Gajski Conflict of Interest in Medicine

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Lidija Gajski, Conflict Of Interest In Medicine, p. 1

Conflict Of Interest In Medicine

Pervasiveness And Far-Reaching Consequences

by Lidija Gajski, Croatia

This article has been published in: Schweidler, Walter (ed.), Bioethik Medizin Politik :

Bioethics Medicine Politics : Proceedings of the 6th Southeast European Bioethics

Forum, Sankt Augustin: Academia Verlag, 2012, p. 105-112.

Key words: Conflict of interest, medicine, medical science, medical education, medical experts

Summary

In the last few decades growth of biomedical research and new legislation has led to intensified

collaboration between medicine and industry. Industrial financing creates divided loyalties withineach of the main actors in medicine and health care. This is evident in various fields science,education, clinical practice and regulation.

Individuals and institutions authorized to protect public interest, i.e. the health of the population,become advocates of manufacturers of medical products. Scientists paid by commercial entities

produce scientific evidence in favor of the sponsor. Educators act as an extension of industrialmarketing. Clinicians rewarded by pharmaceutical and medical equipment companies introduce

expensive procedures. Politicians achieve and keep their positions by helping the medical industry.

Thanks to the financial ties of key protagonists in the medical system, new technologies are

introduced without proper evaluation of their efficiency and safety. Modern pharmacotherapy is agood example. Medication is prescribed excessively in cases where it is useless or has minimal

effect, and causes more and more harm. Instead for being useful in curing disease, it is promoted for

lifelong treatment. In the search for drug markets, definitions of disease are extended and newclinical entities are "invented". Looking for individuals who are at health "risk" (screening), in orderto make them eligible for pharmacological intervention, is a growing tendency.

Aided and abetted by medical professionals who experience the conflict of interest, modernmedicine is treating more and more healthy people, diverting limited resources from those who

really need medical care.

1. INTRODUCTION

In the last few decades growth of biomedical research and new legislation has led to

intensified collaboration between medicine and industry. Industrial financing creates divided

loyalties within each of the main actors in medicine and health care. This paper deals with

harmful effects and key protagonists of the conflict of interest in medicine. The phenomenonwill be analyzed on the case of pharmacotherapy, which makes a big and important part of the

medical science and practice.

2. MODERN PHARMACOTHERAPY

In the past, medication has, no doubt, contributed to the improvement of human health and

the prolongation of life. However, in the last few decades there has been no breakthrough in

pharmacotherapy which can be compared to invention of penicillin or insulin. We have not

seen a really new class of antibiotics for a long time; last significant advancements in cancer

treatment happened 30 years ago; there is no evidence that new antidiabetics are any better


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than those we used in the eighties; new antihypertensives and antidepressants are equally

effective as those we had 50 years ago.

Health indicators confirm it. In case of cardiovascular disease, reduction in morbidity and

mortality is modest and only partly can be attributed to medication. Cancer rates stagnate

small progress is made mostly thanks to the early detection. Medicine has not succeeded in

eradicating chronic conditions such as diabetes, asthma, allergies, rheumatism, Parkinson'sand Alzheimer's disease. It still has no answer to the viral diseases from AIDS to influenza.

This is what Ivan Illich wrote in the seventies: "Medicine cannot cure cardiovascular diseases,

most cancers, arthritis, advanced cirrhosis, or the common cold".1 It seems that nothing has

changed since then. The most contemporary pharmacotherapy can do is to alleviate the

symptoms of disease and postpone its complications, which often requires lifelong treatment.

It is so in spite of the fact that pharmacotherapy is being increasingly prescribed and more

and more people are taking drugs. One fourth of the adult population or almost one half of

those older than 55 are treated for chronic diseases in the European Union.2 The medicines

that consume the majority of the ever growing drug budgets are antihypertensives (blood

pressure lowering drugs) and hypocholesterolemics (cholesterol lowering drugs). Quite near

the top are antidiabetics, antidepressants, antineoplastics and drugs for osteoporosis. What is

the actual effectiveness of these most prescribed medicines?

