Policy and Medicine

FTC and Congress on Do Not Track Internet Proposed Rules

 

Last month, the outgoing House Committee on Energy and Commerce Subcommittee on Commerce, Trade, and Consumer Protection held a hearing entitled “Do-Not-Track Legislation:  Is Now the Right Time?” According to a briefing memo released by the Subcommittee, the purpose of the hearing was to examine the feasibility of establishing a mechanism that provides Internet users a simple and universal method to opt-out from having their online activity tracked by data-gathering firms (a.k.a. a “Do Not Track List”). 

Background

When individuals use the internet, details about their lives including age, gender, race zip code, income, marital status, health concerns, recent purchases, and other details that can be collected and packaged into profiles. As a result, a data-gathering industry with an increasing hunger for this information has grown, and over the past several years has sold this information so that companies can target consumers based on their tastes, needs, and even perceived desirability. What policymakers and some consumers are concerned about is that “many Americans don’t know that the details of their online lives are being gobbled up and used in this way, much less how to stop it in the event that such collection offends their expectations of privacy.”

Information about Internet users’ activity is instantaneously sold each day for the purpose of targeting ads to particular consumers (so-called “behaviorally targeted ads”). Spending on behaviorally targeted ads reached $925 million in 2009, and that figure is expected to reach $1.125 billion by the end of 2010. By 2014, spending on behaviorally targeted ads is projected to more than double to $2.6 billion.

In addition, those in the business of selling behaviorally targeted ads can generally command more for those ads than non-targeted ads. In 2009, advertising networks on average charged $1.98 per thousand displays of an untargeted ad, while they charged on average $4.12 per thousand displays of a behaviorally targeted ad.

However, the revenue that is generated by this type of advertising helps finance the free content that many Internet users have come to expect. In fact, “more than half of ad network revenue goes to publishers who host the [targeted] ads.” As a result, industry proponents have argued that regulation of this industry to protect consumers’ privacy could reduce the availability of free content on the Internet and the proliferation of more unwanted and irrelevant ads.

Current Laws and Regulations

No federal law specifically governs the online advertising industry or the practice of tracking internet consumers to deliver behaviorally target ads. Nor are there any federal laws that comprehensively govern the collection, use, and dissemination of consumer information across the board.  

Specific federal laws, however, do address certain categories of personal information or specific entities. For example, the Fair Credit Reporting Act (FCRA) governs consumer report information. Title V of the Gramm-Leach-Bliley Act addresses the sharing of certain nonpublic personally identifiable information by financial institutions, and rules promulgated pursuant to the Health Insurance Portability and Accountability Act apply to the privacy of medical records.

In addition, the FTC may bring actions for unfair or deceptive acts or practices under the FTC Act, which includes the authority to bring actions related to a company’s information collection and use.

Industry Regulations

While no specific law governs online advertising or internet consumer tracking, last October a coalition of media and marketing trade associations launched a self-regulatory program for the behavioral advertising industry. The voluntary initiative began by encouraging companies that track Internet users to display on or near behaviorally targeted ads a clickable “Advertising Option Icon.” Once fully implemented, the  icon will signal to Internet users that an ad was served based online tracking and provide an  avenue for consumers to get more information about the company’s data practices and to opt-out  from receiving behaviorally targeted ads served by some or all participating companies.

The program is based on the seven Self-Regulatory Principles for Online Behavioral Advertising that correspond with tenets proposed by the FTC in February 2009, and also address public education and industry accountability issues raised by the Commission.

Do Not Track

Despite the advertising industry’s attempt to regulate online advertising and tracking noted above, the FTC last month published a preliminary draft for protecting consumer privacy. According to their press release, the report proposes a framework to balance the privacy interests of consumers with innovation that relies on consumer information to develop beneficial new products and services. The proposed report also suggests implementation of a “Do Not Track” mechanism – likely a persistent setting on consumers’ browsers – so consumers can choose whether to allow the collection of data regarding their online searching and browsing activities. Among specific suggestions, the FTC staff recommended that:

Companies adopt a “privacy by design” approach by building privacy protections into their everyday business practice, including reasonable security for consumer data, limited collection and retention of such data, and reasonable procedures to promote data accuracy.

Consumers should be presented with simplified choice about collection and sharing of their data at the time and in the context in which they are making decisions. These would include a “Do Not Track” option.

Marketers should adopt measures to improve transparency of information practices, including consideration of standardized notices that allow the public to compare information practices of competing companies.

Consumers should have “reasonable access” to the data that companies maintain about them, particularly for non-consumer entities such as data brokers.

Stakeholders should undertake a broad effort to educate consumers about commercial data practices and the choices available to them.

FTC Chairman John Leibowitz noted in his prepared comments that the report “lays a foundation for industry innovation – while protecting consumers and their privacy.” In his statement, Mr. Leibowtiz asserted that “despite some good actors, self-regulation of privacy has not worked adequately and is not working adequately for Americans consumers.” As a result, he acknowledged that the FTC “will take action against companies that cross the line with consumer data and violate consumers’ privacy.” Additionally, his comments echoed the recommendations noted above. Specifically, Mr. Leibowitz asserted that companies should collect and retain data only if they have a legitimate business need.

He also specifically acknowledged the need for a Do Not Track mechanism with respect to third-party ads. For the FTC Chairman, the most “practical method would likely involve the placement of a persistent setting on the consumer’s browser, signaling the consumer’s choices about whether or not to be tracked.” He acknowledged that “Microsoft, Google, Mozilla, Apple and a coalition of other companies have already experimented with this method, and such an option would “serve as an easy, one-stop shop for consumers to express their choices, rather than on a company-by-company or industry-by-industry basis.”

In response to FTC’s preliminary report, Nancy Hill, President-CEO of the American Association of Advertising Agencies (4A’s) noted in a press release that there is “little understanding in the report of how complex a task it is to point such a vast, diverse and rapidly changing ecosystem in the same self-regulatory direction.” Ms. Hill pointed to the Self-Regulatory Program for Online Behavioral Advertising, devised by industry, through two years of hard work, and noted that it is just now becoming operational. She asserted that the “new system will provide a very strong case for self-regulation and consumer protection as the roll-out becomes 100% functional.”

Ms. Hill’s concerns were echoed by Dick O’Brien, head of the 4A’s Washington office, who noted that “At its worst, the FTC report could be read as an effort by regulators to push Congress into enacting stringent new laws that would restrict marketers’ interaction with consumers.” The press release acknowledged that the will provide reaction to the report to the FTC during the “comment period” which ends on January 31.

