Public Service and the Rheumatologist

From jury duty to hospital committees, our institutions depend on the people of this country for community and public service. Although trying and often time consuming, this service is usually provided in good humor and with the best of intentions. Unfortunately, community service has recently earned a less lofty reputation. As punishment for miscreants, community service follows right after sincere regrets and rehabilitation for substance abuse in the “stations of the celebrity.” As documented in the news reports, for students applying for admission to top colleges, “voluntary” community service is no less a formal requirement than good grades or SAT scores.

Certain forms of community service can be onerous but I often take pleasure in jury duty despite the time imposition. The joy is not due to just the proximity of Chinatown and its delightful restaurants to the courts in Manhattan. It is interesting to see professionals of a different sort work and take part in a process that is critical to the proper functioning of civil society. Similarly, the drudgery of committee work at my medical center has its gratifications: the satisfaction of a job well done and the sense that the commonweal has been served are their own form of recompense. Needless to say, I get a lot of this sort of satisfaction.

To Serve or Not To Serve?

However, my ambivalence to the claims of public service was recently reinforced by an event that has left me troubled. Several months ago, I was asked to serve on the advisory committee of the Food and Drug Administration (FDA) that was tasked with reviewing the evidence for approval of a new COX2 inhibitor (Arcoxia) from Merck. When initially invited to serve on this committee, I did not think that I had any conflicts of interest. I had spoken for Merck five or six years ago and edited a Web site sponsored by Merck that went under four or five years ago. Since then, I had had little contact with the company.

During the following few weeks as I was being vetted for service, it became apparent that Merck was going to sponsor subscriptions for a review journal that I edit. I told the FDA of this sponsorship and was promptly told that this was an insoluble conflict as my “employer” would benefit from the approval of the drug. Would that I could benefit too, but I never heard any mention of sharing in the profits that would result from the increase in paid subscriptions.

Despite the flattering notion that my opinion of a new NSAID might matter enough to make a difference as to whether or not this drug was licensed and administered to millions of patients, I was actually relieved that I would not have to serve on this FDA Advisory Committee. Going into these deliberations, it was clear that this drug stood little chance of approval; the mention of the name of Merck and COX2 inhibitor in the same sentence is to the watchdogs of the pharmaceutical world what Enron is to Sarbanes and Oxley. Whatever the merits or toxicities of this drug and no matter how many patients were involved in the studies, it seemed a remarkable move on the part of Merck to apply for approval of a new COX2 inhibitor so soon after the Vioxx debacle.

My relief in being asked to step down from the panel was that, if I voted for approval of Arcoxia and the vote was in any way close, I knew that I would be criticized in the press. The press, or at least the New York Times (my hometown paper), portrayed the members of the FDA panel that voted to keep Vioxx on the market as virtual pigs feeding at the trough of the pharmaceutical establishment. Indeed, one of the non-physician members of that panel (who was on the losing side of that vote) has subsequently been quoted in the press and has written that, not only were most of the people who voted in opposition to his opinion on the take from the pharmaceutical industry, but that the remainder had an insoluble conflict of interest that arose from the fact that they took care of patients.

Punishment for Public Service

The tendency to paint the opposition as not only wrong but criminally wrong has added tremendous risk to public service. In the current environment, I often find myself asking for written reassurance that I will not be held liable or that my legal costs will be covered by the institution for service on any committee where decisions must be made. The committees on which I have served for which liability is a possibility have included investigations of scientific misconduct and personal misconduct of individual physicians as well as promotion and tenure committees.

Being confronted with the foibles and imperfections of my fellow scientists and physicians is not only distasteful but potentially financially ruinous if I find myself charged with libel as a result. Service on an advisory panel of the FDA is not lucrative and the major returns for this service are found elsewhere. If current trends continue, the result of any decision made in the name of an institution or in the name of the public will carry with it a requirement for legal defense.

The cost of community service may soon become too onerous for most people to participate. In addition to the time taken from other pursuits, the cost of public service now includes the potential for legal action. Pretty soon, community service will be the exclusive domain of the criminal celebrity and all decisions will devolve upon those least likely to offer wise opinion. This regression to the minimum seems to have occurred, to a great extent, in the political world and it is unfortunate, but inevitable, that the divisions and vindictiveness have spread to the rest of us.

Although I am not nearly as accurate a shoe tosser as the supermodel Naomi Campbell nor blessed with the looks of the rock singer Boy George, I would like to take my turn at serving the public. Nonetheless, I do not wish to serve my community while wearing a reflective vest and pushing a broom through the streets of New York. It might be nice, however, to have a safe, non–GI toxic NSAID to treat the inevitable aches and pains resulting from such unusual exertions.

Dr. Cronstein is Paul R. Esserman professor of medicine at NYU School of Medicine in New York City.