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Social Science & Medicine 62 (2006) 15101519 www.elsevier.com/locate/socscimed

Empirical uncertainty and moral contest: A qualitative analysis of the relationship between medical specialists and the pharmaceutical industry in Australia
E. Dorana,, I. Kerridgeb, P. McNeillc, David Henrya

Discipline of Clinical Pharmacology, School of Medical Practice and Population Health, University of Newcastle, New South Wales, Australia b Centre for Values Ethics and the Law in Medicine, University of Sydney, New South Wales, Australia c School of Public Health and Community Medicine, University of New South Wales, New South Wales, Australia Available online 6 September 2005

Abstract Alliances between the medical profession and the pharmaceutical industry have become increasingly widespread in recent years. While there are clearly benets for doctors and their patients derived from the medical profession working with industry, concern has arisen that the commercial imperative of industry may conict with physicians independence and professional integrity. This paper reports the ndings of an in-depth interview study with 50 Australian medical specialists undertaken to explore how and why they interact with the pharmaceutical industry and to gain insight into specialists moral evaluation of the relationship and its consequences. Analysis of the qualitative data led to the categorizing medical specialists into three typesCondent Engagers, Ambivalent Engagers and Avoidersbased on their descriptions and evaluations of their relationship. The majority of interviewees believed that some relationship with the pharmaceutical industry was inevitable, that there were both risks and benets associated with the relationship and that as individuals they were competent in minimizing the risks and maximizing the benets. However, their views diverged on the extent and magnitude of the risks and benets. The data suggested that there is considerable variance in specialists judgments of what constituted appropriate industry largesse. Specialists relationship with the pharmaceutical industry has inherent tensions that are managed by different doctors in different ways. Moral evaluation of the relationship and its consequences varies and the ethical concerns surrounding the relationship appeared as an area of contest. The ndings suggest that in developing normative guidelines for academic and professional practice, policy makers should recognise and account for the complexity of the relationship and for the variation in medical specialists views and feelings. r 2005 Elsevier Ltd. All rights reserved.
Keywords: Pharmaceutical promotion; Conict of interest; Australia

Corresponding author. Department of Clinical Pharmacol-

ogy, Newcastle Institute of Public Health, Level 5, Medical Sciences Building, Newcastle Mater Hospital, Waratah NSW 2298, Australia. Tel.: +61 2 49211727; fax: +61 2 496088. E-mail address: evan.doran@newcastle.edu.au (E. Doran).

The last two decades have witnessed a rapid expansion in the number and variety of alliances between the medical profession and the pharmaceutical industry. Many of these alliances are necessary and inevitable,

0277-9536/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2005.07.037

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often delivering substantial benets for therapeutics, education and research. However, the potential for the relationship to also undermine the interests of the profession, patients and public alike has generated considerable public and professional unease (Coyle, 2002; Dana & Lowenstein, 2003; Gibbons et al., 1998; Lexchin, 1993; Lexchin, Bero, Djulbegovic, & Clark, 2003). The central ethical concern is that collaboration between health professionals and the pharmaceutical industry may serve the commercial objectives of industry or the acquisitiveness clinicians, more than legitimate health, educational or research goals. This concern is most manifest where profession and industry interaction involves largesse ostensibly offered by industry as a promotional supplement to continuing education or informational activities. The ubiquity of gifts and the dependence on industry sponsorship for individual and collegiate education are considered to potentially impair the independence, scientic rigor or clinical judgment of physicians. Any distortion of the primary ethical obligations of health professionals to their patients could erode public condence that treatments are prescribed only when necessary, based on sound clinical judgment unaffected by inappropriate inuences. The potential ethical problems posed by the relationship have prompted governments, industry bodies and professional and academic bodies to develop normative guidelines for professional practice (e.g. Royal Australasian College of Physicians, 2003; American College of Physicians, 1998). Ethical concerns have also increased research interest in physicians attitude to and interactions with the pharmaceutical industry (Chew et al., 2000; Brett, Burr, & Moloo, 2003; Madhavan, Amonkar, Elliott, Burke, & Gore, 1997; Reeder, Dougherty, & White, 1993; Steinman, Shiplak, & McPhee, 2001; Wanzana, 2000). However, the development of guidelines and the focus of research reect only limited recognition of the commonplace conditions and process of physician/ industry interaction or of the subjective meanings given to the relationship by individual physicians. Surprisingly, given the concern to understand and modify physician behaviour, few studies of the relationship have used qualitative methods such as ethnographic interviews. This is a major omission as qualitative methods are particularly suited to exploration of the meanings that individuals attach to their experiences and actions and to identication of the values and the moral norms that determine behaviour and decisions (Pope & Mays, 1995; Rice & Ezzy, 1999). To address this methodological omission, this qualitative study undertook in-depth interviews to understand how and why medical specialists interact with the pharmaceutical industry and gain insight into specialists moral evaluation of the relationship and its consequences.

