Does it really matter who’s paying for dinner?

Some of the best meals I have ever eaten were paid for by sales representatives from companies with which my library did business or could potentially do business, and some of my favorite events at professional meetings were sponsored by vendors. As the head of a technical services department in a large academic health sciences library in the 1980s, I had many opportunities to be “wined and dined” by sales representatives, and I even developed close personal relationships with a few of them. As nagging doubts about the propriety of these activities began bothering me, I sometimes “reciprocated” with giving small gifts, such as bottles of wine, or by paying for the meal myself. My doubts about the propriety of these activities were solidified in 1990, when I started working in a library for a large federal agency that was embroiled in an influence-peddling scandal. I realized during my first day of work, when I had to take an oath to accept absolutely nothing from companies with which the agency might do business, that I needed to be even more careful about how I interacted with vendors. 
 
Libraries spend a huge amount of money on information resources and services provided by outside vendors, and I think our relationships with vendors pose some of our most difficult personal ethical dilemmas. We need to have a good working relationship with our vendors so that we can get the best products and services possible. An important question to ask ourselves is: “How can we develop relationships with our vendors or potential vendors that enable us to determine which products and services we need, while avoiding conflicts of interest?” 
 
Many members of the Medical Library Association (MLA) have been involved in an ongoing informal debate about ethics issues for years. People sometimes use “ethics” and “conflict of interest” interchangeably in their discussions of these issues. The Merriam Webster's Collegiate Dictionary defines ethics as “the principles of conduct governing an individual or group (professional)” or “a guiding philosophy” [1]. A “conflict of interest” is defined in the Association of Academic Health Sciences Libraries (AAHSL) conflict-of-interest/disclosure policy as follows: 
 
A conflict of interest can be considered to exist in any economic, professional, business, political, volunteer, or personal instance in which the actions or activities of an individual on behalf of AAHSL could involve obtaining personal gain or advantage to the individual or the individual's immediate family and could be unfair to the organization. [2] 
 
Ethical issues generally fall into one of four categories: association ethics, professional ethics, institutional ethics, and personal ethics. However, the lines between these issues are overlapping, and it is hard to discuss one without the others.

Some of the best meals I have ever eaten were paid for by sales representatives from companies with which my library did business or could potentially do business, and some of my favorite events at professional meetings were sponsored by vendors. As the head of a technical services department in a large academic health sciences library in the 1980s, I had many opportunities to be ''wined and dined'' by sales representatives, and I even developed close personal relationships with a few of them. As nagging doubts about the propriety of these activities began bothering me, I sometimes ''reciprocated'' with giving small gifts, such as bottles of wine, or by paying for the meal myself. My doubts about the propriety of these activities were solidified in 1990, when I started working in a library for a large federal agency that was embroiled in an influence-peddling scandal. I realized during my first day of work, when I had to take an oath to accept absolutely nothing from companies with which the agency might do business, that I needed to be even more careful about how I interacted with vendors.
Libraries spend a huge amount of money on information resources and services provided by outside vendors, and I think our relationships with vendors pose some of our most difficult personal ethical dilemmas. We need to have a good working relationship with our vendors so that we can get the best products and services possible. An important question to ask ourselves is: ''How can we develop relationships with our vendors or potential vendors that enable us to determine which products and services we need, while avoiding conflicts of interest?'' Many members of the Medical Library Association (MLA) have been involved in an ongoing informal debate about ethics issues for years. People sometimes use ''eth-ics'' and ''conflict of interest'' interchangeably in their discussions of these issues. The Merriam Webster's Collegiate Dictionary defines ethics as ''the principles of conduct governing an individual or group (professional)'' or ''a guiding philosophy'' [1]. A ''conflict of interest'' is defined in the Association of Academic Health Sciences Libraries (AAHSL) conflict-of-interest/disclosure policy as follows: A conflict of interest can be considered to exist in any economic, professional, business, political, volunteer, or personal instance in which the actions or activities of an individual on behalf of AAHSL could involve obtaining personal gain or advantage to the individual or the individual's immediate family and could be unfair to the organization. [2] Ethical issues generally fall into one of four categories: association ethics, professional ethics, institutional ethics, and personal ethics. However, the lines between these issues are overlapping, and it is hard to discuss one without the others.

