A decade ago, during the Bosnia war, journalists were faced with a dilemma: Should they report the genocide that one side inflicted on another? Or should they take the "balanced" approach to reporting: Simply describing what one side said, and then the other, even though one side was lying? Reflecting back, CNN's Christiane Amanpour now concludes that objectivity meant reporting the truth, not simply describing opposing views.
Balance, objectivity - these are the watchwords of the current debate about medicine and the pharmaceutical industry. But these words are based on the assumption that truth is a mean between extremes, the middle of a scale. Sometimes, at least, the truth is simply the opposite of something that is false.
Conflict of interest, bias - these are other watchwords; the idea is that if you can identify potential, or even real, conflicts of interest, then the ideas of a person are, ipso facto, biased. This view is based on a genetic fallacy: the notion that the origin of a thing explains it. Now consider this scenario: If I believe that 2 x 2 = 4, and a mathematics company (or a university) compensates me financially to teach people about this fact, does that change the truth or falsity of whether 2 x 2 = 4?
Perhaps we can apply these ideas to the pharmaceutical industry debate. The context is that the US Senate is now involved, with a committee investigating specific physicians (it must be mere coincidence that they are all psychiatrists), and describing conflicts of interest. I might have disagreed scientifically with previous figures under their scrutiny, but I agree with most of the ideas of the most recent person singled out by the New York Times, Frederick Goodwin. (Disclosure: Dr. Goodwin was my mentor and I have published extensively with him. I have known him well for about 15 years. This may make me biased; but it does not make my statements false, which is the point of this posting). As this case becomes public, and some bloggers make intemperate comments that do not bear repeating, some calm thinking is in order. First, the issue of conflict of interest stands on its own: if unreported, conflicts should be reported; there is no debate on that issue. (The specific question in Dr. Goodwin's case had to do with an NPR show he hosted; he and his show's producer parted ways about three years ago apparently, and they disagree on whether he had told his producers about his speaking fees). The next aspect is the issue of corruption: if someone receives lecture fees, is he thereby corrupt? Then there is the extension to the next claim: that the ideas of such persons are, of necessity, false. The Times itself drew these implications in a follow-up editorial titled: "Expert or shill?"
Let's take these one by one: Are speakers always biased? I have given such lectures as well, and I have known many colleagues who have done so. Many have observed, and I agree, that some of them seem to abuse the system, and appear biased. But some seem hardly biased at all, saying the same things no matter who pays, or does not pay, them. In my experience (and I have heard dozens of his lectures), Dr. Goodwin is in the last category. The presumption of many critics is an absolutist one: if you receive lecture fees, you are always and fully biased. This is sometimes true, sometimes untrue.
Now the second issue: if you are financially compensated, then what you say is false. But 2 x 2 = 4, no matter how much one is, or is not, compensated. In the case of Dr. Goodwin, he and I have written extensively for years about the risks of antidepressants; we have actively advocated decreased usage of those agents in bipolar disorder (including a period in the 1990s when many pharmaceutical companies actively marketed them, and hardly any marketing occurred for mood stabilizers). In the 2000s, despite many new antipsychotic medications now FDA indicated for mania, I have continually advocated not viewing these drugs as mood stabilizers and not overusing them in bipolar disorder. Goodwin has repeatedly made the same points in his textbook and has done so in his lectures. We both advocate mood stabilizers in bipolar disorder, but this is not controversial: any psychiatric textbook says the same; and, three of the four drugs I view as mood stabilizers (lithium, carbamazepine, and valproate) have been generic for years, hardly promoted by any company. (The other agent, lamotrigine, is produced by GlaxoSmithKline, which was named in the Times article). If one advocates less use of all medications except the appropriate medications for an illness, is that biased and false? Further, I know personally that Dr. Goodwin refused to speak in favor of another putative mood stabilizer in the 1990s, Depakote, even though he would have been well compensated for it. Company spokesmen complained to me at the time that they could not convince him to speak for them. A decade later, he was willing to lecture about another agent, lamotrigine. The shill=expert equation cannot explain why anyone would refuse money for some drugs versus others. Some experts, it would appear, actually believe what they say, irrespective of whether they are paid.
I wish we could be "balanced" about our approach to all this: Can we criticize the pharmaceutical industry without becoming postmodern nihilists? Can we defend psychopharmacological truths, when they are proven, without being biological dogmatists? (See my CrossTalk debate with Dr. Larry Diller.)
There is room for hope: In a symposium I organized at the American Psychiatric Association conference in 2007 (titled: "Data, dollars, and drugs: The pharmaceutical industry and the psychiatric profession"), I critiqued the pharmaceutical industry, and their critics; I also critiqued the psychiatric profession, and tried to appeal to our better instincts as physicians. (I have begun to publish that lecture on this blog in four parts). The feedback I received - from prominent psychiatric leaders seen as highly connected to the pharmaceutical industry, to critics of the industry, to members of the industry - was mainly positive. There seems to be a place where all involved can reach consensus, where a desire for change meets a spirit of good will.
Let the Senate committee meet with leaders of academia, the pharmaceutical industry, patient advocacy groups, and critics of the pharmaceutical industry; and let them produce new and better policies regulating the relationship between medicine and the pharmaceutical industry. Let's put all this Schadenfreude aside, and fix what is broken.
