2023-09-04 12:32:36
At the end of June 2023, the Conference of Deans of Medicine updated their ethics and professional conduct charter. What are the main changes? Does the Charter fulfill its role? the collective for independent medical training at the service of health professionals and patients only (Formindep) draws up a mixed assessment. Here is his analysis.
The Preamble
“The document begins with a preamble, and from the first paragraph, we are entitled to a long footnote which explains to us what a conflict of interest is, how it is different from a conflict of interest and that collaboration with industry is essential. This is clearly a bad start in our opinion, and it suggests that the charter will be watered down.
As a reminder, the distinction between links and conflicts of interest is a uniquely French issue. Moreover, there is no single classification and this distinction is made in an arbitrary and fuzzy way, which makes the relevance questionable. The work of social psychology has amply demonstrated the influence that even very minimal ties might have on our perceptions and our decisions. In the case of physicians, ties of interest can result in particular in a distortion of research, diagnoses and prescriptions.
As a reminder, the analysis of around thirty scientific studies has shown that doctors receiving money from a laboratory act, consciously or unconsciously, rather in favor of this laboratory in their professional activity (1).
Transparency of links does not negate their influence, it can even reinforce it by granting them a form of legitimacy. It cannot therefore be considered as an end, but a simple tool for informing patients and citizens, promoting the independence of health professionals.
This echoes for us this passage written by Marcia Angell professor of Harvard and former editor-in-chief of the New England Journal of Medicine (emphasis added):
“Finally, physicians rarely have a legitimate reason to accept gifts from pharmaceutical companies, even small ones, and they should pay for their own meetings and continuing education.. After much backlash from the media, medical schools and professional organizations are beginning to talk regarding controlling conflicts of interest, but so far the response has been lukewarm. They systematically refer to “potential” conflicts of interest, as if they were different from reality, and to their disclosure and their “management”, not to their prohibition. In short, there seems to be a desire to eliminate the smell of corruption while keeping the money. Breaking the dependence of the medical profession on the pharmaceutical industry will require more than the creation of commissions and other posturing. It will be necessary to break abruptly with an extremely lucrative behavior. But if the medical profession does not end this corruption voluntarily, it will lose the public’s trust and the government (not just Senator Grassley) will step in and impose regulation, which no one in medicine wants. »
Alert launcher
The notion of whistleblower is introduced. The faculty undertakes to enforce the law of March 21, 2022, aimed at improving the protection of whistleblowers.
This law made it possible to create a specific status, simplified the reporting channels and provided a better level of launcher protection.
Referent to integrity
Notion introduced in the 2017 version, the mode of appointment of the integrity referent is modified. This person is appointed by the Faculty Council on the joint proposal of the Dean of the Faculty and the President of the Ethics and Scientific Integrity Commission. Previously, she was elected by her peers.
We lose the democratic aspect of the process and risk seeing people chosen for their common positions with the faculty council and the dean and a loss of independence.
Teacher neutrality
“Teachers must be neutral towards the company or institution with which they have a link.”
This wishful thinking was already part of the 2017 version, no change. However, this ignores the potential effects of the famous “links of interest”. This has been developed above in the part Preamble.
Accumulation of ancillary activities
Details are given concerning the criteria for assessing possible combinations of activities. The opinions given by the commission seem to be only advisory. “Authorization is only given for a single mission and for a maximum period of one year, renewable.” : this notion has disappeared. For what ?
Immersion training financed by a private service provider is made known: these must not give rise to remuneration and require a prior agreement. They are therefore authorized and this makes it possible to maintain a link between the private service provider (pharmaceutical or medical device industry) and the nursing staff, etc.
The following sentence has been removed: “The participation of teachers in the marketing/sales of health products is prohibited.” For what ?
The faculty ensures that external funding does not influence the independence of educational content
Funding by foundations is allowed, there has been no change since the 2017 version. We regret this because it is not detailed that faculties refuse foundations financed by the pharmaceutical industry, which does not is not uncommon.
For example, the Alzheimer Foundation finances research programs and is itself, in part, financed by the pharmaceutical industry, members of the industry are on the Board of Directors (including Servier). The Alzheimer Foundation also finances the Inter-University Diploma in Diagnosis and Management of Alzheimer’s Disease and Related Diseases (DIU MA2) at the University of Lille.
Links with treatment partners
“Marketing representatives of the pharmaceutical and health products industries (in the very broad sense) are not authorized to meet university staff in healthcare areas or in the presence of students. This implies that they cannot organize presentations there in the presence of the students.”
Excellent news ! This therefore means that students are now prohibited from attending presentations by the pharmaceutical industry. On the other hand, it remains possible for qualified caregivers.
Non-compliance with the Charter
No significant modification concerning the actions taken in the event of non-compliance with the charter. As a reminder, the faculty undertakes to alert the supervisory authorities and the professional orders concerned in the event of failure to respect the points of the Charter which are covered by a legislative or regulatory text.
There is no public record of actions taken.
Are penalties applied? And if so, are they shared?
A recent study evaluated the knowledge of the charter by students in a Parisian university. The result is simple: students know little regarding the charter and it is modestly applied. Sanctions are therefore probably not common – although they would be necessary given the results of the study. In the absence of sanction, the charter has little interest. (2)
Conclusion
The charter of independence of the faculties of medicine is evolving towards certain progress such as the prohibition to organize presentations by marketing representatives of the pharmaceutical industries to students or the integration of the law on whistleblowers. Nevertheless, these advances are not sufficient and do not go further than the expected minimum. There is still a basic problem that is obviously not understood by the deans of the faculties of medicine: all links with industrialists are sources of influence and should not be present within the faculties.
It is more than ever necessary to take strong decisions for a better independence of the medical training sector and to no longer be satisfied with highlighting the transparency of links of interest which is only an information tool and not an end in itself.
(1) Aaron P. Mitchell et al. Are Financial Payments From the Pharmaceutical Industry Associated With Physician Prescribing? A Systematic Review, Annals of Internal Medicine, 24 novembre 2020
(2)
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