Should Consumers Trust Big Pharma?

Lots of people don’t trust Big Pharma. And to a significant extent, that’s for good reasons. (I’ve blogged about some of those reasons here, here, here, here, here, here, here and here, just to cite a few examples. See also some of the entries on the other blog I co-author, the Research Ethics Blog.)

Trust in big pharma is an important issue. Pharmaceuticals are responsible for saving and improving a huge number of lives. Vaccines alone have prevented literally millions of deaths. Survival rates for many cancers are better than they used to be. And AIDS, once a death sentence, is now regarded as a chronic disease. So there’s real benefit from pharma, but also an undeniable track record of scandals and general unethical behaviour. What should we think?

The first thing worth noting is that the question in the title above is vastly oversimplified. The question isn’t “should consumers trust big pharma?”, it’s more like “To what extent, and under what circumstances, on what issues, should consumers trust big pharma?”

Setting aside the industry’s spotty track record, the main reason people tend not to think Big Pharma trustworthy is, of course, the fact that Big Pharma consists of profit-oriented organizations. And the general assumption is that money corrupts. Of course, money isn’t the only thing that corrupts judgment (so does love, reputation, ideology, etc etc), and big pharma is far from the only industry where big money is at stake. But still, there’s a real worry here (one I’ve blogged about before).

Now, what about the reasons in favour of trusting Big Pharma? What factors would tend to make Big Pharma trustworthy, to at least some extent?

Now I cannot emphasize this strongly enough: what follows is not intended to imply a general conclusion about the trustworthiness of Big Pharma. It’s just a list of important factors to keep in mind when assessing the trustworthiness of a particular claim, by a particular company, on a particular issue.

1) Ethics. Don’t just think about the organizations; think about the people who work at them. They’re mostly people like you & me. Most of them got into the business to try to help people (and, yeah, to make a living). And most of them were raised by their parents to be decent, honest folks. Most people tell the truth about most things most of the time.

2) Regulation. The pharmaceutical industry is heavily regulated, subject to lots of laws regarding the efficacy and safety of their products, as well as regarding advertising. Criminal and civil sanctions are possible when pharma companies misbehave. Now, that’s not to say that the current level of regulation is sufficient, or that enforcement is adequate. But companies (and individuals) have been subject to serious sanctions. Companies generally want to stay out of court, and so they’ve got a reason — not always a sufficient reason, but a reason — to behave in a trustworthy manner.

3) Peer Review. In few other industries is fundamental information about what makes your product work (or not work) open to public scrutiny. In order for a new drug to receive approval to be marketed, it has to show itself to be safe and effective in clinical trials, and the results and methods of those trials have to be published in peer-reviewed medical journals. Drug companies are not allowed to make claims based on secret data. “Peer reviewed” means that the articles reporting on the trials have to be vetted by a panel of qualified experts if they are ever going to see the light of day. It’s an imperfect system (all systems relying on human judgment are) but bad science tends to get weeded out pretty quickly. Then, once a study is published, it’s there for assessment, and potentially criticism and rebuttal, by hundreds or thousands of other experts.

4) Scientific Overlap. You sometimes hear it implied that physician-researchers (the ones who do most clinical research, as well as doing all that peer reviewing mentioned above) have all been corrupted by corporate money. And it’s true that there really is cause for worry here. Too many docs get too much money (and other perks) from pharma, and are insufficiently transparent about that. So: it’s good to worry…up to a point. Here’s the problem with the pharma-controls-everything theory. Physician-researchers publish in scientific journals that are read not just by other physicians (some of whom don’t have industry funding), but also by biologists, chemists, epidemiologists, statisticians, and so on, most of whom have no corporate funding whatsoever. Further, modern science more generally is an enormously complex process for finding mistakes and exaggerations in each other’s research. And it helps that there’s significant overlap between the sciences, so no one group of scientists is ever truly isolated and free from scrutiny. Oversimplifying, you could say that biologists are double-checking the work done by the physicians, chemists are checking up on the biologists, and physicists are checking up on the chemists. (That’s why any physician who tries to use “quantum theory” in writing about disease had better be careful: there are armies of physicists waiting to explain just how irrelevant quantum mechanics is to human physiology.)

5) Competition. People often talk about Big Pharma as if it’s a monolith, one big organization, rather than a bunch of companies with divergent interests competing savagely with each other. That competition gives them every reason to attack each other’s weaknesses, and to point them out to the public. Add to that the fact that there are hundreds of smaller firms nipping at the heels of the big players. It’s far from a cozy conspiracy. This vicious competition of course means that there’s sometimes an incentive to cut corners in unscrupulous ways; but it also means that when you cut a corner, there’s always someone out there ready to point it out.

