Friday, August 20, 2010

The AAFP, Coca-Cola, and Ethics: Serving the public interest?

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Last fall, the American Academy of Family Physicians (AAFP) (full disclosure: the organization of family physicians, to which I belong) entered into a partnership agreement with the Coca-Cola Company for support of its patient information website, FamilyDoctor.org. The amount of the funding is uncertain, but it is reputed to be in the “mid-six-figures”. The arrangement came in for a great deal of criticism, both within and outside of the family medicine community, and several members of the organization resigned in protest. I addressed this as a small part of a larger blog, Harvard Medical School limits outside income: a good start, on January 21, 2010.

The debate has not gone away, and has been highlighted by two articles in the recent (July-August 2010) issue of Annals of Family Medicine, the research journal sponsored by all the family medicine organizations in the US and Canada. The first is by Howard Brody, the family physician and medical ethicist from the University of Texas Medical Branch at Galveston, “Professional Medical Organizations and Commercial Conflicts of Interest: Ethical Issues”, and the second is response by Lori Heim, President of the AAFP, “Identifying and Addressing Potential Conflict of Interest: A Professional Medical Organization’s Code of Ethics.” Brody’s essay is a clearly written review of the ethics of conflict of interest, addressing both whether the relationship between AAFP and Coke is a conflict of interest (COI) and whether it is ethically worrisome, and an analysis of the reasons and defenses put up by AAFP and Coke. In the first, he notes that a conflict of interest can, and often does, exist even when no “bad” outcome can be identified; it is simply a conflict between the primary set of responsibilities (in this case, of physicians and their organizations’ social responsibility for looking out for the best interests of their patients’ health; in other settings it might be awarding of government contracts or foundation grants) and a second, usually financially motivated set of interest.

Brody distinguishes between two strategies for addressing COI, a Management Strategy in which COIs are divulged so that others (presumably in this case, patients and the public) can take them into account, and the Divestment Strategy, in which organizations rid themselves of COI relationships. He dispenses with the conflation of COI with intellectual conflicts (that an investigator might want to show that his/her “pet hypothesis” is correct and put it in the best light) because readers will always be aware of the latter, but will not know of commercial relationships unless they are divulged. He notes that the Divestment Strategy is favored in most recent ethical literature (and in increasing numbers of medical schools, as per my January 21 blog), although not by the AAFP.

He then addresses the counterarguments and justifications that the AAFP has put forward in this case. These include:

· “Premature Accusation”, in which the AAFP says “you can’t know that we have a conflict until you see the content. He notes the conflict exists regardless, and offers this “crude” analogy: “imagine that a judge who is sitting on a case involving a contract dispute between two companies is discovered to own $100,000 worth of stock in one of the companies. The judge cannot divert criticism of this conflict of interest by saying, ‘But you haven’t waited until I delivered my verdict—how do you know that I won’t rule against the company in which I own stock?’ In the AAFP case, if the final educational material includes a strong statement against sugary soft drinks, we will never know whether, absent the Coca-Cola funding, the statement would have been even stronger. That such questions will inevitably be raised shows the conflict of interest is both present and serious, quite apart from the eventual contents of the educational materials."

· “Other Party not Evil”, in this case Coca-Cola. The issue, of course, is not whether they are evil, but whether their interests may lie in opposition to the interests of the health of doctors’ patients; “The physician has a duty to prescribe medications or make dietary recommendations based on scientific evidence. The companies have an interest in selling more beverages, or more drugs, regardless of the evidence.”

· “Wrong not to Engage” with organizations such as Coca-Cola. “Schafer[1] noted the propensity for engagement with industry, in such discussions, magically to convert itself into accepting large sums of money from industry.…No one is suggesting that the AAFP not engage Coca-Cola if the engagement avoids conflicts of interest and the result of the engagement would be improved public health.” [my bold]

Brody also addresses the similarities and difference between this and the 1997 relationship in which the American Medical Association (AMA) actually endorsed products made by Sunbeam. He notes that the relationship is called a “Consumer Alliance”, when it is more properly a corporate alliance. (I had missed this Newspeak usage in my January 21 blog, where I mistakenly called it a “corporate partnership”!)

Heim’s response states that Brody misses the point, and goes on to make the same arguments that AAFP has made before, that Brody has addressed and debunked, offering nothing new to the discussion. It refers to the AAFP Code of Ethics, and creates the disturbing sense that “we want the money, we don’t think we are doing anything unethical with the money, and so stop criticizing us.” In other words, it purposely and deliberately misses the point.

Does the AAFP’s relationship with Coke go beyond a conflict of interest (which it clearly is) to actually providing unhealthful material? Some authors believe so; public health attorney Michelle Simon, in her blog Appetite for Profit, addresses the issue on July 22, 2010. She notes that FamilyDoctor.org contains the disclaimer “This content was developed with general underwriting support from The Coca-Cola Company,” and comments “That makes it sound as if the Coca-Cola is just paying someone else to do the writing. But it appears the company is directing the substance of the content as well, since the verbiage is pretty similar to that found on Coca-Cola's own website on these very topics. (See for example, the company's page on sweetener ‘facts and myths’.)”

