Practical Concerns with Ethical Dimensions in the Management of Diabetic Retinopathy

  • David J. Browning


In this chapter we will cover a number of diverse, yet practical topics, rarely covered in a book on diabetic retinopathy. What ties them together is the common thread of possessing an ethical dimension. Our goal will be to identify issues that arise daily in the care of patients with diabetic retinopathy that require a response by the ophthalmologist and examine what motivates the possible alternative behaviors by ophthalmologists. Scientific studies touching these topics are few. Whereas analogous issues arise in all fields of medicine, by tying them to our emphasis here on diabetic retinopathy the author hopes to establish immediacy. The perspective will be discursive, but not directive, because in many cases, a correct answer or solution based on evidence may not be clearly discernible or may be controversial. In each case, the concept of medicine as a profession operating under a tacit social contract is crucial. This social contract states that physicians are allowed “a high degree of autonomy in their professional affairs in return for vowing to use their medical and scientific expertise solely to promote the interests of their patients and the welfare of the public.” In fact, the use of the word “solely” in this quotation indicates that the assertion is aspirational, not factual. Cases abound demonstrating that ophthalmologists are human and heir to self-interest. Ophthalmologists exhibit professionalism to the degree that we approach the goal and abjure self-interest and the perception of such in favor of our patients’ interest and that of the public.


Diabetic Retinopathy Fluorescein Angiography Diabetic Macular Edema Proliferative Diabetic Retinopathy Investment Firm 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Cohen JJ, Cruess S, Davidson C. Alliance between society and medicine. The public's stake in medical professionalism. JAMA. 2007;298:670–673.CrossRefPubMedGoogle Scholar
  2. 2.
    Tonelli MR. Conflict of interest in clinical practice. Chest. 2007;132:664–670.CrossRefPubMedGoogle Scholar
  3. 3.
    Browning DJ, Fraser CM, Powers ME. A spreadsheet template for the analysis of optical coherence tomography in the longitudinal management of diabetic macular edema. Ophthalmic Surg Lasers Imaging. 2006;37:399–405.PubMedGoogle Scholar
  4. 4.
    Lattanzio R, Brancato R, Pierro L, et al. Macular thickness measured by optical coherence tomography (OCT) in diabetic patients. Eur J Ophthalmol. 2002;12:482–487.PubMedGoogle Scholar
  5. 5.
    Hussain A, Hussain N, Nutheti R. Comparison of mean macular thickness using optical coherence tomography and visual acuity in diabetic retinopathy. Clin Exp Ophthalmol. 2005;33:240–245.CrossRefGoogle Scholar
  6. 6.
    Gaucher D, Tadayoni R, Erginay A, et al. Optical coherence tomography assessment of the vitreoretinal relationship in diabetic macular edema. Am J Ophthalmol. 2005;139:807–813.CrossRefPubMedGoogle Scholar
  7. 7.
    Early Treatment Diabetic Retinopathy Study Research Group. Photocoagulation for Diabetic Macular Edema. Arch Ophthalmol. 1985;103:1796–1806.Google Scholar
  8. 8.
    Abu El Asrar AM, Morse PH. Laser photocoagulation control of diabetic macular edema without fluorescein angiography. Br J Ophthalmol. 1991;75:97–99.CrossRefGoogle Scholar
  9. 9.
    Diabetic Retinopathy Clinical Research Network. Comparison of the modified early treatment diabetic retinopathy study and mild macular grid laser photocoagulation strategies for diabetic macular edema. Arch Ophthalmol. 2007;125:469–480.CrossRefGoogle Scholar
  10. 10.
    Browning DJ. Diabetic macular edema: a critical review of the early treatment diabetic retinopathy study (ETDRS) series and subsequent studies. Comp Ophthalmol Update. 2000;1:69–83.Google Scholar
  11. 11.
    Pinto JB. The retina practice: economics, benchmarks, and career issues. Retin Phys. 6-26-2009.
  12. 12.
    Dana J, Loewenstein G. A social science perspective on gifts to physicians from industry. JAMA. 2003;290:252–255.CrossRefPubMedGoogle Scholar
  13. 13.
