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LOBBY WATCH Jane Cassidy BMJ.COM Edward Davies American Legislative Exchange Council The health bill—no trust and no U-turns What is it? demanded that the then opposition Last week marked a “humiliating climbdown” for The American Legislative Exchange leader, , withdraw England’s health secretary. Apparently. “Andrew Council (ALEC) is a major US lobbying the congressmen’s invitations to the Lansley is now in open retreat and is being forced to organisation for big business. It is conference and cancel a reception for cave in on issues he previously fought to the hilt,” linked to big tobacco, oil, food, drink, the US Atlantic Bridge. said his Labour nemesis, Andy Burnham. and drug companies. The political blogger Stephen So why does his acquiescence to an amendment Its board of directors is made up Newton started digging and demanding he take ultimate responsibility for the unearthed the link between this of Republican politicians opposed to NHS feel less like a U-turn and more like a cup of tea US anti-NHS politicians’ group and public healthcare. They also promote at Charnock Richard services on a steady journey up the ideas of those people who deny the Fox charity. His complaint to the M6? Time and time again the amendment of this that climate change is happening. the Charity Commission led to its bill has been met with at worst a shrug, and at times Their slogan is “limited government, investigation into the charity. a warm embrace. free market, federalism.” ALEC described the project In this case, when presenting the bill at the One ALEC member, John Campbell, as aiming to “foster positive second reading to the Lords, Earl Howe pointed out a California congressman, said that it relationships between Conservatives that changes to the role of the secretary of state was “nuts” of President Barack Obama on both sides of the Atlantic, so PA were to reflect how the NHS already operated, but to seek to emulate the NHS through that they might further the ideals Link to ALEC: former his healthcare reforms. He attacked exemplified by Ronald Reagan and that of course Lansley and his successors would defence secretary Liam the UK health service as “enormously .” retain ultimate responsibility. But assurances were inefficient, wasteful, and costly.”1 Fox (left) and his friend When the US version of Atlantic demanded, and now they’ve come. Of course they Adam Werrity Bridge was launched five years ago have. Why is it in the news? it had 27 members of the European Rotund MP for Somecityshire: “I would like to ask It emerged during the recent and Adam parliament on its membership list, ALEC said, and my Right Honourable Friend what he intends to Werritty scandal that ALEC funded a charity founded it expected to increase that number substantially do about the 10 year surgical waiting lists and the by the former defence secretary and run by his through the project. closure of all hospitals in Somecity.” adviser and personal friend. The US organisation attracted wealthy and Reclining secretary of state for health: “Absolutely The Atlantic Bridge was set up by Fox, who powerful backers, including many with interests in the nothing my equally honourable friend. I’m merely a resigned as defence secretary last month, in defence sector. “It is hard to escape the conclusion figurehead these days. The chap you want is a GP in 1997 and was run from his taxpayer funded that in the space of five years the Atlantic Bridge Oldham. Nothing to do with me.” parliamentary office with Werritty as executive went from a small, Tory leaning charity, dispensing Rotund MP for Somecityshire: “Apologies. My bad, director. Its stated aim was to promote the special freedom medals in the name of Thatcher, to an your honourableness. Do you have a number for relations between the United States and the influential networking club linking most of the cabinet him?” United Kingdom. The current Cabinet members to powerful business interests, neocons, and Tea The idea that the government would not be held , , Chris Grayling, Party enthusiasts,” summed up the Guardian. to account for health is just possibly possible under and all sat on its advisory board the bill, but utterly unimaginable in the real world. when they were shadow ministers, the Guardian Was this going on when Fox was shadow 2 In a world of infinite possibility there needs to be a reported. health secretary? degree of common sense. There’s nothing about ALEC set up a US arm of the charity with the same Yes. Furthermore, funding from Pfizer to the charity name—the Atlantic Bridge—in 2007 and provided in 2003 was included in Fox’s entry in the register the use of ground unicorn horns as a treatment for Fox’s organisation with £28 528 (€32 830; of members’ interests at the time: “A researcher smallpox in the bill either. Do we need some clarity $45 820) over four years.2 based in my office works exclusively for the Atlantic on that? Fox stepped down from his role as a trustee of Bridge, a UK-American think tank of which I am a And the list for this kind of benign amendment is the UK arm of the Atlantic Bridge in May 2010, founder member. In this role she receives funding long and salubrious. when he became defence secretary. Two months from Pfizer Inc. She has no function in any health One of the initial major outcries was around later the Charity Commission reported that the way role.”4 This researcher was Gabby Bertin, now David Monitor, whose duty to promote competition it carried out its activities must cease immediately. Cameron’s press secretary, who has admitted being caused outrage. A quick “where appropriate” later The commission concluded that the charity’s paid £25 000 by Pfizer when she worked as the “sole and many Honourables were mollified. But of course activities might lead members of the public to call employee” of the charity.5 “where appropriate.” Who would argue otherwise? into question its independence from party politics.3 Werritty took director positions at three The line seemed to suggest that previously there companies in the health sector when Fox, a former was a subclause demanding that Monitor also What was the purpose of the Atlantic GP, was shadow health secretary. All of them are promote competition where “wildly inappropriate Bridge? now dissolved. Both men invested in one of the and potentially dangerous too.” Of course it’s Critics say that it was an attempt to import US style 6 companies, the healthcare consultancy UK Health. possible they might, but there’s nothing in the bill to the UK. In 2009 a group of US Jane Cassidy is a freelance journalist about paying the NHS tariff in Fisher Price pirates’ congressmen who had lambasted President Obama’s [email protected] doubloons either. Should the people be told? healthcare reforms and attacked the NHS in the process Edward Davies is editor, BMJ Careers were invited to the Conservative Party conference in References are on bmj.com. Manchester. The then health secretary, Andy Burnham, Cite this as: BMJ 2011;343:d6916 ЖЖRead this blog in full and others at bmj.com/blogs

