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 Preservation of trust and confidence in the doctor- patient relationship is the single most important facet of developing a harmonious healthcare system. 


The medical profession and the pharmaceutical industry are important partners in the delivery of healthcare to patients and the public at large. The medical profession is expected to put the patients health and welfare above any financial or commercial gain. The pharmaceutical industry is expected to fund and develop new treatment for the benefit of the patients and market them ethically.

However, it is quite clear that a medical doctor or institution (as a drug purchaser, prescriber and dispenser) working in cahoots with a pharmaceutical company (developer and seller) can reap significant mutual financial gain at the disadvantage to the patient and society at large. On the other hand an antagonistic or disharmonious relationship between the profession and the industry would be detrimental to development and delivery of drugs for the benefit of patients and of society. Therein lies several ethical dilemmas. An such an ethical and professional behaviour must regulate the relationship so as to ensure that the patients and public interest are always upheld.

The medical profession at large and the individual physician must assure and be able to show to the patient and public that the medical treatment offered is the most appropriate for the patient (considering benefits, side-effects and cost) and not influenced by commercial or financial gains. Preservation of trust and confidence in the doctor-patient relationship is the single most important facet of developing a harmonious healthcare system. Public confidence and patients’ trust in the medical profession can only be preserved by responsible prescribing by the physician based on scientific and clinical integrity. The medical practitioner must be trained and be able to critically assess a new treatment modality and be aware of the subliminal-effects of drug promotional activity.

In an attempt to assess the impact on medical ethics of the principles and activities or the interaction between the medical profession and the pharmaceutical, a 5 way test is proposed, namely:

    (l)  Will it lead to any harm to the patient’s welfare?
    (2) Is it directly or indirectly beneficial to the patient’s health?
    (3) Will it impede the patients autonomy to choose his treatment?
    (4) Will it be beneficial to the society at large and all 
          parties concerned?
    (5) Will it build better professional integrity and character?

Using the 5 way test, one could classify each practice or activity as:

    (I)   Ethically acceptable practice. Needs minimal monitoring.
    (II)  Probably acceptable but needs professional self regulation.
    (III) Possibly acceptable but with a potential to easily deteriorate into the    
           unacceptable - “A Slippery Slope Situation” best avoided.
    (IV) Ethically unacceptable practice. Avoid at all cost.
The ethical dilemmas in the interaction between the medical profession can be classified under several headings for the purposes of discussion. Some questions arising from these issues are listed.
(1) Discount and Bonus Schemes, Samples
      Will it affect prescribing integrity?
      Should the savings be passed on to patient?
      Should list price be printed on medicine packages?

(2) Gifts - Lucky draw - Quiz Prizes
      Are these necessary for good medical practices? 
      What gifts can improve the standard of medical practice? 
      What are unacceptable gifts?

(3)  Hospitality
      What is lavish hospitality? 
      Should doctors accept hospitality only when associated with CME? 
      Is hospitality extended to families of doctors acceptable? 

(4)  Travel Grants
      Should travel grants be only made through medical societies? Should doctors and    
      pharmaceutical declare publicly the receipients of travel grants? Is lt acceptable to 
      accept travelling expenses for accompanying members of the family? 

(5)  Sponsorship of Drug Promotion Talks, Scientific Meeting (CME) and Medical  
       Is it acceptable for a single pharmaceutical company to sponsor the entire medical 
       meeting? Is it acceptable that a pharmaceutical company spend on a lavish, 
       entertainment program during medical conferences? Should medical societies ask for 
       inappropriate sums of money to sponsor drug promotion talks in the name of CME?

(6) Sponsorship of Public Talks 
     Is it acceptable for medical institutions to ask for sponsorship from pharmaceuticals to 
     sponsor pubilc talk? Are public talks an indirect way of attracting more patients to 
     medical institutions? Are public talks an indirect way to advertise medicine to the public?

(7)  Pharmaceutical Promotional Methods and Materials
      Do promotional material tell the whole truth? 
      Are fancy drug promotional brochures beneficial to the doctors education? Are the    
      doctors able to differentiate a new drug as a new advancement in treatment vs a new    
      creation for a new market? 

(8)   Medical Research and Clinical Trials
       Should clinical trials compare new drug vs standard treatment instead of placebo?  
       Should pharmaceutical companies have the right not to publish “no benefit” results of 
       clinical trials? How can the medical profession ensure ‘no fraud’ when researches are 
       paid to research grants provided by the industry?

Obviously, there are always more questions than answers which however, should not preclude the development of guidelines and consensus. Only open discussion, continuous soul (conscience) searching and realisation of human follies can help us all move along the right direction in promoting an ethical, harmonious relationship in the medical ecosystem.  


The SMA Ethics Convention will be held on 26 October 1997 from 9.00pm to 5.30pm at the College of Medicine Building, 16 College Road, Singapore 169854.