Association ethics
Numerous associations have revised their ethics codes and conflict-of-interest policies, or have written new ones, within the past few years. A recent article in JAMA recommends stringent measures for professional medical associations to use in controlling the conflicts of interest that might affect their associations [3]. The American Library Association (ALA) revised its code of ethics last year and celebrated the seventieth anniversary of its code this year by expanding its ethics educational initiative [4]. The AAHSL Board reviewed its conflict-of-interest and disclosure policies in 2007/08 and expanded the disclosure policy to cover not only board members and committee chairs, but also all committee members and speakers at AAHSL-sponsored events. The purpose of the disclosure policy is to avoid conflict of interest (or the appearance of it) by having staff and volunteers (committee members, officers, etc.) disclose any existing or potential conflict of interest, so the board can either manage or eliminate the potential conflict.
MLA has had several policies that address association ethics in effect for many years. One is a disclosure policy requiring affiliation and financial disclosure by all MLA Board members, committee chairs or chairs-elect, liaisons, authors of MLA publications, continuing education instructors, and presenters [5]. Also, MLA has had a policy in its Finance Manual since 1998 that governs commercial and vendor relations, and all association units are covered by the policy [6]. The policy requires MLA Board approval for named awards, scholarships, and grants; licensing of the MLA name or logo to a commercial entity; and arrangements permitting someone to offer products or services to members at reduced rates.
In light of the growing concern about ethics issues in the health sciences environment and the length of time that has elapsed since the development of MLA's ethics code and related policies, addressing ethics issues was chosen as one of MLA's priorities for 2008/09. An MLA Ethics Task Force was appointed in the fall of 2008 to review MLA's Code of Ethics for Health Sciences Librarianship [7], disclosure policy, and business model, and to recommend revisions as needed. The task force, cochaired by Lucretia W. McClure, AHIP, FMLA, and Millie M. Moore, recently proposed revisions to the documents that are currently being discussed by the MLA Board. If approved by the board, the revisions to the ethics code will be voted on by the membership in the spring.
The Ethics Task Force has proposed ''MLA Guidelines for Ven-dor Activities at the MLA Annual Meeting,'' which state that sponsorships of official activities are welcome, that vendor educational activities (including meals) should not conflict with official MLA or section-sponsored programs, and that receptions or dinners (especially if they include one-on-one interactions with attendees and vendor representatives) are acceptable, but that organizers should realize that our institutional policies may prohibit us from participating in these meal events. The guidelines also state that ''Large, relatively open, purely social events that do not facilitate oneon-one interactions between meeting attendees and vendor representatives are discouraged.'' Though the recommendations did not go as far as I personally would like, I am glad that the Ethics Task Force has recommended discouraging large, vendor-sponsored social events at our annual meeting. I think MLA members need to continue to discuss these guidelines.
I have hoped for years that scholarly societies would stop depending on profits from their journal subscriptions to help support their association activities, because this practice makes the societies' journal subscriptions more expensive for libraries and individuals. Likewise, I am also concerned that MLA accepts funding from vendors with whom our libraries do business to help support association activities. I believe that the cost for sponsorships, as well as the costs of vendor-sponsored parties and meals for attendees, gets passed on to our libraries in the form of higher prices for the vendors' products and services. However, I also realize that support from vendors helps make association benefits more accessible to many of our members who might not be able to afford them otherwise. I hope that in the future MLA can wean itself from outside funding from vendors by identifying other ways to support association activities. I realize this will not be an easy task, but the question we need to continue to consider is ''Can we shield ourselves from undue influence while accepting vendor support for our association?''

Professional ethics
MLA members approved the current Code of Ethics for Health Sciences Librarianship in 1994 [7]. The code contains general statements and is meant to provide a framework for addressing ethical issues, not to tell us what to do in specific situations. The MLA Ethics Task Force has recommended that the following statement to be added to the ethics code: ''The health sciences librarian shall be alert to and adhere to the (his or her) institution's code of ethics and to its conflict of interest, disclosure, and gift policies.'' We will need to depend on the MLA ethics code and our institutional codes and policies, as well as our own personal ethics codes, to guide us through our day-to-day activities.

Institutional ethics
Ethical issues have been of growing concern in academic health sciences centers and hospitals for many years. The marketing strategies of pharmaceutical companies and the potential influence that these strategies have on physicians' prescribing habits have brought ethical issues to the forefront, and these issues have been written about extensively in the literature recently. Studies have shown that even small gifts, such as pens and cups, have an influence on physicians' prescribing habits, even though the physicians may not be aware of the influence [8]. While the importance of maintaining a relationship between health-related companies and health sciences institutions and hospitals is acknowledged, attempts are being made to better ensure that these relationships are objective and that safeguards are established to keep the interests of the public protected.
The Association of American Medical Colleges recommended a few years ago that academic health centers develop and implement strong conflict-of-interest policies to ensure that researchers, clinicians, and others follow ethical practices in their dealings with outside companies. Many of the institutions and hospitals in which MLA members work now have strong conflict-of-interest policies in place. My institution implemented a revised conflict-of-interest policy a few years ago that limits my activities with the companies with which my library does business. The University of Arkansas for Medical Sciences policy states that employees cannot accept gifts from vendors. However, we are still trying to figure out exactly how this policy affects our relationships with vendors, including our interactions with them at MLA annual meetings and chapter meetings. Some institutions have policies that say that as long as an event (such as a vendor party) is open to everyone attending a meeting or if the event includes an educational component (such as the Sunrise Seminars at MLA), it is okay to attend. We still need to answer the question of whether attending a vendor party or accepting a gift from a vendor is wrong because it might influence us and because it adds to the cost of the products we buy from those vendors.

Personal ethics
The MLA ethics code and conflictof-interest policies of our institutions and professional associations leave a lot of room for interpretation about ethics issues. It is up to us to determine for ourselves exactly what our personal ethical philosophy and decisions will be.

Conclusion
At the open forum sponsored by the Ethics Task Force at MLA '09 in May, someone asked what harm is done if we make decisions based on undue influence from vendors; he said it was not a matter of life and death. I responded that I think that the work we do and the decisions we make are important to the ultimate safety of the pa-Editorial tients treated at our hospitals and institutions and that we need to be very aware of what factors influence the decisions that we make. If we make a decision to purchase a particular product because we like the sales representative, instead of purchasing a competing product that might be of more use to our institution, then we could be affecting the treatment of patients. Or if we cannot afford to purchase a particular product because the cost of the product is too high, partly because the vendor spends a lot of money on marketing and passes the marketing costs on to us in the form of higher prices, then it could be a problem affecting patient safety.
I appreciate all of the work that the MLA Ethics Task Force has done to help us address difficult ethical issues on an association and professional level. The task force recommended, and I agree wholeheartedly, that we as an association should continue to engage all stakeholders in establishing practices that balance the interests of all of us. I think a continuing public dialogue will help us to be more aware of ethical issues and different perspectives on them, the awareness of which will help us in making our individual decisions.