Marketing Rx&D: one step forward, two steps back

The Mar. 18 edition of CMAJ contained two somewhat extraordinary documents related to Rx&D, the umbrella group for “Canada's Research-Based Pharmaceutical Industry.” The first,¹ an “Announcement” of recent changes to the Rx&D Code of Marketing Practice,² is co-signed by the presidents of Rx&D, the College of Family Physicians of Canada, the Royal College of Physicians and Surgeons of Canada and the CMA. The second, a “Message” to doctors about the announcement, is signed by the CMA's president.³

The impression created by these documents is that, in consequence of recent discussions among the four organizations, Rx&D has brought its marketing code into greater conformity with the CMA policy on physicians and the pharmaceutical industry.⁴ The publication of a joint communiqué from professional medical organizations and Rx&D is quite unusual, if not unprecedented. The ostensible purpose is to announce good news: “I am pleased,” Dana Hanson writes, “that Rx&D has agreed to harmonize its code with the CMA policy on one of the points of disagreement.”³

This matter is of no small importance: the CMA policy is a key component in the accreditation of continuing medical education in Canada, which is heavily funded by industry. In the past year, industry funding of CME has come under increased public scrutiny, as reflected by an exposé on CTV's W-FIVE⁵ and in various news and opinion pieces critical of physicians being funded by the pharmaceutical industry to attend CME events. The CMA policy has been quite principled and prohibitive with regard to such practices. A move on the part of Rx&D toward harmony with that policy should indeed count as progress and as something the profession might announce with pride. But, in fact, recent changes to the Rx&D code do not amount to a net gain in ethical practice; they take one step forward and two steps back.

The CMA policy specifically disallows pharmaceutical industry funding for physicians to attend CME events unless they are faculty or organizers. Item 24 states, “the industry sponsor should not pay for travel or lodging costs or for other personal expenses of physicians attending a CME/CPD event.”⁴ This prohibition, like others in the CMA policy, is grounded in the common-sense wisdom that he who pays the piper calls the tune. It seeks to preserve the physician's independence by constraining the payer's ability to exert undue influence. Although many physicians do not believe they are susceptible to industry influence, common sense and evidence⁶ suggest otherwise.

Beginning in 1997, the Rx&D code contained a provision (4A.3.5) that allowed industry funding of specialists to attend CME events in Canada. This was inconsistent with the CMA policy, and therefore as a matter of principle was the subject of dispute with Rx&D. In January 2003 Rx&D removed this provision, and this, taken by itself, could indeed be described as a step toward “harmonization.” However, what is not stated in Rx&D's announcement and is understated in the CMA's message, is the effect of a new provision (4B) added by Rx&D to its marketing code in June 2002. This “exception,” as glossed by the CMA president, “allows industry funding of some physicians attending CME events held outside Canada if certain conditions are met.”³

If one puts the pieces together, the following picture emerges: whereas previously only specialists were eligible for funding, now any physician is; whereas previously this largesse was available only in Canada, now it is available only outside of Canada. The provision added last June does impose “conditions” (e.g., the sponsored physician must write a report), but these are not likely to amount to much of an impediment and in any event do not mitigate the violation of the principle. With respect to the issue of principle this is, to say the least, very odd. The net effect of these changes is not greater but lesser “harmony” with the letter and spirit of the CMA policy. In fact, in consequence of the new provision, Rx&D claims even greater license to fund nonfaculty to attend CME events than it had before the discussions with the professional associations began!

The influence of the pharmaceutical industry over physicians is a matter of serious concern that goes to the heart of professional ethics. There are few areas in which careful ethical oversight is more important and needed. The CMA policy on physicians and the pharmaceutical industry has been the flagship of the CMA's work in professional ethics and, historically, its Committee on Ethics has been closely involved and vigilant as concerns the issue at stake here.

The two documents refer to ongoing discussions between Rx&D and the professional organizations. There is reason to be concerned about who is leading in this dance and who is following, about who is influencing and who is being influenced. The heralded changes, it must be noted, were taken by Rx&D while discussions were in progress with the professional associations. Why, as seems apparent, were the associations either unable or unwilling to dissuade Rx&D from altering their policy in June 2002?

Anyone who supports the existing CMA policy should be apprehensive about what new agreements will count as “progress” in the future. The CMA president indicates that the Committee on Ethics has been asked to “undertake another review [of the CMA policy] to ensure that it is up-to-date and reasonable.” Judging from the direction of influence discernable in the announcements made so far, it seems more likely that the CMA policy will be brought into conformity with the Rx&D marketing code (“updated” and made more “reasonable”) than vice versa.

β See related articles pages 1274 and 1275