Methods Sample This study was part of a larger study in which Australian medical specialists were surveyed on their relationship with the pharmaceutical industry. In the larger study a questionnaire was mailed to 2120 specialists; specialists with minimal prescribing responsibility e.g. surgeons, anesthetists were excluded. Eight hundred and twenty-three specialists completed the survey (overall response rate 39%). Fifty medical specialists were drawn from respondents to the questionnaire who indicated a willingness to be interviewed (n 273). The interview sample was a convenience sample of specialists able to be interviewed within the study time frame. Efforts were taken to ensure the sample included at least one participant from all medical specialties available among willing respondents represented in the larger study (Table 1); specialists from all Australian States and Territories; urban and regional based specialists; and included both female and male medical specialists. The study was approved by the University of Newcastle Human Research Ethics Committee. Data collection Four trained interviewers conducted semi-structured interviews by telephones. The interviews were guided by an interview schedule consisting of open-ended questions designed to elicit specialists experiences with and views about their relationship with industry. The interviews sought data on the types of interaction specialists have with industry, what they believed resulted from their interaction, how this was evaluated and how they
Table 1 Specialty Cardiology Dermatology Endocrinology Gastroenterology General Phys. Geriatric Infectious disease Medical Oncology Neurology Paediatric Psychiatry Renal Respiratory Rheumatology Total N 2 1 2 2 5 1 1 3 2 5 13 5 3 5 50

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felt about the relationship with industry in general. Interviewees were advised that the study did not assume any moral position and were encouraged to openly express their views on the relationship. The majority of interviews lasted between 20 and 30 min. With the permission of interviewees, all interviews were recorded by TelstraTM and were subsequently transcribed verbatim. Analysis The interview data were qualitatively analysed following the version of Grounded Theory developed by Strauss and Corbin (1998) an interpretive methodology employing inductive reasoning to identify and relate emergent themes. The units of analysis were the concepts (words grouped together that represent ideas, objects, events or actions) that appeared in interviewees descriptions of their relationship with and views about industry. Segments of interviewees talk were coded according to the concept each segment was interpreted as representing. Coded segments of text were compared for similarities and differences of ideas, events and actions and then categorised. Categorisation followed four axes: action/interactionwhat was described as occurring in the relationship; consequenceswhat was described as resulting from the relationship; conditions what was described as shaping what occurs in and what results from the relationship; and recommendations what was described as should occur in and result from the relationship. Categorised concepts were subjected to theoretical questions, such as what is the relationship of one concept or category to another? Relationships between concepts were also explored to identify the connections between contextual factors and the actions and views of individuals and to identify the major, recurrent themes (Strauss & Corbin, 1998). Code development was undertaken by two researchers with regular consultation with the research team. The coding scheme was applied by two coders to the same 25 interviews and then compared for consistency of coding. Once reliability was established the remaining 25 interviews were coded by a single coder (ED). Categorisation and relating of concepts and identication of major themes was undertaken through presenting data to, and discussion among, the research team.

involve exchange, was believed to be always accompanied by promotion and was felt to always require some degree of management by the doctor involved in the interaction. The consequences of the relationship were acknowledged to include both risks and benets. The conditions described as shaping the relationship included the imperatives of the market, the need for continuing medical education, limited sources of support available for education, maintenance of professional expertise and ethics. Recommendations for the relationship ranged from a laissez-faire leave-it-toindividuals approach to more interventionist calls for greater scrutiny and regulation. Interviewees were categorised into three types on the basis of how they described their interactions with industry. These types are used heuristically as a basis to discuss the major emergent themes about the relationship and to highlight where actions and views diverge and converge. Interviewees who described a tendency to eschew direct contact with industry were categorised as Avoiders (n 5). Those who described actively engaging with industry in order to access what they considered to be benets available from this interaction were categorised as Condent Engagers (n 25). Those interviewees who described engaging with industry with a degree of reluctance or unease were categorised as Ambivalent Engagers (n 20). While this categorisation delineated differences between interviewees, there remained considerable convergence of opinion on many of issues surrounding the relationship between doctors in each category.