4A’s and other marketing groups are preparing responses to the FTC report, which can be submitted here and are due January 31, 2011. While O’Brien agreed that “online marketing must provide transparent, simple and consumer-friendly options,” he noted that groups “will be meeting with Members of Congress to let them know what the industry is doing already and what the new industry efforts will mean to consumers.”

Subcommittee Hearing

The growing awareness about the pervasiveness and invasiveness of online tracking noted above has sparked renewed interest in creating a Do Not Track mechanism by privacy advocates. In light of all the recent developments and changes, outgoing Subcommittee Chairman Bobby Rush (D-IL) discussed at last month’s hearing HR 5777, the Best Practices Act, which he introduced back in July of 2010. The purpose of the bill is to foster transparency about the commercial use of personal information and provide consumers with choice about the collection, use, and disclosure of such information. The bill applies to both the online and offline contexts.

Although the bill outlines specific protections for consumers and gives the FTC certain responsibilities for reporting and enforcement, HR 5777 does not include a provision to establish a mechanism that provides consumers a simple and universal method to opt-out from having their online activity collected and used by the tracking industry. Privacy advocates first proposed a version of such a “Do Not Track List” in 2007.

Congressman Rush noted in his opening statement that through such a mechanism, consumers could advise would-be trackers unambiguously and persistently that they do not wish to be followed by digital snoopers and spies across web sites and their various fixed and mobile computing devices. Mr. Rush made comparisons of the Do-Not-Track Legislation to the Do-Not-Call Registry that the FTC had successfully implemented several years ago. Accordingly, Mr. Rush then went on to hear testimony from:

Daniel J. Weitzner, Associate Administrator for the Office of Policy Analysis and Development, Department of Commerce, National Telecommunications and Information Administration, Department of Commerce

David Vladeck, Director, Bureau of Consumer Protection, Federal Trade Commission

Susan Grant, Director of Consumer Protection, Consumer Federation of America

Joe Pasqua, Vice President of Research, Symantec Corporation

Joan Gillman, Executive Vice President and President, Media Sales, Time Warner Cable

Eben Moglen, Ph.D., Legal Advisor, Diaspora*, Professor of Law, Columbia University, Founding Director, Software Freedom Law Center

Daniel Castro, Senior Analyst, Information Technology and Innovation Foundation

Conclusion

With the comment period closing at the end of this month and with several consumer groups having already filing a complaint with the FTC over online marketing and behavioral advertising, Congress will likely have to address this issue during its new session. However, with Republicans in control of the House, it remains uncertain whether any legislation will move forward to create the Do Not Track mechanism necessary to carry out the recommendations in the FTC report.

The use of the internet is growing exponentially each day, and consumers are finding valuable information about healthcare, mental health, financial help, education, nutrition, and numerous other resources. Accordingly, as policymakers consider comments from consumer groups on both sides of the argument, Congress and the FTC should ensure that the proposed regulations do not create obstacles for consumers to learn about products and get valuable information because online advertising and marketing is an extremely important tool for both consumers and companies.

To submit comments:

https://ftcpublic.commentworks.com/ftc/consumerprivacyreport/

Nader Backed Consumer Groups File FTC Complaint on Pharma Social Media

 
The explosion of social media and its use are widespread in almost every industry. Each day, companies in all industries make use of social media in a number of ways to reach consumers to transmit information, support or service. However, according to several consumer groups, “consumers now confront a sophisticated and largely stealth interactive medical marketing apparatus that has unleashed an arsenal of techniques designed to promote the use of specific brand drugs and influence consumers about treatments for health conditions.”

Accordingly, these consumer groups filed a lengthy and nasty complaint at the Federal Trade Commission (FTC) last week charging far ranging wrongs about pharmaceutical companies using social media and digital marketing to reach consumers. These groups sent copies of their complaints to Capitol Hill, FDA and the media. It appears from their strategy that the groups are trying to get FTC and Congress to limit all digital marketing by pharmaceutical companies.

The filing groups include the Center for Digital Democracy, Consumer Watchdog.org, US PIRG and the World Privacy Forum.   In interesting coincidence, all of these organizations except for the World Privacy Forum are either started by consumer advocate Ralph Nader or their executives worked for Nader.

Although it asks FTC to investigate health media, including WebMD, HealthCentral, Google and AOL, it is aimed also at pharma and pharma marketers and is designed to smear virtually all use of digital media to target patients and professionals. It calls out several digital targeting techniques and asserts that they are unfair and deceptive, thus subject to FTC jurisdiction.

According to a press release posted on the Center for Digital Democracy’s website, the 144-page complaint called on FTC to investigate and remedy unfair and deceptive digital marketing and advertising practices that consumers and patients face as they seek health information and services online. The Center also published an executive summary, detailing the techniques identified in the complaint, which the consumer groups believe “threaten consumer privacy and potentially put the public health at risk.” A summary of some of the techniques are listed below.

• Medical or Disease Condition Targeting, in which consumers or patients who express a particular health concern or interest are digitally profiled, tracked, and served ads and content based on the collection and analysis of such information. Among the many sensitive categories used in condition targeting are depression, COPD, diabetes, and asthma.

 

• Social Media Monitoring, through which health and drug marketers engage in online surveillance of the conversations consumers and their networks of friends have about brand pharmaceuticals, medical conditions, and treatments. 

 

• Behavioral Targeting, based on online data collection that analyzes a consumer’s Internet activities (which some call the “patient online journey”), in order to deliver marketing and advertising that zeros in on their medical concerns. Health and medical condition behavioral targeting is also used by online ad auction exchanges that sell access to a particular consumer in real-time for advertising purposes.

 

• Viral and word-of-mouth “buzz” marketing campaigns sponsored by pharmaceutical companies or health-related marketers that seek to drive sales of specific prescription and over-the-counter drugs.

 

• Unbranded online medical condition websites that appear to provide independent information on a particular disease or condition, but which are actually sponsored by a company whose products include treatment for the medical condition or problem addressed by the site.

 

• Seemingly independent testimonials or advice online, including through social networks and online video channels or sites, that are in fact the result of sponsorship arrangements and financial support by a pharmaceutical or health marketing company.

 

• Free online newsletters (WebMD alone offers nearly 50, covering such topics as arthritis, cancer, and weight control) and discount coupons (FirstRxSavings.com offers “hundreds of coupons for prescription and non-prescription drugs”) are used to collect personal and other digital information from consumers, which is then used for profiling and targeting.

 

• The practice of “e-Detailing,” where physicians, nurses, and other health professionals are targeted via sophisticated digital marketing techniques designed both to influence their decision-making regarding specific drug brands and closely monitor their behaviors. These practices, unknown to patients and consumers, can have a direct effect on their healthcare costs and methods of treatment.

