HEALTH: The Morality of Medicine
Ignatius, David
Health: The Morality of Medicine by David lgnatius Since the time of Hippocrates the healing arts have turned to their great teachers for moral as well as technical leadership. Today the...
...By now, Stare has become notorious as a commercial booster...
...The problem with “combinations” is that they can lead to sloppy and irrational prescribing habits...
...Meanwhile, Squibb commissioned the Roswell Park Cancer Institute in Buffalo, New York, to study the effects of Mysteclin-F components in the treatment of terminal cancer patients...
...Stare has said that he receives retainers from two cereal companies and the Cereal Institute which equal one quarter of his salary...
...Dale A. Console was medical director for Squibb until he “reached a point where I could no longer live with myself” and resigned...
...By 1972 Harvard medical students were wondering whether it made sense to pay for equipment which they could be getting for free...
...The conclusion, they said, was that Mysteclin-F was more effective in treating certain types of fungal infections than tetracycline given alone or a placebo and should therefore remain on the market...
...In the fall of 1972, the evidence had finally been gathered...
...Stating simply that his “continued membership on the board could be subject to misinterpretation,” ha resigned...
...Since 1942, Dr...
...from Oxford in 1939 and returned to Chicago, where he received his M.D...
...Ebert’s watchful eye...
...After coming to Harvard, the range of Dean Ebert’s public activities broadened...
...It’s a soft-sell operation...
...Stare blandly told the Senators that “breakfast cereals are good foods...
...A nutrition professor might be expected to maintain considerable critical distance from commercial food processing and marketing interests, but Dr...
...Stare’s behavior has been far more flagrant than Ebert’s, but in a sense it is less disturbing...
...If Ebert’s consulting work for Squibb had remained discreet, his return to the corporation would never have become public knowledge...
...One might have expected an even greater outcry in 1972, since Ebert’s post-1969 involvement with Squibb was in many ways more questionable than his directorship had been...
...in 1942...
...In 1967 the National Academy of Science’s National Research Council concluded an exhaustive study of prescription drugs...
...Cleans, assignable wherever the veneer of honesty is wearing thin...
...equivalent to an American Ph.D...
...The Council acknowledged that “involvement in public affairs by academic people, particularly those with substantial responsibility, will necessarily pose problems of conflict of interest...
...not to mention the added inducement of the free cocktail party and the golf outing complete with three golf balls stamped with the name of the doctor and the company in contrasting colors...
...The Yale Medical School Council attempted to raise the basic ethical questions confronting academics who want to make practical use of their knowledge without compromising their honesty or objectivity...
...It is our firm conviction that the promotion and sale of such combinations should be discouraged...
...For example, in August, 1970, Dr...
...Students wondered if they had leapt to conclusions,‘ if they had caused grief at too slight a provocation...
...But Squibb apparently felt that the research findings alone would not be enough to convince the FDA to rule in favor of Mysteclin-F...
...The FDA had been trying to get the drug off the market since 1969, but Squibb had managed to postpone final FDA action several times by pleading that it was awaiting new evidence of the drug’s effectiveness...
...When the country doctor from Paducah sees that the Harvard Medical School is worlung along with Squibb, he may get the idea that they form a kind of holy alliance against disease, that the Squibb pills are turned out under Dr...
...But despite some protests, Ebert was able to ride out the 1972 affaire Squibb without resigning his consultantship or making any extensive public statements...
...Dean Ebert’s decision to go to bat for Squibb takes on new meaning in light of another doctor’s experience...
...h o t h e r said privately that he “could not support a recommendation that Mysteclin-F be marketed,” and he added, “1 don’t think [the Deans] showed efficacy...
...Cavin M. Kunin, chairman of one of the NASNRC panels, told a special Senate investigative committee why he and his colleagues opposed combination drugs: These combinations are expensive, deny the physician flexibility in dosage, are primarily promotional devices, and have the inherent problem that the patient undergoes the risk of serious adverse reaction to two or more drugs rather than a single defined agent...
...But an important first step before winning the doctor’s confidence is winning certification for a drug from the FDA...
...By October, 1972, Squibb’s Mysteclin-F was in trouble...
...Ebert Is Not Consoled In November, 1969, the FDA affirmed NAS-NRC’s judgment against combinations and issued a “final order” to deny certification for Mysteclin-F...
...Health: The Morality of Medicine by David lgnatius Since the time of Hippocrates the healing arts have turned to their great teachers for moral as well as technical leadership...
...That same year, Dr...
...From 1959 to 1963 he had served on a special advisory group of the Veterans Administration...
...Frederick J. Stare has been chairman of the Department, of Nutrition at Harvard’s School of Public Health...
...Each tinkers away at his own special project, hoping to strike it big with a new textbook or the next coup from the lab...