Avoiders A minority of interviewees (10%) described a tendency to avoid contact with industry as much as possible, although as the quote below suggests, it is difcult to avoid the proliferation of industry promotional objects and advertisements. I dont see drug company reps nowadaysyI just dont have anything with drug company things written on ity. Interviewee #34 For the Avoiders, interaction with industry involves an inappropriate exchange of specialists potential product preference for industry information and material support. For these specialists interaction with industry is synonymous with promotion from industry and underlying any exchange there is always an agenda. I personally dont see any representativesyI try to avoid any sponsored meetings ytheres always an agenday. Interviewee #6

Results The interviewees described a range of experiences with and views about the pharmaceutical industry. While there was consensus on some issues there was also considerable difference on others. A number of major themes emerged along each of the axes used to analyse the data. Interaction with industry was held to inevitably

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Im actually fairly circumspect about dealing with the drug industryy I dont see drug reps at all. I think [it] tends to subtlely steer peopley. Interviewee #23 For Avoiders, the fact that the pharmaceutical industrys intention is to inuence their prescribing practice renders the relationship ethically awry. Interaction means exposure to detailing or promotion, practices concerned primarily with generating sales and prot and less concerned with scientic objectivity or clinical necessity. This group of specialists believed that in seeking to inuence clinical practice, the industry is likely to derive greater benet from any interaction with doctors and may seek to not only inuence but to co-opt or corrupt specialists in pursuing its own ends. yideally the health consumers and the health profession would be exploiting the drug (companies) rather than being exploited by themy. Interviewee #34 yits just corruptionyIts hidden because everybody does well out of itycompanies do well out of it because they get greater sales and we do well out of it because we get goodiesy. Interviewee #45 For the Avoiders, exchange is the medium of the interaction. The information provided by industry is intended to persuade through distortion of potential risks and benets. The material support for practice, education and research is intended to induce obligation. And for this group of specialists persuasion and obligation were inappropriate mechanisms for securing doctors product preference. ythe basic point of drug reps coming to see one is to promote their drug. They often do so not so much [by] lying, but by distortiony. Interviewee #6 Avoiders were also skeptical of the quality of information provided by industry, believing it to be biased and consequently of little value and characterizing it as pseudo-scientic salesmanship Interviewee #34. ydrug company visits, [are] very much a marketing ployycontributing absolutely nothing whatsoever to my professional knowledge. Interviewee #6 I see it as a waste of time, having any interactionyin terms of them trying to tell me about a drug that they want to og. I dont tend to believe what they say, Im happier sourcing my own information about new drugs. Interviewee #46 And for the Avoiders, awareness of the bias of pharmaceutical industry information is insufcient protection against the harms of the interaction as there remains the potential to be subliminally inu-

enced; a potential they believed is often underestimated by specialists. ythere could be subtle things on one practicey most doctors say theyre not inuenced by exposure, but in fact, they are because a lot of it (is) subliminaly. Interviewee #6 Advertising affects people who are arrogant enough to think it doesntywhich I think involves most of the medical profession. Interviewee #45 For this group of specialists the gifts (e.g. pens, stationery, bottles of wine) and other minor largesse (trimmings such as events held in attractive venues, subsidized travel and accommodation) that often accompany the provision of information and education were manifestations of the industrys agenda and emblematic of the inappropriateness of the majority of industry promotion. For this group, regardless of the monetary value of the inducement, doctors should not prot or be perceived as proting from their product preference. A companys pen or note pad could be the thin edge of the wedge. ytheres no free lunchytheyre going to expect something from mey. Interviewee #6 ytheyre straight out bribes. Theyre trying to inuence the way you prescribe and I dont see much difference between a pen and a paid-for trip and a hotely. Interviewee #46 For the Avoiders, directly interacting with industry created a signicant personal difculty because they believed it implicitly endorsed the industrys agenda and methods. I think also, it encourages them too to an extent. I mean, Im only one little pebble in a big beachy one has to have one own standards. Interviewee #6 Im trying to in my own, one person way, to discourage them from doing that to others as well. Not that one person can have any inuence, but still, youve got to try. Interviewee #45 For these specialists, promotion must effectively serve the industry agendathe obviousness of this being manifest in its persistent and pervasive use and the expenditure that industry devotes to it. Indeed, the belief in the effectiveness of industry promotion was expressed by Avoiders as a proposition that holds cogent intuitive force. ythe drug companies put all this money into promotion because it worksy. Interviewee #34 ythey wouldnt spend those squillions on it if there wasnt (an effect)y. Interviewee #45