 

• The growing promotion for the use of electronic medical records by online health advertisers, such as Google and Microsoft, that also have a significant business in digital health marketing.

 

• Neuromarketing practices, which draw on the techniques of neuroscience to develop advertising campaigns for medical products that make direct appeals to the consumer’s subconscious.

Claims About Social Media & Pharma

For the groups who filed the complaint, their main concern seems to be that the pharmaceutical industry is spending approximate $1 billion on social media marketing without any sort of rules or regulations regarding its use. As a result, these groups feel that the “online marketing health industry has presented to the FDA and the public a fairytale version of digital marketing, where all consumers become empowered “e-patients,” able to form powerful helping communities. While some might view this as a positive thing—patients seeking out health information and ways to treat their conditions—consumer groups believe that medical information provided online thus far “has been structured to engage in aggressive tactics that threaten privacy, raise questions about the fair presentation of independent information, and advance the sales of prescription drugs and over-the-counter products.”

For example, Jeff Chester, executive director of the Center for Digital Democracy (CDD), stated that “By using powerful digital marketing tools, pharmaceutical and online health information companies now have unprecedented abilities to take advantage of consumers.” He further noted that the marketing techniques described above “have been purposely designed to tap into the concerns and anxieties of individuals who are going online to seek health information.” CDD believes that this puts patients at risk for unfair, deceptive and non-transparent practices,  that will only increase as the country moves to digital medical records. To others, “Online health marketers are taking advantage of consumers at time when they are most vulnerable--worried about their own or a loved one's health.” For consumer groups, this trend undermines patient privacy.

Accordingly, the consumer groups want FTC to “protect consumers by ensuring that their health and medical data--including their use of online health services -- receives the highest form of privacy safeguards.” Ed Mierzwinski, director, Consumer Program, USPIRG said that “No consumer should be forced to confront a vast system of invisible and unaccountable online profiles that label them as someone who has or is concerned about a life threatening disease, serious medical problem, and then be ‘condition-targeted’ across the Internet and likely off-line as well.”

Recommendations

The consumer groups expect that in its forthcoming new privacy report, new and effective safeguards will be proposed by the FTC to protect consumer health and medical privacy online. Nevertheless, the four groups called on the FTC to undertake the following actions:

• Examine and analyze the data collection and usage practices of pharmaceutical advertisers, in order to assess the extent of consumer information collected through websites, social networks, online video sites, and other interactive means.

 

• Require companies engaged in digital marketing of health products to provide information on the kinds of online targeting techniques and methods they employ, especially behavioral advertising and retargeting.

 

• Conduct a review of the privacy policy pages on health and pharmaceutical websites and services, including the leading social networks promoting health products.

 

• Analyze how health-related social media marketing influences consumer behavior and attitudes concerning drug use and various medical conditions.

 

• Investigate whether there is a violation of the FTC’s Endorsement guidelines (which have been extended to the Internet) when advice is given to patients or consumers from seemingly independent health bloggers who fail to disclose that they are paid or sponsored by pharmaceutical or other companies.

 

• Investigate the use of “unbranded” sites funded by pharmaceutical companies, in order to assess whether such sites are structured and designed to support the promotion of specific drugs.

 

• Conduct an inquiry on the use of neuromarketing-related techniques designed to influence or measure subconscious responses.

 

• Work with the Food and Drug Administration and other appropriate agencies to develop a set of policies for regulating the use of behavioral targeting, data collection, and other digital techniques in the marketing of drugs and health-related products.

A good recommendation for these groups is to conduct some research first. It would be interesting to see how patients used information conveyed through social media and what they thought about these practices. Given the use of social media is a recent tool in medicine, and the legitimacy unknown to many, one would assume that like commercials or advertisements, patients armed with information from social media would bring questions to their doctors about such drugs or treatments.

If that is the case, then social media serves an important purpose for connecting patients with their doctors to address their health concerns. This data would also prove valuable because it could show what forms or mediums of social media patients desire to receive information about drugs from, and which forms are most effective. Information such as this could provide a useful tool to health marketers to reform practices within their industry to provide more useful, unbiased and patient-centered information.

Discussion

The impact of this complaint is significant because it represents a dangerous extension of the attacks on pharma marketing in Washington and will feed press attacks on the pharmaceutical industry. One commentator however, noted that the compliant is perhaps “the best review of healthcare-related digital marketing techniques” he has seen. While he recognized the innovativeness of many of these techniques, he noted that the consumer groups believe such practices are unfair and deceptive.

Consequently, the complaint could lead the FTC to open an investigation and create a protracted public relations problem. Presently, the online industry is already in a tough battle with some in Congress and the FTC over their proposals to increase regulation of behavioral targeting. This complaint will essentially extend this inquiry into professional marketing of health information and will increase the public visibility of many important marketing tools. The leading online marketing trade associations, including AAAA, the Direct Marketing Association, Association of National Advertisers and the Interactive Advertising Bureau, have created a significant self-regulatory program that has gained considerable government support, but is discounted by these consumer groups.  The health products industry will more than likely be joining these groups to find additional self regulation to protect online privacy

As all stakeholders in this process wait for guidance on the use of social media in drug marketing and advertising from the FDA or FTC, pharma and other health online marketers are pressing the FDA for new rules that would allow them to expand digital and social media advertising. The main thrust behind their argument is to reach populations of patients who do not adhere to their medications and to provide more resources for patients currently undergoing treatment to better understand the nature of their condition and any negative side effects or concerns that might create an obstacle to achieving the desired outcome.

Expanding the reach of social media is also seen as an important role in reaching patients who go untreated or spreading awareness about conditions that go undertreated or undetected. It is also seen as a potential resource for patients with chronic diseases who may decide to take “drug vacations” when symptoms from their illness disappear, although the underlying medical problems are still present. It is obvious that there are many good reasons why pharma wants to reach patients but there is also clearly a need for guidance about what is ethical and appropriate.

Before consumer groups call for a ban on truthful commercial speech that is likely to help patients, reduce health care costs, and lead to better detection, prevention, and treatment, a middle ground should be sought. Every industry uses social media and similar tactics to target populations, when the outcomes are clearly not as beneficial.

Given the rapid pace of society and the growing demand for health information from patients and practitioners, social media can act as a bridge to help the public access information in a convenient and reliable way. While demanding transparency and protection for privacy are legitimate claims, these consumer groups must realize that by attempting to eliminate or severely restrict an extremely valuable resource of information for patients could produce more harm to patients than good.