Simon quotes Dr. Heim’s article, “To gauge an individual or organization’s ethics, one must view its behavior over time, define the goal of that behavior and compare the outcome with the mission and values. Within this context, one can determine whether the assumption or appearance of conflict of interest or ethical lapse was, in fact, correct.” And comments: “What? She lost me somewhere between outcome and values. Taking money from Coca-Cola is not a science experiment that you watch over time, gather data, and then publish the analyzed results. But if one were to approach the issue that way, there's no shortage of evidence of Coca-Cola's 'ethical lapses.' Whether your concern is marketing to children, labor abuses, or contaminating water supplies in developing nations, Coca-Cola would be the one company you'd not choose as a partner. Journalist Michael Blanding has written an entire book called The Coke Machine: The Dirty Truth Behind the World's Favorite Soft Drink, due out in September, which chronicles these misdeeds and more.”

Certainly, the AAFP is not the only organization that has potentially undermined its public trust. For another big one, the American Dietetic Association (ADA) has a partnership (I don’t know if they’ve dared to call it a “consumer alliance”) with – Hershey! (see ADA’s press release at its own website; also see the Fooducate blog).

Maybe the ADA’s partnership is more outrageous, but as a family doctor and educator, I take the AAFP’s relationship with Coke more personally because it undermines me. At the time of this deal, several of the other family medicine organizations, including the Association of Departments of Family Medicine (ADFM, academic department chairs, to which I also belong) expressed serious concerns about this relationship to the AAFP leadership. These concerns related particularly to the fact that, to the public, family medicine is family medicine, and when the largest family medicine organization, AAFP, does something the entire discipline is affected; for example, medical students, or faculty in other departments, who may be distressed by the relationship express that concern to the faculty of family medicine. AAFP, the big dog on the block, listened. It didn’t change its policy, though. Money talks, of course, but if AAFP’s 55,000 active members (not including students, residents, and retirees) each sent in $10, it would be about the same amount as they received from Coke. Are we that cheap? As far as the content on FamilyDoctor.org is concerned, check it out for yourself. You can start by clicking on the benign (but somehow familiar) logo at the top of its web page.

Brody concludes his essay with: “Family physicians are widely trusted by their patients and communities. Merely by having chosen our specialty, family physicians have demonstrated a commendable commitment to putting the health needs of their patients ahead of personal financial gain. They deserve to be represented nationally by an organization that fully reflects those high ethical commitments and standards.” I couldn’t agree more.

[1] Schafer A. Biomedical conflicts of interest: a defence of the sequestration thesis—learning from the cases of Nancy Olivieri and David Healy. J Med Ethics. 2004; 30(1):8–24

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4 comments:

Sarah G said...

Excellent post. There are plenty of blogger watchdogs for pharma involvement w/physician groups, but fewer people kick about other questionable alliances.

I'm still annoyed about SparkPeople.com's redaction of its material on HFCS after complaints from the industry... backed up by the AMA.

(SparkPeople is a site focused on weight loss.)

martin donohoe said...

8/23/10

The corporate alliance of the AAFP with Coke is shameful. Soft drinks contain high fructose corn syrup, a major contributor to obesity; per capita HFCS consumption has increased 1,000-fold over the last few decades (and per capita soft drink consumption by 100% over the last few years), and soft drinks account for 20-24% of calories consumed by those age 2-19yo, and all of this in the face of a massive obesity epidemic. For more information see the slide show and the articles on obesity at http://phsj.org/beauty-body-modification-cosmetic-surgery-obesity/. The AAFP has prostituted itself and sold its soul here, but this is not the first time.

The following is excerpted from a letter I wrote on behalf of the Oregon Physicians for Social Responsibility to AAFP, to which no response was received):

"On page 152 of the American Academy of Family Physicians’ (AAFP’s) 2004 publication, "Family Doctor: Your essential guide to health and well-being." an ad shows a pregnant woman eating tuna and touts the benefits of tuna consumption by pregnant women, is sponsored by the manufacturers of three different brands of canned tuna. The ad’s text briefly mentions, in a bracketed portion of the next-to-last sentence, that “the Food and Drug Administration (FDA) recommends limiting fish consumption during pregnancy to 12 ounces per week.” In fact, the FDA recommends limiting canned light tuna to 12 ounces per week, and albacore tuna, which contains higher levels of mercury, to only 6 ounces per week(1). On page 158, in the article “Eating for Two,” the brief section entitled “Fish with Mercury” does not even mention tuna

Mercury is a potent neurotoxin which adversely affects fetal development. AAFP’s juxtaposition of the tuna industry ad with articles about the health of pregnant women and newborns (and pictures of healthy, pregnant mothers and babies), will undoubtedly give readers the impression that tuna is safer than it really is. This example, along with the guide’s juxtaposition of fast food ads with dietary advice (which sends the wrong message to readers, given the epidemic of obesity in the US) illustrates the pernicious influence of corporate advertising on medical organizations and on the dissemination of sound public health recommendations. We ask the AAFP to exclude misleading ads from the tuna industry from future issues and to spell out the exact guidelines regarding consumption of mercury-containing fish, including tuna, by pregnant and nursing women. We also call on AAFP to issue a clarification regarding the true risks of mercury exposure from tuna consumption in upcoming issues of FP Report and American Family Physician."