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For the avoiders, the risks of interacting with the pharmaceutical industry are greater than any benets that may be derived from that interaction. Receiving information and accepting largesse may inappropriately inuence treatment preference through persuasion and obligation. Avoidance satises these specialists sense of ethical responsibility by minimising exposure to these mechanisms of inuence, mechanisms that are effective despite the expertise and awareness of specialists. And even if interaction does not empirically inuence an individuals practice, interaction is still best avoided as it may tacitly endorse promotional practices. These are tangible harms, harms that greatly outweigh the benet of information devalued by commercial bias. Condent engagers The largest group (n 25) was classied as condent engagers. These specialists typically described themselves as engaging with industry in the belief that the relationship between themselves and the pharmaceutical industry is essentially sound and benecial and can be effectively managed to maintain benets to both parties. ymy general philosophy about relations with drug companies is that its mutually benecialy. Interviewee #1 I see it as a symbiotic structure whereby they need myself and other doctors around townyand I can sort of utilise their nancial resources toyfacilitate better medical educationy. Interviewee #20 The view of these doctors is that interacting with industry presents an opportunity for exchange from which both parties, and ultimately patients, may benet. These specialists engaged with industry in a number of roles: as a clinician, researcher, and teacher; as an attendee at a medical education seminar or conference; as a presenter at company sponsored events, and as an organiser of such an event who has sought industry support. yIve had regular contacts with the repsy [I] was taken to Prague by [company name] on a sort of conferenceyI also went to a conference sponsored by [company name] in Phuket. Interviewee #16 yIve been offered several overseas trips etcetera, so Ive had lots of involvement with drug companies over time. Interviewee #18 All described engagement with industry as a means of improving their professional practice. For Condent Engagers the motivation for interacting with industry is to access the signicant benets it offers; including information about new products, support for patient

care (e.g. samples or patient literature) and funding for continuing education and research. ytheres clearly very big ethical issues involved in my relationship with drug companies, there are positive factors that outweigh negative factorsyand so thats why Im quite happy to initiate contact about sponsorship for conferencesy. Interviewee #18 ysome of them will offer free samples, which Im happy to use for patients if theyre otherwise faced with a two hundred dollar billy. Interviewee #19 They make all the drugs, governments dont develop drugs, so to ignore them isy futile anywayythe more links you have, the more you can learny. Interviewee #50 The exchange between industry and medical specialists was seen as appropriate and fair, with interviewees regarding material support for education and research as a reasonable exchange for specialists time, clinical experience and advocacy. yIm happy for them to pay us for the time that we spend actually seeing the patients and running the trial because Im obviously not going to do that for lovey. Interviewee #19 yif theyve sponsored a meeting that Ive been toythe least I can do is give them ten or fteen minutes of my time a couple of times a yearyits a trade-off and it has to bey. Interviewee #43 Despite their willingness to interact with industry, a number of specialists expressed an awareness of the potential for conicts of interest in these interactions and the need to maintain ethical standards. ytheres always a potential conict of interestyand if youre aware of the possibility then its able to be counteracted if necessaryytheir interest is in marketing their producty. Interviewee #1 I think medical specialists have to be very conscious ythat it can become a mutual dependency and that at the end of the day, the pharmaceutical industry is concerned with protsy. Interviewee #48 Specialists in this group described a number of management strategies that they employed to reduce the possibility of conicts of interest arising in their interaction with industry. These strategies included: seeing all company representatives in order to achieve a balanced input of biased information; remaining skeptical of company product claims; maintaining an awareness of the potential of largesse to induce obligation; actively challenging claims and demanding further evidence to support them; rejecting offers of

