German-Australian Udo Schüklenk is Head of the Wits University Faculty of Health Sciences Division of Bioethics. He’s a co-editor of Bioethics, the journal of the International Association of Bioethics. His research interests are in research ethics and clinical ethics. He invites readers to visit the extensive bioethics on-line resources library available free of charge at http://www.wits.ac.za/bioethics.
Like many other academics in South Africa’s health sciences faculties I have been part of continuing professional development (CPD) activities. I have given lectures or tutorials as part of CPD events organised by schools or departments within my own faculty. I have also participated as a speaker at events organised by professional organisations that were sponsored by pharmaceutical companies, and I have been involved in events organised and sponsored entirely by pharmaceutical companies. On occasion I have been the only speaker for the evening, at other times I have been part of a day-long or week-long ‘CPD-festival’ whereby I was part of a line-up of speakers lecturing on medical and ethical issues. I should like to begin with a description of ethically problematic issues that I encountered during these events. These concerns only pertain to events organised or sponsored by pharmaceutical companies.
I am concerned about events featuring the hidden and sometimes overt marketing of drugs by pharmaceutical companies - events that have been and continue to be given CPD accreditation.
I have seen the following:
· Academics presenting pharmaceutical company-authored materials pertaining to drugs the company wishes to sell as if they (i.e. the academics) had authored these materials. CPD accreditation was given for these presentations.
· Pharmaceutical companies get CPD accreditation for presentations on the basis of next-to-no information on the speaker. In some instances I was told that they had a ‘blanket’ CPD accreditation for their event (including my ethics presentation), and that they would need no information on me or the content of my lecture.
· Doctors asking for, and pharmaceutical companies obliging to supply specific presenters (for example, as I was told, a speaker on ethics because ‘ethics points are difficult to come by’) in return for doctors’ participation in marketing events for certain drugs.
· At least some commercially sponsored events not being taken seriously by either the companies or the participating doctors. I have been asked on more than one occasion to cut back my presentation to 15 - 20 minutes because doctors had already sat through numerous other talks. In other words, short-cuts to ethics CPD points were seriously suggested by the company organising the event. No controls were in place to ensure that the accredited presentation was actually provided as accredited.
Arguably, there is something fundamentally wrong with the involvement of commercial organisations providing CPD-accredited events pertaining directly to their product range. Despite sometimes genuine efforts on the part of a presenter to remain impartial, it is unlikely that a pharmaceutical company would invite back a presenter who argues repeatedly that the sponsor’s products are inferior to those of a competitor, or as efficient as a substantially cheaper generic drug. Pharmaceutical companies have a conflict of interest that effectively rules them out as organisers of CPD events. Events organised solely by a pharmaceutical company should not be given CPD accreditation. Equally as important, specialists in universities or private practice should not involve themselves in this type of product marketing. Personally, I will no longer speak at such events, with immediate effect.
There are other ethical reasons to discourage doctors from participating in such marketing activities, namely the magnitude of expenditure necessary to stage such events.1 From scuba-diving weekends and Victoria Falls vacations to golf weekends at Sun City, there is everything the interested freeloader could wish for. In addition, there is the further enticement of ‘free’ CPD points. These points, of course, are anything but free. It is the patients, directly or indirectly through their medical aid schemes, who pay for these industry-sponsored extravagances. Evidence has accumulated to show that these events work. They work in the sense that they affect the prescribing habits of doctors.2,3 In other words, doctors do not necessarily prescribe the most cost-effective agents. Often their prescription habits will be influenced by the latest CPD-accredited marketing exercises staged by pharmaceutical companies. It is the patients who eventually foot the bill for these follies.
During my participation in these events I noticed that a number of pharmaceutical companies regret ever having gone down the road of scuba-diving exercises, weekends at Victoria Falls, etc. The difficulty for them is to turn the clock back. Doctors seem to expect that free lunch. In fact, students in medical schools are already geared toward this mentality. They are quickly turned into living marketing tools for pharmaceutical products. Dentistry students, for instance, begin their first semester with a free bag sponsored by the manufacturers of a popular mouthwash. Our students seem to think nothing of this, neither do their teachers. They happily advertise the product until the bag reaches the end of its half-life. Of course, as we all know, there is no such a thing as a free lunch in the real world. These free lunches, vacations and other incentives are paid directly by cash-strapped medical aid schemes and struggling individual patients who try to meet their drug bills. Millions of rands are spent on these events.
I think that two actions should be implemented simultaneously:
1. No CPD accreditation should be given to pharmaceutical industry-organised marketing events, no matter how carefully they are billed as educational activities.
2. Pharmaceutical companies ought to agree on an industry-wide operating spending cap on product marketing. If all companies agree to such a code of conduct, doctors will simply have to accept that the ‘free lunches’ are a thing of the past. The resultant savings could be used to reduce drug prices in the country.