Now, again, this list is not supposed to lead to any particular conclusion about just how trustworthy Big Pharma is. It’s just a list of social and institutional mechanisms we need to take into consideration, in addition to the obvious bad track record and obvious financial incentives. Each of those mechanisms will apply to a greater or lesser degree with regard to specific situations. For particular issues, we need to think carefully both about what’s at stake, and about whether the above factors are likely to be sufficient to reassure us.

——
Late-breaking Note:

I’ve been getting (and rejecting) comments full of unsubstantiated, and in some cases very dangerous, claims on some topics related to the above. When it comes to matters of health, if you’re not going to cite reliable sources, I cannot take responsibility for allowing your comments on here. There’s too much at stake, in terms of public health.

9 comments so far

  1. skipper on

    Dear Chris;

    Having worked in big pharma for over 15 years, I understand the point you are trying to make. For the most part, the people who work at a big pharma corporation, are just like you and me. Unfortunately, they do as they are told for fear of losing that job. I was repeatedly asked to promote off label, and get the business. Most of these companies are willing to risk a FDA slap on the wrist because the sales will far outweigh the fine.
    I have been out of the biz for 4 years – and I haven’t looked back…

  2. jmurray21cfr on

    Chris,

    A good start. I think you’re right when you’ve injected the post with the caveat of potential oversimplification. Separation of business and medicine is inevitably impossible, and therein lies most critics’ fatal flaw. The solutions are to create systems where problems are detected, fixed and later prevented from happening again. There is a recognition in this that there will be problems, no matter what ethics or compliance systems are put in place.

    Pharma is perceived to have systemic problems and the good that it does is overshadowed by these perceived problems. Just like in sports, winning cures all ills. The allegory for pharma is that innovation cures all ills. When pharma shows a leap forward in innovation and does so in a way that is accessible and perceived affordable to patients, you’ll see a difference in the ethical perceptions. It just may be that simple.

    Also, the business model for pharma needs to find a way to use helping patients as a surrogate for business success. Today, business success is used as a surrogate for helping patients. (more sales equals more patients helped –versus–more patients helped equals more sales) That is backward, and it leads to the perception pharma is simply profiteering. When medical success is measured directly on the dollar you have an inevitable perception problem. You’re presumed to act out of financial benefit when anything goes wrong.

    This won’t be fixed any time soon. Pharma co’s are slaves to Wall Street and activist directors that want to see nothing but profits and growth or you’re out.

    If someone TRULY demonstrates a success of a forward model (measureable patient benefit is a validated business surrogate for success)then you’ll see progress.

    Also, if you could fix the flawed presumption that is a bedrock to your analysis, then we’ll make real progress.

    “And most of them were raised by their parents to be decent, honest folks.”

    I’m not sure that’s really believable. Most people I know have an underlying sense of decency and an equally strong and consistent tendency for self interest and rationalization (staying out of jail, but not staying out of trouble). That’s a whole nother story.

    John Murray

  3. Chris MacDonald on

    John:

    Thanks for the useful comments.

    With regard to my claim about individual character: I guess what I’m getting at is that the people within Pharma are just that: people. They have consciences, and pride, and hopes, and want to do well for themselves and their families. They’re like the rest of us. Yes, of course that goes along with a bunch of human weaknesses (also shared by the rest of us.) But those weaknesses are on the other side of the equation, and it’s important to note that there’s no reason to think that those always carry the day.

    Chris.

  4. Charles Green on

    All good points, and right, and relevant. However, I have to concur with the ex-pharmacy person re marketing practices.

    As a doctor once put it, “in 30 years, I never once heard any rep from any company ever recommend any drug from another company. So I don’t trust any of them.”

    He’s right. The pharmacy companies are largely hooked on the most simplistic, manipulative, zero-sum sales approaches around. Consultative selling? Needs-based selling? Listening to customers? Very little in evidence. Hence they created a situation whereby they get only 60 seconds per visit, which drives more and more canned one-sided conversations, etc.

    It is rather tragic: an industry of very smart and well meaning people, who are genuinely pained by the world’s suspicions of them. But with every revelation of a buried document coming to light, and with every hard sell interaction, they dig rhemselves deeper.

    They are already terribly constrained by lawyers at ever turn, but the paradox is: nobody will trust them until they trust their customers. Their lawyers may go batty, but I’d say the best thing they can do is mount a massive campaign of transparency.

  5. Chris MacDonald on

    Charles:

    Thanks.

    I agree with all of that. And nothing Skipper above said really contradicts anything I’ve said, either.

    Maybe my title should have been “Why We DO Trust Pharma.” Almost all of us do, at some point, put our trust in pharma, at some level. Try having a tooth extracted without trusting the makers of the drugs that kill the pain and reduce the inflammation. Most of us have relatives who are only alive because they trusted one or more pharmacological products.

