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Abstract

Developed societies are reliant on qualiﬁed education of persons in the ﬁeld of science. This is part of societies’ self-understanding. Moreover, the way in which they exist depends on scientiﬁc progress. Scientiﬁc progress has brought countless products for diagnostics and therapy to the fore and made them commercially available. At the same time, modern technical methods and products impact on the biological foundations of human existence. Scientiﬁc training is not to be separated from research in universities and research institutes (postgraduate education). Rather, scientiﬁc-based culture is the cause for a growing demand for training and has, primarily in the ﬁeld of applied research, brought commercialism into education and teaching. Empirical studies have shown that manifold conﬂicts of interest arise in medicine and continuing medical education. Such conﬂicts can be uncovered even when we consider bioethics in the broader sense, encompassing nutrition and the production of food and environmental and animal protection. Conﬂicts of interest can threaten adherence to the core values underlining academic training: objectivity, independence, and altruism. The adverse consequences of commercialism in scientiﬁc education need to be addressed through appropriate avenues: transparency, funding from independent sources and state subsidies, and the strengthening of academic virtues. Moreover, prevention of conﬂicts of interest situations must become part of academic education.

Introduction

Modern developed societies are knowledge societies. They are culturally molded by a way of life that is dependent on the historically unparalleled scientiﬁc progress of the last decades. This holds true for a variety of aspects of life: the way economic affairs are conducted and the conditions under which goods are produced are but a few examples. Scientiﬁc culture has a lasting inﬂuence when dealing with the biological foundations of human nature and with people themselves in the area of medicine (in the broadest sense, referring to all forms of biomedicine).

In addition, a high respect for knowledge for knowledge’s sake characterizes all cultures that stem historically from the interspersing of the Jewish, Greek, and Christian worlds to the present day. The pursuit of science is aimed at overcoming of boundaries of recognition and also the naturally given limits on action.

As a result, modern societies are in need of personnel that is trained in the science and, hence, are dependent on qualiﬁed educational systems in the scientiﬁc ﬁeld. This is in keeping with their self-understanding on the one hand, while on the other hand, it is indispensable for self-preservation.

The rapid progress in the ﬁeld of biomedicine has led to the development of a myriad of products that have become commercially available for diagnostic and therapeutic uses in medicine. Otherwise, we can look at the impact of modern technological processes on the biological foundations of human existence (use of nuclear energy, CO2 emissions, the production of genetically modiﬁed and/or artiﬁcial foodstuffs).

Scientiﬁc training was until the middle of the twentieth century principally offered by state institutions, foundations, religious or not-for-proﬁt institutions, and independent universities. The developing scientiﬁcation of the environment led to a diversiﬁcation of these institutions. At the same time, the use of educational resources for scientiﬁc training grew considerably. Due to the possibilities for marketing, there grew a demand in industry for well-trained scientists. Subsequently, scientiﬁc education was also underlined by commercial interest. The result in the ﬁeld of biomedicine is an array of ethical conﬂicts, mostly conﬂicts of interest.

History

The history of higher educational training is closely bound to the history of the university, which emerged from the Christian educational system of the Middle Ages (Ruegg 1993). The University of Bologna is considered to be one of the ﬁrst universities to be founded. Training was made possible by foundations or royal or private patronages. Conﬂicts also arose in earlier times, mainly about the freedom of research: this was particularly the case when, due to the interference of the state or certain patronages (sometimes churches), certain beliefs or ﬁndings were not allowed to be taught. In modern societies, freedom of research is of the utmost importance, and in many countries this is a constitutionally vested right, such is the case, e.g., in Germany.

The rapid technological process of the last hundred years has also changed training systems fundamentally. Higher education, in particular postgraduate training, takes place in universities and nonuniversity research institutes, but is also carried out by commercially active undertakings. Furthermore, supposedly independent research institutes and universities receive a signiﬁcant portion of their resources from external sponsors, not least private patrons. It is important to note that a strict conceptual division between research and teaching is not possible, because it has just been the ideal, which can be traced back to Wilhelm von Humboldt, that the scientiﬁc researcher teaches at the same time as he or she conducts research. As a consequence, the commercial environment also puts its stamp on scientiﬁc training.