JAMA: Creating the Conflict of Interest Academic Police State – Thinly Veiled Threats and Accusations

 
Continuing his crusade to end all collaboration between physicians and industry, and in doings so, chilling the progress of research and discovery in medicine, David Rothman, PhD, wrote a commentary about academic medical centers’ conflict of interest policies. The commentary, which was published in the Journal of the American Medical Association (JAMA), discussed how “a number of academic medical centers (AMCs) have taken the lead in implementing new policies that more strictly manage the relationships between physicians and industry during the past 4 years.”

We have previously summarized many of these changes (Harvard, Minnesota, Wisconsin, Yale, Stanford, Michigan), which include “new measures to prohibit accepting gifts, food, and drug samples and restricting faculty consulting and speaking arrangements.” In light of these measures, Rothman recognizes that there is still a heated debate about these changes, with some feeling that they “are long overdue, and others complaining that the policies sully their reputations and reduce their income.”

He also acknowledges that because these “measures break new ground, uncertainties about their short- and long-term consequences are widespread.” Given this uncertainty, you would think that a member of academia, whose mission is to remain objective in searching for evidence, would call for more research to gain a better understanding of the wide ranging impact these policies could have and the unintended consequences and harm that are likely to result (i.e. MIT study).

Not surprisingly however, Rothman instead says that rather than do more research about the consequences of misguided conflict of interest (COI) policies, it would just be “simpler, more equitable, and more effective if all AMCs adopted $0 thresholds for all faculty, staff, and adjuncts.” He offers no empirical evidence or logical reasoning to how he arrived at such a conclusion, also not surprising, since to date, no evidence has been produced suggesting that physician-industry relationships have caused any harm to patients.

Commentary

Given the various changes in AMC policies listed above, Rothman uses this commentary to discuss what he believes are “accomplishments at the leading institutions and evaluate prospects for future change.” Other than these institutions actually adopting or changing COI policies, he does not explain why this stands as an accomplishment. Have these policies improved patient care? Have they led to more discoveries of new drugs or treatments? How many more lives have they saved now that these policies are in place? Does the public trust AMCs more now than before?

The clear problem that Rothman identifies about COI policies, but strategically underscores, is that “Implementing conflict of interest policies demands substantial time and resources, as well as a deep commitment to effective oversight.” While many justify COI policies as a way to ensure professionalism and to keep public trust, others argue that they also serve to reduce health care costs. On the latter point, critics of industry-physician collaboration believe that physicians who work with industry can lead to overprescribing, extra tests, use of brand name drugs, and other things that lead to increased costs.

But how does creating a COI police state at an AMC reduce health care costs? As Rothman recognizes, “issuing a policy is merely the first step; next come the appointment and staffing of a faculty/administration committee that, together with an expanded compliance office, answers faculty queries, investigates violations, reviews disclosure forms, and develops and implements individual management plans that must become embedded in the institutions' governance and culture.” This all costs significant amounts of money on not only resources, but also training and compliance.

Based on the extremely limited budgets of most AMCs already, coupled with the threat that AMCs will prevent industry-funded research, grants or continuing medical education (CME), how can the overwhelming majority of these institutions expect to pay for all of this? Rothman does not answer that question.

Discussion

To Rothman, COI policies should exist at AMCs to show “a deep sense of professional values and by the conviction that, left unregulated, industry marketing practices undermine patient well-being and scientific integrity.” He neglects however another equally, if not more important sense of professional value: the need for physicians to learn continuously about new advances and research to improve patient outcomes, and a duty to educate and train others with that information.

By focusing solely on what he sees as beneficial for patients, Rothman himself undermines patient well-being and scientific integrity by not realizing that patients will be the first to suffer when physicians can no longer collaborate with industry to discover new breakthroughs and treatments to continue the progress in medicine America has enjoyed for decades. Patient well-being will also suffer from biased proposals such as Rothman’s because once physician-industry collaboration begins to decrease, the training and education of physicians will be insufficient and inadequate to deal with the revolutionary pace of medicine and science. Doctors, who barely have enough time to see patients presently, will simply fall behind the standard of care in many areas because critics like Rothman want to impede the flow of truthful and valuable scientific information between physicians and industry.

Despite these contradictions, Rothman’s commentary reads more like a warning: since industry Web sites are reporting payments to physicians, there is the potential that an AMC may be the subject of “unflattering media coverage, and no institution wants to receive an inquiry from a senator's office about a faculty physician's ties to industry, which almost inevitably produces reputation-damaging media coverage.” But Rothman too quickly forgets that AMCs are constantly under a microscope on a number of unflattering media and legal issues such as malpractice, adverse events, clinical trials, research protocol, hospital borne infections, and so on.

While physician-industry payments are a popular topic in the media now, they are no more unflattering than the issues previously stated. Yet we still have hundreds of thousands of deaths in hospitals and AMCs from adverse events and hospital acquired infections. Why should AMC resources and staff be filling out and reading COI forms when they could be fixing real problems of life and death instead?

Essentially, Rothman reasons that AMCs should fear working with industry and should adopt his $0 threshold because “such an inquiry into payments may adversely affect funding from the National Institutes of Health and even spur investigations by state attorneys general.” This reasoning is both counterintuitive and counterproductive. The purpose of NIH funding is to bring tangible medical discoveries to the market for patients, and without the interaction and collaboration of industry, the chances of this happening are minimal. You can’t just have NIH funding and no industry support. And you can’t have industry support and no clinical trials or testing. This is why we need collaboration. Moreover, if an individual researcher is found in violation of COI policies, it is highly likely that only that person will be restricted from NIH funding, and not the institution as a whole.

Consequently, Rothman discusses a number of specific prohibitions and policies in place, most of which are reasonable. These include prohibition of gifts and food from industry. However, Rothman’s suggestion that there is “extensive literature on the effect of gifts on physician decision making” is inappropriate. There is only one such article by Wazana, that did not even use clinical outcomes to show if such gifts were harming patients. In other words, the study was meaningless.

Another problem with Rothman’s portrayal of such policies is that he does not explain the role of physicians on speakers’ bureaus adequately. Speakers are not salespeople because they use company slides. FDA requires, by law, that speakers must use slides from companies that the agency has approved to ensure that adequate risk/benefit information is included, there is no discussion of off-label use, and only clinical evidence is being presented.

In addition, Rothman’s suggestion that samples be “less frequently used, and detached from interactions between the drug representative and the physician” is also problematic. Many of these samples are given to doctors for the explicit purpose of giving to patients who do not have sufficient financial resources. Samples are also useful for doctors to test a patient’s tolerance and monitor for any side effects before deciding a specific and costly treatment.

