The ethical dilemma of accepting gifts from drug makers
By William J. Hall, FACP
My first encounter with pharmaceutical industry gift-giving occurred during my second year of medical school, when my classmates and I received an imitation leather doctor's bag, equipped with a reflex hammer and tuning fork. To me, it represented the first mystical step into the profession and made a deep impression on me.
I never used these gifts after medical school, but I can still remember which pharmaceutical company supplied them, though more than 30 years have passed and I've forgotten the names of many of my classmates. Critics of physician interaction with pharmaceutical representatives would call my experience "early bonding," designed to engender good will and acceptance of subsequent pharmaceutical detailing.
The problem of gifts
Pharmaceutical gifts have been part of the medical scene for decades, but over the years, changes in the industry's marketing strategies have given us ample reason for concern.
The sheer volume is staggering. The industry spends more than $11 billion annually on promotion and marketing, and approximately $6 billion on direct detailing to physicians. Drug makers spend $8,000 to $13,000 per physician each year, and they employ one drug representative for every 11 physicians in the United States.
In the past decade, gifts and hospitality offered to physicians in their offices and at professional meetings have been at times either silly or lavish and not linked in any clear way to the products' medical benefits.
For example, drug makers now provide lunch on a daily basis for doctors and staff at many offices around the country, with no semblance of educational exchange. In some communities, "dine and dash" programs are little more than an upscale food subsidy program for physicians. Likewise, various post-marketing "consultantships" are offered under the most dubious circumstances.
At the very least, these practices give the perception of impropriety, especially to older adults who have seen the average price of drugs rise 48% between 1992 and 2000. Moreover, evidence-based literature strongly suggests that gifts and amenities do have a major influence on physician prescribing habits.
An ethical response
The College was one of the first medical professional societies to develop a policy regarding the relationship between pharmaceutical companies and physicians. Our position was made very clear in the College's "Ethics Manual": The acceptance of individual gifts, hospitality, trips and subsidies of all types from the health care industry by an individual physician is strongly discouraged. The acceptance of even small gifts has been documented to affect clinical judgment and heightens the perception (as well as the reality) of a conflict of interest.
Because this issue has heated up in the past decade, the College recently revisited it. As a result, the Board of Regents approved a new position paper on physician-industry relations, which will be published in an upcoming issue of Annals of Internal Medicine. This paper reaffirms the "Ethics Manual's" strong statement regarding gifts, and it provides the following questions to help physicians determine whether a gift is ethically appropriate:
- What would my patients and the public think of this arrangement? How would I feel if the media reported about the gift?
- What is the purpose of the industry offer?
- What would my colleagues think about this arrangement? What would I think if my own physician accepted this offer?
It is entirely appropriate and necessary for the pharmaceutical industry to market its products to physicians and provide information to help us make informed therapeutic decisions. However, we need to evaluate pharmaceutical representatives' data and recommendations in light of their obvious bias. We should critically scrutinize their message with the same degree of caution we would use when hearing a managed care representative explain the advantages of a restricted formulary or strategies to reduce length of hospital stays.
Our professional responsibility dictates that we provide for our patients to the best of our abilities in both situations. I like to think of it as another added value an internist brings to the doctor-patient relationship. Problems arise when a gift or amenity obfuscates or replaces the educational message. At that point, the very core of our professionalism is called into question.
Internists and patients would be better served if we strongly encouraged the pharmaceutical industry to invest more in unbiased education and less on pencils, cups and pizza.
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