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ETHICS MAN Daniel K Sokol Boxing: is the BMA confused? The BMA’s current stance on the fighting arts is inconsistent

The BMA’s handbook Medical Ethics Today harms himself and his opponent.” This rules). There was less blood on show than states unequivocally that “competent adult objection, however, is valid only if the in many of the matches of the recent Rugby patients have the right to refuse any medical opponent objects to stepping into the World Cup. Still, I can appreciate why others treatment, even if that refusal results in their ring. Mr Smith’s opponent benefits from may find it offensive. If we accept the liberty permanent physical injury or death.”1 Yet the liberty principle as much as he does. principle, however, offensiveness to some the BMA’s latest statement on its proposed Yet there are limits, in law and in ethics, to does not justify banning it for others. In a ban on boxing and mixed martial arts what individuals can consent to. I cannot free society there should be a gulf between states with equal certitude that “the BMA’s lawfully consent to someone causing me disapproval of an activity and banning it. opposition to boxing [and mixed martial grievous bodily harm, unless the activity Tut-tutters need not watch the fights. They arts] is based on medical evidence that falls within an exception, such as surgery, do not take place in public places. reveals the risk not only of acute injury but tattooing, and boxing. In its call to remove If studies show that mixed martial also of chronic brain damage in those who boxing and mixed martial arts from the list arts, boxing, or indeed any other sport is survive a career in boxing.”2 of exceptions, the BMA invokes the risk of dangerous, doctors should emphasise the These two statements are difficult medical harm. dangers, insist on safety precautions, and to reconcile. On the one hand the BMA There is little empirical evidence on In the debate even discourage participation on medical says that we should respect Mr Smith’s the dangers of mixed martial arts, in part on the fighting grounds. We should be wary, however, of

decision to refuse lifesaving antibiotics for because the sport is relatively new. More “arts, J S Mill’s assuming that a person’s best interests his septicaemia but on the other that we evidence may exist on other combat sports, amount to no more than his or her or

should not respect Mr Smith’s decision to such as judo and karate. Since its inception pithy statement medical best interests. How impoverished step into a boxing ring against a consenting in 1993, when rules and safety precautions is apposite: life would be—and how much slower

opponent. The consequence of not were few, mixed martial arts has sought “Over himself, human progress—if our desire for health intervening in the first case is probable to protect competitors by requiring over his“ own conquered all other desires. Would Mount

