Pharmaceutical sponsorship of educational events : what can we learn from healthcare ethics ?

In the UK, postgraduate medical educational events are commonly sponsored by pharmaceutical companies, often with the provision of food and gifts with a small monetary value (e.g. pens and torches). The involvement of pharmaceutical companies with doctors has been discussed extensively (Abbasi & Smith, 2003; Shooter, 2005). We have chosen to consider sponsorship of educational events from an ethical point of view in order to see if this approach can provide guidance for a situation that is the norm in many hospitals, but of increasing concern to educationalists.We also hope to illustrate how the application of ethical principles can be applied to a medical education issue.

Pharmaceutical sponsorship of educational events: what can we learn from healthcare ethics?
In the UK, postgraduate medical educational events are commonly sponsored by pharmaceutical companies, often with the provision of food and gifts with a small monetary value (e.g.pens and torches).The involvement of pharmaceutical companies with doctors has been discussed extensively (Abbasi & Smith, 2003;Shooter, 2005).We have chosen to consider sponsorship of educational events from an ethical point of view in order to see if this approach can provide guidance for a situation that is the norm in many hospitals, but of increasing concern to educationalists.We also hope to illustrate how the application of ethical principles can be applied to a medical education issue.

Ethical background
The four core principles of medical ethics expounded by the American ethicists Beauchamp and Childress (2001) are shown in Box 1.The four principles are claimed to be culture-free concepts which can be universally applied and therefore offer a framework for tackling any ethical problem within medicine.Although this methodology is not unanimously accepted (Campbell, 2003), the four principles do provide a useful structure and starting point to look at ethical issues.
Why should a doctor eating a sandwich given free by the representative of a company whose products they would regularly prescribe anyway involve any breach of the ethical principles outlined above?One way to approach this problem is to look at an extreme example of conflict of interest that most doctors would agree on, see what ethical principles are involved and then gradually work down a hierarchy of scenarios where the ethical issues are less clear.

Three scenarios showing conflict of interest
Scenario 1 A doctor accepts direct payments from a pharmaceutical company to prescribe a particular drug to his or her patients.

Scenario 2
A related scenario would be that of a doctor receiving »10 000 in cash from a pharmaceutical representative every year to attend an annual educational event organised by a drug company with 'no strings attached'.

Scenario 3
Many doctors are flown abroad by drug companies to attend meetings.Some of these are sponsored conferences that may launch a new product or present research about one or more of the company's products.Others are high profile international conferences not organised by the pharmaceutical firms but 'guests' will be encouraged to attend sponsored satellite talks and perhaps visit the company's offices.

