The folks at the Swiss pharmaceutical giant Roche really know how to organize a good meal. Not long ago they treated more than 200 lucky cancer specialists to a night out at one of Australia’s top restaurants, inside the world-famous Sydney Opera House.

The harbourside restaurant boasts a “degustation” menu of sterling caviar, kingfish sashimi and the best of French and Australian wines. The meal was priced at more than A$200 a head, and the whole night cost Roche over A$65,000.1 I know that for fact because a disgruntled diner leaked me a copy of the bill. “The gluttony of the whole thing was mind-blowing,” she told me.

Rather than showing any embarrassment at being caught out, the global drug company defended the wining and dining as standard practice: “It seems reasonable to us that a dinner of this type was on offer,” a Roche spokesperson said. Incredibly, doctors’ groups saw nothing wrong with the lavish nosh-up. The then president of the Australian Medical Association argued that the A$200-a-head meal at an exclusive restaurant was totally acceptable. “It’s understandable why it’s done there,” Dr. Mukesh Haikerwal told me, “rather than doctors slumming it somewhere in a budget chain motel.”

Those who are hoping that self-regulation will solve the global crisis of entanglement between the medical profession and the pharmaceutical industry may need to wait a long time, if recent developments in Australia are any guide. Mandatory disclosure of all financial ties, underwritten by strong legislation and followed through with genuine enforcement, is the next inevitable step toward ending this unhealthy corruption and restoring public trust in medicine.

Just days after details of the $200-a-head dinner made news around the world last year, the Australian Consumer and Competition Commission issued new guidelines that would force drug companies to disclose all sponsored “educational” events for doctors. There are perhaps 10,000 of these events in Australia every year and more than 300,000 in the United States.2 The medical profession immediately attacked the plan, and the pharmaceutical industry challenged the new rules in court. In June 2007, Australia’s Federal Court handed down a lengthy decision, finding solidly against the pharmaceutical industry. It was an indictment of the existing processes of self-regulation and a call from the judiciary for mandatory public disclosure all company-sponsored events.

Having no doubt read the literature on industry–profession interactions, the judges argued that drug company gift-giving and hospitality “has the potential to result in positive harm or, more likely, less than optimal treatment choices” and “risks distortion of the medical decision-making processes of healthcare professionals.”3 Company benefits discussed in the court ruling included hospitality, travel, accommodation, advisory fees and other financial ties. The judges concluded: “It is difficult to accept that pharmaceutical companies would go to the effort of providing such benefits if they did not think there was likely to be a positive return.”3

From now on, drug companies in Australia will be required to regularly and publicly disclose details of which restaurant they used for their educational events, how much the meals cost, and how many doctors where attending. The new rules are a small but significant reform, comparable to the public registries of disclosure that have been set up in some American states, including Minnesota and Vermont.

The pharmaceutical industry body Medicines Australia described the court ruling and the new disclosure regime it ushers in as disappointing, while the Australian Medical Association called it “overkill.”4 Reform groups such as Healthy Skepticism believe that the judges’ ruling did not go far enough because there will still be no requirement on the drug companies to name the doctors who take advantage of the company-funded hospitality.

Given the newness of the Australian rules, it is far too early to know how they will work in practice. It’s uncertain how well they’ll be enforced, and by what tactics drug companies and professional associations may try to subvert them — for example, using ostensibly arm’s-length front groups to host events. Already, however, the limitations of the new rules are clear. Apart from there being no requirement to disclose the names of individual doctors, the rules are not comprehensive and therefore do not mandate the public disclosure of all forms of potentially corrupting financial interactions between doctors and drug companies.

As Joseph Ross and colleagues found in their recent research, the experience with mandatory disclosure in Vermont and Minnesota has been mixed.5 In these and a number of other states, drug company payments to doctors are now supposed to be made publicly available. However, in Vermont, most payments were not made available to the public because drug companies designated the payments as “trade secrets”; in Minnesota, only a small proportion of companies reported their payments to doctors. Despite the limitations of these disclosure laws, the researchers found that many physicians received significant annual payments. In Minnesota the median amount received was $1000, and at least one individual received close to $1 million.

Elsewhere, others have argued for doctors to provide full disclosure of all their financial ties to all their patients, in the form of a chart on the wall of a consulting room.6 This would include all details of company ties, including consultancies, hospitality, free travel, accommodation, personal gifts, free samples, and so on. The chart would also reveal the names of the companies and the relevant drugs. As Tattersall and Kerridge ask, if doctors are required to disclose potential conflicts of interest to medical journals, why shouldn’t they be required to disclose them to their patients?

Although the next step is to design comprehensive and enforceable disclosure regimes, disentanglement is surely the desired ultimate aim within any rational health care system. Clearly, some health care professionals will always need to work closely with pharmaceutical companies on research and other activities, and have a legitimate right to be remunerated fairly for their work. But such a situation is a far cry from the situation today, where many within the medical profession are the beneficiaries of industry largesse simply because of their power to prescribe.

Echoing earlier manifestos by the activist group No Free Lunch, Troyen Brennan and colleagues have recently proposed a tough new plan for disentanglement at Academic Medical Centers in the United States.2 The plan would see many forms of financial ties severed, including gift-giving, directly sponsored medical education, and membership of company speakers’ bureaux, while research-related consultancies would be allowable, but made more transparent.

Four years ago BMJ published a provocative theme issue on physicians’ financial ties, called “Time to untangle doctors from drug companies.”7 The issue’s front cover featured a cartoon depicting porcine figures tucking into a meal, with a smart-suited lizard writing the cheques at the end of the table. In a two-part article published in that issue, entitled “Who Pays for the Pizza?”8 I identified at least 16 forms of entanglement between doctors and drug companies, and highlighted nascent moves toward disentanglement. Since that time, public interest in these unhealthy relationships has escalated greatly, yet in most corners of the medical establishment those relationships continue virtually untouched.

Data about the corrupting influences of inappropriate professional–industry ties are now indisputable. The debate is moving on, as it must, to the question of how to fix the problem. Waiting for the mainstream of professionals — the major beneficiaries of this largesse — to start untangling their own ties is no longer an option for anyone interested in genuine reform. For courageous policy-makers committed to rational health systems, fixing this mess could prove immensely rewarding and would simultaneously save money and improve health outcomes. Canada has led the way in key recent health reforms, including the nurturing of evidence-based medicine and of support for the Cochrane Collaboration. There seems little reason why it should not also lead the way to disentanglement.