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ETHICAL ISSUES in theRELATION of PHYSICIANS withthe PHARMACEUTICAL

INDUSTRYANGELICA D FRANCISCO, MD, MSc

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GlaxoSmithKline ne! "#$n afte% $%i$in& !o'to%( toin'%ea(e !%)&( (ale(

Sales reps in the US encouraged to is!sell antidepressants "a#il and $astha treatent Ad&air

'he pharaceutical group Gla#oSith)linehas %een *ned +%n -./01%n2 a3ter adoctors and encouraging the prescription o3 unsuita%le antidepressants to childre#pected to adit 3ailing to report sa3et4 pro%les 5ith the dia%etes drug A&andcourt in 6oston on 'hursda40

'he copan4 encouraged sales reps in the US to is!sell three drugs to doctors hospitalit4 and 7ic7%ac7s on those 5ho agreed to 5rite e#tra prescriptions, incluresorts in 6eruda, 8aaica and Cali3ornia0

'he copan4 aditted corporate isconduct o&er the antidepressants "a#il andastha drug Ad&air0

"s4chiatrists and their partners 5ere 9o5n to *&e!star hotels, on all!e#penses!pspea7ers, paid up to +:,;

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ear Copan4Settleen

tBiolation-s2 "roduct-s2

:

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$K 'KE CONCERN

COS' OF DRUGS

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DRUG "ROMO'ION

DOC'ORS MEDICAL SALERE"RESEN'A'IBE

$KO "AS

"A'IEN'S

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"KARMACEU'ICAL INDUS'RS"ENDING ON MAR)E'ING

'KE GLO6AL "KARMACEU'ICALSMAR)E' IS $OR'K US+

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FIDUCIAR CKARAC'ERIS'ICOF "KSICIAN!"A'IEN'

RELA'IONSKI"A FIDUCIAR IS ONE $KOKOLDS A S"ECIALIPED )NO$LEDGE OR EQ

KOLDS 'KE 'RUS' OF O'KERS

IS KELD 'O KIGK S'ANDARDS OF CONDUC

ABOIDS CONFLIC'S OF IN'ERES'DOES NO' SEE) "ERSONAL GAIN

IS O68EC'IBE

IS ACCOUN'A6LE OR O6LIGA'ED -E'KICAL

LEGALL2So)%'e* AMA Mo!)le 0

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EFFEC' OF GIF'S ONRESIDEN'S

1HT o3 residents sur&e4ed 5ere carr4ingites 5ith a pharaceutical copan4 logo

or product %rand on the01T o3 residents sur&e4ed had also eaten a

least one pharaceutical copan4!pro&idedeal soetie in the pre&ious /: onths0

A' "ERCEN'AGE OF RESIDEN'S SURBEED $EREMS $I'K A "KARMACEU'ICAL COM"AN LOGO"RODUC' 6RAND

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EFFEC' OF GIF'S ONRESIDEN'S

1/T o3 residents sur&e4ed ac7no5ledgedthat gi3ts and eals in9uenced their

prescri%ing patterns0As gi3ts in9uence prescri%ing patterns, the4decrease o%=ecti&it4 and increase thepossi%ilit4 o3 prescri%ing %ased on decisionsother than the %est interests o3 the patient0

$KA' "ERCEN'AGE OF RESIDEN'S SURBEED AC

'KA' GIF'S AND MEALS INFLUENCED 'KEIR "RES"A''ERNS

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GIF'S AND "ERCE"'ION

S'UDIES FOUND 'KA' COM"A'O "KSICIANS, "A'IEN'S $EJJJJJJJJJ 'O FIND GIF'S

ACCE"'A6LE0LESS LI)EL0 COM"ARED 'O "KSICIANS,"A'IEN'S $ERE MORE LI)EL 'O FIND GIFINA""RO"RIA'E0

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GIF'S AND "ERCE"'ION

O'KER S'UDIES FOUND 'KA' COM"'O "KSICIANS, "A'IEN'S $ERE JJJ'O 6ELIEBE 'KA' GIF'S FROM INDU6IASED "KSICIANSV DECISIONS A6O"RESCRI"'IONS0