In this context, the increase in health spending in developed countries is to be remarked upon. For example, this spending accounts for 17 % of GDP in the USA, while this ﬁgure sits at 12 % in the Netherlands and 11 % in Germany and Switzerland (Bundeszentrale fuer politische Bildung 2013). The provision of healthcare has itself grown to be a signiﬁcant portion of the economy. From these ﬁgures it is evident that for healthcare, commercialism and commercialization have become part of the system. The development of new products that can improve diagnostics and therapy is one of the driving forces in the healthcare industry ﬁeld. The share of private investment, for example, by pharmaceutical companies, overtakes public sector funding, a point that holds true for the USA, for Europe, and for Asia/Oceania.

A relevant proportion of expenditure is also spent on contracts with (administratively) independent research institutes (Lo and Fields 2009). However, because of this there is no longer freedom in the choice of subjects that research activities can be directed toward. More and more frequently, institutions that are thought to be independent (administratively) are in fact dependent on support from the private sector.

Given that research institutes are involved in academic and postgraduate training in various ways, the inﬂuence of commercialism on education deserves special attention. Since the enlightenment, that is to say, since the 1800s until the middle of the twentieth century, the freedom and independence of research and teaching were a source of conﬂict especially from the perspective of independence from state paternalism. Since then the freedom of research and teaching has obtained the status of an important right that can only be limited when other rights, such as the rights of individuals, are threatened by it.

So, today the terms of research and teaching have changed. Due to our more sustained exposure to modern technologies and the inﬂuence of ever more interest-led research into our living environment, it is a challenge for society to protect education in science (as well as the freedom of research) from undue external inﬂuences.

Conceptual Clarification

When looking at ethical challenges brought about by the commercialism in education, it is advisable to make some preliminary distinctions in advance. Firstly, the following considerations are not made in relation to primary teaching in the area of school education. They relate to academic education, postgraduate training, and particularly for doctors’ mandatory and essential continuing medical education.

In addition, various scopes of application can be differentiated that refer to the reach that the concept of bioethics has. In the one sense, bioethics refers to the ethical challenges in the ﬁeld of the practice of medicine (including medical training and research). In another wider sense, it refers to a broader concept of bioethics that is concerned with the interaction between man and the natural foundations of human existence, environmental protection, and the protection of animals. The signiﬁcance of the commercialism of scientiﬁc education has been the subject of ethical and political debates in the ﬁeld of medical practice for several years. However, from the perspective of bioethics more broadly understood, the issue of commercialism in science education has, for a long time, remained a subject seldom discussed and evidently underestimated. With this respect the argument is extended to the area of education of the public.

In the following consideration of the ethical dimensions, these aspects are discussed separately.

Ethical Dimensions

In the ﬁeld of medical practice (including research and development and training), the ethical problems of commercialism/commercialization have been discussed for many years. In a number of countries, guidelines have been produced, compliance with which is partially ensured by legislation (e.g., Rothman et al. 2009). In the USA in particular, manifold social-empirical ﬁndings have laid bare the ethical clashes and conﬂicts of interests that arise through commercialization, also in the ﬁeld of scientiﬁc education. Ethical problems in the ﬁeld of medicine and biomedicine are therefore comprehensively covered; they are the subjects of consideration in section “Commercialism in Science Education with Respect to Medicine and Medical Research.”

If we consider bioethics more widely understood, so including also aspects of the environment, food, and animal welfare, the inﬂuences of commercialism are less well studied. However, there is reason to suspect that they operate in a similar manner and also entail ethical conﬂicts; these are discussed by way of example in section “Commercialism in Science Education and the Wider Scope of Bioethics.”