death; in the second, perhaps injury and a the wearing of gloves, gum shield, body and mind, Everest have been scaled, the oceans’ minuscule chance of death. and protective cup under the shorts.4 the individual is depths plumbed, or Antarctica explored? The principle of respect for autonomy Competitors are also required to undergo a sovereign”“ Even if we concede the gravity of the forms a cornerstone of modern medical range of medical tests, including magnetic physical harms of combat sports, it is ethics. The principle requires, subject to resonance imaging, HIV and hepatitis tests, Mr Smith who is normally best placed to limited exceptions, that people be allowed and an ophthalmic examination.5 Contrary decide whether the activity is, all things to make decisions about how they want to to common belief, the sport of mixed considered, in his best interests. The BMA’s conduct their lives. This principle underpins martial arts is not “no holds barred” but stance on this issue, which seeks to impose the BMA’s position that patients have a contains 31 possible fouls, including head its own moral value on others, is at odds right to refuse treatment, a right that is butting, strikes to the groin, throat, and with its emphasis on respect for autonomy. itself anchored in the liberty principle, most back of the head, and abusive language. In the debate on the fighting arts, clearly put by John Stuart Mill in On Liberty One study examined data from 635 Mill’s pithy statement is apposite: “Over (1859): “The only purpose for which mixed martial arts fights that took place in himself, over his own body and mind, the power can be rightfully exercised over any the state of Nevada between March 2002 individual is sovereign.”3 At present this is a member of a civilised community, against and September 2007.6 It concluded that philosophical knockout. Further empirical his will, is to prevent harm to others. His when regulated the sport has low rates of studies could change the outcome. There own good, either physical or moral, is not a critical sports related injury and that rates are limits beyond which a civilised society sufficient warrant.”3 of acute injury are similar to those in other should not go. If two goliaths stepped into For Mill, and for most democratic combat sports. Mixed martial arts bouts an arena, even with consent, and fought societies, this principle ensures that have fewer rounds than boxing, and the with clubs until one was dead, the liberty people can develop and flourish according focus on the whole body rather than the principle would give way. But we are not to their own individuality. A democratic head and torso means that blows to the there yet. society thrives on this diversity. The liberty head are likely to be rarer than in boxing. Daniel K Sokol is honorary senior principle is entrenched in English law and If medical harm alone is the issue, it is lecturer in medical ethics, Imperial embedded in many of the protections curious that the BMA does not call for a ban College London, and barrister granted by the European Convention on on other risky sports, such as skiing and [email protected] Human Rights. taekwondo. Competing interests: DS, in his capacity as Why, then, should respect for autonomy, In 2007 I attended as part of a research a journalist and researcher, obtained a free • bmj.com standard ticket to the mixed martial arts at work with Mr Smith the septicaemic project a mixed martial arts championship. Xxl dltgf dl fgld gfld fgld competition in 2007. The organisers of the event patient, not apply to Mr Smith the boxer? To my oafish eyes it was skilful, fair, and Previous columns by gld gld gld gfueid gld gld imposed no conditions on the free entry. “The patient Smith harms only himself,” entertaining (although as a traditionalist Daniel K Sokol are References are on bmj.com you might reply, “whereas the boxer Smith I prefer boxing under the Queensberry availablegld gld gld on gld bmj.com gld gld g Cite this as: BMJ 2011;343:d6937

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REALITY CHECK Ray Moynihan Is journalism pharma’s new dance partner? Exploring the new frontier in influence peddling

Just as many doctors contemplate an end to you, it’s all about building relationships. In 2008 in the BMJ Lisa Schwartz and their dance with drug company marketers, It’s about creating friendships, alliances, Steve Woloshin, professors at Dartmouth a fresh new crew is stepping lively onto the and back channels, lubricated with drug College, Hanover, New Hampshire, and I floor: journalists and media organisations company largesse—whether within laid out several examples of drug industry looking for easy ways to fund their universities, hospitals, or, now, media sponsorship of journalism education, reporting, travel, and education. companies. Next time there’s a call to awards, and practice and urged more The BMJ reported last week that the the editor’s office from a drug company, scrutiny of this new form of entanglement.3 Murdoch empire’s flagship newspaper it’s not just another promotional player As it happens, one study of the financial in Australia has accepted an undisclosed on the line, it’s a co-sponsor of the ties between journalists and the industry amount of sponsorship money from the paper’s journalism. To engage with these is currently under way in Australia. It’s drug industry for a series of articles on sophisticated public relations strategies is qualitative and is based on interviews, and health policy—and that the idea arose to endorse them. although no results are yet available, the from a meeting between advertising The drug industry sponsorship at investigator and medical ethicist Wendy agents.1 News Limited’s the Australian is simply Lipworth, from the University of New South When a drug Defending the deal, the Australian’s the latest example of a growing global Wales, told me that she’s “worried by the editor said that independence and trend.3 In the past few years there’s been company has a broader impacts” of relations such as those integrity were maintained; but as others controversy over the National Press “valuable product being built between the Australian and pointed out, this new form of financial Foundation in the United States accepting or a valid point the drug industry. Although she says that