    Diabetic Retinopathy Clinical Research Network, Scott IU, Edwards AR, Beck RW, Bressler NM, Chan CK, et al. A phase II randomized clinical trial of intravitreal bevacizumab for diabetic macular edema. Ophthalmology. 2007;114:1860–1867.Google Scholar
  14. 14.
    The Economist. This is going to hurt. The Economist 2009 Jun 27; p.13.Google Scholar
  15. 15.
    Hardin G. The tragedy of the commons. Science. 1968;162:1243–1248.CrossRefGoogle Scholar
  16. 16.
    Eye care: percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the on-going care of the patient with diabetes regarding the findings of the macular or fundus exam at least once within 12 months. 6-20-2009.
  17. 17.
    Rothman D. The Effect of Financial Incentives on Physician Behavior and Physician Groups. Abstr Academy Health Meet. volume 21. 2004.
  18. 18.
    Super N. From capitation to fee-for-service in Cincinnati: a physician group responds to a changing marketplace. Health Aff. 2006;25:219–225.CrossRefGoogle Scholar
  19. 19.
    Kralewski JE, Rich EC, Feldman R, et al. The effects of medical group practice and physician payment methods on costs of care. Health Serv Res. 2000;35:591–613.PubMedGoogle Scholar
  20. 20.
    Lichter PR. Continuing medical education, physicians, and Pavlov: can we change what happens when industry rings the bell? Arch Ophthalmol. 2008;126:1593–1597.CrossRefPubMedGoogle Scholar
  21. 21.
    Lichter P. Debunking myths in physician–industry conflicts of interest. Am J Ophthalmol. 2008;146:159–171.CrossRefPubMedGoogle Scholar
  22. 22.
    Harris G. In article, doctors back ban on gifts from drug makers. New York Times 2006 Jan 25.
  23. 23.
    Millard WB. Docking the tail that wags the dog: banning drug reps from academic medical facilities. Ann Emerg Med. 2007;49:785–791.CrossRefPubMedGoogle Scholar
  24. 24.
    Chren MM. Interactions between physicians and drug company representatives. Am J Med. 1999;107:182–183.CrossRefPubMedGoogle Scholar
  25. 25.
    Krasner J. Mass. group links drug costs, marketing. Boston Globe A.D. Jan 17.
  26. 26.
    Wang SS. Drug firms' medical staffs say what salespeople can't. Wall Street Journal 2009 Jun 26; B3.Google Scholar
  27. 27.
    Ferguson J. My $100,000 sideline. Med Econ. 2009;81:28–29.Google Scholar
  28. 28.
    Petersen M. Merck is said to limit perks in marketing to physicians. New York Times 2002 Jan 18.
  29. 29.
    Wall LL, Brown D. The high cost of free lunch. Obstet Gynecol. 2007;110:169–173.PubMedGoogle Scholar
  30. 30.
    Birch DM, Cohn G. Standing up to industry. Baltimore Sun 2001.,0,6517965.story
  31. 31.
    Shimm DS. Human Trials. Scientists, Investors, and Patients in the Quest for a Cure. 7-31-2001.Google Scholar
  32. 32.
    Galewitz P. Cutting-edge option: doctors paid by drugmakers, but say trials not about money. Palm Beach Post 9 A.D. Feb 22.Google Scholar
  33. 33.
    Orlowski JP, Wateska L. The effects of pharmaceutical firm enticements on physician prescribing patterns. There's no such thing as a free lunch. Chest. 1992;102:270–273.CrossRefPubMedGoogle Scholar
  34. 34.
    Camilleri M, Cortese DA. Managing conflicts of interest in clinical practice. Mayo Clin Proc. 2007;82:607–614.CrossRefPubMedGoogle Scholar
  35. 35.
    Leary WE. Doctors given millions by drug companies. New York Times 1990 Dec 12; B13.Google Scholar
  36. 36.
    Lempert P, Packer S. Ethical conflicts in university-based research. Arch Ophthalmol. 2000;118(1):148–149.PubMedGoogle Scholar
  37. 37.
    Ehringhaus SH, Weissman JS, Sears JL, Goold SD, Feibelmann S, Campbell EG. Responses of medical schools to institutional conflicts of interest. JAMA. 2008;299:665–671.CrossRefPubMedGoogle Scholar
  38. 38.
    Campbell EG, Weissman JS, Ehringhaus S, et al. Institutional academic–industry relationships. JAMA. 2007;298:1779–1786.CrossRefPubMedGoogle Scholar
  39. 39.
