BIG PHARMA? BIG DEAL…

Those of us who trust scientific methods to evaluate medical treatments are frequently faced with challenges that take the form of the “argumentum ad big pharma”, which claims that since the pharmaceutical industry funded a given study it cannot be trusted.

Some dismiss this immediately as a fallacy, a form of argumentum ad hominem, that is, the argument is invalid because it disqualifies the source, and not the proposition itself.

Not so fast; this critique applies when propositions have a standing on their own. If, using a comic book reference, the Joker said that 2 + 2 equals 4, the fact that the Joker said it shouldn’t come into consideration, the discussion should be exclusively whether 2 + 2 indeed equals 4.

But there are situations when the source is relevant, and the proposition cannot be evaluated without it, or at least it has to be weighed against the trustworthiness of the source. If someone says that she witnessed a given happening, whether one accepts or not that proposition as true depends on how much the person saying it can be trusted.

Additionally, we live in a complex society, with many different specialized forms of expertise being called into action for all kinds of purposes, and no matter how well educated, trained or informed one is, there are many more areas in which we are incompetent than not. A Nobel winner in chemistry can be a complete ignoramus in matters of plumbing, for instance, and thus will have to rely on a trusted expert when fixing a leak in her house.

When it comes to the scientific evaluation of medical treatments, those are available in articles published in biomedical journals. Although anyone can read what is in there (in terms; although there are many good open access journals, unfortunately for a large number of the main publications one still has to pay dearly for getting access to them if they are not lucky enough to be an institution that is capable to provide for this, but that’s yet another problem), actually being able to criticize what is being presented requires a level of expertise that usually involves a lot of time and dedication, something that will not be achieved by a few minutes of internet searching. And here lies the rub; the whole scientific publishing enterprise relies on assumptions of trust, and unfortunately we have had evidence in many occasions of manipulations of drug assessments, for instance, due to commercial reasons.

Acknowledging that this might constitute a problem, the International Committee of Medical Journal Editors instituted a long time ago standard policies requiring that any potential conflict of interest should be declared by authors and made public by journals. Unfortunately what was conceived as a means to curb excesses ended up normalizing them (Chalmers I. From optimism to disillusion about commitment to transparency in the medico-industrial complex. J R Soc Med. 2006;99(7):337-41. DOI:10.1258/jrsm.99.7.337). Numerous authors have been documenting the contemptible practices of some companies in the health sector which distort the procedures of science in order to promote their products (McGarity, T. D., & Wagner, W. E. Bending science: How special interests corrupt public health research. Cambridge, Mass. & London, UK: Harvard University Press, 2010), and the pharmaceutical industry is no exception (see for instance Goldacre B. Bad pharma: how drug companies mislead doctors and harm patients. New York: HarperCollins, 2012), in fact, a study based on a narrative review of internal documents of a specific company uncovered in the course of a legal process concluded that “Research, publications, and educational programs (including ‘independent’ events) were used as marketing opportunities, augmented by opinion leaders and local physician champions to engage their physician colleagues. Since the promotional intent of these activities may not have been widely recognized, their impact on physicians was probably greater than interactions with known commercial intent, which are typically approached with greater skepticism. (Steinman MA et al. Narrative Review: The Promotion of Gabapentin: An Analysis of Internal Industry Documents. Annals of Internal Medicine 2006;145(4):284-93. DOI: 10.7326/0003-4819-145-4-200608150-00008).

As another, more serious example, there has been much hay made about the deplorable rofecoxib fiasco. There is no room here to go through the whole thing, but basically a new anti-inflammatory drug was found to increase the risk of cardiovascular mortality and there are signs that the clinical research had shown that, but these results were suppressed (Psaty BM, Kronmal RA. Reporting mortality findings in trials of rofecoxib for Alzheimer disease or cognitive impairment: a case study based on documents from rofecoxib litigation. Jama. 2008 Apr 16;299(15):1813-7; more information on that here: The danger of drugs … and data).

Although this is something that should never have happened and point out to serious flaws in the current regulatory model for registering new drugs, the moral of the story is that it was further research that uncovered the problem.

Does this mean that the “argumentum ad big pharma” is correct? No. Although the pharmaceutic industry may be an uncomfortable ally at times, the benefits of modern pharmacotherapy (and science-based medicine in general) cannot be overstated. Just consider the case of aids; thanks to an unprecedented effort, in a relatively short time we managed to identify a causal agent, develop increasingly sophisticated and accurate means of identifying its presence and, finally, whole new families of drugs that transformed the panorama of the fight against the disease.

So, are there problems in the system? Undoubtedly so. But those derive from malice, not inherent flaws in the research methodology, and the scientific enterprise does have this kind of self-correcting mechanism that gives us reason to trust it. The solution is more, not less, science; just as an example, provided by the same Goldacre cited before (see Funnel Vision), a relatively simple device, called a funnel plot, can evidence the practice of hiding bad results.

As two sociologists of science put it, “Science may be wrong (…) but this does not make the opposite view right. In the absence of careful research about the opposite view, science is probably the way to bet. This is even more likely to be the case if science is continually put under scrutiny.” (Colins H & Pinch T. Dr. Golem: How To Think About Medicine. Chicago:The University of Chicago Press, 2005).

And, last but not least, it should be pointed out that conflicting interests due to commercial interference are not a privilege of any specific sector of the health care industry at large. This is not about a fight pitching crooked physicians and a corrupt industry versus pure disinterested individuals; just to give an example, the NIH estimates that “The $14.8 billion spent on nonvitamin, nonmineral, natural products is equivalent to approximately one-third of total out-of-pocket spending on prescription drugs ($47.6 billion)”. In other words, big money is being made in “alternative ways”; pot, kettle, black. Which is not to say that there are not well-meant people on both sides of this divide. The problem is that meaning well is not enough to take responsibility to care for other people’s lives.

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