Clinical trials show that in the group of older people and cardiovascular patients,

antihypertensives and hypocholesterolemics reduce the rate of heart attack and stroke from

approximately 4 % to 2.5-3 % per year, i.e. about 80 patients must be treated to prevent one

cardiovascular event per year. In the younger and healthy population, reduction of unwanted

events will be from about 0.8 % to 0.5 %, i.e. it will take a few hundreds of treated people per

year to prevent one heart attack or stroke.3 As for antidiabetics, strict pharmacological

regulation of blood sugar saves one complication of diabetes in 200 treated patients per year. 4

Antidepressants, except for the severe depression, are equally efficient as the placebo.5

Chemotherapy works for some relatively rare types of tumors, notably hematologic, while themost common cancers, such as the carcinoma of the lungs, stomach or intestine, are resistant

to pharmacotherapy.6 The effect of drugs for osteoporosis on the only really relevant bone

fracture the hip fracture, in clinical trials was below statistical significance.7

What about the cost-effectiveness of drugs? Due to high prices and excessive prescribing,

in the typical case cardiovascular events are, according to the calculations made in Great

Britain, prevented at the cost of approximately 120 000 .8 As for the oncology, in the final

1 Illich, I. 1974. Medical Nemesis. London, Calder & Boyars.2 European Commission. 2007. Health in European Union. Brussels, European Commission. Available:

http://ec.europa.eu/health/ph_publication/eb_health.en.pdf3

Gajski L. 2009. Lijekovi ili pria o obmani [Medicaments or a matter of deception]. Zagreb, Pergamena. (inCroatian).

4 UK Prospective Diabetes Study (UKPDS) Group. 1998. Intensive blood-glucose control with sulphonylureas orinsulin compared with conventional treatment and risk of complications in patients with type 2 diabetes(UKPDS 33). Lancet, 352, 837-53.

5 Kirsch I, Deacon BJ, Huedo-Medina TB, et al. 2008. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PloS Medicine, 5(2), e45. Available:

http://medicine.plosjournals.org/perlserv/?request=get document&doi=10.1371%2Fjournal.pmed.00500456

Moss RW. 1995. Questioning chemotherapy. New York, Equinox Press.7

Cranney A, Wells G, Willon A, et al. 2002. II. Meta-analysis of alendronate for the treatment ofpostmenopausal women. Endocrine Reviews, 23, 508-16.

8Marshall T. 2003. Coronary heart disease prevention: insights from modelling incremental cost effectiveness.

British Medical Journal, 327, 1264-7.


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year of life of the cancer patient 38 000 USD is spent on chemotherapy, which is more or less

useless.9 The main problem in this context is that older drugs are being replaced with the new

ones, equally effective, but much more expensive.

How safe is a modern pharmaceutical product? Here are some of the agents withdrawn

from the market mostly for lethal complications terphenadine (antiallergic), troglitazone

(antidiabetic), phenfluramine (weight reduction), astemizole (antiallergic), grepafloxacin(antibiotic), bromfenac (antirheumatic), mibefradil (antihypertensive), alosetron

(antidiarrhoic), cisapride (stomach and bowel motility regulator), cerivastatin

(hypocholesterolemic), rofecoxib (antirheumatic), sibutramine (weight reduction),

rosiglitazone (antidiabetic). The real insight into the harm produced by the medication does

not exist. Health statistics data do not reflect the real situation, because only a fraction of the

side effects of drugs is reported. The scientists who were actively researching this issue came

up with the number of 106 000 hospital deaths from drug toxicity per year in the USA, which

makes drugs one of the leading causes of death in this country.10

Considering all this, we might conclude that a modern drug is characterized by modest

effectiveness, high prize and considerable toxicity. What is the reason we do not have better

medicinal products? How come they possess the image of the excellent quality good and what

is the secret of their ever increasing sale and market success?

The answer is in the conflict of interest.

3. CONFLICT OF INTEREST AND ITS KEY PROTAGONISTS

Conflict of interest is defined as a conflict between the professional responsibility and the

personal interest, of the individual in the position of confidence. It is the situation in which

two duties, i.e. values are confronted the primary, professional duty (in medicine the one to

the patient and the society), and the secondary, personal interest (mostly financial, but also

academic promotion, scientific rewards etc.). In such a setting, a person may act according to

his/her personal, and not the public interest, and this is too often a case. What goes for theindividual conflict of interest, applies to the institutions as well.

The conflict of interest in medicine has been actualized in the last few decades, with the

increasing interaction and cooperation between medical professionals and the industry.

Starting in the eighties with the specific legislation passed during Reagan era in the USA,

private enterprise has quickly penetrated and spread within the vital segments of medicine.

Through the partnership with companies which produce drugs and other diagnostic and

therapeutic equipment, key protagonists of the medical system found themselves in the

position of divided loyalties.