Commercialism In Science Education With Respect To Medicine And Medical Research

Medical training is carried out by medical schools and universities. The inﬂuence of commercialism/ commercialization on academic training is to be distinguished from the inﬂuence it has in the ﬁeld of continuing medical education.

Commercialism In Academic Medical Education

Training for medical practice must be independent. Education has to be committed to the truth, handle knowledge objectively, and be altruistic with respect to the goal of medicine, which is to care for patients. These requirements are endangered by commercial inﬂuences, as has been conﬁrmed by a plethora of studies, especially from the USA (for an overview of the literature, see Lo and Fields 2009; Sahm 2013). These show, e.g., that more than half of medicine students have been in contact with industry representatives and have been given gifts by them (Rogers et al. 2004); educators are also under their inﬂuence insofar, e.g., as they test new pharmaceuticals and other medical products in clinical trials (Lo and Fields 2009).

Continuing contact with industry representatives changes psychological behavior: a consciousness of entitlement – having a claim to receive gifts – arise (Sahm 2013). Psychological research has shown that even small gifts, such as invitations to lunch or small items with the trademarks of pharma products on them, can have an inﬂuence. And it goes without saying, teaching does not get away unaffected, as many studies conﬁrm (Lo and Fields 2009). The relationship of a teacher with the industry has an inﬂuence on the way current research ﬁndings are represented and impacts on the choice of content for courses. In many cases, educational institutions are dependent – either directly or indirectly – on industry-sponsored research funding, for example, in the ﬁeld of clinical research (Lo and Fields 2009, p. 101 ff).

The above mentioned values that are the basis of academic education are made vulnerable by this increasing commercialism. Especially in the USA, professional associations as well as the Institute of Medicine have produced documents with detailed proposals on how to avoid conﬂict of interest situations (Lo and Fields 2009; Morris and Taitsman 2009; Rothman et al. 2009). This includes making scholarships provided by industry players transparent and, in addition, provides that universities and institutions must act independently when selecting which candidates should receive scholarships (i.e., this choice should not be inﬂuenced by the industry sponsor).

Moreover, the risks arising from conﬂicts of interest themselves must be taught. It is important to ensure that the majority of courses will be ﬁnanced by independent public funding, which is an essential element to ensure independent, objective, and evidence-based teaching. As the requisite regulations differ from country to country and the policies are necessarily varied, these will not be outlined in detail. They are speciﬁc to the structure of the given educational system, the way research is funded, the dependence of institutions, and their modes of ﬁnance. However, it can be said that in many countries so far the importance of commercialism/commercialization in teaching has not been considered satisfactorily.

Of particular importance is the psychological impact of accepting even small gifts; research has shown that the independence of decision-making capacities are inﬂuenced considerably by this (Dana 2009). Keeping educators free from commercial interests is an indispensable condition for the independence of teaching.

Commercialism Of Postgraduate Medical Training

The conditions in postgraduate training do not substantively differ. Here it should be noted that many young researchers and doctors conduct their ﬁrst independent scientiﬁc research. The choice of their research is itself driven by interest because a signiﬁcant proportion of this research is funded by commercial sponsors. The orientation of this research is itself also not free, as the Humboldtian ideal and the independence of academic activity would dictate. Here societies have to make tradeoffs: on the one hand, interest-led research is undoubtedly a blessing for future patients because it helps develop new methods for diagnosis and therapy (Sahm 2013); on the other hand, certain areas for research remain neglected because there is no commercial interest. An example here would be the development of drugs to treat rare diseases (so-called orphan medical products): the pharmaceutical industry is not interested in such ﬁelds because of the lack of proﬁt to be made in conducting such research. However, from an academic-medical point of view as well from the perspective of medical practice and health policy, to give support to public funded research in order to develop treatments of such diseases is vital and may be of great importance (Stevens et al. 2011).