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excessive largesse; demanding control over content of educational events and the insisting on independence and integrity in research. Ive always tried to limit it to something that contains some educational component. I havent ever accepted or participated in any drug deal thats just purely for entertainment of doctors. Interviewee #16 yI obviously realise that its as if theyre selling one type of car or anotheryI think I get a fairly balanced view by listening to a lot of different people. Interviewee #22 Some of the strategies involve the manner of interacting with the representative and the appraisal of the information provided by industry. yI like to think that I can sort of listen to what they say, but also interpretyseparate the chaff from the wheaty put it into the sort of the broader context. Interviewee #26 yI ask lots of questionsyI make them use an evidence base to prove to me the points theyre trying to make. Interviewee #47 Condent engagers tended to acknowledge that promotion accompanies all interaction, but accepted that this was both legitimate and manageable. They believed themselves quite capable of managing the interaction, partly because of their expertise and authority, and partly because of their status as consumers wholly familiar with the aims and techniques of marketing. For many of these specialists the potency of promotion is largely overstated, as the mechanisms of inuence are well-recognised and transparent and the impact of such inuences only signicant where they are not recognized or respected by the clinician. ythe idea of simply prescribing a drug from somebody whos just given you dinner is a bit less sophisticated than most doctors would bey. Interviewee #1 ythe industry are generally ethical in their detailing and marketing and I would think in most cases practitioners are responsibleyI would not like to think that my colleagues would be unduly inuenced in their prescribing patterns by the free biro or the desk clocky. Interviewee #49 But while condent engagers were sceptical of the power of promotion, they did not deny that interaction with industry inuenced prescribing practice. However, they tended to regard the inuence of industry as arising from the interaction per se, rather than simply as a function of persuasion and obligation. These doctors also tended not to regard industry promotion as categorically negative, on the grounds that it had an

educative valueaffording specialists greater awareness of the opportunities offered by pharmaceuticals. yif Im attending or giving a talk thats an industry sponsored, the main intention is to inuence clinical practice. My understanding is we call that education. Interviewee #15 ymost of us think that that doesnt inuence our prescribing but presumably it does in subtle waysythey may inuence my prescribing habits in a positive way. Interviewee #43 yI think doctors are seduced by the ability to use new therapies in general as much by whats written in the New England Journal as it is by what the academic detailer came and talked to me about. Interviewee #47 Many of the specialists within this group expressed concern that the relationship between the medical profession and the pharmaceutical industry had been being characterised as ethically suspect by critics, and frustration at what they regarded as over-zealous attempts to impose guidelines on this relationship. I think the pharmaceutical industry plays a very important part in education and keeping people up to date. I think a lot of mealy mouthed people dont give them enough credit. Interviewee #38 ythe people that draw up these guidelines are usually senior peopleyProfessors and Heads of Departmenty I think its all very well for some people to make these high moral ground guidelines, but in the real world, I dont think theyre realisticy. Interviewee #33 In addition, many of this group expressed the concern that failure to engage with industry will ultimately result in diminished support for continuing medical education and medical research. Generally the national meetings couldnt take placeywithout pharmaceutical industry support. Interviewee #28 ywithout the involvement of some very good and decent people in the industry, I wouldnt have been able to get some of the research done that weve done. Interviewee #50 The condent engagers described conducting a cooperative and mutually benecial relationship with industry. They exchanged their time to listen to the claims about a product, they exchanged their clinical experience for further information, they presented at company sponsored functions in return for support for education, and they participated in company sponsored research to secure research funding. The exchange was