Let's start with the driving force of the phenomenon the pharmaceutical industry.

3.1. PHARMACEUTICAL INDUSTRY

What is the interest in drug business? Enormous. Estimations are that the global

pharmaceutical market is worth almost seven hundred billion USD a year. The revenue of

today's ten top corporations amounts more than 280 billion USD.11 World's company No. I,

9Gottlieb S. 2001. Chemotherapy may be overused at the end of life. British Medical Journal, 322, 1267.

10Lazarou J, Pomerantz BH, Corey PN. 1998. Incidence of adverse drug reactions in hospitalized patients.Journal of the American Medical Association, 279, 1200-5.

11Consumers International. 2007. Drugs, doctors and dinners. London, Consumers International. Available:http://www.consumersinternational.org/shared_asp_files/GFSR.asp?NodeID=97128


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Pfizer, is financially more powerful than Sweden, and Glaxo-Smith-Kline can compare to

Croatia. The most successful drugs, the blockbusters, bring in several billion USD per year.

Although the rise of the profit has slowed down a bit in the last few years, since the beginning

of the last century the investment in the pharmaceutical sector has been steadily increasing. So

is the value of shares and the salaries of the management. Chief executives of bigger

companies earn around 70 million USD a year.12

In order to keep their lucrative positions, thecorporation managers must fulfill the expectations of the shareholders and investors. For the

sales to keep going up, new products and new markets are needed. A good and useful

commodity sells easily by itself. In order to sell the product of the characteristics earlier

described, much more effort is needed. The manufacturer has to engage in the scientific

research, medical education, health politics, media and the patients' groups.

In the last few decades pharmaceutical industry has overtaken the most of the applied

medical research. In 1980 it was sponsoring 32 % of biomedical research in the USA (the

remainder was financed by academic institutions). By 2000, pharmaceutical participation had

grown to 62 %.13 Similar trends are present in the rest of the world. Numerous evidence and

affairs show that industry manipulates the results of the drug studies to make their products

look better than they really are. Studies that have analyzed the relationship between outcomesof the studies and their sponsorship found that those financed by the pharmaceutical

companies are four to five times more likely to produce results in favor of the sponsor,

compared to studies financed by other sources.14 By demonstrating "efficiency" of drugs,

clinical trial, as well as observational and fundamental studies, increase indications for the

medicines and enlarge boundaries of disease, which are spread into the areas of mild or

temporary discomfort. In the same way new clinical entities which "require" medication are

created, e.g. osteoporosis or menopause.15 With the help of the risk factor concept, millions of

healthy people are turned into patients liable for lifelong treatment in order to prevent future

disease.16

In industrially sponsored research, scientists are technicians who receive partial access todata, hired solely to give legitimacy to the scientific product.17 The masters are marketing and

PR experts. They decide not only how the study will be performed and presented, but what

will be studied in the first place. And when marketing determines the subject of the research,

it has little to do with the public interest and welfare. It only has to do with money. 18 Hence

one more useless hypocholesterolemic and antidiabetic is "invented" rather than performing

12 Angell M. 2004. The truth about the drug companies: how they deceive us and what to do about it. New York,Random House.

13 Bekelman JE, Li Y, Gross CP. 2003. Scope and impact of financial conflict of interest in biomedical research:

a systematic review. Journal of the American Medical Association, 289, 454-65.14

Bekelman JE, Li Y, Gross CP. 2003. Scope and impact of financial conflict of interest in biomedical research:a systematic review. Journal of the American Medical Association, 289, 454-65; Lexchin J, Bero LA,Djulbegovic B, et al. 2003. Pharmaceutical industry sponsorship and research outcome and quality: systematicreview. British Medical Journal, 326, 1167-70; Als-Nielsen B, Chen W, Gluud C, et al. 2003. Association offunding and conclusions in randomized drug trials. Journal of the American Medical Association, 290, 921-8.

15 Moynihan R, Heath I, Henry D, et al. 2002. Selling sickness: the pharmaceutical industry and diseasemongering. British Medical Jourmal, 324, 886-91.

16Gajski L. 2009. Lijekovi ili pria o obmani [Medicaments or a matter of deception]. Zagreb, Pergamena. (inCroatian).

17Bekelman JE, Li Y, Gross CP. 2003. Scope and impact of financial conflict of interest in biomedical research:a systematic review. Journal of the American Medical Association, 289, 454-65.

