A reply to Thomas Stossel on the AMA-CEJA draft report.

In his commentary on the recently released Council on Ethical and Judicial Affairs, American Medical Association (AMA-CEJA) draft report on industry support for professional education, Dr. Stossel raises several issues worthy of comment[1]: The risk-benefit ratio of commerce in medicine The definition of “professionalism” and its relation to commerce The nature and management of conflict of interest in medicine Risk-Benefit Ratio In the present commentary as well as in previous work,[2,3] Dr. Stossel has generally expressed surprise and dismay that anyone could imagine that commercial influence in medicine has had any negative consequences. From his vantage point, commerce is an unalloyed good. No physician today can manufacture drugs the way our forebears could go off into the woods and collect baskets of herbs. Without commerce, the treatments that prolong lives and improve health today would be impossible. Dr. Stossel has suggested that those of us unable to perceive this obvious truth must be blinded by the envy of our colleagues who have invented useful new treatments, collected royalties and other due rewards, and therefore are richer than we are.[3] Dr. Stossel accuses his interlocutors of selective review of the evidence and of citing only those sources that agree with their biases. Dr. Stossel notes that his opponents often cite books, and that is because it usually requires a book-length analysis to discuss all the evidence in any detail.[4–8] My own impression is that on balance, those arguing against the dangers of commercial influence in medicine are more nuanced and balanced in the evidence that they address. None of them are luddites wishing to sever all ties between medicine and industry, and none deny that industry today produces many useful drugs and devices. By contrast, Dr. Stossel seldom cites evidence such as that provided by Turner and colleagues,[9] showing a systematic bias in the way that trials of newer antidepressants have been reported in the published literature, to such a serious extent that any recommendation to use these drugs routinely in the management of depression must be called into question. If one were only to read Dr. Stossel's papers, incidents like the concealment of the cardiovascular risks of rofecoxib (Vioxx) never occurred, or else they are the work of a small number of bad apples rather than the routine way today's pharmaceutical industry appears to do business.[7]