Commercialism In Continuing Medical Education

One of the essential duties of practicing doctors is to undertake continuous training throughout his or her professional life. Unlike other professions, doctors have the right to access and prescribe highly regulated and costly products at the expense of third parties (e.g., insurance companies). Not surprisingly, it is in the interests of manufacturers of such products (e.g., pharmaceutical companies) to inﬂuence the subject matter of continuing medical education (Sahm 2013).

Industry sponsorship in the ﬁeld of continuing medical education has increased considerably, as is shown through various studies from the USA (Lo and Fields 2009). There, the promotion of events in this ﬁeld increased 300 % in the ﬁrst 10 years of the new millennium. Half of medical schools’ funding for medical education now comes from the industry.

No ﬁgures are available for Europe and other developed countries to make a comparison. However, a visit to a medical congress or a glance at the advertisements in medical journals highlights the dependence of events and journals on commercial advertising. The big conferences of all medical associations are, to a sizeable extent, sponsored by manufacturers of medical devices and pharmaceuticals. And various studies have shown the inﬂuence of industry on the design of further training (Sahm 2013). The largest of medical congresses, held for the most part in the USA, are attended by doctors from around the world, and, as empirical studies have shown, often these doctors do not travel at their own expense; their costs are instead taken on by industry players (Eckardt 2000). Supposedly, doctors would often become interested in other topics if reimbursement of travel costs would not be a factor in directing their interest to attend a particular meeting. Their choice of subject of continuing medical education would change.

The inﬂuence of the pharmaceutical industry and manufacturers of medical devices on continuing medical education has been observable for the past 20 years. A number of court cases have revealed that the representations made about the effects of pharmaceutical products speciﬁcally have been inﬂuenced (see Sahm 2013). Promotional activities of the pharmaceutical industry in the ﬁeld of continuing medical education change the behavior of doctors when prescribing medicines. As well, increases in sales in the wake of such activities are measurable (for an overview, see Lo and Fields 2009). On the other hand, congresses and symposia solely organized by academic faculties tackle a wider array of topics in the ﬁeld of medicine than industry-ﬁnanced symposia which tend to be focused on new products for sale.

A set of ethical standards has been developed to reduce commercial inﬂuences in continuing medical education. This includes, among other things, creating transparency where there might be a conﬂict of interest. In some European countries and the USA, doctors and speakers are obliged to make their connections with industry known and include them in a comprehensive (online) source. This is stipulated, e.g., in the US Sunshine Act and in comparable guidelines in Germany. Yet, one has to be aware that even creating transparency and establishing respective rules may have an obverse effect as research has shown. For example, among other advisors, educators may feel licensed to act immoral after having disclosed potential conﬂict of interest (Loewenstein et al. 2011). So transparency alone will not be sufﬁcient to prevent conﬂicts.

Despite adhering to transparency rules, the inﬂuence of industry-sponsored continuing medical education remains signiﬁcant. As a countermeasure to protect the independence of continuing medical education, it has been proposed that industry funding should be collected in a fund. The ﬁnancial means should be available for educational training, but their distribution should not be dependent on the sponsor. An even more desirable situation is one in which a considerable part of continuing medical education could be carried out independently of any industry promotion. Some activities stemming from within the medical community are aimed in this direction, such as “no-free-lunch organizations.”

Medicine is undoubtedly a ﬁeld where continuous training at an above-average level is needed. Therefore, the expenses necessary to undertake this training must be ﬁnanced judiciously and should not rely on interest-led funding. However, there are no viable concepts for achieving this in any healthcare system in the developed world, with the result that various conﬂicts of interest arrive to the detriment of patients. This threatens all the essential preconditions for medical action: independence of medical decision-making, objectivity, and altruism.