For the whole text, see http://phsj.org/files/Food%20Safety%20Issues/AAFP%20mercury%20tuna%20ad%20letter.doc.

Finally, Coke bottling plants in Guatemala have been excoriated in the human rights community for labor rights violations, including rapes, etc. In fact, International Rights Advocates recently sued the Coca Cola Company for a campaign of violence (including rape, murder, and attempted murder) against two Guatemalan trade unionists. Coke has also had trouble with pesticides in soda in India, depleting water tables to obtain bottled water in India, etc., etc. (Coke also markets Dasani water.) Multiple refs exist on google re this. For more on bottled water, see http://phsj.org/wp-content/uploads/2008/03/bottled-water-pdx-tribune-lte-publ-v-2-08.doc.

Shame to the nth power on the AAFP.

martin
Martin Donohoe, MD, FACP
Adjunct Associate Professor, School of Community Health
Portland State University
Chief Science Advisor, Campaign for Safe Foods and
Member, Board of Advisors
Oregon Physicians for Social Responsibility
Senior Physician, Internal Medicine, Kaiser Sunnyside Medical Center
http://www.publichealthandsocialjustice.org
http://www.phsj.org
martindonohoe@phsj.org

Josh Freeman said...

Posted for Martin Donohoe, MD, FACP:

8/23/10

The corporate alliance of the AAFP with Coke is shameful. Soft drinks contain high fructose corn syrup, a major contributor to obesity; per capita HFCS consumption has increased 1,000-fold over the last few decades (and per capita soft drink consumption by 100% over the last few years), and soft drinks account for 20-24% of calories consumed by those age 2-19yo, and all of this in the face of a massive obesity epidemic. For more information see the slide show and the articles on obesity at http://phsj.org/beauty-body-modification-cosmetic-surgery-obesity/. The AAFP has prostituted itself and sold its soul here, but this is not the first time.

The following is excerpted from a letter I wrote on behalf of the Oregon Physicians for Social Responsibility to AAFP, to which no response was received):

"On page 152 of the American Academy of Family Physicians’ (AAFP’s) 2004 publication, "Family Doctor: Your essential guide to health and well-being." an ad shows a pregnant woman eating tuna and touts the benefits of tuna consumption by pregnant women, is sponsored by the manufacturers of three different brands of canned tuna. The ad’s text briefly mentions, in a bracketed portion of the next-to-last sentence, that “the Food and Drug Administration (FDA) recommends limiting fish consumption during pregnancy to 12 ounces per week.” In fact, the FDA recommends limiting canned light tuna to 12 ounces per week, and albacore tuna, which contains higher levels of mercury, to only 6 ounces per week(1). On page 158, in the article “Eating for Two,” the brief section entitled “Fish with Mercury” does not even mention tuna

Mercury is a potent neurotoxin which adversely affects fetal development. AAFP’s juxtaposition of the tuna industry ad with articles about the health of pregnant women and newborns (and pictures of healthy, pregnant mothers and babies), will undoubtedly give readers the impression that tuna is safer than it really is. This example, along with the guide’s juxtaposition of fast food ads with dietary advice (which sends the wrong message to readers, given the epidemic of obesity in the US) illustrates the pernicious influence of corporate advertising on medical organizations and on the dissemination of sound public health recommendations. We ask the AAFP to exclude misleading ads from the tuna industry from future issues and to spell out the exact guidelines regarding consumption of mercury-containing fish, including tuna, by pregnant and nursing women. We also call on AAFP to issue a clarification regarding the true risks of mercury exposure from tuna consumption in upcoming issues of FP Report and American Family Physician."

For the whole text, see http://phsj.org/files/Food%20Safety%20Issues/AAFP%20mercury%20tuna%20ad%20letter.doc.

Finally, Coke bottling plants in Guatemala have been excoriated in the human rights community for labor rights violations, including rapes, etc. In fact, International Rights Advocates recently sued the Coca Cola Company for a campaign of violence (including rape, murder, and attempted murder) against two Guatemalan trade unionists. Coke has also had trouble with pesticides in soda in India, depleting water tables to obtain bottled water in India, etc., etc. (Coke also markets Dasani water.) Multiple refs exist on google re this. For more on bottled water, see http://phsj.org/wp-content/uploads/2008/03/bottled-water-pdx-tribune-lte-publ-v-2-08.doc.

Shame to the nth power on the AAFP.

hakan altan said...

thank you

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