Conclusion

Rothman’s commentary presents assumptions stated as fact, and uses a clear framing bias to suggest that physician-industry collaboration must be eliminated or heavily regulated. Throughout his entire commentary, he does not mention one benefit, of the thousands that have come from physician-industry collaboration (ones that he himself has probably personally benefited from i.e. vaccination). His ideas are not only problematic because of their extreme view and lack of objectivity in evaluating the significant role industry plays in advancing medicine and improving patient care, they are also conflicted. Specifically, Dr. Rothman is the president and a board member of the Institute on Medicine as a Profession (IMAP), which is funded by George Soros, a philanthropist with a very liberal agenda.

Ultimately, transparency is important, and AMCs should continue enforcing and creating policies that promote transparency to ensure a high sense of professionalism and public trust in academic institutions. This does not mean however, as Dr. Rothman suggests, that these measures should completely abolish physician-industry collaboration. Policies must strike the proper balance to ensure ethical collaboration without hindering innovation and creating obstacles. Since the consequences of these policies are unknown and will likely be widespread, AMCs have a duty to the public to first determine whether more harm than good will come from COI policies, and the potential negative consequences they could have on patient outcomes and physician training and knowledge.

Physician Payment Sunshine: Media Support Equals More Stories

Continued media coverage of the sunshine provisions in the Senate and House health care reform bills continued today as the New York Times reported that such efforts may not be enough.  (They want more stories)

 

The sunshine provisions require the makers of drugs, medical devices and medical supplies to file annual reports to the government about their financial ties to doctors.

The legislation would also require the establishment of an online public database that patients could search, to see if their own physicians had been paid by the companies whose products the doctors prescribed.

Extreme radical pharmascolds believe this kind of disclosure and reporting is not comprehensive enough because there have already been instances “of doctors who, despite strict disclosure policies by their academic employers or the National Institutes of Health, failed to report payments from industry.” As we have covered such cases numerous times, the overwhelming majorities of such errors were never intentional, and were mostly due to confusion on the requirements by various journals and institution policies.

Internist and Stem Cell Ethicists Dr. Bernard Lo at University of California, San Francisco, who served as chairman of the IOM committee on Conflicts of Interest in Medical Research Education and Practice essentially called on “Congress to mandate industry disclosure of payments to all kinds of health care providers, medical researchers, medical institutions, professional medical associations, industry-sponsored foundations and disease advocacy groups.”

As the provisions in the Senate stand right now public disclosure of industry payments would be required to doctors and teaching hospitals, as well as ownership stakes in medical facilities and medical products companies. Groups not presently required to disclose include people like nurses and biomedical researchers or groups like professional medical associations.

Consequently, such a gap leaves open the possibility that Senator Charles Grassley (R-IA), a co-creator of the sunshine provision according to his spokeswoman is open to “expand the payment disclosure requirements to other medical players,”

According to the NYT article, “the health overhaul effort in the House goes further, calling for public disclosure of industry payments to a wide array of medical entities and medical professionals — a group as diverse as physicians, pharmacists, biomedical researchers, professional medical associations and health insurers.”

Proponents of such disclosure requirements believe that since these entities “are making determinations as to what procedures and drugs will be used,” sunshine provisions cannot leave any loopholes. For example, Representative Pete Stark (D-CA) believes that companies could give rebates to outpatient clinics to favor certain medical products over others, a scenario he uses to call for stronger measures.

In response to sunshine provisions, the Pharmaceutical Research and Manufacturers of America (PhRMA) told NYT “that any federal legislation requiring payment disclosures must be written in a way that did not imply that industry relationships with health care providers were automatically inappropriate.” Others who are skeptical of disclosure address the need for a federal database to use that would offer more detailed information than the few doctor payment listings now available to the public.

States like Minnesota and Vermont already require drug companies to report payments to physicians, and drug companies like Eli Lilly and Merck have introduced their own Web sites listing fees paid to doctors as we have previously written.

Eli Lilly and Sunshine – More Stories for Papers

Since Eli Lilly started reporting payments the first half of this year, they have paid 3,971 doctors and other medical professionals an average of about $11,230 each. The payments were for participating in an average of 12 speaking or consulting engagements during those six months, according to a company spokeswoman.

A separate NYT article focused on payments from Eli Lilly to Dr. Manoj V. Waikar, a psychiatrist in Palo Alto, Calif., who is also an adjunct clinical instructor in the department of psychiatry and behavioral sciences at the Stanford University School of Medicine. So far he has received $74,850 for consulting and speaking at 51 events. The company caps payments at $75,000 for each health care provider in any calendar year. As a result of just $1,500 per event, the article tried to determine why Dr. Waikar received such payments.

Dr. Waikar wrote in an e-mail message to NYT that he received fees for speaking to other health care professionals about disorders like schizophrenia and depression, which can be treated with the Lilly drugs Zyprexa and Cymbalta respectively. Having spoken so many times about the treatment of such diseases that affect millions should not be underscored by payments he received for such services, when doing so is not only legal, but essential for improving patient care.

In addition, Dr. Waikar’s speaking need not be overly scrutinized because Stanford only prohibits full faculty members from participating in drug company speakers’ bureaus. Dr. Waikar, who is an unpaid adjunct instructor, was allowed to engage in these critical educational events because he did not use his Stanford title, as the school’s policy requires.

Stanford announced they are reviewing the policy for adjunct professors, which is not surprising given that Philip A. Pizzo, MD The Dean of the Stanford Medical serves on the board of the anti industry group Prescription Project (which the Prescription Project has since taken down the board names from their website – so much transparency for these guys).

Not only was Dr. Waikar following Stanford’s rules explicitly, he even indicated in his email to reporters that not only were the “drug company presentations standardized to comply with drug marketing regulations, he and other speakers provided suggestions on the content.” Moreover, Dr. Waikar acknowledged that he was even able “to answer questions from doctors in the audience, drawing from his own practice experience or opinions, as long as he explained the basis of his answers.” Evidence of such “spontaneity” only goes to show how unbiased his work truly was.

As a result of his service, Dr. Waikar has been contacted by many doctors after his talks to consult about difficult cases, especially from primary care providers who have to treat complex psychiatric problems. Having this ability to reach out to him could not have been possible if it were not for the support of such talks by Eli Lilly.

Misinterpretation of Disclosure

The work of Dr. Waikar should ring loud for proponents of more disclosure like Dr. Lo, who still maintain that drug companies control the content of such speeches. If there continues to be a push for more disclosure, as others have indicated, the government will only begin to use this information against doctors, which will in the end only hurt patients.

