Commercialism on the rise, again

EDITORIAL

Commercialism on the rise, againDavid L. Turpin, Editor-in-Chief

In March 2006, the American Dental Association(ADA) and the American College of Dentistscosponsored an ethics summit on commercialism

in dentistry. In his introductory remarks, David Cham-bers1 noted that commercialism is a major issue facingthe profession of dentistry. He defined commercialismas “attitudes or methods that excessively emphasizeprofit or business success.” Throughout the summit,much emphasis was placed on the fact that the successof the profession is built on public trust, and anythingthat could erode this trust is harmful. (To read the entirereport, go to www.dentaleditors.org.)

Financial conflicts of interest played a major role inthe formative years of organized orthodontics. EdwardH. Angle was heavily involved in developing patentsfor new appliances, while at the same time starting newschools and publishing textbooks—all commercial ac-tivities from which he received substantial remunera-tion.2 He lived in the age of the ”expert,” and the pushto succeed financially was strong throughout the earlypart of the 20th century.

But questionable historical practices are no reasonto turn a blind eye to the injurious effects that commer-cialism can have on our delivery of patient care today.I believe we need to draw a line in the sand beyondwhich we, as universities and professional associations,do not go. We don’t have to look beyond the dailynewspaper to see physicians behaving badly. The NewYork Times recently reported on payments made tophysicians in Minnesota by pharmaceutical compa-nies.3 Records showed that most of the doctors receivedmoney for delivering lectures about drugs to otherdoctors. The doctors who received the most moneyeven sat on committees that prepare guidelines instruct-ing physicians nationwide when to prescribe thesemedicines. At first glance, you might ask, “What’swrong with this alliance if it benefits everyone in-volved? It could be a win-win.”

But doctors who have close relationships with drugmakers tend to prescribe more, newer, and pricierdrugs—whether or not they are in the patients’ bestinterest. In addition, doctors in Minnesota said they

Am J Orthod Dentofacial Orthop 2007;132:1-20889-5406/$32.00Copyright © 2007 by the American Association of Orthodontists.

generally did not tell their patients about these arrange-ments. And what did their patients think? Polls laterfound that 85% of the respondents thought it “notacceptable” for their doctors to be paid by drug com-panies to comment on prescription drugs. Eighty-fivepercent also said that such payments would influencethe doctors’ decisions about patient care. The lecturingby those receiving funds from pharmaceutical compa-nies is even more disturbing. According to the Times,“Doctors said that lectures were highly educational, andthat drug makers hired them for their medical expertiseand speaking skills. But former drug company salesrepresentatives said they hired doctors as speakersmostly in hope of influencing that doctor’s prescribinghabits.”3

There is even more to be embarrassed about whenexamining how guidelines were developed for the useof medications. According to the Times article, “Asurvey found that more than 80% of the doctors onpanels that write clinical practice guidelines had finan-cial ties to drug makers.”3 This is a task that requiresabsolute impartiality when the individual decisions ofthese ”experts” play such a critical role in the deliveryof health care.

It is one thing to find fault with a group ofphysicians in Minnesota, but quite another to look atourselves. We don’t need to worry about the pharma-ceutical industry throwing money our way, but thereare an increasing number of newly empowered com-mercial entities seeking to influence the delivery oforthodontic care. As a clinician myself for over 38years, I can see many benefits from changes in the wayorthodontic treatment is being delivered to nearly 5million people in the United States today. If this is thecase, why do I ask for a line in the sand? I believeconcerns exist in several areas.

PROPER DISCLOSURE OF RESEARCH FUNDINGWHEN RESULTS ARE PUBLISHED

Contracts have been written in the past betweencompanies and researchers that prohibit the publicationof negative results without the permission of all partiesinvolved. This practice puts undue pressure on theresearcher and is considered unethical in most circles.

1

American Journal of Orthodontics and Dentofacial OrthopedicsJuly 2007

2 Editorial

clear when the results of a research study are published.This line in the sand has been around a while but needsenforcement.

UNIFORM ENFORCEMENT OF ADVERTISINGSTANDARDS BASED ON EVIDENCE

As competition increases, many commercial com-panies seem to feel increased pressure to stretch thetruth when advertising. As the pressure grows, the“puffery” in these ads expands until the messagebecomes unbelievable. Every year, the American As-sociation of Orthodontists (AAO) appoints a boardcommittee that is challenged to differentiate betweenwhat is “puffery” and what is simply untrue. Althougha company might say that its new widget makes lifemore enjoyable, we will not allow it to say that itswidget moves teeth faster than another widget withoutscientific proof. Proof consists of 2 acceptable researcharticles published in a refereed journal. The AAO andthe ADA have both drawn lines in the sand withspecific advertising guidelines, but this position de-pends on continued public support.

STANDARDS FOR CONTINUING EDUCATIONPROVIDED BY UNIVERSITIES, PROFESSIONALASSOCIATIONS, AND COMMERCIAL ENTITIES

When the education of our membership is con-cerned, responsibility for evaluating content resides

financial conflicts of interest must be made in everycase. If someone is lecturing on a topic that has beenaround a while, the appropriate evidence can be locatedand referred to in the literature. If the evidence is nothigh, that can also be made known. But if the topic isdirectly related to a new product or technique that hasnot been on the market long enough to be tested, thenthe lecturer has an even greater responsibility to dis-close any conflicts of interest. Where would you drawthe line in the sand for this topic? When it comes to arelationship between the speaker and the company thatproduces the product, this conflict of interest must bemade very clear to the audience. Where would youdraw a line in the sand?

Please let me know whether you see increasedcommercialism as a threat to our specialty. I lookforward to your logic—but please make it clearwhether you have a financial conflict of interest. Fairenough?

REFERENCES

1. Dentaleditors.org (Internet website). Chicago: Association of DentalEditors. Ethics summit on commercialism–Chicago, February 28-March 1, 2006. Available at: www.dentaleditors.org.

2. Peck S. The world of Edward Hartley Angle, his letters, accountsand patients. 2007.E. H. Angle Education and Research Founda-tion; Vol 3, 1889-1934. Lawrence, Kan.

3. Harris G, Roberts JA . State’s files put doctors’ ties to drug makers