No free lunch

The following is my article originally published in Ethical Times (No. 16, Fall 2008), the bulletin of the Program in Medicine and Human Values at California Pacific Medical Center. Since this piece appeared, PhRMA has voluntarily suspended the distribution of branded items and certain food gifts to doctors (see my post).  The ethical argument still holds and is, I believe, still widely overlooked.  Reprinted by permission.

Pharmaceutical promotion is big business. In the US alone, the industry spends billions each year (about $16 billion in 2000) to market its products. Most of this budget pays for extensive, multifaceted marketing to doctors, much of it delivered in person by salespeople called “pharmaceutical representatives.” A smaller but still sizable portion of funds produce direct-to-consumer “ask your doctor” ads on television and elsewhere. Pundits debate whether such lavish promotion drives up the cost of health care or helps to contain it, whether it enhances or detracts from patient care. Most of this focus has been on the industry side of the equation. Yet medical ethics demands that we physicians assess the other side of the equation: our own participation in these promotional efforts.

Advertising and product promotion are everywhere in our society, exerting their influence in largely non-rational ways. We imagine that we rationally weigh the features and benefits of competing products and make logical choices. Yet advertisers “sell the sizzle, not the steak.” Catchy jingles, the look of a product and its packaging, celebrity endorsements, associations with attractive people or lifestyles — these appeal to our emotions, often bypassing intellect and logic.  In everyday life we sense no ethical impropriety in allowing ourselves to be influenced this way. Who knows, or cares, why we prefer one brand of soap over another? If we choose a household product for its captivating name or fancy packaging we may be misguided or superficial, but we are certainly not evil. We face no ethical dilemma in accepting a free food sample at the supermarket, even if it evokes pleasant associations in us about being fed or induces a subtle wish to reciprocate the generosity. Marketing works at both surface and subterranean levels. As a society we accept that.

Likewise, it is not ethically problematic for patients to respond to television ads by “asking their doctors” about prescription medicines, even though these ads employ the same non-rational enticements used by other industries, such as memorable product names, evocative catch phrases, and scenes of active, happy people. (Some argue it is unethical for the companies to advertise this way, but that is not our focus.) A patient may inquire about a particular medicine for countless reasons, ranging from careful research, e.g., on the Internet, to an offhand comment by a friend. There is no requirement or expectation that a patient’s interest be rationally based. From the patient’s perspective, there is nothing wrong in hearing about a medicine, even from an ad, and asking one’s doctor about it.

The physician, however, is in a very different position. There is an expectation that a doctor’s interest in a particular treatment be rationally based. Moreover, medical ethics requires it.

The doctor-patient relationship is fiduciary. It is founded on the patient’s trust that the doctor always practices medicine in the patient’s best interest. Like other fiduciary relationships (e.g., bank-customer, corporation-shareholder, and attorneys and accountants with their clients), the doctor-patient relationship is vulnerable to conflicts of interest that can undermine trust. In all of these fields, professional ethics dictate that the trustee take reasonable steps to avoid conflicts of interest and divided loyalties.

Physicians in particular must strive to practice medicine in an unbiased, scientific fashion. This is more difficult than it sounds, since influences that are widely accepted and considered benign in everyday life can represent trust-threatening conflicts of interest here. The non-rational influences of product promotion — the gratifying visits by friendly, attractive salespeople bearing personal gifts and free food — directly threaten the fiduciary doctor-patient relationship. By participating in these encounters, physicians actively invite non-rational bias into treatment decisions, in direct violation of the trust patients place in us. It follows that medical ethics should condemn active involvement in this process by physicians, and that reasonable steps should be taken by ethical physicians to avoid participation in promotional activities.

Many physicians defend current practice by claiming that they are immune to non-rational promotional efforts. The pharmaceutical industry does its best, they say, but smart doctors see through the attempted influence and “ignore” it. This rebuttal is not new.

A historical review (1) in a recent issue of JAMA quotes the same view from apologists 50 years ago. However, then as now, there is no evidence that doctors enjoy any special resistance to non-rational product promotion. On the contrary, several empirical studies document the effectiveness of such promotion in swaying the prescribing patterns of doctors. It is tortured logic to assume that a sophisticated industry wastes billions every year on harmlessly ineffective promotional efforts — especially when the very same strategies work well in other industries. Wishful thinking and hubris alone cannot stand up to this evidence.

Increased public scrutiny has prompted modest reforms over the past few years. A growing number of medical centers and teaching institutions now restrict promotional activities on campus. The pharmaceutical industry itself has voluntarily dropped or limited some types of product promotion. Congress is working on legislation requiring public reporting of industry largesse to doctors. These actions recognize the seriousness of the problem. But, beyond all efforts to prevent undue compensation or to make it transparent, the ethics of the physician are the strongest bulwark against improper influence on prescribing practices. Unfortunately, at this time only a small percentage of individual doctors decline sales calls and similar contact with industry. Surveys show that patients express more concern than physicians over this issue.

Being a physician bestows many rewards and gratifications. These are balanced by the restrictions on our actions that are part of ethical practice. We must act professionally and always in our patients’ best interest. We must be competent and skillful, stay current in our field, and use evidence-based approaches when possible. And we must strive to avoid making clinical decisions based on non-rational factors. While this ethical restriction may deprive us of branded coffee mugs and pens, free lunches, and opulent sponsored “educational” dinners, it is a small price to pay for earning our patients’ trust.

(1) Podolsky SH, Greene JA, “A Historical Perspective of Pharmaceutical Promotion and Physician Education,” Journal of the American Medical Association 300(7), 20 August 2008, p 831-833.

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