Ethical Triage For Doctors
By Clare BlumerOctober 15, 2013
New, stricter guidelines on how doctors should handle the potential conflicts of interest, when interacting with the medical and pharmaceutical industry are in the process of being finalised, but the ethics body that was debating the conundrums involved has been ditched.
Managed by the Royal Australasian College of Physicians (RACP), the group developing the fourth edition of the benchmark Guidelines for Ethical Relationships Between Health Professionals and Industry has recently undergone changes that caused a furore among college fellows. The controversial draft guidelines, three years in the making, urged doctors not to accept free drug samples, nor to enjoy free hospitality from medical industries courting influence with the physicians.
But just three days after the heavily revised guidelines were made public in draft form, they were removed from the RACP website, prompting The Global Mail to report on the turmoil behind-the-scenes.
Within 24 hours of the article’s publication, the president of the college, Associate Professor Les Bolitho, submitted a letter to The Global Mail taking issue with our report, saying the ethics group once charged with the job is being replaced by “time limited and purpose driven Working Parties”.
To the confusion of some members of the ethics group, Bolitho’s letter to the editor says the group will continue until the end of the year and complete its review of the guidelines.
The hair being split here is whether or not the Ethics Advisory Group (EAG) that would have finalised the guidelines still exists. The chair of the group, as evidenced by his protest letter on September 8, wrote that Bolitho told him it does not exist. Bolitho’s recent letter to The Global Mail says it does.
Bolitho has not responded to requests for an interview. The college and ethics group have been in dispute, circulating both open and private letters arguing that losing the group could “cause serious damage to the college and its national and international standing”.
Professor, physician, bioethicist and member of the ethics group, Dr Ian Kerridge, says, “There’s obviously an internal inconsistency in [Bolitho’s letter to the editor] … they’ve either disbanded these EAGs or they haven’t.”
The Global Mail spoke to several members of the ethics group; none had been informed of the changes outlined in the letter to the editor.
Kerridge argues the ethics advisory group — disbanded, as he understood it, or soon-to-be-disbanded, according to Bolitho’s letter — was far more suitable than the new model proposed by the college.
“I think the model that they’re pursuing deeply misunderstands the way that ethics work, both as a feature of medicine, as a social practice, and it misunderstands the idea that ethics are constantly about examining oneself.”
The college represents specialist physicians — the extremely influential doctors who inform health policy and prescribing. These opinion leaders are cultivated by pharmaceutical companies, who want the doctors on their advisory boards and supporting new medicines; and by medical-equipment manufacturers, who want their latest half-million dollar inventions in these physicians’ surgeries.
The guidelines not only inform the RACP fellows’ relationship with industry, but previous editions have served as a gold-standard template for other medical professional colleges in Australasia and around the world.
The new draft argued against the common practice of distributing free drug samples to patients, and against accepting industry hospitality. The Global Mail’s Drug Money series tracks data showing that pharmaceutical hospitality alone spends an average of $1 million a week duchessing doctors and other health professionals.
Bolitho’s letter says that the new working-parties approach would “allow a larger group of RACP Fellows and Trainee members to lead and contribute to policy work within the College”.
But Kerridge says the new model would potentially operate “according to the priorities of the organisation itself rather than a reflective group that may involve people from outside of the College”.
He says that, “Medicine is not simply a science and it’s not simply the domain of professionals. Health care is the domain of the entire community and all of these things are heavily value-laden... ethics involves recognising all the non-scientific and non-clinical aspects of what we do.”
The draft guidelines were posted on the RACP website on September 4, with a request for public comment, but within three days college administration had removed all trace of the document without explanation.
Bolitho did not deny this in his letter but wrote that, “Publication of draft policies and guidelines on the RACP website is not the standard consultation procedure practised by the College.”
According to members of the ethics group, previous editions of the guidelines have been publicly aired for a couple of months with invitation for comment.
Bolitho added that the guidelines have been circulated to almost 100 internal and external organisations and individuals for feedback and comment.
Members of the guidelines task force say that while it may not be a standard procedure for other drafts in the college, extensive public consultation was undertaken for the last complete edition in 2006, and was expected for the new one.
Furthermore, a letter from members of the group to Bolitho criticised the comparatively small number of responses to the draft received by the college in the equivalent time period — 140 responses were received by the college in the first month of public consultation of the 2006 edition, while the new edition had received just five responses in the same time. They blame the diminished feedback on the college’s removal of the guidelines from the website.
Sources have said the decision to disband the ethics group was taken by Bolitho. His letter says it was a decision of the college board, based on a college-wide review of committees. When Bolitho was unavailable for an interview last week we asked for a replacement spokesperson, but no other members of the board, executive or college fellows were proffered by the organisation’s communications unit.
Bolitho’s letter to the editor also claimed there were “factual inaccuracies” in The Global Mail’s coverage of the RACP’s new approach to the guidelines. TGM has sought further clarification from the RACP about any points of inaccuracy. We also asked for more information about the “College-wide review”. Neither the college nor Bolitho has answered our questions. Our offer to visit the College’s Sydney headquarters to read the review of committees was not accepted.
Bolitho’s letter has caused TGM to correct one fact in the story.
The Global Mail published that the RACP has 13,500 members, information sourced to the college’s website; the page “About the RACP” says it has 13,500 members.
However, Bolitho writes that there are “14,300 Fellows” and “6,500 Trainee members”. This has now been amended in the original story.