External influences on treatment choices
Everyday practice rarely resembles textbook medicine, and there are numerous external factors that influence medical decision making. In rural settings, practitioners may of necessity lean more heavily on psychotropic medications when other care options do not exist. In other contexts, the fact that government or commercial insurers offer limited benefit coverage may cause psychiatrists to implement care quickly and to organize treatment around only the most severe symptoms rather than optimizing all aspects of the patient’s care.
In recent years, other factors that may distort the choice of treatment have been increasingly recognized. Perhaps the most topical and controversial is the influence of the pharmaceutical industry in sculpting the practice and science of psychopharmacology, with consequences for patients, physicians, and society.22 Interactions of physicians with the pharmaceutical industry have been widely reported in the literature and lay press. Advertising, gift giving, providing incentives for the use of certain medications, and research funding have all been identified as ethically problematic.
Psychiatric educators have discussed problems that arise when commercial interests play a role in educating trainees about pharmacology and the pervasive influence of industry-sponsored faculty and research on the practice of psychiatry.23 It is becoming well-established that gifts given in the context of intensive advertising campaigns may create an unconscious bias in prescribing practices. Wazana24 analyzed more than 20 published studies and found that receipt of gifts adversely affected physicians’ prescribing behavior in several ways (eg, incorrect information about a medication, rapid application of a new drug, requests for newer medications that rarely hold an advantage over existing ones).
The scientific and ethical caliber of industry-funded research is also under scrutiny. In their pharmacoeconomic examination of published data, Baker and colleagues25 found that studies sponsored by drug manufacturers favored newer antidepressants over older antidepressants.
Conflicts of interest naturally occur in all of medicine because of the societal imperative for physicians to participate not only in patient care but also in research and as leaders and educators. These dual roles have inherent tensions that produce conflicts, because the goals of one role typically do not align exactly with the goals of the other.
Thompson26 described a conflict of interest as “a set of conditions in which professional judgment concerning a primary interest (eg, patient’s welfare) tends to be unduly influenced by a secondary interest (such as financial gain).” Thompson emphasized that it is not necessary to eliminate financial gain incentives but to prevent secondary factors from dominating the relevant primary interest in the making of professional decisions. It follows that psychiatrists who receive income from industry have, at a minimum, a potential conflict of interest in their relationship with patients and, at worst, a disruption of their ethical duty of fidelity and obligation to the primacy of patient welfare.
There have been greater efforts to explicitly manage conflicts of interest related to interactions with industry.27 Since 2004, many steps have been taken at institutional, state, and national levels to limit such relationships. Gifts and incentives physicians have received from the pharmaceutical industry have been sig-nificantly reduced.28
Excellence in psychopharmacology demands sensitivity to the associated ethical considerations. The key considerations of psychiatry are both complex and dynamic, and psychiatrists who develop and refine their ethics skill set will be in a better position to anticipate and respond to ethical dilemmas as they arise in their practice.