BMJ  2003;326:1155-1156 (31 May), doi:10.1136/bmj.326.7400.1155

Editorial

No more free lunches

Patients will benefit from doctors and drug companies disentangling

Free pens and pizza lunches. Sponsored conferences and compromised medical education. Courtesy golf and unaffordable holidays. Thought leaders and ghost writers. These are the trappings of doctors and drug companies being entwined in an embrace of avarice and excess, an embrace that distorts medical information and patient care. An article in this theme issue of the BMJ identifies 16 ways in which doctors are entangled with the drug industry.¹ You can probably identify more. The issue explores the extent of this relationship, its effects on research, its influence on prescribing, and the consequences for patients. Our central argument is that doctors, drug companies, and most importantly patients would all benefit from greater distance between doctors and drug companies.

It does of course take two to entangle, and we hope that nobody will see this theme issue as anti-drug company. Virtually all of the new drugs developed in the past 60 years—drugs that have transformed medicine—have been either developed or manufactured by drug companies.² Doctors and drug companies must work together, but doctors do not need to be banqueted, transported in luxury, put up in the best hotels, and educated by drug companies. The result is bias in the decisions made about patient care. Drug companies are commercial companies that must market their products. Sometimes they bend the rules, but it is doctors who are perhaps more to blame in coming to depend on drug company largesse. How did we reach the point where doctors expect their information, research, education, professional organisations, and attendance at conferences to be underwritten by drug companies? Both doctors and drug companies know there is something unhealthy in this relationship, but seem unable to stop themselves.

Some countries and professional organisations—including most recently the World Medical Association—have recognised the dangers in this proximity and have developed codes of practice.^{3 4} The industry itself has codes. Why is that not enough? Again both sides are at fault. Codes of practice are mere window dressing unless they are explicit and vigorously observed. Industry marketers will inevitably see them as the impetus to devise increasingly imaginative campaigns that test the boundaries of the codes. Doctors, meanwhile, too easily convince themselves that their professional integrity is immune to seduction by drug companies. For too many doctors the laws of economics can be broken and the free lunch does exist. Unfortunately it is only in their imaginations.

There is growing evidence that doctors' prescribing habits are influenced by drug companies, either through discussions with sales representatives or through sales drives dressed up as medical education. A British research group finds that doctors who have frequent contact with drug representatives are more willing to prescribe new drugs, do not like ending consultations with advice only, and are more likely to agree to prescribe a drug that is not clinically indicated.⁵ It is hard not to be persuaded by a warm smile, a free meal, and a touch of flattery, and an accompanying editorial describes how information supplied to doctors by drug companies is systematically distorted.⁶ There is danger too in the glossy reprint from a prestigious journal that the drug company representative brings. Unsurprisingly, the representatives do not bring reprints that are unfavourable to their products.

Journals are caught between publishing the most relevant and valid research and being used as vehicles for drug company propaganda.⁷ If a journal publishes a trial that favours drug A over drug B, is that a scientific judgment or a business investment to be repaid in lucrative reprint sales? Certainly there are dangers in pharmaceutical advertising in journals and sponsored supplements, which is why journals need systems to prevent advertising influencing editorial content. But the stark reality is that without pharmaceutical sponsorship many journals would not survive.⁷

Even so, journals are late in a research process that takes many years of planning, execution, and interpretation. Care in weeding out drug company influence and protecting patients begins at the planning stage. Research ethics committees have a vital role in ensuring that new clinical trials are scientifically justifiable.⁸ Drug development and marketing is a multi-billion dollar industry, where financial interests influence the design and planning of clinical trials. Many tricks can be used to give companies the results they want, including comparing the new drug with a placebo rather than a standard evidence based treatment or comparing the new drug with an inappropriate existing drug or with too low a dose of the existing drug.^{7 8} Two new studies support these concerns. A systematic review by North American researchers finds that studies sponsored by pharmaceutical companies are four times as likely to have outcomes favouring the sponsor than are studies funded by other sources.⁹ European researchers look at placebo controlled studies of selective serotonin reuptake inhibitors and find a literature riddled with multiple and selective publication of studies showing significant drug effects and selective reporting by ignoring the results of intention to treat analyses but highlighting per protocol analyses.¹⁰

While these machinations eventually affect patient care, drug companies have many other avenues of influence, including funding—often secretively—patients' organisations and public relations companies.^{11 12} These methods of exerting influence on doctors help the drug industry disguise its self interest.

The pharmaceutical industry is immensely powerful. It is one of the most profitable of industries, truly global, and closely connected to politicians, particularly in the United States. Compared with it, medicine is a disorganised mess. Doctors have become dependent on the industry in a way that undermines their independence and ability to do their best by patients. Medical reform groups in the United States are calling for this greater distance in relationships with industry and for independent education and sources of information.¹³ The University of California is considering ending free lunches sponsored by drug companies, and American medical students are being asked to take a revised Hippocratic oath that forbids the accepting of money, gifts, or hospitality. These are moves that doctors worldwide should follow.

BMJ

BMJ

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We must acknowledge our debt in the title of this article to the website No Free Lunch (www.nofreelunch.org/), which has long advocated greater distance between doctors and drug companies. Visit the site, take the pledge, and join the pen amnesty.

Competing interests: KA and RS both work for BMJ Publishing Group Ltd, which has a considerable income from the pharmaceutical industry. Both are paid a fixed salary. For more information access www.bmj.com/aboutsite/comp_editorial.shtml

References

1. Moynihan R. Who pays for the pizza? Redefining the relationship between doctors and drug companies. 1: Entanglement. BMJ 2003;326: 1189-92.[Free Full Text]
2. Bonaccorso S, Smith R. In praise of the devil. BMJ 2003;326: 1220.[Free Full Text]
3. Wager E. How to dance with porcupines: rules and guidelines on doctors' relations with drug companies. BMJ 2003;326: 1196-8.[Free Full Text]
4. Mayor S. World body reviews doctors' links to drug industry. BMJ 2003;326: 1165.[Free Full Text]
5. Watkins C, Moore L, Harvey I, Carthy P, Robinson E, Brawn R. Characteristics of general practitioners who frequently see drug industry representatives: national cross sectional survey. BMJ 2003;326: 1178-9.[Free Full Text]
6. Liberati A, Magrini N. Information from drug companies and opinion leaders. BMJ 2003;326: 1156-7.[Free Full Text]
7. Smith R. Medical journals and pharmaceutical companies: uneasy bedfellows. BMJ 2003;326: 1202.[Free Full Text]
8. Garattini S, Bertele V, Bassi L. How can research ethics committees protect patients better? BMJ 2003;326: 1199-201.[Free Full Text]
9. Lexchin J, Bero LA, Djulbegovic B, Clark O. Pharmaceutical industry sponsorship and research outcome and quality: systematic review. BMJ 2003;326: 1167-70.[Abstract/Free Full Text]
10. Melander H, Ahlqvist-Rastad J, Meijer G, Beermann B. Evidence b(i)ased medicine—selective reporting from studies sponsored by pharmaceutical industry: review of studies in new applications. BMJ 2003;326: 1171-3.[Abstract/Free Full Text]
11. Herxheimer A. Relationships between the pharmaceutical industry and patients' organisations. BMJ 2003;326: 1208-10.[Free Full Text]
12. Burton B, Rowell A. Unhealthy spin. BMJ 2003;326: 1205-7.[Free Full Text]
13. Moynihan R. Who pays for the pizza? Redefining the relationship between doctors and drug companies. 2: Disentanglement. BMJ 2003;326: 1193-6.[Free Full Text]

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