Ethical Issues in Medical Practice Where Medicine and Business Meet
Stuart D. Yoak, Ph.D.
Executive Officer and Lecturer in Professional Ethics Center for the Study of Ethics and Human Values Washington University
Ethical Challenges in Medicine
Research Fraud
Marketing Drugs and Physician Prescription Decisions Decisions at the End-of-Life
Ethical Challenges in Medicine – Research Fraud
Woo Suk Hwang
– Researcher at Seoul National University accused of falsifying stem cell data.
Vioxx Case
– New England Journal of Medicine claims Merck concealed heart attacks suffered by three patients in a study published in the NEJM in 2000.
Ethical Challenges in Medicine – Marketing Drugs
In 2003 the pharmaceutical industry in the United States spent $25.3 billion in Marketing. By comparison, the industry spent $33 billion on Research and Development. In 2001 prescription drugs accounted for 10% of the total $1.4 trillion spent on health care in the United States.
– “Are Physicians “Easy Marks”? Quantifying the Effects of Detailing and Sampling in New Prescriptions,” Mizik, N. and Jacobson, R., 50(12) Management Science 1704 (2004).
Ethical Challenges in Medicine Marketing Drugs
In 2003, the pharmaceutical industry spent 23% of their total marketing budget ($5.8 billion) on direct marketing to physicians.
– This does not include the $16.4 billion spent on free samples given to physicians.
In 1999, it has been calculated that direct marketing to physicians represents on average between $8,000 and $13,000 per physician in the United States.
– “Physicians and the Pharmaceutical Industry: Is a Gift Ever Just a Gift?” Wazana, A., 283(3) JAMA 373 (2000).
Marketing through Gifts
Drug companies have used a variety of methods to influence physician prescription practices:
– Cheap gifts – pads, pens, mugs, notebooks, – Medical products – textbooks, stethoscopes, reflex hammers – Non-medical products –clocks, sports equipment, clothing – Entertainment – lunch, dinner, tickets, trips – Expensive gifts – consulting fees
Marketing through Gifts - Should We Be Concerned?
Study of drug company materials found that 42% failed to meet the FDA requirements for “a fair balance of information.” Studies have documented that a majority of physicians would not attend educational events sponsored by drug companies without financial or personal incentives.
– “Physicians and the Pharmaceutical Industry: Is a Gift Ever Just a Gift?” Wazana, A., 283(3) JAMA 373 (2000).
Ethical Challenges in Medicine – Decisions at the End of Life
Terri Schiavo Case
– Lessons Learned from this Conflict in Values? – Advance Medical Directives
Palliative Care Programs
– Integrating Curative Care and Comfort Care – A Team Approach to Patient Care
Ethical Challenges in Medicine and the Business of Medicine
Medicine as a caring profession Business as a competitive marketplace
Basic Question: What are the values driving the decisions?
Ethical Challenges in Business – The Big Cases
WorldCom – Bernie Ebbers, former CEO found guilty of securities fraud, masterminding $11 billion conspiracy, sentenced to 25 years in jail. Tyco – Dennis Kozlowski convicted of grand larceny.
Enron
– Andy Fastow plead guilty to fraud and conspiracy. Ken Lay and Jeff Skilling will go to trail this month.
Ethical Challenges in the Business of Medicine
Fraudulent Billing Practices Harassment and Discrimination
Whistleblowing
Ethical Challenges in the Business of Medicine - Fraud
Florida U.S. Attorney charges 64 defendants in criminal cases with $20 million fraud. New York State's Medicaid program a $44.5 billion target for fraudulent billing. California doctor convicted of 24 counts of health care fraud and four counts of money laundering for billing Medicare $7.6 million for unnecessary or nonexistent treatments.
Ethical Challenges in the Business Office
Sexual Harassment
– Quid Pro Quo – Hostile Work Environment
Harassment also based on
– – – – – – – Race Color Religion National origin Age Disability, and Reprisal
Harassment Policies
A clear explanation of prohibited conduct; Assurance that employees who make claims will be protected against retaliation; A clearly described complaint process; Assurance that employer will protect confidentiality; A complaint process that provides a prompt, thorough, and impartial investigation; and Assurance that the employer will take immediate and appropriate corrective action.
Ethical Challenges in the Business Office
Whistleblowing – Example of Moral Courage?
– Jeffery Wigand – Brown & Williamson – Watkins – Enron
What motivates the whistleblower? What can an employer do to discourage whistleblowing?
Medical Values in Private Practice
Traditional Medical Model for PhysicianPatient Relationship
– Beneficence & Nonmalfesience – Fiduciary Relationship
Challenges to the Physician Patient Relationship
– Conflicting Interests – Patient Distrust – Increasing Costs
Business Values in Medical Practice
Business Values Model
– Service to the Customer – Competitive Marketplace
Competing Stakeholder Interests
– – – – – Physicians and Nurses Support Staff Health Maintenance Organizations Private Insurance Government
Values in Medical Practice
Leadership
“Management is doing things right; leadership is doing the right things.” Peter Drucker
Values in Medical Practice
“In looking for people to hire, you look for three qualities:
integrity, intelligence, and energy.
And if they do not have the first, the other two will kill you.”
Warren E. Buffet
Values in Medical Practice – A Culture of Values
What values really drive decisions here? What does it mean to work in a culture of values?
Do we look the other way? Do we honor moral courage?
Where are the pressure points for unethical conduct? Do our values apply across the organization
Values in Medical Practice – Building A Culture of Values
Commitment – Values Do Not Happen by Accident Professional Organizations – MGMA Education Training Community Involvment
Center for the Study of Ethics and Human Values
Comprehensive and Collaborative Center for Ethics and Human Values
– All professions – medicine, law, business, etc. – Students, scholars, and practitioners, – Community and government leaders
Teaching Research Community Outreach
Center for the Study of Ethics and Human Values
Dr. Ira J. Kodner, Director Dr. Stuart D. Yoak, Executive Officer Washington University One Brookings Drive, CB 1019 St. Louis, MO 63130 Voice: 314-935-9358, Fax: 314-935-9359 Email: Stuart_Yoak@.wustl.edu