Saudi Journal of Gastroenterology
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Year : 2021  |  Volume : 27  |  Issue : 6  |  Page : 317-318
Despise the free lunch

1 Division of Gastroenterology, Department of Medicine, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia; Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, Montreal, Canada
2 Program for Health Assurance and Purchasing, Vision Realization Office, Ministry of Health, Riyadh, Saudi Arabia

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Date of Web Publication09-Nov-2021

How to cite this article:
Almadi MA, Altowaijri A. Despise the free lunch. Saudi J Gastroenterol 2021;27:317-8

How to cite this URL:
Almadi MA, Altowaijri A. Despise the free lunch. Saudi J Gastroenterol [serial online] 2021 [cited 2022 Dec 3];27:317-8. Available from:

See accompanying article on page 342

In Robert Greene's book “48 Laws of Power,” the 40th law warns against the acceptance of free gifts. Such a gesture would put the recipient under a conscious, or unconscious, obligation to return such favors, or at least some gratitude or loyalty. Although such emotional bonding and human interactions are favorable in general, when it comes to making judgments and when there are stakes, whether financial or otherwise, maintaining judicial independence is not negotiable. Furthermore, trust is a fundamental part of the physician-patient relationship and maintaining it is echoed in oaths and teachings among medical practitioners across cultures and nations. Tainting it with political influences, as we have seen in the pandemic, or other influences including financial ones are frowned upon, to say the least, and erodes into the matrix of the relationship between the healthcare sector and the public.

The Physician Payments Sunshine Act is a United States federal legislation that was passed in September 2007[1] and attempts to address financial conflicts of interest, through transparent reporting, between manufacturers as well as group purchasing organizations, and physicians and teaching hospitals. However, since 2021 it has been updated to include physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and anesthesiologist assistants, as well as certified nurse-midwives.[2] There have also been suggestions to expand the reporting of financial interactions between industry and patient advocacy organizations as a similar moral trap could develop in that domain also.[3]

This policy of disclosure of financial ties has been emulated in numerous other countries like Australia, Canada, France, Japan, Scotland, Slovenia, and Turkey.[1] But this has not been universally accepted and other countries remain to debate the value of implementing such a process,[4],[5] let alone the practitioners who are required to file these reports, and their perspectives on the matter have been mixed.[6]

Public oversight on the financial transactions of health practitioners is not new. Hammurabi of Babylon (ruled from 1792 to 1750 BC) had in his code a “price list” for surgeries. In his 215th law, he states, “If a physician performs major surgery with a bronze lancet upon an awılu [a free citizen of high birth] and thus heals the awılu or opens an awılu's temple with a bronze lancet and thus heals the awılu's eye, he shall take ten shekels of silver [as his fee].” While in his 216th law he states, “If he [the patient] is a member of the commoner-class he shall take five shekels of silver.”[7] We can sense the intention of equality way back then, when the variation of pricing was based not on the procedure per se but on the status of the patient. I think we can agree that we are still struggling with these concepts today. Such public oversight on these financial transactions might create a Hawthorn effect as depicted in decreased industry transfer to physicians between 2014 and 2016, but the effect on the prescribing behavior of those receiving transfers remained detectable and present.[8]

Although the interaction between industry and other elements in the healthcare ecosystem is an important factor in the advancement of science and medical breakthroughs, this should be governed in a transparent manner to maintain the trust of the public as well as the medical community. In this issue of the Saudi Journal of Gastroenterology, Al Sulais et al.[9] looked into the financial conflict of interest declarations among Inflammatory Bowel Disease guidelines authors. Despite the study being limited in scope and duration, it still shows that such a reporting mechanism remains far from perfect and relies on self-reporting, which might fall short either intentionally or due to the perceived notion that such interactions need not be reported. The effect of the Sunshine act on scientific publications has been explored and its effect is yet to be quantified.[10] The article by Al Sulais et al.[9] also shows that although the scientific community had “self-regulated” the process of who should, and should not, be involved and the proportions of those included on guideline panels, we have failed to abide by our own rules.[11]

Even though disclosures of conflicts of interest might be an advancement in the process of transparency, it is not the holy grail to address it. There have been criticisms that the mere act of disclosure will not curtail cognitive biases nor the distillation of institutional unwanted practices, and experiences from the financial sector and Wallstreet has demonstrated that declaration on its own did not prevent the 2008 financial crises.[12] The process of disclosure shifts the risk from the regulators to the public to make use of the information, accurate or otherwise, and make judgments. It does not put regulations to these transactions nor consequences to the parties involved in these perceived conflicts, and is elegantly explained in Mark Wilson's commentary,[12] where we hope that the market's “invisible hand” will regulate and correct the imbalances in the system on the long term, although there is a knowledge imbalance and the public would not have the skill nor regulatory power to “correct” the problem. The issue with such an approach is that the cost of such a journey could be years of life lost and years lived with disability, and we need to find a better way to address it.

   References Top

Thacker PD. A few tiny steps towards transparency: How the Sunshine Act shone light on industry's influence in medicine. BMJ 2020;370:m3229.  Back to cited text no. 1
Centers for Medicare and Medicaid Services newly added covered recipients. Available from: [Last accessed on 2021 Oct 07].  Back to cited text no. 2
McCoy MS. Industry support of patient advocacy organizations: The case for an extension of the sunshine act provisions of the affordable care act. Am J Public Health 2018;108:1026-30.  Back to cited text no. 3
Macleod S. A sunshine payment act for the UK. BMJ 2021;374:n1900.  Back to cited text no. 4
Ross JS. Kept in the dark: Scotland rejects “sunshine” legislation. BMJ 2019;364:l1379.  Back to cited text no. 5
Chimonas S, DeVito NJ, Rothman DJ. Bringing transparency to medicine: Exploring physicians' views and experiences of the sunshine act. Am J Bioeth 2017;17:4-18.  Back to cited text no. 6
Pearn J. Hammurabi's code: A primary datum in the conjoined professions of medicine and law. Med Leg J 2016;84:125-31.  Back to cited text no. 7
Brunt CS. Physician characteristics, industry transfers, and pharmaceutical prescribing: Empirical evidence from medicare and the physician payment sunshine act. Health Serv Res 2019;54:636-49.  Back to cited text no. 8
Al Sulais E, Alsahafi M, AlAmeel T. Undisclosed payments by pharmaceutical manufacturers to authors of IBD guidelines in the United States. Saudi J Gastroenterol 2021. DOI: 10.4103/sjg.sjg_426_21.  Back to cited text no. 9
Toroser D, Robinson M, Gegner J, Smith G, Nilsen J, Hyatt L, et al. Systematic review of reports describing potential impact of the Sunshine Act on peer-reviewed medical publications. Curr Med Res Opin 2016;32:547-53.  Back to cited text no. 10
Institute of Medicine (US) Committee on Standards for Developing Trustworthy Clinical Practice Guidelines; Graham R, Mancher M, Miller Wolman D, et al., editors. Clinical Practice Guidelines We Can Trust. Washington (DC): National Academies Press (US); 2011. Available from: doi: 10.17226/13058.  Back to cited text no. 11
Wilson M. The Sunshine Act: Commercial conflicts of interest and the limits of transparency. Open Med 2014;8:e10-3.  Back to cited text no. 12

Correspondence Address:
Dr. Majid A Almadi
Professor of Medicine, Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh – 11461

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjg.sjg_541_21

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