One anti industry pundit stated about this case and working with industry in general:  “If you can live with public exposure of your accepting gifts and fees from the pharmaceutical and medical device and imaging industries, then go for it. But in a few years, this information will all be known, not just to you and the few people attending your seminars, but to your patients, to your employers and to the government."  Look out they want to sick the government on physicians working to educate other physicians (ouch)

The problem with reports like the IOM report is that “disclosure requirements often omit information that could help clarify the relationship between physicians and the treatments the doctors prescribe.” This statement is from Lisa A. Bero, a professor of health policy at the medical school of the University of California, San Francisco. In other words, the problem is not always the doctors failing to report.

Regardless of Dr. Lo’s recommendations, even as the New York Times admits, the IOM report itself indicated that “the public could benefit when doctors and researchers collaborated with the industry to develop new and effective products.” Since the report makes such an acknowledgement of the value of researcher-industry collaboration, present disclosure policies are more than enough for the public to judge whether such relationships exerted too much influence on patient care.

In the end newpapers will sell more stories of physicians and others working with industry if they can expand the people covered.  Americans love to hear specifics about others income, we love controversy.

JAMA: HPV and Cervical Cancer Treatment Gardasil - Choosing to Ignore the Facts

Cervical Cancer is a serious disease and the second leading cause of cancer death in women world wide.  In the US it is treatable.  The American Cancer Society estimates that in 2009, about 11,270 cases of invasive cervical cancer will be diagnosed in the United States. Some researchers estimate that non-invasive cervical cancer (carcinoma in situ) is about 4 times more common than invasive cervical cancer.

Cervical cancer occurs most often in Hispanic women; the rate is over twice that in non-Hispanic white women. African-American women develop this cancer about 50% more often than non-Hispanic white women.

But cervical cancer which is caused by a sexually transmitted virus (HPV) is now largely preventable with the vaccine Gardisil developed by Merck.

 

In this weeks, JAMA there are two articles on Gardisil the first titled: Postlicensure Safety Surveillance for Quadrivalent Human Papillomavirus Recombinant Vaccine  is authored by physicians and researchers from the US Centers for Disease Control and Prevention and the Food and Drug Administration  that research article points out that Gardisil is safe and effective in preventing HPV.

 

“We feel confident recommending people get the vaccine; the benefits still outweigh the risks,” “This is the most complete picture we have.” said Dr. Barbara A. Slade, the study’s first author and medical officer with the Centers for Disease Control and Prevention.

 

But ignoring evidence even from the CDC and the FDA Catherine De Angelis, MD Editor and Chief of JAMA issued another “Special Communications”  (special communications is JAMA code for anything the editor wants it to be selected by the editor bypassing traditional channels, lately focused on anti industry articles) this time taking a blow at Gardasil, Merck’s new vaccine against 4 types of human papillomavirus (HPV). 

 

The recent Shelia and David Rothman, PhD (sociologists, not cancer researchers with the Institute of Medicine as a Profession) Special Communication in JAMA published suggests that there are “critical and unresolved questions ... [concerning the] manufacturer’s decision to market its HPV vaccine primarily as an anticancer vaccine.” JAMA authors then asked the following:

 

 

· Is the vaccine being targeted to adolescents at greatest risk and who stand to benefit?

· Do professional medical associations (PMAs) that received funding from the company provide members with unbiased educational materials and balanced recommendations?

· Did the PMAs ensure that marketing strategies did not compromise clinical recommendations?

· Was the design and implementation of vaccine policy for adolescents consistent with scientific knowledge?

 

Interestingly, JAMA itself acknowledges that “the new vaccine against 4 types of HPV … appears to be a cost-effective intervention with the potential to enhance both adolescent health and the quality of their adult lives.” So the problem does not appear to be with the science of the medicine, rather “the messages and the methods by which the vaccine was marketed.”

 

In other words, JAMA believes that the means (the development of an HPV vaccine) used to accomplish the end (Gardisil), are somehow “unethical” because industry was involved. Regardless of the fact that without industry this “cost-effective intervention…that will enhance adolescent health and quality of their adult lives” would not exist, JAMA continued to discredit the manufacturers.

 

JAMA further claimed that “by making the vaccine’s target disease cervical cancer, the sexual transmission of HPV was minimized, the threat of cervical cancer to adolescents was maximized, and the subpopulations most at risk practically ignored.” Another claim by JAMA is that the vaccine manufacturer which provided educational grants to (PMAs) “did not address the full complexity of the issues surrounding the vaccine and did not provide balanced recommendations on risks and benefits.”

 

JAMA goes on to further describe that Gardasil was “promoted primarily to “guard” not against HPV viruses or sexually transmitted diseases but against cervical cancer.” The article somehow tries to correlate this promotion with enabling “its manufacturer to circumvent possible parental and public unease with an antidote to sexually transmitted diseases.” The drug was approved by the FDA, and went through all the clinical trials and research necessary, what more do parents need?

 

Continuing through the article, the authors assert that Merck only concentrated on “populations in geographic areas with excess cervical cancer mortality, including African Americans in the South, Latinos along the Texas-Mexico border, and whites in Appalachia.” According to JAMA, Merck did this so they could market to consumers “that every girl was at equal risk” and that “Your daughter could become 1 less life affected by cervical cancer.”

 

PMA’s

 

In order to further the goal of treating patients and finding effective treatments for cervical cancer, Merck funded established Professional Medical Associations (PMAs)  such as the American Society for Colposcopy and Cervical Pathology (ASCCP).

Instead of looking at these educational grants neutrally for what they provided to research and academia, JAMA asserted that the American Society for Colposcopy and Cervical Pathology (ASCCP) “perceived the vaccine promotion as an opportunity to turn a potential financial liability into an asset.”

 

Somehow JAMA interpreted ASCCP’s prediction about the need for new practitioners to educate about HPV and cervical disease as a risk. Moreover, the educational grants allowed the ASCCP to create an “Educate the Educators” program, training members to promote vaccine use, especially in “smaller and mid-sized communities that lack clinicians who have expertise in this area.” What is so unethical and wrong with that?  Is this not what CME is supposed to do meet the unmet needs of communities?    I would venture to say that these programs would receive commendation for such targeted actions, reaching physicians and patients with the greatest need.

 

In fact, the ASCCP also “arranged opportunities for CME accredited courses through “grand rounds, in-service opportunities, patient education forums, risk management and quality improvement meetings, and professional association society meetings.” With statistics like “worldwide, cervical cancer as the fifth leading cause of cancer death in women, 473,000 cases of cervical cancer, and 253,500 deaths per year” why would

JAMA even try to question such a breakthrough?