Put simply, there is a lack of competence in the country with regard to medical ethics or bioethics. We have a few philosophers lecturing on medical ethics, medical doctors with a personal interest in the subject, but only very few specialised biomedical ethicists. Bioethics is a specialised discipline in the medical humanities with a fairly well-established curriculum that has been taught for a few decades in medical schools in developed and increasingly in developing countries.4
Current accreditation practices in South Africa suggest that accreditation committees (usually lacking biomedical ethicists competent to evaluate applications) think of biomedical ethics as a free for all. It has also been suggested that the initial idea to include ‘ethics’ as a CPD-related requirement was based on a misunderstanding of what ethics is really about. Supposedly this requirement was meant to ensure legal education regarding doctors’ legal obligations. Certainly the Truth and Reconciliation Commission’s proposal to introduce ethics education into medical curricula meant ethics and not something else. Legal education is useful and necessary, but could or should it replace ethics education? Certainly not. The law is able to guide us to some degree, but many decisions will have to be made in spheres where there is no guiding law, for instance in the area of resource allocation in public hospitals. Also, of course, there is the issue of legislation that is unethical. Surely we don’t want to see doctors who slavishly follow the rule of whatever law a given government passes, irrespective of its content. Still, these ethics education-related resentments could be an indication of a larger misconception of ethics as a discipline where everything goes and everything is relative. Experts in biomedical ethics have dealt with this issue satisfactorily.5 Indeed, the very existence of specialised research ethics committees suggests strongly that society has accepted the idea that there is such a thing as a specialist in the ethics of clinical research.6 With regard to CPD accreditation, however, it seems that if a given medical professional feels strongly enough about a given bioethics topic, no matter what his or her qualifications, the accreditation is awarded. The result of this attitude is that CPD accreditation committees seem to be prepared to award ethics accreditation to all sorts of presentations given by all sorts of people as long as their presentations are vaguely related to ethics. Quality controls are more or less absent. ‘International experts’ are responsible for high-priced multiple-choice test-based CPD activities. A standard feature of their marketing is that they are advertised as ‘easy-to-get’ CPD points. Generally speaking, the objective of CPD providers that charge for their services seems to be to award CPD points ‘easily’.
What is at issue, again, is the absence of a body qualified to evaluate such proposals.
I suggest that a special accreditation committee be instituted as soon as possible with the primary objective to evaluate the quality of ethics-related CPD applications. This committee ought to be constituted exclusively of professionals with formal doctoral qualifications in bioethics. Failing to find a sufficient number of formally qualified professionals in the country, the requirement may be a minimum of five publications in peer-reviewed bioethics journals. A Masters degree in an ethics-related field should not be considered sufficient for the purposes of membership in this committee.
The various players in the field have quickly discovered that provision of CPD is a means of making money. Pharmaceutical companies make it indirectly through marketing products and nurturing contacts with doctors during CPD events. Underpaid academics have discovered that it can be a means of supplementing their salaries. Various commercial operators, usually hiding behind pseudo-academic names, have decided that CPD education is a means of awarding 'easy'CPD points, and, of course, making money equally as easily.
On the other side are the targets of these operators, namely doctors, who refuse to pay any (or very much) money for attending CPD events. They appreciate that in itself CPD is a good idea. Indeed, it is a standard feature of continuing medical education across the developed world. The question is how to square the circle. The answer to this probably lies in the establishment of a non-profit educational foundation that offers cost-effective CPD-accredited educational events across the country. It should operate in close collaboration with CPD accreditation committees or (and that would be the ideal solution) with a national quality control body. The fees charged by this institution would be higher than those for events sponsored by pharmaceutical companies because the free resort accommodation and scuba-diving-based CPD activity would be a thing of the past, but fees should be substantially lower than those charged by the various commercial operators in the field.
In conclusion: (i) we can only expect doctors to take ethics in their professional practice seriously if we take the accreditation of ethics-related CPD events seriously; (ii) organisations with a conflict of (commercial) interest should not be involved in the provision of CPD events; (iii) a non-profit educational foundation should be set up on a national level with the objective to provide low-cost/cost-effective CPD events; and (iv) with regard to bioethics, a specialised CPD accreditation body should be set up in order to ensure the quality of biomedical ethics-related educational events.
1. Giannakakis IA, Ioannidis JPA. Arabian nights - 1 001 tales of how pharmaceutical companies cater to the material needs of doctors: case report. BMJ 2000; 312: 1563-1564.
2. Chren MM, Landefeld CS. Physicians’ behavior and their interactions with drug companies. A controlled study of physicians who requested additions to a hospital drug formulary. JAMA 1994; 271: 684-689.
3. Rothman DJ. Medical professionalism - focusing on the real issues. N Engl J Med 2000; 342: 1283-1286.
4. Myser C. How bioethics is being taught: a critical review. In: Kuhse H, Singer P, eds. Companion to Bioethics. Oxford: Blackwell, 1998: 485-500.
5. Rachels J. Can ethics provide answers: In: Howell JH, Sale WF, eds. Life Choices. Washington, DC: Georgetown University Press, 2000: 3-21.
6. Moreno JD. Ethics committees and ethics consultants. In: Kuhse H, Singer P, eds. Companion to Bioethics. Oxford: Blackwell, 1998: 475-484.