No Free Lunch: Gifts from Pharmaceutical Companies

Introduction:

The marriage of patient care and science has clearly benefited us all. One aspect of that relationship is the complicated interaction between medicine and the pharmaceutical industry. In our society and market structure the latter plays a central role in developing and distributing the therapeutic agents on which physicians and patients depend. Recently, special attention has been brought to the practice of producers of medical supplies -- pharmaceutical houses, medical equipment manufacturers, etc. -- to give gifts or offer other inducements to physicians who might or do use, recommend or prescribe their products. Your readings contain the positions of the AMA and ACP on this issue. If not already, you are soon to be solicited as beneficiaries of this industrial largesse; we thought it important you consider the implications of your choices.

Physicians have always been offered things by many kinds of folk -- patients, hospitals, pharmaceutical companies, other physicians, et al. These offerings are typically characterized as a gift rather than a quid pro quo. Not all donations are enticements nor are enticements wrong per se. Nonetheless, some are. The mobster's "offer that can't be refused" is probably the archetype of an odious gift. But there are more subtle problems when one thinks more deeply about things given and received.

Cultural anthropologists have long known that systems of gift giving carry important social implications. In some cultures in the Pacific basin, for example, reciprocal gift giving replaces buying and selling as the mode of exchange. Commerce is conducted by reciprocal "donations." The receipt of a gift binds the recipient to give an equivalently valued gift back to the initial donor. This obligation is sometimes onerous and, until repaid, burdens the recipient. We can see traces of this same social mechanism in our culture when we worry about returning dinner invitations or holiday cards or taking "gifts" to those who host us. The failure to return a favor carries noticeable social significance.

There are a number of ways to evaluate the morality of a gift.

1. One formalist approach is to appraise the intent of the donor or recipient. Do pharmaceutical houses offer gifts to physicians out of affection, gratuitously, to influence, to bribe? Do physicians who take gifts intend to remain objective about the donor? A formalist might also ask questions like: who bears the costs of the gifts and do they do so willingly? Who bears the cost of the drugs, pens, lunches, or trips donated by drug companies?
2. A virtue theorist would ask: what is the impact of giving or receiving gifts on the character of the donor or recipient? You might have noticed that much of the discussion about blood or organ or ovum transfer involves attention to the impact of giving vs. selling on the parties involved.
3. A consequentialist would ask: Does the gift adversely influence a physician's judgment or objectivity? Does it result in a more educated medical community? What are the costs of gifts and could those resources be better spent?

1. Differentiate acceptable from non-acceptable inducements in a traditional market place, say selling televisions, and the medical marketplace where drugs are sold. Explain the difference, if any, between the two enterprises.
2. Summarize the data on the influence of gifts from pharmaceutical houses on the behavior of physicians and researchers.
3. Express and defend a position on the moral propriety of accepting gifts from pharmaceutical companies.
4. Suggest ethically acceptable ways in which medical suppliers can, in a capitalist economy, compete for physician business.

1. There are a number of cases available for this weeks class.  One suggestion would be for the leader to assign a case to each member of the group to prepare - another would be to choose a few cases and ask each member of the group to read them over.  Either way leaders should communicate this to others in the section as early in the week as possible. Either way, try to distribute the cases between the A and B group.
2. Read the AMA and ACP positions on the resources page and the general readings for all. Also read the special “B” readings for the case assigned to you.
3. The leader for the week should assign each member of the section two cases to analyze. One case should be from group A and the other from group B.  Some will need to double up where there are more students than cases. Suggestion: Try to double up on the more complex cases.
4. Suggestions for Writing assignment:
• You might use the case assigned to you as the basis for a position paper providing an ethical opinion and supporting justification for the case assigned to you.
• You might also choose another case for just such a paper.
• Write a letter to the editor defending physician impartiality / integrity against a series of editorials charging undue influence in physician prescribing patterns on the part of drug companies.
• Write a review of Dr. Viccellio’s lecture.
• Review one of the numerous articles provided this week.

1. We will start in lecture today.  Dr. Peter Viccellio (Emergency Department) will talk about the most recent finding regarding gifts and their impact on the judgments made by clinicians and researchers.
2. Then, in section, you will discuss the lecture, readings and writing assignment. Be sure to relate the discussion to the list of objectives and study questions.
3. Discuss each of the cases given for the week.  The student who was assigned to the case should offer their ethical opinion on the legitimacy of the gift and/or research and the others should critique their reasoning and logic.

1. What is the difference between a bribe and a gift?
2. It has been suggested that the price of drugs would be substantially lower were pharmaceutical houses not to spend money a) in inducements to prescribers and b) for advertising to prescribers and customers.
• Should this question be raised about breakfast cereals or toothpaste? Why or why not?
• In a capitalist or market economy, why is any of this the business of professional associations like the AMA or ACP?
3. What, if anything, is problematic about accepting gifts from people who are trying to solicit your business?
4. Do you scrutinize research findings differently when reported by reputable scientists funded by someone interested in establishing a particular outcome (e.g., a pharmaceutical company seeking FDA approval of its drug, the American Tobacco Institute seeking to influence rules on passive smoking, Dow-Corning looking at the safety of silicone gel breast implants, the Sierra Club funding an environmental impact study)? Why or why not?
5. Is there any room for pharmaceutical companies to offer gifts to physicians? What are your criteria of acceptability?
6. Is it acceptable for program directors to offer food to medical students to entice them to attend educationally valuable programs?
7. Should doctors accept gifts from patients? Why or why not?