The New York Times

December 16, 2005

Op-Ed Columnist

Drugs, Devices and Doctors

By PAUL KRUGMAN

Merck, the pharmaceutical giant, is under siege. And one side effect of that siege is a public relations crisis for the Cleveland Clinic, a celebrated hospital and health care organization.

But the real story is bigger than either the company or the clinic. It's the story of how growing conflicts of interest may be distorting both medical research and health care in general.

Merck stands accused of playing down evidence that Vioxx, a best-selling painkiller until it was withdrawn last year, increases the risk of heart attacks. The most recent accusation of obscuring the evidence came from The New England Journal of Medicine, which discovered that the authors of a Merck-supported paper published in the journal had removed data unfavorable to Vioxx. The journal called on the authors to issue a correction.

Dr. Eric Topol, a famed cardiologist at the Cleveland Clinic, has been warning about the dangers of Vioxx since 2001. In videotaped testimony at a recent federal Vioxx trial (which ended in a mistrial), he accused Merck of scientific misconduct, and also testified that Merck's former chairman had called the chairman of the Cleveland Clinic to complain about his work - an action Dr. Topol called "repulsive."

Two days after that testimony, according to Dr. Topol, he was told early in the morning not to attend an 8 a.m. meeting of the clinic's board of governors, because the position of chief academic officer, which gave him a seat on the board, had been abolished. A clinic spokeswoman denied that the abrupt elimination of this post had any link to his Vioxx testimony.

A few days later, The Wall Street Journal reported on a web of financial connections between the Cleveland Clinic, its chief executive and AtriCure, a company selling a medical device used in a surgical procedure promoted by the clinic. Dr. Topol - whose demotion also cost him his seat on the conflict-of-interest committee - was "among those who questioned the ties," the newspaper said.

O.K., it's sounding complicated. But the essence is simple: crucial scientific research and crucial medical decisions have to be considered suspect because of financial ties among medical companies, medical researchers and health care providers.

That should come as no surprise. The past quarter-century has seen the emergence of a vast medical-industrial complex, in which doctors, hospitals and research institutions have deep financial links with drug companies and equipment makers. Conflicts of interest aren't the exception - they're the norm.

The economic logic of the medical-industrial complex is straightforward. Prescription drugs and high-technology medical devices account for a growing share of medical spending. Both are products that are expensive to develop but relatively cheap to make. So the profit from each additional unit sold is large, giving their makers a strong incentive to do whatever it takes to persuade doctors and hospitals to choose their products.

The tools of persuasion go beyond hiring cheerleaders as sales representatives. There are also financial inducements, sometimes disguised, sometimes blatant. A few months ago, Reed Abelson of The New York Times reported on a practice in which device makers give surgeons who are in a position to choose their products (with others paying the cost) lucrative consulting contracts, in some cases running to hundreds of thousands of dollars a year.

Above all, the line between medical researcher and medical entrepreneur has been blurred. In her book "The Truth About the Drug Companies," Marcia Angell, a former editor of The New England Journal of Medicine, writes that small companies founded by university researchers now "ring the major academic research institutions ... hoping for lucrative deals with big drug companies." Usually, she says, "both academic researchers and their institutions own equity" in these companies, giving them a strong incentive to make the big drug companies happy.

The point is that the whiff of corruption in our medical system isn't emanating from a few bad apples. The whole system of incentives encourages doctors and researchers to serve the interests of the medical industry.

The good news is that things don't have to be that way. Economic trends gave rise to the medical-industrial complex, but only because those trends interacted with bad policies, which can be fixed. In future columns I'll talk about how serious health reform can reduce the conflicts of interest that taint our current system.

 

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