closeness between journalists and the annual sponsorship from Pfizer for an “all to make, let’s it’s clearly valuable for journalists to report companies they scrutinise raises real expenses paid” visit for health journalists report on it fairly on commercial products, she’s concerned

concerns. to an educational conference.4 Again, the and accurately, that direct or indirect financial ties may be A few years ago the industry body organisation accepting the sponsorship without having to having a “more insidious, unconscious Medicines Australia started sponsoring says that the money has no effect on effects on reporting, in the same way sell our“ credibility annual journalism awards, with the prize the educational programme—which and threaten the that they can impact on prescribing and for the health journalist of the year award we have no reason to doubt. But there’s medical research. It’s exactly the same set including $A1000 cash (£660; €760; little doubt that Pfizer sees the deal very future of of issues.” $US1060) and an international study as a chance to associate itself with a journalism One of the most insidious effects will be tour. Presumably all recipients will swear respected foundation and slowly to spread self censorship—invisible, immeasurable, that the award and the world trip had goodwill about the sponsor among the but chilling in its effect on the free flow of no undesirable effects on their future annual cohorts of journalists who attend. public debate. Already so much decision coverage, and they may well be right. But Presumably it’s an attempt to buy a better making in healthcare takes place in the what we’re witnessing is a slow and subtle corporate image, at a time when Pfizer shadows of drug industry sponsorship. At attempt to buy influence and goodwill has been forced to pay out $2.3bn in civil a time when the medical establishment within the media, which in general have and criminal penalties to settle the biggest is asking how it might start to move more become increasingly rigorous in their healthcare fraud case in the history of the into the sunlight of genuine independence, coverage of the unhealthy aspects of US Justice Department.5 it seems ironic and tragic that elements pharmaceutical marketing. What’s not clear is why educational within journalism may be moving in the Spreading around cash, free travel, and outfits or media organisations are so keen other direction. When a drug company sponsorship has an effect—if it didn’t, the to lend their credibility to companies with has a valuable product or a valid point to industry wouldn’t do it. Moreover, as the fistfuls of dollars seeking new friends. make, let’s report on it fairly and accurately, Institute of Medicine’s landmark 2009 The simple answer is money—which may without having to sell our credibility and report made clear, there’s a mountain of be an added bonus at first but may soon threaten the very future of journalism. evidence from the world of healthcare become an expected source of ongoing Ray Moynihan is an author, journalist, indicating that financial ties bring the risk revenue and very hard to do without. Yet it and conjoint lecturer, University of of “undue influence” and may “jeopardise” is possible to say no. Unlike other groups, Newcastle, Australia patient care, scientific integrity, and the US based Association of Health Care [email protected] objective education.2 The hollow claims of Journalists has a strict policy of accepting Publisher’s competing interests: The BMJ overpaid “key opinion leaders” that they no funds from for-profit healthcare Group runs an annual awards scheme for bmj.com innovations by health professionals that help can regularly take the money and stay companies—and not so coincidentally • patients, which is partly funded by sponsorship, independent look less and less credible their representatives often lead criticism Previous articles by Ray including from some pharmaceutical companies. by the day. of the new deals between drug companies Moynihan are available References are on bmj.com As any former drug salesperson will tell and media outlets.1 on bmj.com Cite this as: BMJ 2011;343:d6978