...It’s been a good thing for Nixon that his enemies haven’t gotten a close look at the kind of moral example Harvard is actually providing...
...By the end of 1969 he had resumed the consultant position he had held for several years before joining the company’s board...
...Modern universities have been characterized as large-scale “knowledge factories,” but the professors themselves are the last great class of individual entrepreneurs...
...For good measure, the Council reaffirmed its “high esteem for the integrity and credibility of Dean Lewis Thomas...
...He may have been motivated by a desire to spare Ebert from trauma, but his silence left the impression that the university did not consider the conflict-of-interest problem worthy of serious consideration...
...The FDA has not yet made a final ruling on the appeal...
...He was angry and bitter...
...In 1969 medical school protesters had forced Ebert’s immediate resignation from the Squibb board of directors...
...Since Mysteclin-F has been among the 200 best-selling prescription drugs for the last 12 years, certification was literally a multi-million dollar matter for Squibb...
...The idea is for the detail man to gain the confidence of the doctor so that the doctor will equate the kindly demeanor and knowledgeable opinions of the detail man with his company’s products...
...From 1942 to 1967 he also served as editor of Nutrition Reviews, a publication of the Nutrition Foundation...
...Harvard administrators did their best to create an impression that they had suddenly been struck deaf and dumb on the Ebert issue...
...After taking a B.S...
...Ebert, by contrast, is still regarded as an exemplary physician...
...Giant corporations are good to their friends...
...Last year Mysteclin-F was one of the 100 most popular prescription drugs, even after so much adverse publicity...
...In turn, the medical faculty takes its model from the leadership of the school, especially the dean...
...But having posed the question, the Council ducked answering it, concluding with the lame assurance that conflict of interest “is a risk that can, and indeed must be faced...
...So the company rolled out its two big guns from academic medicine to present the findings to the FDA...
...In 1966 he was appointed a trustee of the Rockefeller Foundation...
...The academics have managed to keep the wraps on their long-running hustle, so that outside the university an Ivy League professor is still the very model of respectability...
...Stare testified before the Senate consumer subcommittee on behalf of Kellogg’s and Nabisco, the cereal industry giants...
...This distance is essential for the doctor’s objectivity...
...Since the doctor is in a unique economic position, namely that of directing what the consumer will buy, strict objectivity is his obligation to the patient...
...More significantly, along the way he built a reputation as a physician sensitive to public concerns...
...Ebert served his internship at Boston City Hospital, leaving after two years to join the Naval Reserve...
...Today the equivalent of the plane tree beneath which Hippocrates delivered his lectures is the imposing mockclassical quadrangle of the Harvard Medical School...
...Drug advertising and promotion efforts encourage the doctor to believe that there is an easy way to practice medicine...
...The doctor will then instruct his patients to buy a particular brand-name drug...
...that a director owes a loyalty that is undivided and an allegiance that is influenced in action by no consideration other than the Corporation’s welfare...
...When Robert H. Ebert was appointed dean of the Harvard Medical School in 1965, all agreed that he was well suited to discharge both the administrative and ethical responsibilities of the deanship...
...Reviewing Stare’s remarkable career, James Turner concluded in The Chemical Feast that Stare was “one of the leading apologists for the food industry...
...But in addition to giving general advice on research and development programs, Ebert represented Squibb before a Food and Drug Administration (FDA) hearing on a drug which has received withering criticism from the medical profession...
...So, when things got too sticky for Harvard, Squibb turned elsewhere for help...
...In addition, the 1971 -1 972 financial report to the Board of Overseers of Harvard College listed contributions to the School of Public Health’s Department of Nutrition from the following corporations and industry foundations: Beech Nut, the Council for Tobacco Research, First National Stores, the International Sugar Research Foundation, Nabisco, the Nestle Foundation, Procter and Gamble, E. R. Squibb and Sons, the Sugar Association, the Tuna Research Foundation, and the United Brands Foundation...
...The subcommittee was investigating charges that breakfast cereals which were being marketed through high-pressure sales campaigns directed at children were shockingly low in nutritional content...
...Phi Beta Kappa) at the University of Chicago in 1936, Ebert traveled to Oxford on a David Ignatius is a recent graduate of Harvard who has worked for Ralph Nader’s Congress Project...
...Results from this study-in which neither Ebert nor Thomas had participated-made up the Deans’ testimony at the special FDA hearing...
...While the combinations’ defects have not prevented them from attaining commercial success, the drugs have been under attack for years...
...Politicians seem especially taken in by this air of patrician morality...
...In the same spirit of medical courtesy, students have abandoned the harsh moral tone which caused such unpleasantness during the 1960s...
