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Howard Brody is a professor of family medicine and director of the Institute for the Medical Humanities at University of Texas Medical Branch in Galveston, Texas.  Prior to joining the faculty at UTMB, Dr. Brody was a professor of medicine at Michigan State University and director of the Center for Ethics and Humanities in the Life Sciences.  He holds an M.D. and Ph.D. in Philosophy from Michigan State University and has written five books, including most recently Hooked: Ethics, the Medical Profession, and the Pharmaceutical Industry.  Brody, a member of the National Physicians Alliance, also keeps the Hooked blog, a terrific companion to the book which tracks medical conflicts of interest in the news.  

PS: You do a good deal of touring and giving talks about the ethical conflicts between medicine and pharmaceutical dollars. Do you get the sense that the medical students you encounter are the right amount of worried about pharma influence?

HB: Well, among general audiences, there’s always the question of preaching to the choir.  But it seems from the talks I give that those who didn’t see this as an issue before are more concerned and engaged now. I sense an amount of general commitment increasing, and actions being taken to do something. 

For instance, when I did Grand Rounds at the dept. of medicine at UC Irvine a few weeks ago, they told me they had already ended all drug lunches a couple of years ago. I talked to some med students who were having trouble convincing the administration, but on the other hand they were already engaged in doing something.

PS: You mentioned general audiences: is public outrage and involvement key to this movement?

HB: Well, a superficial look might indicate it’s not the public’s business. From that standpoint, this is an issue of medical professionalism, an internal matter for physicians to decide. But at the next level we say: okay, this absolutely has to do with public trust. Physicians should be making decisions based on science and their patients’ well-being, not which rep just took them to dinner last. The public ought to be able to trust that your physician can trust what he reads in the med journals, and that the content there hasn’t been influenced by who buys the ads.

So there needs to be a dialogue with the public eventually. We have to turn to them and say, “If we do these things, will you trust us?” 

Reform has to be a two-pronged thing. First, a professional level of reform: individual physicians growing a certain underdeveloped piece of anatomy….we need our professional spines to be strengthened. And the second piece is regulatory reform: We need to take back medical research from the pharmaceutical industry. There’s got to be some accounting for the bennies that these contract research organizations and investigators get from the drug companies. 

The public simply cannot demand further tax cuts unless they confront the fact that they are selling medical integrity to the hands of private industry.  I think that means we are going to have to pay so that science remains a public good, and not property of the commercial outfits.

PS: Do you consider yourself a doctor or ethicist first? Did you have a wakeup call that linked the issues for you, or is your interest in bioethics just the transfer of a worldview into academic pursuit?

HB: Fast backward: I’m in med school, it’s the early 1970s and students are uppity, they’ve been throwing their weight around.  When stuff comes in from the drug companies, there was a vocal group that said we don’t want this stuff, maybe it came from a general distrust of traditional authority. In a drawer at home I still have my Eli Lilly stethoscope that I was given my first day of medical school—so I’m not saying I was totally pure about that stuff back then. But somehow, as a med student I got the idea it was not a good use of my time to see drug reps. 

During my residency in family medicine at Virginia, each resident rotated for two months as head resident at the clinic, which meant you saw every drug rep that came in.  At that time, we gave out a lot of stuff from the sample cupboard. I told my chief I wasn’t really into seeing the reps.  And he said tough, it’s your job.  So okay, I said, for two months I’ll have to see all the drug reps, and this is my chance to see what I’ve been missing.  I had already finished my Ph.D. in bioethics but it wasn’t about this–these issues just weren’t on my ethic radar screen yet. There was one rep out of all of them that might have taught me something, but that’s it. One. It seemed it’d be a much better use of my time to spend that same time reading The Medical Letter.

Over the years, I served on a residency committee on industry relations and became known as anti-drug rep for trying to push policy in that direction. At no time was I thinking this is an ethical issue; this is just me in my medical existence.

But then in 1997, I read Drummond Rennie’s editorial, “Thyroid Storm,” which described the saga over publication of an article on generic vs. brand-name levothyroxine that showed that the generic was equivalent to the brand name. The article was blocked for four years by the brand name manufacturer, Boots-Knoll. At one point JAMA tried to resolve the impasse by seeking independent reviewers to referee the paper, and in this editorial, Rennie noted that it was extremely hard to find any thyroid experts in the U.S. who were not paid consultants of Boots-Knoll.

I had no idea that the waterhole of science was so polluted by industry funding. I thought: “Where is this in the bioethics literature?  I’ve got to get involved here.” And that lead to [writing] Hooked. 

But it took me awhile for the ethics piece to come on board with the doctor piece of my thinking.

PS: Has this issue begun to get attention in bioethics?

HB; Yes, I think so. There was a panel on these topics last year at the American Society for Bioethics in the Humanities. So that barometer would suggest that some people are working on this.
 
PS: Why only now?

HB: For too long, it appeared all we were talking about small scale stuff: pens, lunches, that sort of thing.  But then the article, “All Gifts Large and Small” (Katz, Mertz, Caplan. “All Gifts Large and Small,” American Journal of Bioethics 3(3):39-46)  came out, and that paper was a pivotal moment because it demonstrated that we are not just talking about pens and coffee mugs, we are also talking about principles. 

In writing Hooked, one of the things I thought was important to do is get at: how did this all happen? And I found the degree by which the pharma rep and the investigator rose up as dual presences in American medicine was very gradual—a case of the proverbial fish not noticing the water. Physicians and ethicists both were lulled because it was such a gradual intrusion.