Is your doctor "under the influence"? September 1, 2003
Most people have gotten
a doctor's prescription at some point in their lives
for a medicine they have needed. Some people need
prescription medication on a regular basis due to
their medical problems. The question is, to what degree
can you trust that your doctor writes a prescription
based only on your best interests as a patient?
That seems like a strange question - after all, what
else would a doctor have in mind? Shouldn't the doctor's
choice of medication depend solely upon what your
needs are as a patient? That does sound like the way
things should be, but recent revelations suggest that
something very different is going on: pharmaceuticals
companies may be exercising undue and unethical influence
on doctors and what doctors prescribe.
Drug makers have readily admitted that they routinely
pay insurance companies to increase the use of their
products and to be added to the recommended list of
drugs. They admit that they give rewards to both pharmacists
and doctors for switching patients from one brand
of medication to a rival. Finally, they admit that
they provide all sorts of gifts and gratuities to
doctors, ranging from financial aid to educational
programs to bags and writing pads, in the hopes that
they will encourage doctors to remember and perhaps
prescribe their brand of drugs.
Not everyone approves of such actions. In October
of 2002, the Department of Health and Human Services
stated that many gifts and gratuities are suspicious
because they looked like illegal kickbacks. Various
consumer groups such as the AARP have expressed their
support for further restrictions on such gifts, and
the government is considering implementing such restrictions.
Unfortunately, further restrictions may be unlikely
because the consumer groups are vastly outnumbered
by doctors, insurers, and of course drug companies
who have flooded the government with letters criticizing
proposals to restrict gifts. Perhaps the first impression
about giving gifts is mistaken and there are good
reasons for them - so, what arguments do the companies
use in their defense?
It seems that the most common defense is that the
practice of giving gifts is, well, common. According
to Solvay Pharmaceuticals, "a policy statement
that declares well-established commercial practices
potentially criminal creates a chilling effect on
commerce and ultimately harms all consumers."
A a coalition of 19 pharmaceutical companies, including
Pfizer and Eli Lilly has said proposals to restrict
gifts were "not grounded in an understanding
of industry practices."
The recipients of the gifts agree. According to the
American Association of Health Plans, representing
most of the nation's H.M.O.'s, the proposed changes
would "cast doubt on the propriety of many well-established
practices undertaken by health plans to develop and
administer their drug benefits."
In other words, because it is a common industry practice
for drug companies to give gifts to those who prescribe
more of their drugs, it should be permitted to continue.
That, unfortunately, is a logical fallacy; the mere
fact that something is common does not make it ethical.
If that is the best that the various interest groups
can offer, the practices should be discontinued.
Fortunately, there are a couple of other arguments
to consider. One is that restrictions on gifts could
have a "chilling effect" on efforts to cut
costs - for some reason, HMOs think that if it becomes
illegal for them to receive financial gifts from drug
makers, then drug makers will be afraid to give bulk
discounts. That sounds like nonsense, but just to
allay their fears, it would be reasonable to make
a provision permitting bulk discounts.
Another argument, this time from the American Medical
Association, contends that drug companies should be
allowed to give doctors pens, notepads and other items
of "nominal value" that have "no correlation
to any service provided by the physician to the pharmaceutical
company." According to the AMA, such items are
That leads us to address just what all of the fuss
is about in the first place. Who cares if drug companies
are giving pens, pads, bags, or even cash to doctors,
HMOs, and others who make decisions about what drugs
you use? The problem is, patients are under the perception
that doctors recommend particular drugs because they
will have the best balance of good effects vs. bad
effects for their particular situation. In other words,
this drug should do the best job at alleviating symptoms
and curing an illness without producing too many negative
However, gifts from powerful drug companies begin
to skew that situation. What if a doctor is being
influenced to prescribe heart medication A over heart
medication B not because it is more effective, but
because the manufacturer provides greater financial
gifts to her and and to the insurance plan? To return
to the statement from the AMA, are even "nominal"
gifts really so "harmless"?
The fact of the matter is, even though the gifts
are "nominal" to the physician, the costs
of producing so many are not insignificant - and the
drug manufacturers would not bother if they didn't
serve as an effective form of advertising. As the
Massachusetts Medical Society has asked:
Is the physician who writes a prescription with a
company's logo on the pen more likely to write a prescription
for that advertiser? Are patients more likely to request
a certain drug because they see the notepad on the
Sadly, physicians themselves don't seem to be entirely
cognizant of the problem. In the January 19, 2000
edition of the Journal of the American Medical Association,
Dr. Ashley Wazana revealed that while 85% of medical
students belived it improper for politicians to accept
gifts from lobbyists, only 46% thought it improper
for doctors to receive gifts from drug companies.
Evidently, while they distrust the ability of politicians
to remain uninfluenced, they do trust themselves to
be free of such burdens.
The next time your doctor prescribes a medication,
considering asking why that drug rather than some
other drug. Consider asking the doctor if she receives
any financial gifts or benefits from the manufacturer
of that drug. If you see "nominal" items
advertising the drug, consider asking if they influence
the doctor's decision. Such questions are uncomfortable,
but ethical questions often are - and they may be
more uncomfortable for your physician than for you.
Note: In a guide released on April
27, 2003, the Department of Health and Human Services
stated that practices like those described above run
"a high potential for fraud and abuse."
The guide was written by Janet Rehnquist, inspector
general of the DHHS.