Conceptually, there is a connection between the ﬁeld of continuing medical education and conﬂicts of interest in the ﬁeld of medical research. A host of studies have laid down the negative impacts of, for example, ghostwriting or providing speakers from industry-sponsored speaker bureaus on the independence of publications and their presentation in the context of medical congresses (Sahm 2013). As the results of clinical research are communicated at such events, it is important to look at the ethical challenges of commercialism/commercialization of continuing medical education in direct connection with the threat to the independence of medical research.

In addition to proposals to curtail industry’s inﬂuence on science education (see above), some groups from the medical ﬁeld have started to stop it. For example, there are the organizations such as MEZIS in Germany and No Free Lunch in the USA that counter commercialism. They promote the idea that medical staff should not accept any gift, lunch, or other items or personal beneﬁt at all. They try to stand up against pharmaceutical industry guiding medical practice. As well some institutions have changed their policies with respect to continuing medical education. The Accreditation Council for continuing medical education in the USA has stated that providers of education “cannot receive guidance, either nuanced or direct, on the content of the activity or on who should deliver that content” (quotation in Lo and Fields 2009, p. 157). Opinion-leading medical institutions such as Memorial Sloan Kettering Cancer Center in New York and Stanford University Medical Center would not accept any commercial support for continuing medical education at all (Lo and Fields 2008, p. 152 ff).

Commercialism In Science Education And The Wider Scope Of Bioethics

An extended concept of bioethics is concerned with ethical conﬂicts when dealing with the environment, animal welfare, and the natural condition and fundamentals of human existence. Here also we see conﬂicts of interest arising from commercialism of research funding and science education. However, these have been far less well studied, as compared with the ﬁelds of medical practice. Hence, the degree of the inﬂuence that conﬂict of interest situations has in these areas is evident from empirical evidence to a lesser extent. Yet, in particular with respect to the area of education of the public, some observations give rise to concerns (Miller and Harkins 2010). A variety of conﬂicts can be assumed. By way of example, we can look at the so-called food industry. Recently, a network of inﬂuential measures emanating from food companies was uncovered (Gornall 2015; Anderson and Miller 2015). The aim of these measures was to call into question the scientiﬁc evidence demonstrating a link between the consumption of sugary drinks and food (e.g., soft drinks) and being overweight. Obesity now represents one of the most major health threats in a number of Western countries; however, manufacturers of such products have entered into ﬁnancial relations with scientists who have then appeared in the public eye as experts denying such a link (Gornall 2015). A thorough analysis shows furthermore that lobbying by the food industry blocked a proposal for the regulation of food labeling standards (Kurzer and Cooper 2013). Scientists that served as public educators are inﬂuenced by undue conﬂicts of interest (Miller and Harkins 2010). There are no studies that reveal the extent of inﬂuence that may be exerted on science education in the ﬁeld. Yet, it would be quixotic to assume that no such inﬂuence would exist.

In the areas that relate to the wider concept of bioethics, conﬂicts of interest in the ﬁeld of research, but also scientiﬁc education, are still being given insufﬁcient attention.

Conclusion

Freedom in teaching is a valuable commodity. Scientiﬁc education must aim to be objective and committed to the truth. In the ﬁeld of medicine, educators must teach these responsibilities and must convey the altruistic motivations of the profession because increasing commercialism risks the pursuit of these goals insofar as it creates various conﬂicts of interest.

The most important measure to be taken is therefore transparency: ﬁnancial relationships underlying the receipt of advantages from product manufacturers must be made known. Further, how to deal with conﬂicts of interest must be made the subject of academic teaching, at the university and postgraduate training levels. Not the least, it is important to strengthen academic attitudes of physicians and scientists. It is in the public interest that in any given country the vast proportion of institutions offering academic education and postgraduate training are independently ﬁnanced. There must be adequate offers for education to indemnify against the effects of commercial interests; it is only then that an independent education can be guaranteed.

Despite overwhelming evidence of the unwanted effects of commercialism in science education, there are no structures in place to guarantee with any reasonable certainty that education remains objective, seeks the truth, and strengthens altruism which are held to be its core virtues.

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