“If you think your doctors prescribe medications for you on the basis of their unbiased judgment and objective medical research, Carl Elliott’s book, White Coat – Black Hat, will disabuse you of that old-fashioned notion. In his superb exposé, Elliott shows how the big drug companies have bribed and corrupted the medical establishment so that we no longer know which drugs are effective or why our doctors prescribe them.”
This is an impressive endorsement by Marcia Angell, an American physician, author, and the first woman to serve as editor-in-chief of the New England Journal of Medicine. Angell resigned in despair saying, “If we had set out to design the worst system that we could imagine, we couldn’t have imagined one as bad as we have.”
Her endorsement gets to the heart of why Carl Elliott’s book, published in 2010, is so important to patients and the medical profession. Medical journals are of the places where busy doctors go to find out about the safety and effectiveness of drugs they’re prescribing, possibly for you or a family member.
How I wish that, now almost fifteen years later, we weren’t so behind in hearing about the unsafe drugs that have unknowingly been prescribed over the years. How I wish drug companies and the NIH, the FDA, and the CDC were transparent health agencies. And that drug companies couldn’t advertise their products on television and in every print magazine, newspaper, and brochure that fill your doctor’s offices.
Carl Elliott has a medical degree as well as a doctorate in philosophy and is well qualified to take a hard look at bioethics. Bioethics is the study of ethical, social, and legal issues that arise in the life sciences, health care, and technology. The book comprises six chapters, each of which discusses an issue that troubles Dr. Elliott – and should trouble the medical profession and patients.
Chapter One – “The Guinea Pigs” describes the subjects who volunteer for medical research. Most of the chapter focuses on (a) the economics involved in getting people to submit to becoming guinea pigs and (b) the sometimes inadequate protections to ensure their safety. Some people do it to help humanity; most do it as a source of income, sometimes a generous payment plus room and board while the trial is ongoing.
Chapter Two – “The Ghosts” outlines in detail how many academic papers are actually authored by ghostwriters working for pharmaceutical companies. The part the academic person plays is limited to editing and signing off on the research. This practice is a response to the pressure on academics to publish, while the ghost remains anonymous.
Chapter Three – “The Detail Men” – concerns the role of the pharmaceutical companies representatives. The term “detail” is a historical term that means to give a doctor information about a company’s new drugs with the aim of persuading the doctor to prescribe them. Along with the sales pitch comes a host of freebies including gadgets for the office staff and sometimes paid-for expensive dinners and trips to “learn more.” More recently, women who are attractive and perky have begun to crowd the men out of this career.
Elliott questions whether doctors really do reject any possible influence from reps’ gifts or pitches. He poses the question: “Are physicians so weak and lacking in integrity they would sell their souls for a pack of M&M candies and a few sandwiches and doughnuts.” As a response, Elliott points out (and studies confirm) that the pharmaceutical companies wouldn’t give away things if the gifting wasn’t effective.
Chapter Four – “The Thought Leaders” describes the role played by key opinion leaders “managing the discourse around a given product – a discourse that is equal parts scientific study, commercial hype, and academic buzz.” And let’s not forget the financial incentives. This chapter focuses on how pharmaceutical companies identify, cultivate, and choose these so-called thought leaders. Some are, some really aren’t.
Chapter Five – “The Flacks” – describes the role played by the public-relations folks or the flacks. Elliott goes into informative, detailed accounts of how branding of certain conditions are changed to sell products. Here are just some of the language techniques:
- Portray the condition as common, yet underdiagnosed. For example, clinical depression which opens the door to drugs for every sector of the population.
- Destigmatize an embarrassing or shameful condition. For example, “urge incontinence” became “overactive bladder.” It makes it the bladder’s fault.
- Direct-to-consumer advertising. The AMA reversed its opposition in 1992, and in 1997 the FDA relaxed its warning requirements that had essentially precluded TV ads. This led to big pharma sponsoring more than half of the nightly news, the Super Bowl, popular magazines, and mainstream media.
Chapter Six – “The Ethicists” – discusses Elliott’s fear that ethicists like himself are becoming slaves to the pharmaceutical industry. Much of the chapter concerns institutional review boards (IRBs), which are “the committees responsible for overseeing the ethics of medical research in the United States.” Historically, IRBs have been academically based, but now many are for-profit and plagued with conflict-of-interest.
Author, MD and Professor at the Center for Bioethics at the University of Minnesota – Carl Elliott
It seems important to share a bit of Carl Elliott’s thoughts and accessible writing in the following paragraph from the Introduction to White Coat Black Hat. “A well-played confidence trick takes advantage of certain predictable characteristics of human psychology – the susceptibility to flattery, the deference to authority and status, the willingness of the eye to see what it wants to see and ignore the rest. Like a good scam artist, a good drug rep or PR expert figures out what a mark wants to believe and then gently helps him believe it. The most interesting kinds of scams reveal larger insights about the way we live now – the things we desire, the sources of our fears, the nature of our aspirations.”
Elliott sums up the challenges we face as consumers and for doctors treating patients. “Doctors used to be more powerful than healthcare corporations; medicine was once seen as a profession, not a business; and medical research was housed largely in universities. . . Today, of course, things are very different. The financial stakes in medical enterprises are enormous; the center of drug research has moved to the private sector; even medical education has become a big business.”
Photo credit: Hold that pill – etactic-ink, Truth – jon-tyson.