 

ASCCP materials also advocate for physicians to help in “convincing states and federal agencies to pay for the vaccine, convincing insurance to pay for it [and] encouraging state mandates for use.” What else more could JAMA want in order to help patients with an effective treatment?

 

Surprisingly, JAMA did get one thing right in this article: “Professional medical associations are obligated to provide members with evidence-based data so they can present relevant risks and benefits to their patients.” That is exactly what Merck and the CME providers they support have done, and continue to do.

 

About the Authors

 

One colleague noted that it is almost impossible for the article in JAMA to have been peer reviewed prior to publication, because the bias was so pervasive throughout the commentaries (they tried to make it to look like research but in reality it was nothing but pure commentary).

 

This article is pure David Rothman, PhD Director of Columbia University’s - Institute of Medicine as a Profession, who has received closed to $10 million  from George Soros and his Open Society Institute  to discredit the pharmaceutical and device industry, he is the lead author of this past springs JAMA published paper calling for an end of all relationships between industry and Professional Medical Associations (PMA’s). 

 

In addition, David is the founder of the Prescription Project whose total goal is the same to eliminate “conflicts of Interest” code for all interest and relationships between industry and healthcare providers.  He lives in a world were all drugs and devices are for the betterment of man and should be given away free of charge.

 

Fortunately the press did not follow the religious zealot line that Rothman portrayed and focused on the benefit that young women receive from getting the vaccine.   This even includes the NY Times plus a plethora of other news papers.  (Sorry but science sells and propaganda does not)  But you keep ignoring the truth David, you must or your funding will dry up.

 

ASCCP Response

 

In response to the article, ASCCP issued a press release asserting that their “mission of ASCCP is to improve clinician competence and patient outcomes through provider education.” As a result, the organization endeavored into the research of an HPV vaccine because of the “widespread ignorance about HPV and its role in cervical oncogenesis.” Therefore, ASCCP wanted to educate clinicians about HPV vaccines, and in order to do so effectively and efficiently, accepted funds from a variety of sources, including HPV vaccine manufacturers.

 

The reason ASCCP accepted such funds from industry is because “funding for this purpose has not been available through government or nonprofit sources.” How else does JAMA expect physicians to cure the world’s second highest killing disease for women?

 

Specifically, ASCCP noted that although “the current prevention system based on Pap testing, colposcopy and destruction of precursors is effective, it remains expensive, intrusive, insensitive and nonspecific.” Moreover, they noted that “because it cannot be determined which women with CIN are fated to develop cancer, it results in overtreatment of thousands of women each year, with consequent cost, procedure-related injury, and perinatal morbidity resulting from cervical compromise.” That is why ASCCP accepted funds to develop a more effective treatment, and why “industry representatives played no role in the development or content of ASCCP educational materials.”

 

ASCCP also wrote a asserting the following points:

• The Food and Drug Administration (FDA) has approved HPV vaccination as safe and effective, reflecting the opinion of cervical cancer experts—which Rothman and Rothman are not—that vaccination will decrease the burden, not only of cervical cancer, but also of precancer, with fewer abnormal Pap tests, colposcopies, and cervical treatments.

• Materials were peer reviewed and financial support disclosed.

• While the authors argued that ASCCP failed to emphasize vaccination of high-risk populations, some 80% of sexually active women will acquire HPV, though most clear infection, so all women are at risk. Cervical cancer rates are highest in unscreened women. ASCCP has supported efforts to protect these women, including education of clinicians who serve them, collaboration with government agencies, and primary prevention through HPV vaccination.

• ASCCP supports a dialogue to advance efforts to provide vaccine to low income, immigrant, and minority women at greatest risk. Some controversial aspects of vaccination, including “catch-up” vaccination for sexually experienced women, were evaluated and approved by the FDA and subsequently adopted by the Advisory Committee on Immunization Practices (ACIP); ASCCP reported and explained ACIP positions in its educational materials but did not influence their adoption.

• ASCCP will continue to use income from a variety of sources including industry to support our mission of improving the lives of women through education about HPV, conventional screening and treatment, and HPV vaccination.

  

In the end, ASCCP put it best: “it is unethical to deny a generation of women access to HPV vaccination while waiting to demonstrate a decline in cervical cancer rates.” We should praise these entities for their breakthroughs with industry, and Americans should all appreciate the lives they will save.

 

If you have a choice who do you believe anti industry zealots David and Shelia Rothman or the researchers at the FDA and CDC?  My money goes on the CDC and FDA, I would encourage everyone else to do the same and get your daughters vaccinated.  I certainly will.

 

Thomas Sullivan, Author of Policy and Medicine is the President of Rockpointe

In 2005 – 2006 Rockpointe/Potomac Center for Medical Education produced CME activities on HPV and Cervical Cancer supported by Merck US Human Health.   We are confident our efforts have contributed to lives saved by educating health professionals on preventing cervical cancer in women. 

 

 

Pharmascolds an Official Term

Pharmascolds has been added to the American vocabulary this week according to Schott’s Vocabulary column in the New York Times.

Definition:  Those critical of the relationship between (the pharmaceutical) industry and academic medical research. (Pharmaceutical + scolds).

So from now on, critics of industry, the Angell-Relman’s, DeAngelis, the Prescription Project, the Institute of Medicine - as a Profession, the Macy Foundation, and the small group of academics they influence, now can all be defined as Pharmascolds.

Institute of Medicine as a Profession: Next Stop Patient Advocacy Groups

Last week, the Institute of Medicine, as a profession, launched an attack on medical societies in The Journal of American Medical Association (JAMA) entitled, “Special Communication” Professional Medical Associations and Their Relationships with Industry a Proposal for Controlling Conflicts of Interest.

The report was planned for several years and paid for by Pew Charitable Trust monies through the Prescription Project to Institute of Medicine as a Profession: IMAP-Prescription Project: Report on Conflict of Interest in Medical Societies  (December of 08 Post).

According to Merrill Goozner:  During a conference call, three of the eleven co-authors on the paper predicted many major medical societies will seriously consider the proposal.

"Ten years ago (concerns about conflicts of interest) was a breeze, five years ago a wind, now it is a gale storm," Rothman said.  "Change is going to come.  The likelihood of these recommendations being implemented is quite strong."

Only two current leaders at professional societies -- Ralph W. Hale of the American College of Obstetricians and Gynecologists and James H. Scully of the American Psychiatric Association (APA) -- were among the 11 signers.  Last week, the APA made news by declaring it would stop taking money from industry.