Ethical debate
In Scenario 1, it might be argued that the drug prescribed is a licensed treatment for the disorder, that other doctors would prescribe that drug anyway and no more harm is likely to happen to the patient than if other drugs had been prescribed.However, the main factor affecting treatment decisions is the payment received from the drug company rather than the well-being of the patient.A core feature of the relationship between doctors and patients is trust (Green & Bloch, 2001): patients entrust their well-being to doctors who in turn are expected to Vassilas and Mathews Pharmaceutical sponsorship of educational events Box 1.The four ethical principles of Beauchamp and Childress (2001) .Respect for autonomy -we should respect the rights of others to make their own decisions.
. Beneficence -we should do good for our patients.
. Non-maleficence -we should do no harm.
. Justice -doctors should act fairly.
act for their benefit.It is clear that this latter principle is being breached and would be recognised as such by both doctors and patients as being unethical.Any beneficence that results for the patients is merely an incidental effect and there is a risk of maleficence.This behaviour would be considered illegal in most Western countries, including the UK, although it does occur (Burgermeister, 2004).
In Scenario 2, the arguments supporting this behaviour might be that the doctor is simply accepting money from the drug company to compensate him or her for their time in going to the educational event.There is no explicit agreement to prescribe and even if there were, the same arguments in support of Scenario 1 would apply.However, the sum of money involved is such that the perception of others would be that fidelity to the patient is compromised in exactly the same way as in the first scenario.
In Scenario 3, doctors may believe these events benefit them and their patients because they are educational and that the sponsorship enables them to attend talks that they would not otherwise be able to hear.Few trusts would fund doctors to go to international conferences, such as those held by the American Psychiatric Association (APA).However, as reported by Baird in this issue (pp.161^162) pharmaceutical companies have sponsored UK psychiatrists to attend the annual meeting of the APA for many years.Doctors may believe they are able to come to balanced decisions and that the events contribute to their continuing medical education.
Relationships between pharmaceutical companies and doctors in the UK are governed by a code of practice (Association of the British Pharmaceutical Industry, 2001), which is reflected in the guideline on the website of our own College (Royal College of Psychiatrists, 2003).This states that the level of hospitality provided at meetings must be 'appropriate and not out of proportion to the occasion' and costs 'must not exceed that level which the recipients would normally adopt when paying for themselves'.We would argue that the level of hospitality provided at international meetings in Scenario 3 does not comply with the spirit of these guidelines.
The association between the receipt of hospitality from a pharmaceutical company and the prescription of their drugs may not be as direct as in Scenarios 1 and 2. However, drugs may be prescribed for reasons other than best clinical indications.Doctors who attend courses sponsored by a particular company are more likely to preferentially prescribe that company's product after the event (Bowman & Pearle, 1988).Despite physicians believing that attending sponsored conferences has no effect on their prescribing, this is contradicted by the evidence (Orlowski & Wateska, 1992).
Doctors are influenced by many sources but they are expected to evaluate opinions and evidence and arrive at decisions that provide the best care for their patients.By attending sponsored events they are allowing drug companies to exert undue influence.Again, a failure of fidelity towards their patients arises and a breach of the ethical principles.

Hospitality
What harm could there be from the scenario we gave in the introduction to this article?Sponsorship of hospital educational events does not breach guidelines, the food and token gifts encourage doctors to attend educational meetings.The provision of sandwiches saves time for busy clinicians.Pharmaceutical companies could be seen as supporting education in a way that is not always done by NHS trusts.As the monetary value of the gifts offered is small, less than »6 (Association of the British Pharmaceutical Industry, 2001), they may be perceived as being insufficient to exert any influence.However, the social obligations that result from receiving even small gifts are immensely powerful.The marketing departments of pharmaceutical companies take advantage of these obligations in selling their products (Cialdini, 2001).Similarly, providing food seems to have a marked effect on making individuals receptive to information (Janis et al, 1965).Pharmaceutical representatives set up a relationship encouraging doctors to reciprocate.This may lead to changes in prescribing that compromise fidelity to patients in a way that is analogous to the situations in the above scenarios.
Professionals, such as doctors, should agree to moral standards that oblige them to place the good of those they serve above their own self-interest (Pellegrino, 1983).We know that the public has concerns about psychiatrists' relationships with pharmaceutical firms (Shooter, 2005).There is a view that routine acceptance of small gifts and hospitality will influence prescribing which may not benefit, and may even harm, patients (Mainous et al, 1995;Gibbons et al, 1998).

What is the way forward?
The majority of physicians see pharmaceutical company representatives and attend company sponsored medical education sessions (Lexchin, 1993).Although the pharmaceutical industry has contributed greatly to the improvements in health and life expectancy (Abbasi & Smith, 2003), the interests of physicians and pharmaceutical companies do not always coincide.Involvement of the pharmaceutical industry with medical education, even at the very low level of providing lunch for an educational programme, may result in a breach of ethical principles.Our own College has begun to address this issue (Shooter, 2005).Within individual trusts, the starting point must be to develop clear guidelines for the relationship between all staff and commercial organisations.At least one medical school in the USA has started a programme that helps residents to deal with drug company representatives (Watkins & Kimberly, 2004).Waud (1992) argued that drug companies should not subsidise education in any form, using as his guiding ethical principle the Hippocratic oath, 'In every house where I come I will enter only for the good of my patients'.