Proverbs 16:8 (ESV)
Better is a little with righteousness
than great revenues with injustice.

I was thinking this week about the business ethics of medicine. I'm rotating with a group of private practice vascular surgeons. I mean, the kind that make mid-six figures. I've gotten to see the ins and outs of the practice. The little squabbles with partners. Interactions with referring physicians, pharma and equipment vendors, and patients. A few observations:

Unproven therapy I heard of one small group of major stockholders in a medical device company which sells atherectomy catheters. In case this sounds obscure, consider that atherosclerosis, or hardening of the arteries, affects millions of Americans. And the same plaques blocking arteries to the heart also block abdominal and leg arteries, making the potential market for these devices enormous. Well, there are no good trials of this device yet, comparing it with best medical management or surgical bypass, and the device is not FDA approved for use in the "peripheral vasculature", i.e. the legs. Well, some of these physician stockholders happen to give expert "lectures" espousing the benefits of this device. Apart from being abysmal medical ethics, this is, in fact, illegal.

Conflicts of Interest This would be actions such as transferring a patient across town to the specialty hospital in which I am a stockholder, so that I benefit from a move that should only be based on patient benefit. Or consider such business arrangements as a group of cardiologists in practice with cardiac surgeons. Is there really an objective assessment of what a patient needs when the referring doctor and the consulting doctor both benefit from a referral for surgery? Physicians MUST combat this, or be subject to oversight from more governing boards and government commissions.

Unfortunately, the medical literature is rife with examples of conflicts of interest. In the February 24, 2005 New England Journal of Medicine, results of a large randomized trial of recombinant Factor VIIa (manufacturer: Novo Nordisk) appeared. This was a big deal. rFVIIa is supposed to stop intracranial hemorrhage (brain hemorrhage), whether from trauma or high blood pressure. If you read the fine print at the end of the article, the principal investigators were employees, stockholders, and paid consultants of Novo Nordisk. Oh, and the study (which costs big bucks) was funded by none other than ... Novo Nordisk! And we're not talking about a $20 prescription here. A single dose of rFVIIa for an 80-kg person costs about $10,080.00! You simply cannot take at face value what is published, even in reputable journals.

I recently heard a broadcast lecture about business ethics and public relations. The speaker said "Big Pharma is in danger of becoming the next Big Tobacco." I applaud our surgery chairman at UTHSCSA for banning pharmaceutical reps from our grand rounds and official conferences. To us, a bagel and coffee on Monday morning might seem trivial, but a great deal of moral rectitude is lacking in medicine today, and our patients must trust us to do what is right.