Goozner also notes:  The next target on IMAP's radar screen: patient advocacy groups, many of which receive all or nearly all of their funding from the drug, biotechnology, or medical device companies.  "We are going to address these patient advocacy groups, some of which are grass roots and some of which are astro-turf," Rothman said.

Patient advocacy groups need to be alerted that this very effective strategy as seen with Academic Medical Centers (Brennan paper 2006, followed by AAMC Taskforce 2008, followed by major reforms 2009), and now Medical Specialty Societies is a model that is working for IMAP.  This will be used against them.

They want to cause shame for doing the right thing (working with industry to develop new products that saves lives) even if it costs more in the short run. 

This strategy should be exposed for what it really is, short sighted contempt.  Medical societies, academic medical centers, and patient groups need to stand-up against this bullying tactic; otherwise as a society we will all suffer the consequences of a lost medical research and education base.

Prescription Project Conference: Drug Free Zones

Finally, the White House and the U. S.Capitol Building have become “drug-free” zones from the corrosive and corrupting influence of lobbyists for the pharmaceutical and medical device industries.  State Senator Richard Moore, MA

This was the undercurrent of the recent conference of the Prescription Project held last month in Washington DC.

Presentations included “Reform of the Food and Drug Administration (FDA),” by Bruce Psaty, M.D. and Steven Nissen, M.D., both unofficial candidates for the job of FDA Commissioner, and “Incentivizing Drug Discovery and Drug Safety,” by Alastair Wood, M.D.  These presentations are actually quite balanced.

Barbara Barnes, M.D., of the University of Pittsburg and Chairman of Accreditation Council for Continuing Medical Education (ACCME) Board of Directors, gave a presentation on “Interactions between Industry and Academic Medical Centers: Managing the Boundaries.”

They also included their typical list of industry bashers, including Daniel Carlat, M.D., whose presentation was “Industry Funding of continuing medical education (CME): How Drug Companies Have Taken Over Medical Education,” (I am not certain what year he is living in, but it is certainly not 2008 or 2009). 

Remarks by Henry Waxman, the newly elected Chairman of the House Energy and Commerce Committee, gave some insight on the direction he will be taking.

State Senator Richard Moore, of Massachusetts, the Chairman of the Joint Committee on Healthcare Financing titled his presentation “Never Trust the Lamb to the Custody of the Wolf” (this one is worth looking at, because he will be sitting in as Chairman of any additional industry bills that Massachusetts may want to pass this year.

Overall this was an interesting conference and worth downloading many of the remarks and presentations. 

Full presentations, remarks, a list of organizations that attended, and agendas are available online at the Prescription Project Website.

IMAP-Prescription Project: Report on Conflict of Interest in Medical Societies

Prescription Project who’s stated goal is Ensuring that industry-physician relationships are free of conflicts of interest …(kicking industry out of medicine), has hired The Institute of Medicine as a Profession to write a report on Conflict of Interest Policies in Medical Societies is expected to be released in Early 2009.

According to both parties the Report will be very similar to the AAMC report on conflict of interest in medical education released earlier this summer but without any of the constraints that the AAMC report had by including university leadership and industry.

 Rather than engaging the associations, the staff at IMAP has selected to cherry pick “friends” who are former and current association leaders and officers to write the report. 

The report will be closer to the Macy Report in that it will come from a single perspective and the participants will have their names and affiliations listed at the end as authors to give the impression of society endorsement without having to go though the trouble of getting the actual buy in of the medical societies and their leadership.   

The report will be released with much fan-fair, including articles in major papers who will write this up as a seminal event.

The report will outline the current “problem”: industry cooperates with associations on sponsorships of exhibits at annual meetings, grants to support CME, support of data registries, and other activities and then direct associations to loose all these ties with industry in the interest of “professionalism” and include an outline on how to implement the proposed policy with no realistic plan to replace the lost income to the societies.

Though I think that these types of efforts are useful in helping to define potential problems and proposed policies and procedures, they fail to get the input of all parties effected by their proposed policies, and are usually from a single perspective, leaving them suspect of exclusion.

To understand just how effective the Prescription Project and IMAP are and how they work hand in hand I encourage you to read the recently published JAMA article by David Rothman, MD the Director of IMAP: New Developments in Managing Physician-Industry Relationships in JAMA

Physician Payment Sunshine: No Good Deed Goes Unpunished

Several months ago, I met a young woman who was the chief lobbyist for a well know anti-industry group.  In our discussion she mentioned that her group was in favor of the revised Physician Payment Sunshine Act, because they see it as a first step in their march towards eliminating all pharmaceutical and device marketing.  She explained how this data would be useful in embarrassing physicians not to work with industry.  At the time I shrugged off the comments due to her youth.

This week Eli Lilly announced that as a company they are going to disclose payments to physicians.  At this announcement one who expect accolades from those who have been saying “we want disclosure”.

Senator Kohl the sponsor of the physician payment sunshine act stated: "Eli Lilly is leading the charge for transparency in the relationship between pharmaceutical companies and doctors by fulfilling the obligations of the Physician Payments Sunshine Act before it has been enacted,"  and  "It takes a lot of courage to be the first. They have made a principled decision that I believe will benefit both their business and the consumers of their products."

So what did the anti-Pharma crowd do, did they applaud the effort, like any reasonable person,  absolutely not,  they even went so far as to accuse Eli Lilly of atrocities. 

In one of the most conflicted and prolific of the pharma critics,  Carlat’s Psychiatry Blog  Eli Lilly: Ethical Confusion Continues  Dr. Carlat writes:

So why do I say Eli Lilly is "ethically confused"? Because they still shamelessly participate in marketing deception. They hid risks of Zyprexa from doctors long after they knew about them, and still deny that this was wrong. They continue to fund a malpractice insurance company, PRMS, to provide sham risk management education to psychiatrists in an effort to prevent them from switching patients to less toxic antipsychotics. In this particularly ugly marketing tactic, they are paying attorneys to do their "education," payments which would remain hidden even under their new disclosure policy.

The blog is a case study in that the true goal of the anti-medical manufactures crowd is:

A)    To stop all new drugs from coming on the market

B)     If this drug slips by the FDA disavow and discredit any benefit that a new drug or device may bring

C)   Stop all pharmaceutical marketing.

Dr. Carlat is influential, when I pulled the records from a anti industry marketing hearing at one of the states, it was full of blog postings and articles from Dr. Carlat.

The words of Dr. Carlat once again confirm their true agenda and that no good deed goes unpunished.