MORE LI)EL0 COM"ARED 'O "KSICIANS,"A'IEN'S $ERE MORE LI)EL 'O 6ELIEBE 'GIF'S FROM INDUS'R 6IASED "KSICIANSDECISIONS A6OU' "RESCRI"'IONS OR 'KA'"KSICIAN MA NO' KABE 'KE "A'IEN'VS 6IN'ERES'S IN MIND0

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"A'IEN'SV A''I'UDES ONGIF'S 'O MDS

Saple W "atients'4pe o3 Gi3t "ercent

A5arenessNot alright

4%ee !%)&(am+le

56 6-7

8all+en( 99-# 06-9

Me!i'al $oo2( #:-7 07-;Infant fo%m)la .5-7 ::-.

Dinne% at a%e(ta)%ant

..-: :5-:

Co Ea%l? EK- "atientsX attitudes a%out gi3ts to ph4sicians 3ro pharaceutical cop

= Am 8oa%! 4am P%a't- 0;;9 No@3De'5B7*:9637:-

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"A'IEN'SV A''I'UDES ONGIF'S 'O MDS:0;T DISA""ROBE OF MDs ACCE"'ING"AMEN' 6 "KARMACEU'ICAL COM"AN OFMEDICAL CONFERENCE EQ"ENSES

:!WT DISA""ROBED OF MDs A''ENDINGSOCIAL EBEN'S S"ONSORED 6

"KARMACEU'ICALSH

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"A'IEN'SV A''I'UDES ONGIF'S 'O MDS

CONCLUSION

A""ROBAL RA'ES $ERE KIGK FOR GIF'SCONSIDERED 'O 6E 'RIBIAL OR 'KA' KABE"O'EN'IAL BALUE 'O "A'IEN' CAREYDISA""ROBAL RA'ES $ERE RELA'IBEL KIGK

FOR GIF'S 'KA' KABE SOME MONE'AR BALUE6U' KABE LI''LE OR NO 6ENEFI' 'O "A'IEN'S0

O"INIONS A6OU' GIF'S $ERE RELA'ED 'O"ERCE"'ION OF EFFEC'S ON "RESCRI6ING6EKABIOR AND COS'S0

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GIF'S AND "RESCRI6ING"RAC'ICES

IS 'KERE A "OSI'IBE ASSOCIA'ION 6E'MEE'INGS OF "KARMACEU'ICAL INDUSRE"RESEN'A'IBES AND "KSICIANS, ANCKANGE IN "RESCRI6ING "RAC'ICES

ES0 A "OSI'IBE ASSOCIA'ION $AS NO'ED 6E'$MEE'INGS OF "KARMACEU'ICAL INDUS'RRE"RESEN'A'IBES AND "KSICIANS, AND ACKANGE IN "RESCRI6ING "RAC'ICESACCE"'ING FUNDING FOR 'RABEL OR LODGIAND "RESCRI6ING "RAC'ICES

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"KSICIANS AND GIF'S

GIF'S, FREE MEALS, 'RABELSU6SIDIES, S"ONSORED'EACKINGS, SM"OSIA

O68EC'IBE 'O IDEN'IF 'KEIM"AC' ON 'KE )NO$LEDGE,A''I'UDES AND 6EKABIOR OF"KSICIANS

aana A- "h4sicians and the pharaceutical industr4 is a gi3t e&er =ust a gi3t =AMA ./// =an 0;

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"KSICIANS AND GIF'S

INCREASING REZUES' OF "KSICIANSFOR ADDING 'KE DRUGS 'O 'KEKOS"I'AL FORMULAR

CKANGES IN "RESCRI6ING "RAC'ICES

DRUG COM"AN S"ONSORED CMEKIGKLIGK'ED 'KE S"ONSORVS DRUGS

aana A- "h4sicians and the pharaceutical industr4 is a gi3t e&er =ust a gi3t =AMA ./// =an 0

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"KSICIANS AND GIF'S

A''ENDING S"ONSORED CME EBEN'S ANDACCE"'ING FUNDING FOR 'RABEL ORLODGING FOR A''ENDING SM"OSIA $EREASSOCIA'ED $I'K INCREASED "RESCRI"'IONRA'ES OF 'KE S"ONSORVS MEDICA'ION

