Is Your Doctor Selling You to the Highest Bidder?

Until relatively recently, human experiments to determine whether or not drugs work as intended were deemed too complex to entrust to non-academic physicians. But things progress slowly in the groves of Academe, and pharmaceutical company executives of late have come under increasing pressure from stockholders for ever-larger dividends. As a result, the focus of experimental medicine is moving away from the bureaucratic, stodgy campus environment to venues where studies can be completed more rapidly. Increasingly, industrial sponsors of new products are turning to private practice physicians’ offices for research subjects.

But how to recruit research subjects from private practices when doctors are already swimming in a sea of clinical work and insurance company forms and procedures? In a society where everything (and, apparently, everyone) is a potential commodity, can it be any surprise that the solution favored by the pharmaceutical industry is—you guessed it—the almighty buck. Physicians are frequently offered thousands of dollars in “finder’s fees” merely for plumbing their patient lists for eligible patients and then referring them to the industry as potential subjects.

An article in the British Medical Journal raises serious questions about these practices. As Drs. Jammi Rao and Sant Cassia point out, “cash payments can influence doctors’ motives for joining a clinical trial.” Worthy research (and clinical care) can be displaced by more remunerative drug company funded research, often dedicated more to the creation of the blockbuster drugs sought by the industry than to true scientific progress. (Many of these drugs aren’t blockbusters at all, offering little or no advantage over existing, cheaper, generic drugs—but that is another story.) “A system that allows commercially driven and clinically dubious research to crowd out good and much needed clinical trials, and that denies patients their opportunity to put their altruism to the best possible use,” say the doctors, “is unethical and unacceptable.”

Even if the research is legitimate, finder’s fees are improper. As questionable a guardian of medical ethics as the American Medical Association declared in 1996 that “[o]ffering or accepting payment for referring patients to research studies (finder’s fees) is also unethical.” A companion organization in Britain, the Royal College of Physicians, requires that recruitment fees be disclosed to research ethics committees.

But as Drs. Rao and Cassia point out, patients also have a right to know about these sometimes shady fiscal arrangements. “Not to require a similar disclosure to patients is as cynical as it is demanding of blind and unquestioning trust.” Moreover, while modestly reimbursing physicians for research-related services rendered beyond what would ordinarily be provided to the patient is acceptable, trial sponsors and parti-
cipating physicians can circumvent any restrictions by “claiming to pay for the work involved in conducting the trial (rather than for recruiting patients), and then overestimating the amount of time required for each patient.”

As usual, patients are ahead of physicians on this issue. In a 1995 U.S. survey, approximately 90 percent of patients thought they should be told who paid for the study, 80 percent wanted to be told if the researcher owned stock in the company, and 85 percent wanted similar disclosure if the investigator was paid for each patient enrolled. For each of these questions, doctors recommended disclosure at somewhat lower rates. Similar disparities are apparent when doctors and patients are asked about the appropriateness of accepting knickknacks, free meals and trips to exotic locations from the pharmaceutical industry. When will the doctors catch up with their patients?