I'm a medicine geek. I love it. I love going through cases in detail, developing a differential diagnosis, tossing around ideas with colleagues. Medicine is great fun. The professional organization for my specialty is the American College of Physicians, and we had our state chapter meeting recently. One of the highlights was a session where experts were given difficult cases to solve. These docs were sharp. They are all respected clinicians and researchers, usually department or division chiefs. Watching them work can be very humbling (well, not for them...).
There are no "grades" for doctors; your reputation is whatever your colleagues and patients say it is. I like to think that these opinions will roughly track with ability. What is certain, though, is that a real reputation can't be bought. But that doesn't stop people from trying.
One of the big stories this week was ProPublica's Dollars for Doctors, an investigation into the relationships between pharmaceutical companies and doctors hired to speak for them. These docs are often touted as experts in their fields. What ProPublica found (and what is unlikely to surprise many doctors) is that many speakers are not exactly experts, and many are not exactly at the top of their fields.
Speaking for drug companies can be very lucrative. I've been approached a number of times, and given that even a few speaking engagements per year can significantly supplement the salary of a primary care doc, it's not surprising that many say "yes".
Having a financial relationship with a drug company is not prima facie unethical. But there are all sorts of ethical pitfalls, some subtle, some not, that emerge from such a relationship.
So, here's a case:
You're sitting at dinner and start to feel some indigestion. You burp a few times, but aren't getting any better. In fact, you rapidly feel worse, and the "heartburn" starts to make your arm and neck ache. You start feeling panicked, and are having a little trouble breathing. Your spouse calls 911 and you're brought to a tertiary care hospital where you are found to be having an "acute coronary syndrome", but not an active heart attack. The ED docs put you on medications and transfer you to the cardiac unit. A cardiologist recommends going for an angiogram and possible stent placement in the morning.
Depending on the results of the angiogram, possible solutions to your problem may include coronary artery bypass graft surgery, angioplasty with stent placement (with either a bare metal or drug eluting stent) or medical therapy. There may be further findings that suggest the need for an implantable device such as a defibrillator or pacemaker.
The cardiologists at the hospital have seen their (substantial) incomes decline significantly over the last couple of years due to a combination of better treatment of heart disease (not as many people need expensive interventions) and cutbacks in what they are paid for diagnostic tests and other procedures. Some of the docs supplement their income by speaking for drug and device manufacturers. The department has a national reputation, however, with the cardiologists actively involved in research and publication.
You don't have a lot of time to shop around.
What sorts of ethical problems might be involved here? Are the doctors' judgments inherently invalid?
Remember some of the basic ethical principles: beneficence, non-maleficence, autonomy, justice.
There are a number of obvious questions here, but also a number of non-obvious problems. I'd like to hear what you think.