Chief executives of multinational pharmaceutical companies have much to celebrate this week. They saw spending on prescription drugs in the USA soar by a remarkable 17% in 2001, according to figures recently released by the National Institute for Health Care Management Foundation. As bonuses for corporate leaders ratchet upwards, so does the unalleviated financial pressure on the elderly, the largest users of these drugs. Direct-to-consumer advertising campaigns for cholesterol-lowering agents, anti-ulcer medications, anti-arthritics, and antidepressants have been strikingly successful. Total retail spending on prescription drugs was US$155 billion in 2001, almost double what it was in 1997.

The escalating influence of big pharma in medicine persuaded editors of medical journals to come together last year and agree strict rules on reporting sponsorship and conflicts of interest (see Lancet 2001; 358: 854-56). While this consensus sets the highest standards yet for disclosing commercial influences in medical research, there are signs that it does not go far enough--or, at the very least, that this guidance is not being fully heeded.

A study of the interactions between authors of clinical practice guidelines and the pharmaceutical industry, published in JAMA in February, found serious omissions in declarations of conflicts of interest. Almost 90% of authors received research funding from or acted as consultants for a drug company. Over half had connections with companies whose drugs were being reviewed in the guideline, and the same proportion indicated that there was no formal procedure for reporting these interactions. The guidelines studied covered all fields where prescription drug use has seen the greatest increases.

An especially corrosive example of such a commercial influence, involving one of the most respected US specialist societies--the American Heart Association--was described in the BMJ last month. Was the AHA sensible to accept US$11 million in donations from Genentech while at the same time producing guidelines about thrombolytics in stroke? Genentech is the US producer of one such thrombolytic, which was recommended for use in the AHA 2000 guidance on stroke management.

Prestigious institutions are also not averse from mixing research with commercial gain from industry partnerships. The Seattle Times has conducted one of the most thorough investigations of how such relations threaten to poison patient care. In a series of articles published last year, staff reporters Duff Wilson and David Heath claimed to reveal how investigators at the Fred Hutchinson Cancer Research Center completed experiments with biotechnology products in which they had a direct financial interest. The journalists allege that doctors did not tell patients that others had died using these products and that there were safer alternatives available. The Center denies these allegations but admits that it "could have handled better" perceptions of conflict of interest.

These concerns extend to journal editors, especially those who edit part-time while continuing to work in clinical practice and research. The rules issued by the International Committee of Medical Journal Editors state that, "Editors who make final decisions about manuscripts must have no personal, professional, or financial involvement in any of the issues they might judge". However, the editor of the British Journal of Psychiatry was recently questioned about his membership of a drug-company sponsored "educational organisation", for which he received £2000 annually, together with his decision to publish a paper favouring a drug manufactured by the same company. Only after receiving the letter questioning his behaviour did the editor change his journal's procedure, excluding himself from decisions about work sponsored by that same company. He avoided the issue about whether he should have any commercial liaisons while acting as editor of a supposedly independent medical journal. The Lancet's policy is that editors should divest themselves of all such links upon assuming their new duties.

To return to our first question: how tainted by commercial conflicts has medicine become? Heavily, and damagingly so, is the answer. A more important question arises: do those doctors who support this culture for the best of intentions--eg, to undertake important research that would otherwise remain unfunded--have the courage to oppose practices that bring the whole of medicine into disrepute?

The Lancet