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MEDICINE AND THE MEDIA Online is not a private space The banter of the doctors’ mess may have moved to Twitter, but now patients and the media can listen in too, writes Margaret McCartney

recent news story has been that I’m not sure we have evidence that there is in the public domain about their work or the doctors combine slang and cyni- such a relationship; but it’s easy to see why the provision of healthcare must respect patient cism when talking about patients. media are interested in doctors’ chat. Access confi dentiality.” On what constitutes profes- Yes, we moan and grump and bitch to this kind of informal conversation would sional behaviour, it refers to already published about our work, our patients, and previously have been closely guarded, usually guidance that says such things as, “You must Aour managers. But of course there is no news behind closed doors, or, in Shem’s case, ano- treat your colleagues fairly and with respect.” in this: ever since the US psychiatrist Samuel nymised and served with liberal amounts of It is also concerned with what might “under- Shem told the world that “gomers” were frail artistic licence. The beauty of social media is mine public confi dence in doctors generally.” elderly people who should “get out of my emer- also their curse: posting on them takes place Although this seems vague but reasonable, gency room” in his  book The House of in real time and is uncensored, unadulterated, it may be useful also to remember that Niall God , the public has been aware that doctors identifi able, and available to anyone. There Dickson, chief executive of the GMC and who are not always complimentary about their are probably three groups of doctors who use issued the statement, said recently on the patients when behind closed doors—or pseu- social media. The fi rst group use them as pri- Today programme on BBC Radio Ÿ that junior donyms. Since then there have been numerous vate individuals, not as doctors. The second doctors were the “lowest form of medical life.” anonymous columns in newspapers and the identify themselves as doctors and use real Perhaps this is an example of how hard it is, medical press, as well as books written by doc- names. The third group identify themselves under pressure, to maintain high standards tors about their work and patients. as doctors and use pseudonyms. All present of confi dence in the profession. Nevertheless, More recently bloggers and tweeters have potential problems. there is a problem with doctors and social taken up writing about the practice of con- The UK General Medical Council is currently media, and sooner or later, for right or wrong, temporary medicine, which is where the Daily consulting about what standards should be a lawyer is going to quote what someone said Mail comes in. “Birthing sheds, the cabbage expected of doctors in their private lives (BMJ online as evidence against them. patch, and madwives,” it headlined, outlining Careers , ”• Oct ), but it’s perhaps our pub- The disintegration of old fashioned, bru- a recent online row about whether a doctor was lic lives that need more attention. Yvonne tal ways—close, overworking teams of jun- wise to use these terms on a Twitter account McCombie, a medicolegal adviser for the Medi- iors—has been replaced by shift systems and identifying him as a health professional (www. cal Defence Union, is aware of problems that vaguer team associations, such that the mess dailymail.co.uk ). The Daily have occurred when patients may eff ectively have moved to the web. There T elegraph followed with, “They As a patient I would have used social media to con- is also the matter of unintended harms. As a wouldn’t win any awards for not relish the thought tact doctors. “Although you patient I would not relish the thought that my their bedside manner. But the that my surgeon [as a doctor] can be clear what surgeon was unhappy at a weekend to be on online banter between a group was unhappy at a your privacy settings are, this call in the “labia ward.” Neither would I want of doctors has provided a reveal- can give a false sense of secu- to know that my relative was on the “cabbage ing glimpse of the secret terms weekend to be on call rity,” she says. “If you are mak- patch” nor that a procedure performed on me they use to refer to patients and in the “labia ward” ing comments about day to day was being discussed online, later on. And as colleagues. In doing so they work, even if anonymous, there became apparent in online discussions, there have started an online row between medics is still a risk that the information will not be are reasons behind such names that are more who think that their slang terms are off ensive anonymous enough and will break confi den- to do with puns than to cause offence. But and unprofessional, and those who insist that tiality.” this is the problem: there are people who can black humour is an essential coping mecha- What about discussing work environments, understand and share a joke and others who nism for people with highly stressful jobs” even if comments about specifi c patients aren’t will read it but can’t. Doctors should and need ( www.telegraph.co.uk ). Phil Hammond, a made? “I’d be concerned about what is profes- to use social media. But if you couldn’t say comedian and doctor, commented in the Daily sional to discuss about work environments in it, loud voiced, in the waiting room, beware. Telegraph , “I don’t mind doctors and nurses such a forum,” she says. The GMC says in a Online is not a private space. using black humour, indeed I’ve made a career statement, “The use of social media by doc- Margaret McCartney is a general practitioner, Glasgow out of it. But if black humour is a marker of tors raises some challenging issues which we [email protected] bad care, you can’t just laugh it off . You’ve got will look at as part of our current review of Full URLs are available on bmj.com to blow the whistle” ( www.telegraph.co.uk ). Good Medical Practice . Doctors who comment Cite this as: BMJ 2011;343:d7109

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