Letters
Letter from Australia
Doctors face many ethical challenges in their daily work. One
of these—how to behave in relation to the pharmaceutical
industry—has generated widespread discussion in the Australian
print and electronic media over the past year. A prominent
plastic surgeon and former Australian of the Year was forced
to admit that her decision to appear in an endorsement for the
over-the-counter drug Nurofen, in exchange for a donation to a
research foundation of which she is chairperson, was a
regrettable mistake because of the negative perception it
created. The Australian Medical Association’s ethics committee
said that patients expect to receive unbiased, evidence-based
advice from doctors, not recommendations that unthinkingly
parrot marketing claims of a company, especially when money
considerations may have influenced that advice. The Federal
Government has now extended its pre-existing legislation that
made it illegal for doctors to appear in advertisements
endorsing prescription drugs to cover over-the-counter drugs
as well.
Publicity was also generated when a
Melbourne oncologist lodged an affidavit with the Federal
Court in Sydney that alleged improper inducements made to
doctors by drug companies as part of their marketing strategy.
These included business class travel to attend international
company-sponsored meetings (as a delegate, not a speaker),
accommodation at lavish hotels and dinners at high quality
restaurants. Code of Conduct Guidelines published by Medicines
Australia, the Pharmaceutical Industry’s own watchdog, states
that in relation to whether sponsorship is appropriate or not
‘the test is of being able to withstand public and
professional scrutiny and the ability to conform to any
relevant professional and community standards of ethics and
good taste’. The Australian Competition and Consumer
Commission (ACCC) considered that what the oncologist was
describing breached these standards and it demanded that
Medicines Australia should be made to publish data on
hospitality expenditure by all drug companies on a regular
basis. Not surprisingly, this was vigorously opposed.
Rational prescribing is at the heart of
good medical practice and in Australia, promotion of rational
prescribing depends on a strong regulatory system operating at
the community level, supplemented by the activities of
increasingly powerful drug utilization committees in public
hospitals and underpinned by the Code of Professional
Behaviour published by each of the Royal Australasian
Colleges.
Australia has a Pharmaceutical Benefits
Scheme to subsidize the cost of prescription drugs and its
computers are able to scrutinize the prescribing habits of all
prescribers. Doctors whose prescribing is found to fall
outside the certain percentiles are subjected to practice
reviews and can be referred to an inquiry by the Professional
Services Review. If evidence of serious unprofessional conduct
emerges, the practitioner may be referred to the Medical Board
for a hearing that can lead to disciplinary action, even
withdrawal of medical registration. On a more positive note,
the Federal Government funds the publication of Australian
Prescriber, an excellent independent magazine about the
rational use of medications. It is available online at
www.australianprescriber.com.
The hospital where I work has a Drug Utilization Committee
that has the power to decide which drugs can be prescribed
within the hospital and to promulgate guidelines on how drugs
are to be used throughout the hospital. An excellent
innovation has been the production of small laminated cards
carrying guidelines on antibiotics and drugs used in
emergencies, which clip on behind the doctor’s identification
badge for use at any time. Online clinical guidelines and an
online hospital pharmacopoeia makes evidence-based drug
information available at the fingertips of all staff and as
well, to all doctors in the community via the internet.
The Royal Australasian College of
Physicians’ Code of Professional Behaviour says that ‘the
physician should not ask for nor accept any inducement, gift
or hospitality which may affect or be seen to affect his/her
judgement, and not offer such inducements to colleagues; not
accept more than reasonable costs of travel and accommodation
when invited to speak at a meeting . . . (and) be cautious
when giving personal endorsement of new medical techniques or
therapeutic goods.’ Most physicians are happy to receive these
recommendations because they clarify what has, for many, been
a murky area.
In many developing countries, rational drug
use is something to be aspired to and fought for. Reports from
Indonesia describe a widespread practice, mainly in private
clinics that serve the middle class, of prescribing powders
that contain a cocktail of drugs for treating childhood
illnesses. One mother of a child (23 months old) provided a
prescription for a powder containing no less than 23 different
drugs. A survey reported in the Jakarta Post on 27
January 2006 showed that 70% of Indonesian parents gave their
young children more than 4 drugs at once to treat common
illnesses and in 35% of cases, 5–7 drugs were given.
Eighty-five per cent of powders examined contained antibiotics
and many contained antituberculous drugs, antihistamines,
bronchodilators, even corticosteroids. Attempts by concerned
doctors to warn the public of risks such as the spread of
antibiotic resistant organisms in the community not only fall
largely on deaf ears, but attract fierce criticism from other doctors whose income depends on being able
to service a large clientele. Needless to say, research
studies to document the adverse effects of irrational drug use
in Indonesia are few and far between, but awareness of the
problem is growing, thanks largely to the efforts of
Jakarta-based paediatrician, Dr Purnamawati Pujiarto. Dr
Purnamawati has been supported by WHO to develop the Health
Education for Parents Program (HEPP), which aims to empower
consumers of healthcare. It has, so far, been very successful.
It is interesting that in Indonesia, the group most at risk
from irrational drug use is the middle class. The poor, who
attend government-run community health centres known as
puskesmas, receive evidence-based treatment according to
protocols.
It was most heartening to hear that the
Indonesian Paediatric Society has taken a brave stance to
reduce the involvement of drug companies at scientific
conferences. All promotional material displayed will, from now
on, have to be evidence-based and displays will only be
allowed in the exhibition hall. A selective approach to which
drugs and products can be promoted will be practised and only
those whose use is supported by strong evidence will be
admitted. The promotion of infant formulas will be banned.
Sessions debating controversial subjects will be encouraged
and conference organizers will defend their independence, even
if it means holding meetings in less luxurious venues than
before.
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