    Packer S, Parke DW, II. Ethical concerns in industry support of continuing medical education: the con side. Arch Ophthalmol. 2004;122(5):773–776.CrossRefPubMedGoogle Scholar
  40. 40.
    Flach AJ. Letter regarding debunking myths in physician – industry conflicts of interest. Am J Ophthalmol. 2009;147:562–563.CrossRefPubMedGoogle Scholar
  41. 41.
    Brennan TA, Rothman DJ, Blumenthal DJ, et al. Health industry practices that create conflicts of interest. A policy proposal of academic medical centers. JAMA. 2006;295:429–433.CrossRefPubMedGoogle Scholar
  42. 42.
    Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA. 2000; 283(3): 373–380.CrossRefPubMedGoogle Scholar
  43. 43.
    Zipkin DA, Steinman MA. Interactions between pharmaceutical representatives and doctors in training. A thematic review. J Gen Intern Med. 2005;20:777–786.CrossRefPubMedGoogle Scholar
  44. 44.
    Morelli D, Koenigsberg MR. Sample medication dispensing in a residency practice. J Fam Pract. 1992;34:42–48.PubMedGoogle Scholar
  45. 45.
    Spingarn RW, Berlin JA, Strom BL. When pharmaceutical manufacturers' employees present grand rounds, what do residents remember. Acad Med. 1996;71:86–88.CrossRefPubMedGoogle Scholar
  46. 46.
    Chimonas S, Brennan TA, ROthman DJ. Physicians and drug representatives: exploring the dynamics of the relationship. J Gen Int Med. 2007;22:184–190.CrossRefGoogle Scholar
  47. 47.
    Brett AS, Burr W, Moloo J. Are gifts from pharmaceutical companies ethically problematic? A survey of physicians. Arch Intern Med. 2003;163:2213–2218.CrossRefPubMedGoogle Scholar
  48. 48.
    Stolberg SG. Study says clinical guides often hide ties of doctors. New York Times 2002 Feb 6.
  49. 49.
    Bressler NM. Retinal Anastomosis to Choroidal Neovascularization: A Bum Rap for a Difficult Disease. Arch Ophthalmol. 2005;123:1741–1743.CrossRefPubMedGoogle Scholar
  50. 50.
    Relman AS. Separating continuing medical education from pharmaceutical marketing. JAMA. 2001;285: 2009–2012.CrossRefPubMedGoogle Scholar
  51. 51.
    Heaphy DP, Marrow VB. Industry funding for continuing medical education: is it ethical? Arch Ophthalmol. 2004;122:771–773.CrossRefPubMedGoogle Scholar
  52. 52.
    Chun DW, Heier JS, Topping TM, Duker JS, Bankert JM. A pilot study of multiple intravitreal injections of ranibizumab in patients with center-involving clinically significant diabetic macular edema. Ophthalmology. 2006;113:1706–1712.CrossRefPubMedGoogle Scholar
  53. 53.
    Arevalo JF, Fromow-Guerra J, Quiroz-Mercado H, et al. Primary intravitreal bevacizumab (Avastin) for diabetic macular edema results from the Pan-American collaborative retina study group at 6-month follow-up. Ophthalmology. 2007;114:743–750.CrossRefPubMedGoogle Scholar
  54. 54.
    Ehlers JP, Spirn MJ, Lam A, Sivalingam A, Samuel MA, Tasman W. Combination intravitreal bevacizumab/panretinal photocoagulation versus panretinal photocoagulation alone in the treatment of neovascular glaucoma. Retina. 2008;28:696–702.CrossRefPubMedGoogle Scholar
  55. 55.
    Packer S, Lynch J. Ethics of comanagement. Arch Ophthalmol. 2002;120:71–76.PubMedGoogle Scholar
  56. 56.
  57. 57.
    Berlin J, Bruinooge SS, Tannock IF. Ethics in oncology: consulting for the investment industry. J Clin Oncol. 2007;25:444–446.CrossRefPubMedGoogle Scholar
  58. 58.
    Topol EJ, Blumenthal D. Physicians and the investment industry. JAMA. 2005;293:2654–2657.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Charlotte Eye Ear Nose & Throat AssociatesCharlotteUSA

Personalised recommendations