny and oversight from outside the industry. Despite its best efforts, which were enormously successful in preventing more stringent requirements, legislation now known as Sarbanes/Oxley passed Congress with little opposition. It imposes huge financial and governance costs to all corporations. The accounting profession recognized that even the appearance of impropriety was more than the public or regulators would accept. Congress has yet to realize you cannot legislate morality (nor have they viewed their own public ratings) and they continue to impose more stringent rules with which organizations (for-profit and nonprofit) must now comply.

The chiropractic profession has undergone some issues with individual DCs being convicted of fraud in various reimbursement programs. These infractions by a few have created the perfect way for our opposition to eliminate chiropractic services from programs. California workers' compensation exclusion (even by a chiropractic-friendly governor) is a good example. We see other issues in Medicare in which coding issues, intentional or accidental, can cause a report to be devastating.

There is no doubt that with a new Congress and a new president for 2009, there will be changes in the health care delivery system. From all appearances, it does not appear a reconstruction of the health care system is in the cards. Health care facilities and providers will be subject to the bandage remedies of the past to solve hemorrhages. Be that as it may, we need to formulate some cogent arguments to support our inclusion in a system that is dysfunctional at best and completely broken at worst. All the health care professions will be seeking a part of a pie that is just not expanding, and more than that, the pie makers also are reducing in size.

Integrity, ethics, professionalism and public trust will carry chiropractic further in legislative efforts than any emotional litigation response. In the end, it's all about how professions can manage their own affairs. Do they need oversight and governmental regulations to prevent abuse of the system? My guess is you will be seeing a great deal more "white papers" and "self-study analysis" by various groups in an effort to be proactive and help build public trust and confidence. Will chiropractic respond with the right stuff, or will we wait until it's too late to repair the damage?

If you have a comment, write to your association leaders and voice your desire for change, report your observations about how various groups could improve, expose unethical behavior and become the advocates for change that made our profession great.

Don Petersen discussed the AAMC report in a recent Report of My Findings. See "It's About Time" in the July 29, 2008 issue.

Click here for previous articles by Louis Sportelli, DC.

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