How the drug industry is branding itself with bioethics.
The Wall Street Journal recently reported a story about Xigris, Eli Lilly's new antisepsis drug. Sepsis, an infection of the blood, is a life-threatening illness sometimes contracted by hospital patients. Lilly had hoped that Xigris would be its new blockbuster, but the drug hasn't taken off. One reason for this is that Xigris may not be any better than older treatments for sepsis, but the main reason is that the drug is so expensive. Standard treatments for sepsis (antibiotics, blood pressure drugs) usually cost less than $50 per day, while Xigris costs $6,800 per treatment. To promote the drug, Lilly has hired a public relations agency; the PR campaign they've created is called "The Ethics, the Urgency and the Potential," and its premise is that it is "unethical not to use the drug." To reinforce the point, Lilly has funded a $1.8 million project called the "Values, Ethics & Rationing in Critical Care Task Force," in which bioethicists and physicians from various American medical schools will examine the ethics of rationing certain drugs and services.
It is a brilliant strategy. There is no better way to enlist bioethicists in the cause of consumer capitalism than to convince them they are working for social justice. Many bioethicists see it as part of their job description to write and speak on behalf of those who are ill, disadvantaged, or oppressed. In the words of one prominent practitioner, bioethics is intimately concerned "with liberty, with rights struggle, and with the drama of the one against the powerful authorities." So when a drug company gives money to bioethicists, it's a little like giving money to the poor. This helps explain why bioethicists at the University of Toronto take funding from GlaxoSmithKline, Pfizer, and Merck to write editorials on bringing biotechnology to the developing world. Or why the University of Chicago's MacLean Center for Clinical Medical Ethics cosponsored a recent conference with Pfizer, Merck, and PhRMA, the pharmaceutical industry trade organization, on inequities in American health care. Or why bioethicists at the University of Pennsylvania take money from Pfizer to write an article explaining why physicians should not accept gifts from companies like Pfizer. We may take industry money, bioethicists argue, but we're not industry stooges. We're doing God's work.
Let's assume (rightly, I believe) that most corporate-funded bioethicists are decent people of good conscience who genuinely see nothing wrong with taking drug industry money, as long as no strings appear to be attached. If the drug company makes no effort to influence your work, is there anything wrong with taking their money?
To answer that question, we need to ask another one: Why do drug companies want to give money to bioethicists in the first place? In the public relations business, this approach is called "third-party strategy." Third-party strategy is defined as the art of getting your message into the mouth of an authoritative third party. Often, when a drug company is launching a new drug, it recruits a third party known as a Key Opinion Leader: an influential figure respected by his or her peers and often eagerly sought out by the press. The KOL could be a grand rounds speaker at a teaching hospital, an author on the talk show circuit, or a freelance journalist interested in covering a medical conference. It could also be a socially conscious bioethicist.
While KOLs are frequently offered positions as consultants or advisers, the drug companies do not expect them to push their products directly. That would ruin the KOLs' credibility. Instead, KOLs are expected to generate "buzz"—by talking casually to colleagues, giving lectures at meetings, speaking to the press, or doing virtually anything else that will garner positive publicity for the drug. "While the buzz must appear to be spontaneous," explains the PR agency Chandler and Chicco in PharmaVoice, "it should, in fact, be scientifically crafted and controlled as tightly as advertising in the New England Journal of Medicine."
Of course, KOLs must be convinced of their own impartiality; if they understood that they were being used as industry mouthpieces, they would probably pull the plug on the whole enterprise. Some public relations agencies advise drug companies to encourage their KOLs to work for many different companies in order to maintain a posture of objectivity. As the PR firm Thunder Factory bluntly states, "KOLs must maintain their credibility and integrity in order to have maximum market impact."
But funding bioethics is less an act of corporate good will than the latest move in a larger strategy: buying off the entire apparatus of academic medicine. One way drug companies can achieve "maximum market impact," for example, is through funding medical education. Drug and device manufacturers now supply over half of the $1.4 billion spent on continuing medical education for physicians in the United States. They have also begun funding patient support groups and a handful of prominent bioethics centers, apparently taking to heart Michael Corleone's advice, "Keep your friends close, and your enemies closer."
The drug industry has even managed to turn peer-reviewed scientific literature into a sophisticated marketing device. It has long been known that corporate-funded research studies are more likely than impartial studies to favor the products of their corporate sponsor. But only recently has evidence emerged to suggest how many "scientific" studies have actually been ghostwritten by specialized PR firms—"medical communications" agencies—that represent the drug industry. These firms then pay well-known academic researchers to sign on as authors. Often these academic researchers are not even allowed to see the raw data upon which the published studies are based. A recent article in the British Journal of Psychiatry examined articles on Pfizer's antidepressant Zoloft (sertraline) whose authorship had been coordinated by the communications agency Current Medical Directions. When checked against the raw data, which had come to light in a lawsuit, it became clear that the studies authored by Current Medical Directions omitted or greatly minimized Zoloft's side effects, including the risk of suicidal acts. Yet these studies outnumbered "traditionally authored" articles, were published in more prestigious journals, and were cited by other researchers at a much higher rate.
It's no mystery, then, why pharmaceutical companies want to brand themselves with bioethics. But do bioethicists really want to brand themselves with Pharma? To take only one example: The pharmaceutical sponsors of the University of Pennsylvania Center for Bioethics and its faculty's projects are now facing multimillion dollar fraud sanctions (AstraZeneca), a Nigerian lawsuit for research abuse(Pfizer), massive class-action payouts (Wyeth-Ayerst), a criminal probe into obstruction of justice (Schering Plough), an ongoing fraud lawsuit (Merck and Medco), and allegations of suppressing research data on suicide in children (GlaxoSmithKline).
Somehow corporate-funded bioethicists have not been touched by the bad publicity. Many bioethicists continue to insist that they are learning from their industry relationships and shaping company policy for the better. A task force commissioned by the two major American professional bioethics bodies—the American Society for Bioethics and Humanities and the American Society of Law, Medicine and Ethics—concluded last year that private corporations should be encouraged to seek out paid bioethics consultants, because "bioethics will have an impact on that (corporate) activity only if bioethicists can be part of the dialogue." The task force went on to endorse the practice of bioethicists advertising their own services as private consultants.
Carl Elliott is a professor at the Center for Bioethics at the University of Minnesota and author of White Coat, Black Hat: Adventures on the Dark Side of Medicine.
Illustration by Mark Alan Stamaty.