A''ENDING "RESEN'A'IONS GIBEN 6"KARMACEU'ICAL RE"RESEN'A'IBES"EA)ERS $ERE ASSOCIA'ED $I'KNONRA'IONAL "RESCRI6ING0

aana A- "h4sicians and the pharaceutical industr4 is a gi3t e&er =ust a gi3t =AMA ./// =an

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CONFLIC'!OF!IN'ERES'

A "ERSON IS IN A CONFLIC' OF IN'ERES'SI'UA'ION IF SKE IS IN A RELA'IONSKI"$I'K ANO'KER IN $KICK SKE KAS A MORAO6LIGA'ION 'O EQERCISE KISKER 8UDGMEIN 'KA' O'KERVS SERBICE, AND A' 'KE SAM

'IME, SKE KAS AN IN'ERES' 'ENDING 'OIN'ERFERE $I'K 'KE "RO"ER EQERCISE OF8UDGMEN' IN 'KA' RELA'IONSKI"0

DABIS, /1:

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GIF' ECONOM

COFFEE MUGS, FREELUNCKES

"EN LIGK'S

)NA" SAC)SS'E'KOSCO"ES

"OC)E' 'EQ'6OO)S

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FE$ DOC'ORS ACCE"' 'KA' 'KE 'KEMSELBESKABE 6EEN CORRU"'ED0 MOS' DOC'ORS 6ELIEB'KA' 'KE ARE ZUI'E UN'OUCKED 6 'KE

SEDUC'IBE $AS OF INDUS'R MAR)E'INGY 'KA''KE ARE UNINFLUENCED 6 'KE "ROMO'IONAL"RO"AGANDA 'KE RECEIBEY 'KA' 'KE CAN EN8A COM"ANVS [GENEROSI'V IN 'KE FORM OF GIF'AND KOS"I'ALI' $I'KOU' "RESCRI6ING I'S"RODUC'S0 'KE DEGREE 'O $KICK 'KE

"ROFESSION, MAINL COM"OSED OF KONOURA6LAND DECEN' MEN$OMEN, CAN "RAC'ICE SUCK SDECEI' IS ZUI'E EQ'RAORDINAR0 NO DRUGCOM"AN GIBES A$A I'S SKAREKOLDERSV MONEIN 'KE AC' OF DISIN'ERES'ED GENEROSI'0

Rawlin(> 0;5:

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CODES OF CONDUC' FOR "KARMACEU'ICAL COM"ANIESDEBELO"ED 6 INDUS'R ORGANISA'IONS 'END 'O 6E B6U' ARE OF'EN 6AC)ED U" 6 COM"LAIN'S "ROCEDURE

MOS' SUCK CODES "ROKI6I' COM"ANIES FROM GIBING DINDUCEMEN'S 'O "RESCRI6E 'KEIR "RODUC'S

MAN DOC'ORSX ORGANISA'IONS OFFER GUIDANCE A6OUCOMMERCIALL FUNDED RESEARCK8OURNAL EDI'ORS KAA S'A'EMEN' AIMED A' "REBEN'ING SU""RESSION OFUNFABOURA6LE FINDINGS

GUIDANCE ON GOOD "U6LICA'ION "RAC'ICE FOR"KARMACEU'ICAL COM"ANIES $AS LAC)ING UN'IL RECE

DIALOGUE 6E'$EEN 'KE IN'ERES'ED "AR'IES IS NEEDEDFUR'KER GUIDANCE ON 'KE DOC'OR!INDUS'R RELA'IOISSUED

8M=- .//# Ma? #0 #.7B6://* 00;7F00;5-!oi*0/-00#7,$m1-#.7-6://-00;7PMCID* PMC00.7/99

Ko5 to dance 5ith porcupines rules and guidelines on doctorsX relations 5ith drug copanies

http://dx.doi.org/10.1136/bmj.326.7400.1196http://dx.doi.org/10.1136/bmj.326.7400.1196http://dx.doi.org/10.1136/bmj.326.7400.1196http://www.ncbi.nlm.nih.gov/pubmed/?term=Wager%20E%5Bauth%5Dhttp://dx.doi.org/10.1136/bmj.326.7400.1196http://dx.doi.org/10.1136/bmj.326.7400.1196http://dx.doi.org/10.1136/bmj.326.7400.1196