...To understand why the Deans’ testimony aroused controversy, it is necessary to examine some of the criticisms that had been leveled against the drug...
...As a director Ebert owned about $15,000 worth of Squibb stock in addition to his yearly salary of several thousand dollars...
...Losing ths sort of high-class celebrity was not a pleasant prospect...
...The gifts included doctors’ “black’ bags” and medical instruments such as stethoscopes, tuning forks, and percussion hammers...
...only later, in answer to reporters’ queries, did Squibb Vice President Norman F. k t t e r say that Ebert was receiving “a modest retainer” for his services...
...He felt that we should have kept the Squibb matter within the medical community and that it was not She sort of thing you wrote letters to the Crimson about...
...He obtained a D.Phi1...
...One of the panel members Post that the new data was “marginal at best...
...No announcement was made of the arrangement...
...The Foundation’s sponsors include Coca-Cola, General Foods, General Mills, Nabisco, Safeway, Swift, Standard Brands, and United Fruit...
...Lucy Candib, one of the medical students who had protested Ebert’s activities, recalls that “the Dean became more hostile to students, where before .he had taken a benevolent attitude toward them...
...The students pointed to a Library of Congress Legislative Reference Service study of directors’ responsibilities which noted that “many courts have spoken of the rule...
...The instructors at this most prestigious of the nation’s medical centers set an example not only for their own students, but for the profession as a whole...
...With the dean of the nation’s most prestigious medical school serving as a salaried director of a company in which he also owned stock, skeptics might have wondered whether young medical students were being given the proper example of medical probity, not to mention the influence on their drug-prescribing habits...
...Admittedly, evidence of Ebert’s consumer-advocate role had been slim, but the Dean preferred not to argue about the case in public...
...The only big loser in the 1969 affair was Ebert himself...
...Dr...
...Breakfast cereals are also a $700-million industry...
...Wheaties As Staff of Life In analyzing Ebert’s behavior, it is only fair to note that he may have been influenced by peer-group pressure which forced him to adopt the moral standards of those around him...
...And when approaches are being made to the FDA on behalf of a drug, a pharmaceutical corporation needs a super detail man-someone of stature in the profession, like Dean Robert Ebert of Harvard or Dean Lewis Thomas of Yale...
...There was chagrin in Cambridge when Yale showed signs of taking the Squibb matter seriously...
...At first glance, Stare’s editorship would seem an appropriate outlet for his scientific expertise...
...Stare has embraced them-through direct affiliations with the corporations and through the advice he dispenses in his nutrition column, which is syndicated in over 100 newspapers...
...Yale Tries Harder Ebert might have come back hard against the protest by saying that the “public director” position he filled was the equivalent of whzt Ralph Nader was trying to create at General Motors...
...President Nixon has used his Harvard menElliot Richardson, James Schlesinger, William Ruckelshaus, Henry Kissinger -as all-purpose Mr...
...no one points him out as an illustration of medicine’s noblest aspects...
...Mysteclin-F is what is known as a “combination drug”: it includes fixed parts of tetracycline (a commonly prescribed antibiotic) and amphotericin-B (a less common antifungal antibiotic compound...
...In 1969, the same’ year that students forced Dean Ebert to resign his Squibb directorship, 45 second-year medical students-more than one third of the sophomore class-returned to Eli Lilly and Company, a pharmaceutical manufacturer, a set of expensive gifts which they had received the year before...
...But perhaps more important is the fact that six months after Stare’s 1970 testimony, the Harvard School of Public Health received $2 million from the Kellogg Foundation to support nutritional research...
...The next year, he became Dean of the Harvard Medical School...
...Rhodes Scholarship...
...Another brief illustration from Dean Ebert’s corner of the university suggests how easily professional ethics may be bent...
...He is now studying in England...
...Ebert has written extensively about the social responsibility of the profession, and especially of the medical school...
...In 1967 he joined the Board of Regents of the National Library of Medicine...
...In 1969 he went public and told Senate investigators about the harm that pharmaceutical propaganda could do : How can legitimate education compete with the _carefully contrived distortions driven home by the trip-hammer effect of weekly mailings, the regular visits of the detail man, two-page spreads, and the ads that appear six times in the same journal...
...Stare, like Dean Ebert, has tried to help his corporate friends fend off threats from the federal government...
...High-class Hustlers Ebert’s blandishments were in perfect keeping with the rarefied world of drug salesmanship...
...Although Thomas’ conduct had been virtually the same as Ebert’s, he had not been ,as prominent an ethical and professional leader...
...But in October, 1969, a group of 19 second-year Harvard medical students sent a letter to the Crimson protesting that even if Ebert was no longer on the Squibb payroll, as a director he remained at least subtly bound to uphold Squibb’s interests...