18Angell M. 2004. The truth about the drug companies: how they deceive us and what to do about it. New York,Random House


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long-term and unpredictable research into the cause of the disease, natural remedies, non-

pharmacological interventions, or truly effective pharmaceuticals including those for the

diseases of the Third World.

Since physicians are their main "buyers", in order to sell drugs pharmaceutical industry had

to overtake the medical education as well. By means of continuing medical education and

medical journals various topics are offered to clinicians, but the most consumed are thosesponsored by drug companies. It is because such educational activities and literature are free;

moreover, they come along with the lunch, gift or attractive trip.19 When professional

education is performed without defined curriculum enabling diverse and balanced offer of

various topics relevant for clinical practice, which is the case today, the most energetic and

aggressive distributor of the medical information prevails. Result physicians supplied with

mainly corporative information, unaware of the fact that it is biased and much closer to

marketing than to education.

The same thing happens with the medical education of the patients and the public at large.

By means of PR (public relations) and the media, pharmaceutical industry, as the main

deliverer of medical information, aggressively promotes drugs and illnesses.20

Politics is the place where the destiny of drugs is determined for the most part. That is why

drug manufacturers have powerful lobbies influencing legislature. Law which enabled direct

advertising of prescription drugs (USA) and laws which allowed drug patent extension are

some of their successes.21 Pharmaceutical industry has its advocates in the very top of the

executive, for example Bush family, or former German chancellor Helmut Kohl.22 It has

penetrated drug agencies and other state regulatory institutions where its exponents have

succeeded in loosening the standards of drugs' safety and in the acceleration of the approval

procedure.23 There is evidence that pharmaceutical companies corrupt judiciary as well.

Today, drug industry business projects are carried out as political projects, implemented on

the national and international level with the help of the political institutions; examples

introduction of preventive medication programs, vaccination programs, clinical practiceguidelines which generally promote expensive pharmacotherapy, etc.

Chasing profit and growth, pharmaceutical industry has simply co-opted, devoured all the

collaborative individuals and institutions, creating a gigantic complex in which at the end all

from the scientists to the patients, consciously or unconsciously work for its benefit.

3.2. PATIENTS, JOURNALISTS, PHYSICIANS AND PHARMACISTS

The most unknowing and the least "guilty" assistants of the drug industry are the patients.

By asking their doctor for a new medicine they have heard of in the media, by advocating for

drugs to be included in the reimbursement list or by participating in the health awareness

campaigns, they are convinced that they are doing good for themselves and for other people.

The leaders of the patients' organizations, yet, may not be so sure about it, since they knowwho pays for their activities and who designs them. Pharmaceutical industry is the main

19 Consumers International. 2007. Drugs, doctors and dinners. London, Consumers International. Available:http://www.consumersinternational.org/shared_asp_files/GFSR.asp?NodeID=97128

20Moynihan R, Cassels A. 2005. Selling Sickness. New York, Nation Books.

21Angell M. 2004. The truth about the drug companies: how they deceive us and what to do about it. New York,Random House.

22 Levine B. Eli Lilly, Zyprexa, & the Bush family. May 2004. The diseasing of our malaise. Z Magazine Online.Available: http://zmagsite.zmag.org/May2004/levine0504.html

23 Abraham J. 2002. The pharmaceutical industry as a political player. Lancet, 360, 1498-502.


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sponsor, sometimes even a founder of the patients' organizations today. Its donations to a

commercially attractive disease patients' group can reach several million USD per year. In

such a setting, patients' organizations turn into prolonged arm of the industry, very successful

tool for drug and disease marketing and for the lobbying against the restrictive health

politics.24

Journalists, no doubt, bear responsibility for the fact that medical industry abuses themedia. Too often, reporting about medical issues is being used for drug marketing. However,

journalists are not medical experts and they mainly only transmit the information they get

from the medical professionals. Sometimes they do not even see articles, which come directly

from the PR agency into the hands of the editor. There, in the editorial boards of the media

and among the heads of the journalists' associations, the conflict of interest really takes place.

It is there that meeting corporate needs (corporations are often the hidden owners of the

media) has replaced the professionalism and veracity.

Prescribers of the drugs are in the center of attention of the pharmaceutical industry. So are

the pharmacists. Drug companies spend several dozen thousand USD a year on each

physician.25 Taking gifts from the industry has become normal, even expected part of their

communication. Physicians do not ask themselves what the reason for the hospitality is and

do not feel bribed because they are convinced they are doing the best for their patients.