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described as fair and reasonable with the benets ultimately accruing to patients either through prudent management or by an equal contest where industry and specialists each attempt to maximize their gains. For the condent engagers, the relationship does not inevitably or unalterably present a conict of interests; the interests of industry and specialists may concord as much as conict. Ambivalent engagers The second largest group (n 20) included specialists who described engaging with industry but felt uneasy in this engagement and ambivalent about it. The interaction they described was coloured by wariness of having their autonomy compromised and of creating a conict of interest. I dont actually have any outright opposition with the pharmaceutical companies becauseythe role they have in research and development of drugs is important. The conicts I have is their ability to inuence what I prescribey. Interviewee #3 y the best physicians in Australia are involved in clinical trials because they want to be on the cutting edgeybut then as soon as you put a foot in that water, you get sucked intoythis scenario. Interviewee #31 As with Avoiders, specialists in this group perceived the potential for conict of interest arising from the interaction between doctors and the pharmaceutical industry as very real and substantial, as, for them, the industry agenda was at odds with that of medical specialists. Im aware that the drug industry provides us with a lot of useful information, a lot of sponsorship, assistance to do things that we wouldnt necessarily be able to do, but Im also aware that their agenda is different from mineyThe overriding motive of the pharmaceutical industry is proty. Interviewee #4 yTheyre a commercial enterprise and theyre trying to get the best prots for their shareholders, which is their job. Im trying to get the best product at a reasonable cost for my patients, which is my job. Interviewee #32 This group of specialists tended to be suspicious of suggestions that industrys motives were altruistic, generally accepting the contention that industry wouldnt promote their products in the ways it does if it was not protable. yobviously it is inuencing prescribing otherwise they wouldnt persist in doing it. Interviewee #5

The industry doesnt spend about 750 million dollars a year in Australia on marketing for no resultthey do it because it works So, if theyre doing that then theyre inuencing doctorsy. Interviewee #36 Despite recognizing the potential for conict of interests, ambivalent engagers also recognized that there may be benets of the relationship, such as: information, access to new drugs, and support for ongoing education and research, benets that were unlikely to be available from other sources. ywere all dealing in the same business. They have lots of funds, we have hardly any. To do clinical research in this area isnt that sexyytheres not a lot of other funding aroundy. Interviewee #13 ywithout drug company support, a lot of educational meetings and conferences and things wouldnt go aheady without the sponsorship of the drug companies, then a lot of those things would fall on their face, which would be a decity. Interviewee #27 However, for this group, promotion colours all contact with industry giving rise both to ambivalence about the relationship and concern that contact with industry may inuence practice and create subtle obligations. ythe point is that I would hope that I could maintain my independenceyand if I am not maintaining my independence would I notice or would I have sold out so much I wouldnt seeythats where some of the unease comes fromy. Interviewee #4 my feeling about drug reps is ambivalenty the commercial business is what has driven the drug companies to produce their drugs and weve all beneted by them and so I owe a duty to give them drug reps air time, but I dont particularly like it. Interviewee #11 Interestingly, the specialists in this group also expressed a concern not only that interacting with industry may inuence behaviour but that it may create a perception that they have been persuaded or are under an obligation to the pharmaceutical industry. I worry that the agenda of the industry overall is so alien from what Im trying to do that in some way I become corrupted by associationy. Interviewee #4 I also dont want people to perceive that I may be inuencedyI think I can (interact) with reasonable integrity butyit puts you in a position where you could potentially be claimed to have been compromised. Interviewee #32

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In contrast to Avoiders, this group described structuring and managing their interaction with industry in ways that minimise the potential to be compromised. As with the Condent Engagers, Ambivalent engagers management strategies included seeing all company reps (often in the company of colleagues), declining all offers that do not clearly reect some educational benet and critically appraising all claims made by industry. Ambivalent engagers interact with industry because the benets are seen as greater than the risks. However, like the avoiders, this group expressed the concern that even with maximal care, interaction with industry may negatively effect prescribing practices.

Discussion All medical specialists have some relationship with the pharmaceutical industry; at its most attenuated, simply prescribing a drug product is an action that establishes a relationship of sorts. For the majority of our interviewees, interaction with industry involved more than this academic proposition. Visits from company representatives, attendance at industry sponsored educational events, acceptance of gifts and other largesse and receipt of material support for, and collaboration in industry sponsored research were all commonly described forms of interactions with industry. It was widely accepted that through interaction, the pharmaceutical industry seeks to promote their product and inuence drug preference. It was also widely accepted that industry promotion is likely to be effective, a belief typically expressed with reference to a cogent, intuitive propositionindustry wouldnt devote resources to promotion if it didnt work. However, while the majority believed that interaction with industry effectively serves industry ends, there was no consensus that this inherently and unalterably leads to a conict of interest. We did not so much observe a denial of the inuence of the relationship (Breen, 2004) but rather variation in how this is inuence is interpreted and evaluated. For those specialists who engage with industry, conict of interest arises not from industry seeking to or actually inuencing practice per se, but from whether inuence is achieved through inappropriate persuasion and/or obligation. To be persuaded by advertisements, company logos emblazoned on giveaways and conference banners was considered inappropriate but not felt by most specialists to be likely. Persuasion through uncritical acceptance of expert endorsement or the selective presentation of evidence is also inappropriate but again considered unlikely. However, simply considering a companys product claims and then perhaps trying that product with a patient was not believed by most to demonstrate