    None of that is inconsistent with a deep and abiding (and healthy!) mistrust of the industry’s behaviour as a whole. But, conversely, our general mistrust of the behaviour of the industry doesn’t have to translate into an inability to trust in every product of that industry.

    Chris.

  6. sheldon101 on

    What’s sad is that distrust of drugs from Big Pharma has morphed into distrusting vaccines.

    Because when you take away all the nonsense that’s all those against vaccines have. They don’t have the research and they don’t have the experts. Don’t take vaccines because the people involved are greedy, evil and unethical.

    zz66eeaa99ww123

  7. Chris MacDonald on

    I just received (and rejected) a comment on this blog entry, one full of unsubstantiated and I think dangerous claims about healthcare.

    One of the claims made in that comment is that we ought to mistrust drug companies because “ALL of them have German-Nazi roots.”

    That’s wrong-headed in 2 different ways.

    First, the author of the comment didn’t back up his or her claim, which I believe to be false.

    Second, the argument that a company with origins in Nazi Germany ought to be mistrusted (60 years later!) is an example of what, in my Critical Thinking class, we call “the genetic fallacy.” The Genetic Fallacy consists in critiquing an idea (or in this case a company) based entirely on where it comes from.

    Note that modern rocketry, too, began in Nazi Germany. Should we give up on rockets, too?

  8. SevenCell on

    Hi Chris, Really enjoy the blog! I started traipsing by here occasionally by here occasionally a month or so ago.

    Several things Re Drug industry ethics. The current structure for drug testing/approval is a HUGE artificial barrier to new market entrants. Yes, drugs should be tested. But the testing is enormously expensive: And drug companies use that as protection and proceed to gouge (I don’t use the term lightly) with prices:

    Case in point: Biogen’s Avonex for Multiple Sclerosis
    Around 2002 the average retail was around $10,000 per year. (It was then a good bit less in 1996, but difficult to track down)

    Now they’ve got the price at over $25,000 per year and RAPIDLY climbing.

    http://www.thefreelibrary.com/Rebif+%5Bin+context%5D.-a090331484
    (scroll down to comparison of Avonex, Betaseron, Copaxone, etc)

    Fast forward to 2007:
    http://online.wsj.com/article/SB124774457299150965.html

    I’m not going to mince words. These companies are getting chronically ill (debilitatingly ill) people “hooked” on the “razor blade” and once the solution has achieved 5 to 10 years market acceptance (and already proven profits)…they’re cranking the prices WAY up so that the only hope one has of affording the drug is having insurance through a large company.

    Here is just one long-term ethical rub: and it is a problem of research. There are potential low-cost solutions that may be out there that no one will touch because the profits are too low. Naltrexone is a generic drug going back to the 80’s for addictions. Wonder of wonders, quite a few people discovered that in extremely low doses (compounding pharmacy only) these drugs might be useful for things like cancer and MS…and here is where research gets ticklish. Back in 2007 money was raised for an extremely small study for LDN and MS at Univ of Cal SF.

    http://www.ldninfo.org/research_funding.htm

    The anecdotal study was done, and Univ of Cal quietly REFUSED TO RELEASE RESULTS!….Why? Its a ridiculously small (not enough to qualify for FDA clinical). What is the harm in sharing knowledge? The truth shall set you free. What I can tell you for certain is that Univ of Cal receives massive research dollars from Pharma industry sources.

    The point here is not a beef with UCal. The point is: A hurdle of clinical trials is being leveraged by big pharma to keep out competition…and there may be good motivation to bury meaningful research from time to time. Who knows, maybe frequently.

    Also this: There is almost NO motivation for cure – Then you lose the sale of the razor blade; and the reality is every bit that cold. Sad, really.

    I believe there is also a great deal of anecdotal evidence that the Pharma is abusing phych medicines with potentially HUGE economic consequences.

    The place to poke and dig for ethics lapses in the Pharma industry? Very easy – anything involving CHRONIC illnesses. Also, anything difficult to dupe: Interferons are basically impossible to copy b/c they are highly complex molecules (thousand of atoms) that are manufactured by copyrighted/closely held bacteria strains…

    I’m putting you up as my “Blog of the Week.” (upper right, who knows maybe it will become blog of the month)

    http://sevencell.wordpress.com/

    I’m just starting the blog (3 months) and a bit of a “hack” and kind of loud-mouthed with the keyboard…I’ll pull the link if it concerns you. 😉 Keep up the great work.

    Your fan,
    SevenCell

  9. […] the bits that don’t work, and they tend to toss those out. Is there an error rate? Yes. Do pharmaceutical companies have too much influence? Certainly. Do physicians sometimes prescribe medicines that pose risks but […]


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