Pharmacists, Ethics, Professional Integrity, and Conflicts of Interest

‘It is difficult to get a man to understand something when his salary depends upon him not understanding it.’ -Upton Sinclair (1878–1968)

Facilitator: Dr. Peter Loewen | Assistant Professor | UBC Faculty of Pharmaceutical Sciences | Clinical Pharmacy Specialist, Vancouver General Hospital

Background

By virtue of their specialized knowledge and skills, pharmacists are in a privileged position to make decisions which affect the health of other people. Patients, therefore, expect that pharmacists’ decisions are based primarily on what is in their best interests. In our complex healthcare environment, pharmacists have the opportunity to form many different kinds of professional and personal relationships with a wide variety of people. Each of these relationships has the potential to positively or negatively affect the professional integrity of the pharmacist involved. As such, pharmacists who are interested in maintaining a high degree of professional integrity are well served by appreciating the implications of each relationship from this viewpoint.

Objectives

After the session and upon personal reflection, participants should be able to

  • Articulate a personal vision for what professional integrity means to them
  • Weigh the benefits and risks of entering relationships which may have implications for their professional integrity.

Preparation

Read, think about, and come prepared to talk about the following:

Useful Concepts

Then…

Read and reflect on the first 6 scenarios below from the viewpoint of What are the ethical, professional integrity and/or potential conflict of interest issues here?

During our PHRM 231 session, you will work in a group to address one or more of these scenarios, commenting on:
  • What are the ethical, professional integrity and/or potential conflict of interest issues here?
  • If it’s possible, how do you think the situation could be managed?

Scenarios

Scenario 1 - Group 1

You attend a small-group industry-sponsored dinner/talk at Chambar, and receive a token gift of a Cross pen emblazoned with Effient®.
 You were invited because you are considered to be a local opinion leader. You carry this pen on rounds the next day.

Scenario 2 - Group 2

You are at a conference. The registration was paid for by your institution’s education fund, and you are planning on paying for your hotel. When you go to check out on the last day, the hotel informs you that your bill has already been paid for. When you ask for details, the hotel gives you the name of a pharmaceutical rep you have met with several times as the owner of the credit card who paid.

Scenario 3 - Group 3

While in patient care rounds, discussion ensues regarding a difficult therapeutic issue. You haven’t read any recent literature on this topic, however you did attend an “educational dinner cruise” last night at which this was discussed. You provide a drug recommendation based upon your recollection of last night’s discussions. While the drug isn’t on formulary, you assure the team that you will be able to arrange to bring supplies in.

Scenario 4 - Group 4

While in a community pharmacy, a visit from an OTC drug rep brings in samples for Aerius – which I give to my allergy prone, impoverished university student brother. I have notified him that all non-sedating antihistamines are the same and that these are only free because the drug rep was feeling generous toward me.

Scenario 5 - Group 5

In trying to make a treatment decision for a patient with CAP, you decide that several antibiotics are viable (and have equivalent efficacy/safety). You seek, therefore, to use the least costly one. You notice that the costs of all but two are displayed in your pocket formulary. Upon inquiring with your director about the costs of the other two, you’re told that, “that information is confidential, per the contract we signed with the manufacturers.”

Scenario 6 - Group 6

You are a PharmD working for a drug company. You are responsible for the development of educational/promotional material for a new drug. In your review of the literature you notice flaws in the studies and you are not convinced that your drug did show an advantage over the comparator. Meanwhile, your performance evaluation is coming up. You are the sole source of income for your family.


More Scenarios

Scenario 7

You’re a clinical pharmacist just assigned to work in the new “CV Risk Reduction Clinic” at your institution. You’re aware that the clinic is funded through an “unrestricted grant” from the makers of perindopril. In return, perindopril was added to the instutution’s formulary.

Scenario 8

You are visiting your grandmother at the hospital. She was admitted yesterday for management of myocardial infarction including coronary artery stenting. You sneak a peek at her chart when no one is around, and notice that she is on ASA, clopidogrel, metoprolol, ramipril, simvastatin and warfarin. She is on warfarin for hypomotility of the left ventricle. These medications look appropriate to you, except that she is not on a heparin (the warfarin can’t possibly be therapeutic yet). Armed with this information, you confront the cardiology resident about the absence of heparin from her medication regimen.

Scenario 9

You’re chair of a provincial drug benefits committee, composed of a lay-member plus a bunch of clinicians, researchers, lawyer, etc. At this week’s meeting while reviewing an expensive MS drug for coverage status, the person beside you whispers that they know the lay member’s wife has severe MS.

Scenario 10

You’re looking forward to speaking at a pharmacists CE conference next month. The conference is sponsored in the usual way by industry money laundered through a university’s CE division. The conference organizer asks whether you’d mind if your talk about statins was shown on the program as “supported by an unrestricted educational grant from Pfizer” (maker of one of several statins available).

Scenario 11

Your hospital pharmacist colleague tells you that he has a “side consulting business” where he takes fees from drug manufacturers to counsel them on the processes involved and gives tips for getting their drugs favourably reviewed and approved by regional, provincial, and national formulary committees.

Scenario 12

As the CCU pharmacist, you are invited by Ipsos Reid (contracted by the manufacturers of a new CHF drug) to their offices to participate in an informal focus group. These questions would relate to your opinions about ‘approaches to managing CHF’. It may also involve discussion of the barriers that would may impede formulary approval of the drug at a hypothetical hospital. In return for your time, you would be provided with a $1000 honorarium for your valuable time and a complementary meal during the question period.

Scenario 13

You have acted as a principal investigator for an industry-sponsored bioequivalence trial. Preliminary results do not favour the sponsor’s drug. The sponsor isn’t happy. They inform you that they now believe the study methodology was flawed and do not wish the data to be published. They also inform you that you will receive the full grant funds promised.

Scenario 14

You are an attractive young female PharmD on the Drugs and Therapeutics committee at your hospital. A new antibiotic is being considered for formulary status and you have been asked to provide the committee with an evidence-based review of the drug. The sales rep for this particular antibiotic happens to be an attractive young male and when you meet to ask for information the two of you hit it off and he asks you out. You have dinner in Yaletown and then watch America’s Next Top Model at his place.

Scenario 15

A manufacturer that you have been doing business with on infusion pumps invites you to a users group meeting in which all expenses are paid but no honorarium. Smart infusion pumps are used in about 50% of your hospital at the current time.

Scenario 16

A pharmacy faculty is considering creating a white coat ceremony for their incoming students. A pharmaceutical manufacturer has been asked to and has agreed to cover the costs of the purchase of the white coats on the condition that the company’s logo and/or one of their products be embroidered on the coats. The faculty is discussing whether this should occur. As a student representative on the Faculty Advisory Committee, what is your position?


Bottom Lines

  1. What value you place on maintaining your professional INTEGRITY and the TRUST of your patients/colleagues.
  2. LEARN about the sometimes-unforseen consequences of certain courses of action you take, so they’re no longer unforseen.
  3. WEIGH the pros and cons of each relationship/situation. Don’t just REACT to things reflexively.
  4. Think of COI as merely a part of the broader issue of BIAS, and bias as part of the broader issue of INTEGRITY.
  5. Only presume there’s a CONFLICT when the sway in judgment that’s involved is such that it’s a COMPROMISE in judgment.

Resources and Further Reading