No Free Lunch is an organization concerned with pharmaceutical companies and their influence on the medical profession. They believe scientific evidence, rather than industry promotion, should guide clinical practice. Most of us would agree with that. The problem, though, arises with what the blogger at Pharm Aid considers to be a paternalistic position which assumes that doctors, because they can be “bought” with a slice of pizza or a free pen, are morally bankrupt. That radical idea, proclaimed by a vocal minority, has been subject to little in the way of critical examination. Maybe that’s because its purveyors are more interested in spreading hype than examining evidence and its opponents don’t take it seriously. In any case it’s an increasingly visible public perception as illustrated by New York Times articles cited by Pharm Aid here and here.
The “paternalists”, notes Pharm Aid, argue that because doctors are morally bankrupt their judgment can’t be trusted unless they are shielded from the pharmaceutical industry. Such shielding may take the form of an institutional ban on drug company lunches or a self imposed ban such as the No Free Lunch pledge. The pledge is purported to publicly separate those doctors who base their practice on evidence from those who base it on promotion by posting a web listing of doctors who signed on. It’s as if the true test of evidence based medicine is whether or not a doctor takes the pledge. Absurd though the notion seems there’s been little effort to challenge it.
The web listing of No Free Lunch pledge adherents has yet to appear on line despite having been promised on the site for several years. One wonders if more than a small handful of doctors has taken the pledge. Indeed on close examination very few practicing physicians, at least in the United States, could honestly sign the pledge because of this requirement: “to avoid conflicts of interest in my practice….” That pretty well disqualifies most doctors who practice medicine for a living. Depending on our compensation model most of us practice under either positive or negative financial incentives. These incentives influence the types and numbers of patients we see, the procedures we do, the tests we order and our referral patterns. Compared to the measly drug company pens, note pads and lunches these conflicts are much more powerful. They’re about real money and they impact each and every patient encounter.
Conflicts of interest are pervasive in medical practice and take many forms. Those inherent in doctors’ interactions with drug companies are small in the grand scope of things. If the paternalists are really interested in conflicts that matter why do they focus selectively on the pharmaceutical companies?
Regarding No Free Lunch, Pharm Aid writes: “This organization urges physicians to avoid any interaction with pharmaceutical companies, including pens, lunches, etc. However, their disdain of drug companies doesn’t seem to apply to anyone else (including insurance companies) trying to influence their physician’s prescribing patterns, the diagnostic tests they order and the medical procedures they perform.”
Are we morally bankrupt as a profession? Perhaps. And if we think holding ourselves at arms length from the pharmaceutical companies will cure our moral turpitude we are also profoundly self-deceptive.