It is Time to Shed Sunshine on Informed Consent

Most patients realize doctors receive gifts from the pharmaceutical and device-

A patient having his blood pressure taken by a...
A patient having his blood pressure taken by a physician. (Photo credit: Wikipedia)

manufacturing industry. When we see industry logos on pens, clocks and posters, we don’t assume the doctors ordered these items from the merch page of these companies, but most of us aren’t aware of how lucrative the payments to doctors can be.

A story that ran in the New York Times described the experience of Dr. Alfred J. Tria, who made $940,857 in about two years for promoting products and training doctors in Asia to use them. The article notes that Tria’s experience may be exceptional, but in two and a half years, industry paid out $76 million to doctors practicing in Massachusetts alone.  I’ve been reading about this subject for a while, and even I was surprised that someone could make half a million dollars in a year on a side job.

In a slightly different type of payout, Oregon recently concluded a court case against two doctors who “put heart implants into patients without telling them that a manufacturer’s training program put a sales representative into the operating room.” The doctors would receive between $400 and $1,250 each time they completed a surgery using Biotronik defibrillators and pacemakers. The state argued that patients should know when doctors’ recommendations may not be based entirely on the needs of the patient. One of the doctors in the case earned more than $131,000 from 2007 to 2011 through implant surgeries. Doctors also received speaking fees, expensive meals, and other gifts.

As part of the Affordable Care Act (Obamacare), the Sunshine Act now requires industry to start collecting data on payments to doctors now, and the information will be made available to the public next year on a government website. This will enable patients to learn how much their doctor receives from the industry each year, though there may still be hidden incentives.

For example, doctors may be in profit-sharing arrangements with facilities or they may actually be the owners of the facility. A recent study by Dr. Matthew Lungren found that doctors who had a financial stake at an imaging facility ordered tests with negative results at a much higher rate (33 percent) than doctors with no financial stake. In other words, it appears that doctors order unneeded tests because they are making money off of them, not because the patients need them. Lundgren suggests that patients should ask whether they are being referred to a facility in which the doctor has a financial stake. I say the doctor should volunteer the information.

Beginning next year, the Sunshine Act will make it much easier for patients to discover their doctors’ financial relationships with industry, and I’m thrilled for this development. For those who think Obamacare is a complete disaster, just take a minute to relish this one positive development.  Still, I think the movement should go further. I think financial disclosure should be part of the informed consent process. When your doctor is telling you all the risks and benefits of treatment, I think he or she should also say, “I get paid $1,000 to do this surgery,” “I will make $100 off this MRI,” or “I own stock in the company conducting this medical research.”

I believe patients want this information, and I don’t think they feel it is their responsibility to search for it. True informed consent is only possible in light of complete financial disclosure.

Corporate Greed Is Not The Problem

English: Coalition of Immokalee Workers logo

In the battle between conservatives and progressives, we are generally presented with a false dilemma. We are expected to choose between two positions: 1. Corporate greed is evil. 2. Profit is what drives innovation and improvements to our standards of living. Unfortunately, it is the progressives who are making the mistake here. Greed is only a problem because it results in human rights abuses, criminality, and grave injustice. We do better to focus on the abuses rather than the rather nebulous harm of greed itself.

When I talk to conservatives about specific instances of corporate criminality, they generally acknowledge that something should be done in such cases. For example, seven court cases from 1997 to 2008 resulted in convictions for slavery in Florida.  Those convicted of slavery “threatened the immigrants, held their identification documents, created debit accounts they couldn’t repay and hooked them on alcohol to keep them working.” The workers were also beaten and forced to live in substandard conditions.

As the accounts of slavery came to light, activists organized and demanded that restaurants pay more for tomatoes in order to provide an actual wage for tomato workers. By May 2008, Burger King had joined McDonalds and Yum! Brands in meeting the demands of the Coalition of Immokalee Workers and paying more for tomatoes. It was a notable success, but the activism of the CIW continues. After progressive strides with fast-food restaurants, the coalition ran in to resistance from grocery giant Publix, which refused to join any agreements to improve working conditions. In 2010, a Publix spokesperson said, “If there are some atrocities going on, it is not our business.”  Publix has not budged yet, but the Coalition of Immokalee Workers continue their work and will receive 2013 Freedom from Want Medal from the Roosevelt Institute.

When progressives argue that corporate greed leads to great evil, they may be correct, but they make it too easy for conservatives to simply point out all the innovation and convenience the profit motive has produced. When we argue against slavery, however, we force conservatives to either defend slavery or admit that the industry must be reformed in one way or another. It is not likely that progressives and conservatives will agree on what kind of reform is necessary, but at least the conversation has begun with some possibility of tangible results, as we see in the case of the Immokalee workers. Knowing of specific abuses, such as in the FoxConn factory in China or the sweatshops in Bangladesh, most consumers, both progressives and conservatives, demand reform, and corporations do listen to them. Progress is slow and frustrating, but it is progress.

It may be possible that severe and systemic structural reforms are required to eliminate slavery and other forms of corporate abuse, but it is the abuse and the desire to eliminate abuse that must motivate the change.

How to Destroy Education (And a Nation)

Woman teaching geometry, from Euclid's Elements.
Woman teaching geometry, from Euclid’s Elements. (Photo credit: Wikipedia)
  1. Instead of having instructors rate the scholastic achievements of their students according to effort and ability, rate the performance of instructors by how many of their students pass the class (or a standardized test). Alternatively, rate the performance of teachers by how entertaining their students find them to be.
  2. Turn student assessments over to the same corporation that prepares your textbooks and classroom resources.
  3. Expand online classes and purchase instructional modules prepared by the same corporation.
  4. Use instructional modules for both online and classroom lectures, reducing teaching to rote repetition of corporate-sponsored material.
  5. Tell instructors that the lecture is dead and should be replaced with professionally prepared audio and video materials, conveniently provided by corporate textbook publisher/testing service.
  6. Have students rate professors’ “effectiveness” as teachers.  A study by Scott Carrell and James West found that “student evaluations reward professors who increase achievement in the contemporaneous course being taught, not those who increase deep learning.”
  7. By judging teachers on student success, ensure that teachers at the most selective schools are judged to be the best teachers.
  8. Promote best practices for teaching that are based on the success of teachers at the most selective schools.
  9. Ensure that teachers fear retaliation if sufficient students do not pass their classes. Establish a quota for passing grades.
  10. Give students the impression that they will pass the class no matter how little work they do (see previous). A blog post by Richard Vedder notes that a National Bureau of Economic Research study by Philip Babcock and Mindy Marks found that “In 1961, the average student spent 40 hours a week engaged in their studies—attending class and studying. By 2003, this had declined by nearly one-third to 27 hours weekly.” Probably gotten worse since 2003. Students are doing less and less work while simultaneously being rewarded with better grades.
  11. Cut funding for education, forcing colleges to seek “public-private partnerships,” which enable corporations to determine the educational objectives of the college.
  12. Have adjuncts teach most of your classes with low pay and no benefits.