Saturday, July 29, 2017

Where Are All of the Pizza Shamers?

On the drive home tonight I was listening to a radio piece about the new White House Press Secretary.    Anthony Scaramucci, was apparently a banker and hedge fund manager before he accepted the new role.  He was the head of SkyBridge Capital LLC and sought approval in January to sell this fund to a group of Chinese investors.  He could make as much as $125 million off of the deal.  The deal requires approval of the Committee on Foreign Investment in the United States (CFIUS) since it potentially involves national security issues.  Another interesting aspect of this sale is that the President can apparently veto CFIUS decisions, although that has never happened in the past. Several commentators have discussed the role of White House Press Secretary as being a critical role in the administration.  From an ethical standpoint, the relevant question is - should anyone with a pending large sale to a foreign power that is under review by an agency of the federal government be placed in such a position?

Similar questions and others have been a constant consideration with President Trump and his administration.  He has refused to distance himself from his businesses by placing them in a blind trust like previous members of the executive branch.  That is the most glaring problem even though elected officials apparently get a pass relative to non-elected employees who have to adhere to Standards of Ethical Conduct for Employees of the Executive Branch.  Additional criticisms include the foreign and domestic Emoluments Clauses, prohibiting elected officials from accepting gifts or making a profit from their elected position.  Those criticisms have included hotel deals by foreign concerns in staying at the President's hotels or golf clubs and whether investments by government employee retirement funds in the President's businesses constitute violations of these clauses.  An encyclopedic look at these potential conflicts of interest are included in reference 3 below.  The only offsetting factor in terms of the potential to make money from some of these areas was an analysis in the Economist  - suggesting that the President's business is mediocre and not very dynamic.  That author thought that it would be several years before any profits could be realized due to these constraints.

The lack of transparency for the President and the Executive Branch is stunning, but I think consistent with what could be expected from placing a businessman in the White House.  Americans have general amnesia when it comes to the mistakes of history.  Despite a Hollywood movie, most people forgot that in the financial sector engineered financial crisis of 2008, only one top banker went to jail and that was for concealing hundreds of millions of dollars in mortgage backed securities losses at Credit Suisse (5).  The way around financial conflict of interest is to design a system where everyone's financial security is at risk all of the time and to let the investor know that absolutely nothing can be depended upon.  Pages and pages of boilerplate illustrate this concept.  Lose everything and it always comes down to your lack of due diligence, not the financial adviser who is selling you stock and shorting that stock at the same time.  What do Americans expect will happen when they elect a President from that ethos?        

The standards for physicians are much different.  Physicians can be reported to a database and listed on that database for accepting a meal worth as little as $10.  In the heyday of drug representatives trying to convince physician to use their products the common currency was pizza.  I used to see these reps dragging large boxes of pizza through the hospital where I worked usually to a Grand Rounds.  People would pick up a piece of pizza and eat it during the noon presentation and then go back to work.  Eventually arguments were made that even a single piece of pizza would bias a physician into prescribing a drug from the pharmaceutical representative who purchased that pizza.  Examining the database of physicians who accepted payments shows that the vast majority on on the list because they were pizza eaters or they were listed for attending a company sponsored continuing education event.  Research was presented to prove that pizza or an equivalent trivial reimbursement led to the expected pattern of prescribing.  Psychiatrists were criticized far more than other physicians.  I have posts on this blog that highlight the poor quality of these arguments and the associated research.  Those posts include clear data that refutes the basis for pizza shaming and suggesting that there was something unique about psychiatry.    

The Institute of Medicine argument is that since it is hard to tell the difference between and appearance of conflict of interest from true conflict of interest - in the case of physician they must be considered the same thing.  The IOM rationalizes their opinion as necessary to maintain public trust because of the traditional role of the physician.  Coincidentally their opinion makes sanctioning bodies like the IOM and other organizations that purport to tell physician what to do and how to behave even more important and central to the medical profession.  After all what would physicians possibly do without the IOM and other sanctioning bodies meting out these sacred opinions? The short answer of course is what they have been doing since sometime around the 4th or 5th century BCE and Hippocrates in Epidemics: "As to diseases, make a habit of two things—to help, or at least to do no harm."  The writings are considered the foundation of the main elements of modern medical ethics.

Rather than considering ancient history - ask the question - what is the the larger conflict of interest - a $5 piece of pizza provided by a pharmaceutical company or millions to hundreds of millions of dollars in trading profits? What is the appearance of conflict of interest versus actual conflict of interest in those two scenarios?  In other words, if the party questioned denied they were influenced by a piece of pizza or a million dollars - who is the most likely to be lying? Keep in mind - the pizza is gone after you eat it.  No matter how good it was the benefit is transient and overall trivial.  Most people would not say that about a million dollars.

Considering more realistic  numbers for Congress rather than the Executive Branch, the average donation to a member of Congress from the pharmaceutical industry is $46,579 (averaged across members of both houses).  What will have more impact, the money to a Congressman who is writing laws and regulations that govern the industry or a piece of pizza to a physician who may or may not write a prescription for that company's drug? That is assuming the Congressman is writing the law.  There is plenty of evidence that the lobbyists either write it or directly influence it. You can't get that kind of influence with a slice of pizza.

Taken at another level, the idea of physicians being so important in society that they must be held to a standard that few other citizens are makes sense in terms of individual health care.  It does not hold at the level of society in general.  It takes relatively few politicians to make decisions that affect the lives of tens of millions of people.  Those decisions can result in mass casualties and result in generations of people living in armed conflict and poverty.  Political decisions can result in large segments of society being actively discriminated against.  Economic decisions can transfer wealth from citizens to favored industries at a large cost to individuals and their families.  For all of these reasons - the idea that physicians should be reported for accepting pizza at a conference and members of the executive branch talking to potential business partners when they are supposed to be representing the best interests of the American people is more than absurd - it is an outrage.

Where are all of the pizza shamers when they can really make a difference?  Why aren't they focused where they should be?

George Dawson, MD, DFAPA                


1.  Reuters.  Scaramucci Awaits U.S. Approval for China Deal.  July 21, 2017.

2.  Adrienne Hill.  Scaramucci's hedge fund sale to Chinese firm could pose a conflict of interest.  Marketplace.  July 27, 2017.

3.  Jeremy Venook.  Trump’s Interests vs. America’s, Pensions Edition.  The Atlantic.  July 27, 2017.

4.  The Economist.  Donald Trump’s conflicts of interest.  November 26, 2016. (Contains an infographic of the Trump organization's estimated value).

5.  Jesse Eisenger.  Why Only One Top banker Went to Jail for the Financial Crisis.  New York Times Magazine.  April 30, 2014.


Pizza slices are from Shutterstock per their standard licensing agreement for non-commercial use.
Stock photo ID: 122225896 Cheese Pizza with white background, close up - by Hong Vo.  Accessed on 7/28/2017.

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