The caring profession: Paediatricians and altruism


Professor David lsaacs, Department of Immunology and Infectious Diseases, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, Sydney, NSW 2145, Australia. Fax: +61 2 9845 3421; email:

For my sins, I am on a national committee called the Pharmaceutical Benefits Advisory Committee (PBAC). Actually, I love it. Since 1988, the PBAC has been advising the Australian Government on which medicines should be funded through the national Pharmaceutical Benefits Scheme, based on cost-effectiveness and other criteria. Since 2006, the PBAC has also considered funding of new vaccines. It is a unique approach, designed to improve equity and to reduce the cost of medicines and vaccines to the Australian people. There are two paediatricians on the committee at present.

Applications to the PBAC for funding are prepared by a sponsor, usually a pharmaceutical company. Under the Free Trade Agreement, the sponsor can opt for a special hearing to present their case verbally to the PBAC before the committee considers the application in private. These special hearings add significantly to the duration of an already jam-packed 3-day meeting, and since the companies are not allowed to present new data not already included in the hugely detailed applications, some members of the committee are not exactly enamoured of hearings. The best hearings are generally those in which a clinician is brought along by the company to talk about the implications to the patient of a rare condition or to clarify important clinical queries.

At a recent meeting, the PBAC considered an application for botulinum toxin to be used to treat spasticity in children with cerebral palsy. There was a hearing. To my surprise, a consultant in paediatric rehabilitation who works at the same hospital as I entered with the pharmaceutical company representatives and proceeded to explain the clinical details of the benefits of botulinum toxin for affected children and different ways of assessing the children's response to therapy. He talked beautifully and helped the committee reach what I feel was a good decision. Earlier, there had been some internal committee gossip about the considerable honoraria that some clinicians were reputedly paid for a 5- or 10-min hearing presentation. After his presentation, I emailed my colleague asking him what he had been paid to appear. He replied almost instantly that the pharmaceutical company had only paid for his airfare and asking jokingly if he should have requested an honorarium. I replied that his position as an unpaid advocate for his patients was far more honourable than accepting an honorarium. I shared this exchange with some of the committee, who all responded, to the effect, ‘You paediatricians are all so nice and you care about your patients more than you care about money.’

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Charles Dickens was a genius and a strong advocate of the rights of disadvantaged children, but his least endearing quality was a somewhat saccharine sentimentality. Over-sentimental paediatricians also have emetic potential, but at least paediatricians care. I am proud that altruism in medicine and particularly in paediatrics is not dead.