(Preface: This is the first of a four part series of blogs based on a lecture I gave at a symposium I organized at the 2007 American Psychiatric Association annual meeting, with the above title. I think it may be relevant given a series of ongoing New York Times articles based on a Senate investigation which has raised the profile of this issue. I seek to engage in sober and honest reflection, based on my experience, on this complex and important matter. Other material on this topic can be found in a Cross Talk debate I had with Dr. Larry Diller. Disclosure: As will be clear in these articles, I have received income from the pharmaceutical industry for lectures in the past; currently I limit my lectures to continuing medical education programs; I also have received and still receive funding for research studies - which I design, conduct, analyze, and publish - from the pharmaceutical industry).
What is at stake
My grandfather, Dr. Seyyed Muhammad Ghaemi, was a small-town country doctor. He worked in a sleepy place called Damghan, in northeastern Iran. About a millennium ago, it had prospered on the silk route; in recent centuries, it sat on the edge of the desert, a backward town in a backward country. He worked there in the pre-penicillin era, the practice of medicine mostly involving the giving of herbs discussed since Avicenna, teaching people to avoid mosquitoes (malaria was the biggest killer), and trying to improve hygiene. As Chekhov once said, Dr. Ghaemi's patients probably got more benefit from his compassion and presence than from any specific treatment. Effective drugs basically did not exist. Towards the end of his career, penicillin came to Iran, and my grandfather finally cured some persons who may have otherwise died. A devout Muslim, Dr. Ghaemi was so impressed that he averred that Fleming, though a Christian, undoubtedly would enter heaven.
In fact, for my grandfather the practice of medicine was not separate from his deep belief in Islam. Before penicillin, his work was to console and care for the sick and those in pain, to enact, in the role of doctor, the mercy and compassion that God enjoined us to show to each other. Indeed, he saw medicine much as devout medieval Christian doctors did: Thomas Sydenham once said that on the Day of Judgment, all your patients would be presented to the Lord; those you helped would testify for you, and those you hurt would testify against. The doctor's soul, literally, was at stake in the practice of medicine.
This was because the cost of being a doctor, the price we pay for the privilege of being able to save lives, is that we, almost alone among human professions, are also able to take lives. We kill, as well as save. Every year, according to the Institute of Medicine, up to 100,000 iatrogenic deaths occur in the US: we, doctors, kill up to 100,000 people yearly. And that is only by random error (e.g., poor handwriting on a prescription being misread); how many more do we kill with systematic error (e.g., misdiagnoses, wrong medication decisions)?
This is why my grandfather was worried about his soul, and why Sydenham had visions of Judgment Day. We are killing, at the same time as we are healing, and we need to be aware of our awesome power to harm. Too often we assume that we only help our patients; since that is our intention - to help - we lose sight of the fact that, against our conscious will, we also harm.
Thus, the relationship between psychiatrists and the pharmaceutical industry matters because, if we are colluding with, or being fooled by, corporations in such a way that we are harming our patients systematically, then we are committing treason against our profession and our heritage. This is a deeply moral matter and it deserves careful attention, not avoidance or polemic.
Critiques of the pharmaceutical industry (PI)
Views of the PI might be summarized in four categories: 1. It is evil - there is nothing good about the PI. It is the medical equivalent of the tobacco industry, perhaps worse because it claims to be healing while it is killing. (One might call this the "axis of evil" argument; most books published by trade publishers for the general public in recent years have been of this variety). 2. It is good - it produces drugs that saves lives, with appropriate safeguards against harm; whatever negatives exist are the same as with any aspect of American capitalism, which whatever its faults, is the best economic system ever devised. (The "side of the angels" argument; promoted by PHRMA, the political lobbying arm of the PI). 3. It is neither - Corporations are neither good nor bad; we should take an Adam Smith-oriented view of capitalism and simply accept that everybody, including the PI, is justified to look out for their own best interests, and in the big picture, this competition of interests produces the best social outcomes (the "free enterprise" argument; the view of many academic psychiatric leaders with strong relationships with the PI). 4. It is both - The PI produces both good and bad results; there are both honorable and dishonorable companies; we should seek to identify the bad persons or companies or drugs, and then isolate them; instead of direct belligerence, there should be a Cold War of containment, whereby the good parts of the PI will be promoted and the bad parts starved.
In the second part of this series, I will examine some of the critiques and claims made in these debates.