...In 1964 Ebert returned to Boston to take up a Harvard chair and serve as Chief of Medical Services at Massachusetts General Hospital...
...The drug continued to be sold...
...This year students circulated a petition asking Eli Lilly and Company to bring back its black bags...
...In 1956 he was given a tenur,ed chair and the post of Director of Medicine at Western Reserve University...
...Lewis Thomas, dean of the Yale Medical School, to take Ebert’s place...
...Ebert, quicker to recover, had meanwhile gone back to work for Squibb...
...Under persuasion by the Squibb board, nowever, he agreed that it would be reasonable for him to stay on as a “public director” defending the consumer’s interests...
...another indication of his leadership is his position as head of the Harvard Community Health Care program...
...In other men such an arrangement might have smacked of conflict of interest...
...Squibb appealed the ruling, asking for time to gather more evidence...
...Losing the dean of the Harvard Medical School from its board of directors was a bit of hard luck for Squibb...
...Ebert had risen, in a short time, to the top of the medical profession...
...Although the Dean had put up no resistance and had immediately resigned from the Squibb board, he was embittered by what he considered undue vilification...
...In 1957 an editorial in the Archives of Internal Medicine stated: There are no data or experience which would justify the employment of any fixed combination of antibiotics in a single tablet or capsule for systematic use...
...A specialist in thoracic medicine with liberal political views, Ebert came to Harvard from the Midwest with an extraordinary list of credits...
...They wrote : The medical profession is largely responsible, because it does not maintain proper distance from the industry...
...Indeed, there was soul-searching and regret among some of those who had taken part in the Ebert protest...
...Instead they employ what are known in the trade as “detail men”company representatives who visit doctors, researchers, hospital administrators, and medical students offering free samples of their products and other gifts...
...But if, as expected, the agency tries to suspend marketing of the drug, it is likely that Squibb will appeal the ruling in court...
...In 1961 he had been elected president of the American Thoracic Society, the professional organization for doctors in his field...
...In January, 1969, Ebert took on another post: he was appointed to the board of directors of Squibb-Beech Nut, owners of E. R. Squibb and Sons, the pharmaceutical manufacturer...
...In fact, when one student proposed a university-wide “audit” of consulting work, a very prominent administration official attacked the idea as “McCarthyite...
...University President Derek C. Bok repeatedly refused to comment...
...Because the combination is fixed, it almost inevitably over-prescribes or underprescribes one of the two compon e n t s . Squibb has promoted Mysteclin-F as a good way for doctors to hedge their bets when they are uncertain whether a patient suffering from microbial infection has a fungal infection as well...
...Times had certainly changed...
...In addition to his work for the Nutrition Foundation, for the last nine years Stare has been a director of Continental Can Company, one of the nation’s largest food-packaging comp anies...
...Administra-‘ tors and faculty members in New Haven subjected Dean Thomas to more extensive scrutiny than Ebert had undergone at Harvard...
...One year later, in recognition of Ebert’s remarkable career, the University of Chicago awarded him its Alumni Achievement Medal...
...In a letter to Lilly, the students noted the “unhealthy relationship” that existed between the drug industry and the medical profession and pledged themselves to reform the situation...
...Similar doubts may have entered Ebert’s mind, for in the summer of 1969 he sold his Squibb stock...
...Despite Morton Mintz’s thorough reporting in The Washington Post and several stories and an editorial in the Harvard Crimson, the 1972 revelations of Dean Ebert’s relationship with Squibb were greeted with disdain by the Harvard administration and won a ‘great yawn of apathy from most of the student body...
...Before withdrawing in to silence, Ebert said of his consulting work: “I wouldn’t pretend that what I do now is anything more than what Squibb is interested in...
...The FDA hearing panel was not impressed...
...The company signed up Dr...
...that same year he became a member of the Population Council and of the National Advisory Committee on Health Manpower...
...Pharmaceutical corporations are too sophisticated to rely on ordinary salesmen...
...In examining the career of the man who now occupies that influential position, we may find clues to the riddle of why medical morality is as we know it today...
...In 1949 Ebert joined the Chicago Medical School faculty, and became a full professor in six years...
...How can medicine ever purge itself of men like Stare when the very top of the structure is riddled with so many moral compromises...
...But Nutrition Reviews happens to be the creature of the major food processors and refiners that underwrite the Nutrition Foundation...
...The 30 NAS-NRC researchers-all specialists in the treatment of infectious diseases-concluded that fixed combinations “have no place in the treatment of infections” and requested that the FDA move to have them withdrawn from the market...
...Despite a barrage of evidence from witnesses substantiating the charges against the cereal companies, Dr...
...Squibb couldn’t afford not to wage a protracted fight...
Vol. 5 • October 1973 • No. 8