obvious, inappropriate persuasion. Similarly, most specialists did not believe that accepting giveaways or enjoying trimmings was uniformly likely to create inappropriate obligation. Accepting giveaways may establish an obligation of sorts; however, appropriate satisfaction of this need not be more than a willingness to listen to claims for a companys product. More concern was evident about accepting more substantial personal largesse (e.g. assistance to attend a conference) which could, but not inevitably, create obligation or the perception of it. All of the medical specialists described managing the relationship with industry (in the Avoiders case, by not interacting) to minimise the potential for conicts of interest. We are not able from our data to evaluate the effectiveness of the management strategies employed. However, we wish to note that the condence of many in their ability to control the effects of the relation condence is at odds with the considerable literature on the unconscious and unintentional processes through which obligation may be established (Katz, Caplan, & Merz, 2003). As numerous studies, Dana and Lowenstein (2003) for example, have concluded many physicians do not believe that they are inuenced through their interaction with industry (though they recognize that other physicians might be). In contrast, our qualitative study found no such denial of inuence but rather an acceptance that inuence may result but variation in whether inuence should be evaluated pejoratively. What we observed was substantial uncertainty about the empirical consequences of the relationship. For many the effects of interaction were not held to be certain nor uniform, nor any resulting inuence necessarily negative. This rendered moral evaluation of the relationship subjective and contestable. The tension and ambivalence evident in specialists narratives reect the fact that their relationship with industry does not occur in a vacuum but is embedded in the wider social context. For example, there was considerable ambivalence among and within specialists about the prot imperative of the pharmaceutical industry. On one hand this factor was regarded as the driver behind aggressive industry promotion but on the other hand, this was also recognised as the chief motivator in pharmaceutical innovation. Our market economy rewards pharmaceutical innovation, our society demands that individuals invest in ever increasing their health status, and modern medicine is centred around advances and improving treatment outcomes. Individual medical specialists, and the wider profession, must negotiate through this context. It is clear that specialists evaluation of the relationship and its consequences varies and ethical judgments open to contest. If the relationship is problematic, our data suggests this is as much a consequence of uncertainty

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and ambivalence about its consequences as it is because of any inherent conict of interest. Our study is limited in that it was largely exploratory and that it focused on the views and experiences of medical specialists limiting the capacity to generalize the ndings to the wider medical profession. Further qualitative investigation is necessary to expand and develop these initial ndings and research of other medical professional groups (general practitioners for example) should be undertaken to gain insight into their relationship, its consequences and their moral evaluation.

(3) Merck Sharp & Dohme (Australia) (4) Department of Physiology & Pharmacology, School of Medical Sciences, Faculty of Medicine, University of New South Wales, New South Wales, Australia.

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Conclusion The results of this qualitative investigation suggest the relationship between medical specialists and the pharmaceutical industry has inherent tensions that are managed by different doctors in different ways. Drawing on individual understanding of the broader social context, different specialists gave different weight to the perceived benets and risks of the relationship, this largely determining if and how an individual directly interacts with industry. It was clear that for many specialists the relationship and its consequences deed simplistic good/bad dichotomising and that guidelines for the relationship premised on such good/bad reasoning were unhelpful. To be effective normative guidelines for academic and professional practice need to resonate with the majority of practitioners. To resonate, guidelines must account for the complexity of the relationship and for the variation in medical professionals views and feelings. We believe our study makes it clear that further qualitative study of the medial profession pharmaceutical industry relationship is essential for the development of such inclusive and effective guidelines.

Acknowledgements The authors wish to acknowledge the contribution of the following colleagues: Suzanne Hill, David Newby, Kim Henderson, Jane Maguire, University of Newcastle, Cate Arciuli, University of New South Wales, Graham Macdonald, Merck Sharp & Dohme (Australia), and Richard Day (University of New South Wales). (1) Discipline of Clinical Pharmacology, School of Medical Practice and Population Health, University of Newcastle, New South Wales, Australia (2) School of Public Health and Community Medicine, University of New South Wales, New South Wales, Australia

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