Ivory Tower or Gold Bazaar
Dr. Timothy Anderson and colleagues published a research letter in JAMA on April 2 indicating that 16-out-of-17 U.S.-based pharmaceutical companies had at least one member among its board of directors who was also simultaneously serving as a leader at a medical school, teaching hospital, or other health care system. These leaders included department chairs, deans, hospital CEOs or university presidents, who were paid a hefty $300,000 or more, on average, by the drug companies. This should sound alarm bells and draw close scrutiny.
The authors raised the problem of serving two masters. Members of the board of directors of drug companies have a fiduciary responsibility to the shareholders to achieve financial success for the company. Situations may arise where that obligation comes into conflict with the academic institution whose values, roles, and best interests the leader is also sworn to uphold. If those academic leaders also provide direct care to patients, conduct clinical research, or have direct oversight of those activities, then the potential that their conflict of interest will introduce bias that could undermine the best possible patient care increases.
Some might argue that it is appropriate for leaders in academic medicine to sit on the boards of drug companies. It could benefit the academic institution by facilitating appropriate relationships between industry and academia, such as research. It could also provide the pharmaceutical company with leaders that voice the traditional values of medicine and academe for social good, a valuable counterbalance to purely commercial perspectives.
Furthermore, ethically appropriate consulting relationships between physicians and drug companies are possible. I don’t mean the “pseudo-consulting” deals where pharmaceutical companies pay doctors handsome fees for essentially no real service, which have been used to entice physicians to prescribe and promote the company’s products. Ethically appropriate consulting requires written contracts related to real expertise that the physician has, which is compensated at fair market value. There must be no hidden quid pro quos where the doctor is paid for writing more prescriptions for the drug or doing other marketing for the company. Nor should there be any secondary benefits to the company, such as having that consulting physician use her position to influence purchasing decisions at her institution to increase sales by the company.
However, having academic leaders serve on the boards of drug companies doesn’t live up to the ethical standards and protections in such legitimate consulting contracts. The $312,564 average annual compensation paid by drug companies to board members seems far beyond what is fair market value in academia. And it is dubious whether all academic leaders have specific expertise that would be valuable to the company. It is hard to see how a university president’s Ph.D. in romance languages could be of direct benefit to a drug company, but it is certainly clear that having such a person on the board lends prestige and respectability to the company and might lead to future or continued funding to the institution.
Of equal concern are the secondary effects that having an academic leader on the board of a drug company will have on that leader’s academic institution. No one at the academic institution can know what transpires in the board room of the drug company. If a discussion arises at a board meeting in which the interests of the two institutions are in conflict, who is to assure that the leader has recused himself from the discussion? The leader’s role in the drug company can also dampen any criticism of that company, or its products, by the leader’s colleagues and subordinates.
Academic institutions are sometimes criticized for being “ivory towers” that exist in isolation from real world affairs. But this separation also keeps these institutions insulated from the pecuniary interests of the wider society, where the highest ideals of intellectual integrity, scientific rigor, humanistic values, and healthy skepticism are preserved. I would assert that our society needs such institutions and should do everything to protect and preserve them, for they serve an important social purpose. Having leaders of those “ivory towers” serve on boards of pharmaceutical companies is destructive to those ends.
Leaders of our academic medical institutions occupy a position of public trust because they train future doctors, help care for patients, and spearhead the discovery of new medical treatments. For this they are paid well. But serving a fiduciary role on the board of a pharmaceutical company threatens the impartiality and objectivity they need to do these things in the interest of patients and the public.
Even if they possess a particular expertise that is valuable to a pharmaceutical company, then they can consult for industry, providing specific services at fair market value. Management plans can be put in place to assure transparency and integrity. Our schools and medical students deserve the undivided loyalty of their faculty to academe and society, faculty who are not beholden in any way to the marketplace, no matter how alluring the financial rewards of that gold bazaar.
— Stephen R. Smith, M.D., M.P.H., Community Catalyst physician consultant