Because of the lack of the truthful information, they are not aware that they are prescribing

worthless and overrated substances and have no insight into the fact that they are doing harm;

by spending on useless, expensive medication, they are depriving sick people of the medical

interventions that really help.

3.3. MEDICAL EXPERTS AND POLITICIANS

Not being aware is not the case with the experts. Academic clinicians and pharmacologists

know, or should know exactly what sort of products they recommend and support. A leading

medical specialist is the main authority and arbiter in all the matters concerning drugs. Heembodies many different roles he is the leader of the research project, reviewer of the

scientific paper, member of the editorial board of the journal, graduate and postgraduate

educator, creator of the clinical practice guidelines which affect global medical practice,

author of the drug expertise for the regulatory agency and the health insurance, consultant for

the health authorities, expert witness in court and the source of medical information for the

media, i.e. public. As opinion makers, leading professionals are extremely valuable to drug

industry. In all the areas mentioned, it establishes more or less visible ties with them. And for

the experts, it really pays off. Main researchers make approximately 200 000 USD per clinical

trial, 10 000 for a scientific paper and a few thousand per lecture.26 Who would resist such

collaboration? That is why 90 % of authors who publish in medical journals are financially

tied to the industry.27

If the work is done according to the sponsor's expectations, the expert isengaged for the future projects which not only bring more money, but also foster professional

career, prestige and power. In such a setting, insisting on the research integrity and education

24 Herxheimer A. 2003. Relationships between the pharmaceutical industry and patients' organizations. BritishMedical Journal, 326, 1208-10.

25Gagnon M-A, Lexchin J. 2008. The cost of pushing pills: a new estimate of pharmaceutical promotionexpenditures in the United States. Plos Medicine, 5(1), e1. Available:http://medicine.plosjournals.org/perlserv/?request=getdocument&doi=10.1371/journal.pmed.0050001

26 Elliot C. 2001. Pharma buys a conscience. American Prospect. 24 Sep 2001. Available:http://www.mindfully.org/GE/GE3/Pharma-Buys-Conscience.htm

27 Healy D. 2003. Is academic psychiatry for sale? British Journal of Psychiatry, 182, 388-9.


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credibility means letting someone else take the place. Academic clinicians are the hostages of

the industry, not only because of the present and future ties. Their past binds them to the drug

industry as well. Considering the lack of public money for research and education, the usual

way to obtain the academic title in clinical medicine is by means of the industrial support. In

the academic clinical medicine there are hardly any independent individuals who could

research, teach and talk about illnesses and therapy in an unbiased, objective way. Today'sclinical professors are not only paid by the industry, they are made by the industry. And they

cannot be anything but its servants.28

However, above the profession, there is almighty politics which eventually governs all the

segments and aspects of life. As for the conflict of interest, politics is its birthplace. Too often

politicians prefer to meet the needs of the corporations who enable them to seize or keep

political power, over the needs of the people. Pharmaceutical industry is one of the major

sponsors of the political parties' election campaigns.29

3.4. PRIMARY VS. SECONDARY INTEREST

The idea and the philosophy of the private enterprise is earning money. It is expected to do

whatever it takes to make profit, even if it includes manipulation and corruption, which are

quite common in the business world. Fifty years ago it was possible to cure disease and earn

money at the same time. Meanwhile, thanks to the greed of the owners, i.e. shareholders and

the passiveness of the medical profession and public institutions, pharmaceutical industry has

grown to huge dimensions. On today's level of expansion there are not enough sick people to

be treated. In order to make profit, industry not only must not cure illnesses, but has to keep

them and artificially produce new ones.30 And it is only logical and expected, because treating

disease is not the prime duty of the drug industry. Its principal obligation is the one towards

shareholders. Profit is the primary interest of the company as it is the synonym of its very

existence. Split between treating people and its own survival it actually has no choice.

Because of its aggressive and corruptive methods many accuse drug industry of being themost selfish and arrogant of all industries; it was nicknamed "Big Pharma", which is a

synonym for greed and unscrupulousness. However, drug industry practice is almost

legitimate; it could even be exculpated and amnestied. To blame it for what is happening is

wrong and unproductive. It is the easiest to say: it is pharmaceutical industry's responsibility.

That way the source of the problem is placed beyond our reach, in the private enterprise

domain, inaccessible both to the government and the citizens.

