When we discover political donors have received special favours from the government, or that accounting firms have an interest in the companies they are auditing, there is rightly a scandal. Equally, MPs who fail to declare their financial interests in the Common's register are investigated and disciplined. But when medical doctors and researchers declare that a drug is safe and effective, do we have any way of knowing their financial links with the pharmaceutical companies that make the drug? No, we don't. In recent weeks a whole series of incidents have combined to highlight this worrying conflict of interests at the heart of medicine - one that would not be tolerated in any other profession.
The current edition of the Lancet, for instance, contains a coruscating editorial entitled, "Just how tainted has medicine become", and concluding "heavily and damagingly so". At the end of March, the British Medical Journal (BMJ) published a remarkable article which found that the drug company Genentech had contributed $11m to the American Heart Association (AHA) and that subsequently the AHA had strongly recommended Genentech's stroke drug, Alteplase, on the basis of controversial evidence from just a single trial.
Meanwhile, in Germany, the district attorney's office in Munich is investigating an astonishing 3,500 doctors for alleged "undue financial advantages and corruption", and in New York a civil law suit involving a "whistle-blowing" doctor, who had worked for a drug company, is just beginning. It involves a massive marketing campaign that may have not only been illegal but put patients' lives at risk.
The case of the high-living German doctors involved "excessive marketing" by SmithKlineBeecham (now GlaxoSmithKline) between 1997 and 1999 when they lavished 5,800 payments of over £1,500 each on local doctors and paid for a range of expensive trips and outings, including football championships and formula one racing.
The BMJ's investigation into Alteplase found that, far from being a life-saver, the drug might actually "cost more lives than the disease itself". What's more, six of the eight panellists who drew up the recommendation, had financial ties with Genentech, receiving fees for consultancy, lecturing or research. One member of the board, who had no links to the company, disagreed with the findings. The financial links between both the AHA and the panellists had never previously been made public. Nor had the objections of the one dissenter. The AHA has recently withdrawn its statement that Alteplase for strokes "saves lives".
While it is possible that these secret financial relationships between doctors, researchers and the drug companies is endangering lives, it is certain that they are inflating the size of our drugs bill. An American study published in January into the antibiotics prescribed for women's urinary tract infections found that the use of new and far more expensive versions has doubled, although they are no more effective. The report found that between 1989 and 1998 doctors were "increasingly likely to manage these common infections in ways that encourage antibiotic resistance and waste money". Part of the reason was "pharmaceutical promotions". The newer drugs cost between 11 and 40 times as much as the standard ones.
"If you'd asked me 10 years ago about doctors and researchers having to declare their interests, I'd have said that was absurdly PC," says Richard Smith, editor of the BMJ, "but now I think it is vital. The way bias works is very subtle. That is why we have to have double-blinded controlled clinical trials. At least when we know who is being funded by whom we can take it into account."
There are signs that things are changing. Several medical journals now require authors to state financial links to the drugs they are writing about, while last week the European Medicines Evaluation Agency (EMEA) declared that it will "name and shame" pharmaceutical companies that conceal data about side effects of new drugs. This comes in the wake of the withdrawal of the cholesterol-lowering drug Baycol last year after 30 deaths. The agency has asked for a doubling of its budget to do the job.
In the US, the promotional efforts directed at doctors are astounding. Every year doctors spend an average $8-10,000, much channelled through 80,000 salespeople. They are showered with gifts ranging from pens and bags to all-expenses paid weekend trips to resorts.
The New York whistle-blower case promises to provide a rare glimpse into how the whole process works. When Dr David Franklin, from Harvard Medical School, was hired by Warner-Lambert he believed that he was going to help doctors understand the intricacies of the company's medicines. Instead he found himself part of an aggressive marketing campaign to promote the benefits of a drug called Neurontin.
It had only been officially approved for the treatment of epilepsy, but his job was to persuade doctors of its suitability for at least a dozen other disorders. Company tactics included paying doctors to appear as authors of journal articles on the wider use of Neurontin, that had actually been written by employees of the drug company, as well as paying for hundreds of doctors to attend expensive dinners and weekend retreats where they were urged to prescribe Neurontin. When Franklin found evidence of side-effects in some children he was ordered not to tell doctors about it. At the end of the year, non-epilepsy conditions made up 78% Neurontin's $1.3bn sales.
A quixotic stand against this peddling of influence has been taken by a doctor in New York who has mounted an "anti-promotional guerrilla campaign" called "No free lunch". Dr Bob Goodman urges doctors to "Take the pledge" on his website and declare themselves influence-free. So far, however, only 150 have responded and many doctors post hostile messages on the bulletin board. "I love my drug reps", declares one. Another revels in the "great time on trips, at ball games, and amusement parks".
Of course, there is always going to be a debate about how much doctors are actually influenced. Although examples such as Neurontin suggest it does, many doctors claim to be able to make an independent judgment. According to Smith, UK doctors are not subject to temptation on the same scale as found in America and some southern European countries. "There is a pretty strict code about how much doctors can accept," he says. "Certainly trips to formula one races would be out of the question."
But the problem goes much further than promotional efforts directed at GPs. The case of Alteplase and the AHA appears far from isolated. An alarming study published in the American Medical Journal in February looked at the financial interests of the authors of clinical guidelines - authoritative reports put out to guide doctors on the best treatments on common conditions such as asthma, heart disease and ulcers. The study found that, on average, each of the authors had links with 10 companies, including the ones whose products they were recommending. Only one of 44 carried a declaration of the authors' competing interests. It was impossible to estimate the effect of this conflict of interests, the report concluded, because there were too few independent guidelines to make a comparison.
Just how tricky sorting out this whole issue is going to be is illustrated by two recent developments. The prestigious New England Journal of Medicine has taken a stern line, declaring that no one with a financial link with a drug can write about it for them. They are now having difficulties finding contributors. Meanwhile, the American Medical Association has called for new guidelines to be drawn up, half the cost of which are being funded by drug companies.