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W0 SM"OSIA AND CONGRESSES

C0ANY SPONSORSHIP PROIDED TOINDIIDUAL HEALTHCARE PRO4ESSIONAMUST NOT 8E CONDITIONAL UPON ANO8LIGATION TO PRESCRI8E> RECOMMENOR PROMOTE ANY MEDICINE-

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W0 SM"OSIA AND CONGRESSES

D0 ALL EENTS SHOULD 8E HELD IN ANAPPROPRIATE ENUE THAT IS CONDUCI

TO THE SCIENTI4IC OR EDUCATIONALO8=ECTIES AND THE PURPOSE O4 THEEENT OR MEETING- COMPANIES SHOULAOID USING ETRAAGANT ENUES ORRESORTS-

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W0 SM"OSIA AND CONGRESSESE0HOSPITALITY SHOULD 8E LIMITED TORE4RESHMENTS AND,OR MEALS INCIDE

TO THE MAIN PURPOSE O4 THE EENT ASHOULD ONLY 8E PROIDED*

0-TO PARTICIPANTS O4 THE EENT AND

THEIR GUESTS AND

.-IS MODERATE AND REASONA8LE AS=UDGED 8Y LOCAL STANDARDS-

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W0 SM"OSIA AND CONGRESSESF0 COMPANIES SHOULD NOT PAY ANY COASSOCIATED ITH INDIIDUALSACCOMPANYING INITED HEALTHCARE

PRO4ESSIONALS-

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8M=- .//# Ma? #0 #.7B6://* 00;7F00;5-!oi* 0/-00#7,$m1-#.7-6://-00;7PMCID* PMC00.7/99Ko5 to dance 5ith porcupines rules and guidelines on doctorsX relations 5ith drug copanies

Eli\a%eth $ager, pu%lications consultant/

http://dx.doi.org/10.1136/bmj.326.7400.1196http://dx.doi.org/10.1136/bmj.326.7400.1196http://www.ncbi.nlm.nih.gov/pubmed/?term=Wager%20E%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Wager%20E%5Bauth%5Dhttp://dx.doi.org/10.1136/bmj.326.7400.1196http://dx.doi.org/10.1136/bmj.326.7400.1196

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IF AN INCEN'IBE IS OFFERED 'O A "KSICIAN, A'KESE ZUES'IONS

IS 'KE INCEN'IBE OF NOMINAL BALUE

IS 'KE INCEN'IBE OF BALUE 'O "A'IEN'S ORRELA'ED 'O "RAC'ICEIS 'KE INCEN'IBE OFFERED $I'K NO S'RINA''ACKED$OULD OUR "A'IEN'S 6E "LEASED IF 'KE)NE$ A6OU' 'KE INCEN'IBE

IF 'KE ANS$ER 'O AN OF 'KESEZUES'IONS IS NO, "KSICIANS SKOULDDECLINE 'KE GIF'0

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Aerican Medical StudentAssociationVs "harFree "ledge

I AM COMMI''ED 'O 'KE "RAC'ICE OF MEDICINE IN'KE 6ES' IN'ERES' OF "A'IEN'S AND IN 'K"URSUI' OF AN EDUCA'ION 'KA' IS 6ASED ON 'KE6ES' ABAILA6LE EBIDENCE, RA'KER 'KAN ONADBER'ISING OR "ROMO'ION0

I, 'KEREFORE, "LEDGE 'O ACCE"' NO MONE GIF'S

OR KOS"I'ALI' FROM 'KE "KARMACEU'ICALINDUS'RY 'O SEE) UN6IASED SOURCES OFINFORMA'ION AND NO' REL ON INFORMA'ION 6DRUG COM"ANIESY AND 'O ABOID CONFLIC'S OFIN'ERES' IN M MEDICAL EDUCA'ION0 -AMSA, :

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Re3erences

Aerican Medical Association Modules on $hat ou Should )no5 A%out G

"h4sicians 3ro Industr4 6la7e RL 8r, Earl4 E)0 "atientsX attitudes a%out gi3ts to ph4sicians 3ro pha

copanies0 8 A 6oard Fa "ract0 /11; No&!DecY-2W;H!W0

Goldacre 60 6ad "hara0 Karper Collins "u%lishers, :