On the Take propounds relentlessly the core theme that many doctors, to the not infrequent disadvantage of patients, drink from the oftentimes ethically unwholesome trough of financially conflicted monies flowing from industry.  The author, Dr. Jerome P. Kassirer, is a Distinguished Professor at Tufts University School of Medicine as well as an Adjunct Professor of Medicine and Bioethics at Case Western Reserve University.  Additionally, for more than eight years,

Kassirer was Editor-in-Chief of the New England Journal of Medicine.  With regard to widely ranging financial conflicts of interest encumbering doctors in their many dealings with the pharmaceutical, biotechnology, and device industries, the resultant din and clamor of a multitude of ethics related improprieties, recounted soberingly by Kassirer, resounds alarmingly through the textual body.  Indeed, ethically troubling financial conflicts of interest interconnecting doctors and industry are a veritable raging river, flowing in torrential fashion into a seemingly fathomless ocean of ethical malfeasance.  Robust debate, at public and professional levels, accompanied by full transparency, are prescribed by Kassirer as antidotes for ethically poisoned, financial conflicts of interest affecting doctors on the take.

The book, structurally, is configured into ten chapters.  Preceding the chapters is an "introduction", in which Kassirer, exhibiting refreshing candor, explains pithily how a perceived expanding cascade of ethics concerns impinging deleteriously on the medical profession fueled a burning desire to write the book.  After the chapters, there are fairly copious "Notes", in the form of citations to academic as well as non-academic references.  The prospective reader importantly should understand that many of the bricks used, by Kassirer, to construct the textual edifice are derived from the straw of anecdotal matter.

Throughout the length and breadth of this sorely candid book, Kassirer administers a sound thrashing to many of his medical colleagues.  But, in Kassirer's judgment, the use of considerable intellectual force is warranted; given the gravity of perceived ethical offenses, mere jostling is insufficiently forceful.  For all those interested in preserving the ethical integrity of the American healthcare system, the book admirably rivets rapt, and much needed, attention on financial conflicts of interest, joining doctors and industry, which may have adverse ethical ramifications.  In describing rather plaintively the suffering ethical condition of the U.S. health system, Kassirer is able to draw instructively on very considerable expertise gleaned from his disparate roles as a medical researcher, academic professor, clinical practitioner, and journal editor.  Kassirer's variant hands on medical experiences, blunt gloves off stylistic approach, and frequent use of anecdotally described and substantively empowering details drawn from real life combine synergistically to show an expansively revealing vista of the financial and ethics strata of the American medical profession.

Commencing with the first chapter, Kassirer doughtily plunges deeply into the ethically challenged waters of American medicine.  The thematic emphasis, of Chapter One, is that many doctors have been compromised by ethically tainted financial dealings with industry.  As described by Kassirer, there is a great inflow of money into the medical profession from industry, especially from pharmaceutical companies.  The massive tidal wave of industry money, further, has spawned pervasive financial conflicts of interest, which often have insidious ethics related consequences detrimental to clinical care and also to medical research.

As Kassirer explicates insightfully, in Chapter One, when industry gives "gifts" to doctors (such as:  pens, notepads, books, food, tickets to sporting events, invitations to resorts, drug samples, and concert invitations, to name a few), the gifted doctors, in consequence, become enmeshed in  financial conflicts of interest which may, as well, have untoward ethics consequences.  For instance, industry gifts to doctors may influence improperly the prescribing habits of gifted doctors in ways disadvantageous to patients, thus negatively impacting clinical care.  If industry gifts to medial researchers perversely influence the research and writings of the gifted researchers, then the foundation of ethics underpinning medical research may be undermined also.

As noted by Kassirer, in Chapter Four, many doctors believe sincerely, if naively, that they can reliably separate the chaff, of industry marketing hype, from the unadulterated grain of scientific fact.  But the discerning conclusion of Kassirer is that doctors, in part for psychologically-related reasons, may be far more influenced by gifts from industry than they realize.  A further sobering conclusion proffered by Kassirer, in Chapter Five, is that biased information may infiltrate the ranks of medical information.  As analyzed perspicaciously by Kassirer, financial arrangements with industry may, in ethically improper manner, influence what some medical authors pen in their writings, thus casting a pall of questionable veracity over some of the information published in medical journals, books, and "educational" materials.

Ethically tainted financial arrangements with industry, in the view of Kassirer, affect not only individual clinicians and researchers but medical organizations as well.  In Chapter Six, Kassirer assembles a mass of anecdotal information in  dispiriting support of the critical view that sundry medical organizations, by virtue of nettlesome financial arrangements with big business interests, have degraded themselves by, in essence, engaging in hucksterism.

In Chapter Nine, Kassirer muses pensively on the perceived uprooting of medicine's traditional deeply implanted altruistic roots by the determined, and rapacious, hands of money centric concerns.  The envisaged erosion of medicine's historic altruism by unabashedly entrepreneurial market forces, in Kassirer's judgment, has impacted the medical profession significantly.  In concluding Chapter Ten, Kassirer ruminates thoughtfully on possible real life antidotes to ethically contaminated financial arrangements tethering medicine to industry.

Critics may carp that the picture Kassirer has painted of on the take doctors working in partnership with big business interests is unflattering to a degree that is tantamount arguably to misleading caricaturing.  To some at least, the authenticity of Kassirer's painting may further be questionable because of the extensive use of anecdotally based paint.  With regard to such concerns, the arguable polemicism of the book may have been mitigated if the book had been structured as a collection of papers contributed by authors drawn from widely differing professional backgrounds, including contributors anchored securely to the business world.

In another vein, a philosophic minded critic may ponder that, all humans to some degree harbor innate greediness, and that this inborn behavioral demon cannot be exorcised readily.  Given this ineluctable truth affecting human nature, the real lesson to be learned ultimately from the assemblage of slightly lurid anecdotes marshaled by Kassirer is that America's willingness to tolerate an entrepreneurial, money driven model for healthcare, from the perspective of fostering ethical wholesomeness, is frightfully unwise.

All healthcare professionals, including clinicians, researchers, and persons connected in some professional capacity to the pharmaceutical, biotechnology, and device industries, as well as bioethicists, health policy makers, lawmakers, philosophers, and sociologists should be enthrallingly edified by Kassirer's insightfulness and informativeness encased solidly in bluntness.

© 2007 Leo Uzych

Leo Uzych (based in Wallingford, PA) earned a law degree, from Temple University; and a master of public health degree, from Columbia University.  His area of special professional interest is healthcare.

Categories: Ethics