The real culprits are those without whom the industry could not function its accomplices

in the medicine and politics. And their duty and responsibility is very different from the one

of the industry. We are talking about the civil servants paid by the public money, whose

primary interest the welfare of the patients and the society, is indisputable and

unquestionable. However, dragged into the conflict of interest, they choose the secondary one,their own benefit. They let the private business buy and instrumentalize them for its purposes.

It is about the witting abdication of the entrusted social role and joining those who pay more.


29Brown S. 28 Jan 2004. The Medicare Index. New York Times. Available:http://www.medicalconsumers.org/pages/TheNewMedicareLegislationinContext.html



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LiteratureAbraham J. 2002. The pharmaceutical industry as a political player. Lancet, 360, 1498-502.

Als-Nielsen B, Chen W, Gluud C, et al. 2003. Association of funding and conclusions in randomized drug trials.Journal of the American Medical Association, 290, 921-8.

Angell M. 2004. The truth about the drug companies: how they deceive us and what to do about it. New York,Random House.

Bekelman JE, Li Y, Gross CP. 2003. Scope and impact of financial conflict of interest in biomedical research: a

systematic review. Journal of the American Medical Association, 289, 454-65.

Brown S. 28 Jan 2004. The Medicare Index. New York Times. Available:http://www.medicalconsumers.org/pages/TheNewMedicareLegislationinContext.html

Consumers International. 2007. Drugs, doctors and dinners. London, Consumers International. Available:http://www.consumersinternational.org/shared_asp_files/GFSR.asp?NodeID=97128

Cranney A, Wells G, Willon A, et al. 2002. II. Meta-analysis of alendronate for the treatment of postmenopausalwomen. Endocrine Reviews, 23, 508-16.

Elliot C. 2001. Pharma buys a conscience. American Prospect. 24 Sep 2001. Available:http://www.mindfully.org/GE/GE3/Pharma-Buys-Conscience.htm.

European Commission. 2007. Health in European Union. Brussels, European Commission. Available:http://ec.europa.eu/health/ph_publication/eb_health.en.pdf.

Gagnon M-A, Lexchin J. 2008. The cost of pushing pills: a new estimate of pharmaceutical promotionexpenditures in the United States. Plos Medicine, 5(1), e1. Available:http://medicine.plosjournals.org/perlserv/?request=getdocument&doi=10.1371/journal.pmed.0050001

Gajski L. 2009. Medicaments or a matter of deception. Zagreb, Pergamena. (in Croatian)

Gottlieb S. 2001. Chemotherapy may be overused at the end of life. British Medical Journal, 322, 1267.

Healy D. 2003. Is academic psychiatry for sale? British Journal of Psychiatry, 182, 388-90.

Herxheimer A. 2003. Relationships between the pharmaceutical industry and patients' organizations. BritishMedical Journal, 326, 1208-10.

Illich, I. 1974. Medical Nemesis. London, Calder & Boyars.

Kirsch I, Deacon BJ, Huedo-Medina TB, et al. 2008. Initial severity and antidepressant benefits: a meta-analysisof data submitted to the Food and Drug Administration. PloS Medicine, 5(2), e45. Available:

http://medicine.plosjournals.org/perlserv/?request=getdocument&doi=10.1371%2Fjournal.pmed.0050045

Lazarou J, Pomerantz BH, Corey PN. 1998. Incidence of adverse drug reactions in hospitalized patients. Journalof the American Medical Association, 279, 1200-5.

Levine B. Eli Lilly, Zyprexa, & the Bush family. May 2004. The diseasing of our malaise. Z Magazine Online.Available: http://zmagsite.zmag.org/May2004/levine0504.html.

Lexchin J, Bero LA, Djulbegovic B, et al. 2003. Pharmaceutical industry sponsorship and research outcome andquality: systematic review. British Medical Journal, 326, 1167-70.

Marshall T. 2003. Coronary heart disease prevention: insights from modelling incremental cost effectiveness.

British Medical Journal, 327, 1264-7.

Moss RW. 1995. Questioning chemotherapy. New York, Equinox Press.

Moynihan R, Cassels A. 2005. Selling Sickness. New York, Nation Books.

Moynihan R, Heath I, Henry D, et al. 2002. Selling sickness: the pharmaceutical industry and diseasemongering. British Medical Jourmal, 324, 886-91.

UK Prospective Diabetes Study (UKPDS) Group. 1998. Intensive blood-glucose control with sulphonylureas orinsulin compared with conventional treatment and risk of complications in patients with type 2 diabetes(UKPDS 33). Lancet, 352, 837-53.

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Gajski Conflict of Interest in Medicine