All Rationalizations Large and Small

According to the American Medical Association (AMA), a physician may choose from among a number of gifts, though not more than eight (this would be too much like cash), and each must have a value of less than $100 dollars. The American College of Physicians (ACP), in its position paper (Coyle 2002), states that pens and calendars are okay, but gifts that "obligate the physician to reciprocate" are not. The Pharmaceutical Research and Manufacturers of America (2002) states that golf balls and sports bags may not be provided to physicians but stethoscopes may.

What is the ethical basis for these distinctions? In their outstanding discussion Dana Katz, Arthur L. Caplan, and Jon F. Merz (2003) demonstrate compellingly that there is none: Gifts—large or small, educational or noneducational, whether benefiting patients or improving a physician's golf game—can influence behavior and create the necessary conditions for conflicts of interest, both real and perceived.

One wonders, then, how neither the AMA nor the ACP, and barely Katz, Caplan and Merz, can bring themselves to say that the giving (and receiving) of all gifts—including small gifts—should be prohibited. Indeed one experiences a vertiginous feeling reading the ACP guidelines, as a cogent and compelling argument leads in-eluctably to a conclusion (namely, that it is up to physicians to decide what gifts are acceptable) that clearly contradicts its premises. Meanwhile the AMA distinguishes between gifts that benefit patients and gifts that do not, the former being acceptable, the latter not. While I am not an ethicist, I fail to see the moral distinction between a $100 golf bag and a $100 stethoscope that frees up physician income so he or she can buy the $100 golf bag. It's not as if the physician is telling patients, "Come back in a month—hopefully a drug company will have bought me a stethoscope by then, and I'll be in a better position to auscultate your heart."

What do the AMA, ACP, and, sadly, Katz, Caplan, and Merz all have in common? Dependence, it appears, on pharmaceutical industry money. Just as one might have thought that the AMA—in light of recent debacles—would have been wise enough not to use a gift from the pharmaceutical industry (in this case about $700,000) to fund its initiative to enlighten physicians about its campaign, one might also have thought that Katz, Caplan, and Merz would have thought twice before accepting a gift from industry for a paper about accepting gifts from industry.

Morin and Morse (2003), of the AMA's Council on Ethical and Judicial Affairs, exhibit what Mansfield (2003) would call an "instant rationalization." They state that "it is indisputable that ... industry representatives often are aware of new clinically relevant knowledge." I would like to know two things: Can Morin and Morse cite a single case where a pharmaceutical representative has provided information to a doctor that was not available in the peer-reviewed medical literature? And, if they do know of such a case, is it the position of the AMA that doctors should use information provided by salespersons that is not yet in the peer-reviewed literature in the care of their patients? Does the AMA believe that this is likely to benefit patients? I would hope not.

And what exactly does this have to do with gifts anyway? Morin and Morse go on to say that time with reps is time away from patients (so far I agree!) and this being the case, "courtesy might justify some sort of gift-giving, so long as the gift meets reasonable guidelines and does not result in undue influence." One could not ask for a better example of the sense of entitlement that physicians have developed though the process of socialization that Mansfield describes. Reading a textbook takes up my time; attending a lecture also uses up my time. Do we honestly believe that physicians—a...