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 "harmless."

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 side effects.

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 doctor's desk?

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.

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