Money is not the main motive for most human behavior. Hegel long ago argued that human history is best understood as a battle for prestige, for recognition; we even kill each other for such glory. We have to recognize that doctors, especially academics, are motivated mostly in this way: we want adulation. Go, young man, said the philosopher William James sarcastically, sacrifice all for the "bitch-goddess Success." The coin of the academic realm is publication: the more articles with our names on them, the more famous we are. We get promoted to full professor, become chairmen of departments, are appointed to high posts in organizations or government, interviewed by reporters, seen on TV. This battle for fame is behind the problem of ghost authorship.
Though a matter of public record (see recent issues of JAMA), many do not seem to realize that ghost authorship happens, and how often it does. Here is how it works: After a company conducts a major clinical trial, it then invites a few or more academic leaders to be the authors of the written paper. (Sometimes these authors have been involved with design and conduct of the study; sometimes they have not). The paper is written first by the company or a hired medical education company, and the statistical analysis is done by company statisticians. The academic authors usually revise the content somewhat; sometimes they ask for more analyses or revise the interpretation of the analyses. Rarely, if ever, do they actually see the data or conduct the analyses themselves on the raw data. Academic leaders are judged by the number of their prominent publications, and the citation rate of those papers; major pharmaceutical-funded clinical trials are such studies, and many academics vie to put their names on such papers to raise their profile and to increase their likelihood of academic promotion.
I have been invited to be an author on a randomized clinical trial that I had nothing to with, either in design or recruitment or analysis; I turned down this offer, and suggested the same to my colleague, who was listed as first author, since he too had not been involved with study up to that time. He stayed on as an author and the study is thus cited by his name frequently, and he thus gets nominal credit for it when it is cited.
I once was in a department meeting where a leader commented that I did not have enough highly cited publications with randomized clinical trials in major journals. I could have replied that I did not have them because I refused to participate in the system of ghost authorship, which puts other colleagues who do participate at an advantage in relation to me. In effect, ghost authorship is the steroid problem of academia; some of our experts get there fame artificially, their achievements appearing greater than they really are.
After I made this comment in a national American Psychiatric Association (APA) conference, a former president of the APA and an academic leader at Harvard noted with astonishment that such matters happened; I have also heard similar outrage from lawyers who are suing the pharmaceutical industry. It really is about as surprising, though, as steroids in baseball; not really a surprise at all (one flashes to the scene in Casablanca where the French prefect storms in on the bar where he routinely bet on cards: "I am shocked, shocked, that gambling goes on here!"), but perhaps a matter for some disgust. The question is what we will do about it. The profession has not self-policed this problem, and the US Senate would not seem to be a non-partisan venue. Perheps the best police are the gatekeepers of science: the editors of scientific journals; they can outlaw ghost authorship. Authors need to actually write every word of their papers, and they need to analyze raw data themselves (or in their own institutions with independent statisticians). This is a simple solution, one of the few in this tangled web of the academic-pharmaceutical complex.
The profit motive
Some doctors are particularly exercised by the fact that the pharmaceutical industry (PI) makes profits. The idea is that if money is in the picture, then morality leaves. If profits are the motive, then they are the only motive. Nothing else matters; and we are dealing with human lives here. The indignation rises with the blood pressure.
"Follow the money", writes one critic who admits he stopped practicing medicine to work full time on his book, and thus is relying on his book for income. Yet these critics never criticize themselves; if we follow the money in relation to their interests, it seems relevant that they and their publishers are writing to make profits; do they care only about money, not about the content of their books? Who polices the book publishing industry; or the newspaper industry? They can write and publish whatever they want, true or not. In sum, the same criticisms such critics make of the PI could be made of the book (or newspaper) industry.
Doctors who are private practitioners, of course, receive income. With each patient visit, cash exchanges hands; yet do we claim that the private practice of medicine is about nothing but money? Perhaps we could revise the critique: the problem is that some academics make too much income from their relations with the PI, or that the PI makes too much profit; some profit would be acceptable; too much is the problem. While rational, this critique would also have to be applied to practicing psychiatrists. Too much income in the practice of psychiatry would be unethical. But where are the critics of the private practice of psychiatry? In some places, with some psychiatrists, patients are seen for 10 minutes or so, and treated like checkbooks; the more patients seen, the more income received. Add the fact that usually such practice involves giving drugs for symptoms - that medications are the main activity in such assembly-line psychiatry - and we see the problem. The direct damage done by us, by practicing doctors, who see patients too quickly, for economic reasons, can out-Herod the harm attributed to the PI.
Everybody makes money. The PI makes profit from selling its pills; private doctors make income from giving them in rapid visits; the insurance industry profits from minimizing costs by using pills instead of psychotherapies; and academics receive speaking fees. Everybody is getting rich - except patients. Yet patients are getting something too: pills. And many of them - admittedly not all - want pills; they always have, they always will. I spend much of my clinical practice trying to convince patients to stop taking antidepressants, and it is very hard. Humans love pills.
This is not a new phenomenon; it is not solely the product of pharmaceutical marketing. Listen to William Osler, the father of modern medicine, writing a century ago, before the PI existed: "Man has an inborn craving for medicine. Heroic dosing for several generations has given his tissues a thirst for drugs....It is really one of the most serious difficulties with which we have to contend. Even in minor ailments, which would yield to dieting or to simple home remedies, the doctor's visit is not thought to be complete without the prescription." This is nothing new. Osler taught over and over that the job of the doctor is mainly to explain to patients why they should not take medications, mainly by emphasizing the need to identify diseases first, and only treat them if so identified, and otherwise not to use medications. ("In the fight we have to wage incessantly against ignorance and quackery among the masses, and follies of all sorts among the classes, diagnosis, not drugging, is our chief weapon of offence." This was written before 1900. Anyone who wants to know what the ethics of the medical profession is really all about should read Osler.)
