The Death of Common Sense

In the realm of medical bogeymen the drug companies feature prominently on almost everyone's list of easy targets. The widely praised article by Relman and Angell in The New Republic (2002) enumerates in great detail the sins of the pharmaceutical industry and tries to explain why the American public pays top dollar for less than innovative therapies. Among the greatest evils is the disproportion between money spent on advertising and marketing existing products and funds invested in research and development. Advertising and marketing include efforts directed at doctors as providers and efforts directed at patients as consumers.

Among the most criticized of the drug company methods is the giving of gifts to doctors in the form of free meals, tickets to sporting events, and trips to industry-sponsored conferences. Included in these favors are smaller items such as pens, pads, and office paraphernalia that are worth less than $100. Dana Katz, Arthur L. Caplan, and Jon F. Merz (2003) caution that the influence of these small items on the behavior of doctors has been inappropriately ignored, and they propose that this allowance be reconsidered. They suggest that consideration be given to banning all such gifts in order to ensure the ethical integrity of medical practice.

Let me state at the outset that I have no argument with the assertion that doctors should prescribe only drugs that are medically effective for a given patient without being influenced by any other external consideration such as the novelty of the agent, their own self interest, or the profit to be made by the drug manufacturer. I am suggesting only that attempting to alleviate this potential conflict of interest by banning all pharmaceutical gifts, both large and small, is a futile proposal that is bound to fail for a number of reasons. First, it flies in the face of the everyday experience of doctors as professionals and normal human beings. The authors acknowledge that gift-giving as a way of expressing gratitude or influencing the behavior of those we come in contact with is probably hardwired into our behavior as social animals. While the goal of preventing undue coercion on the recipient dictates that it is sensible to penalize those who apply this strategy of gift-giving in an excessive manner, it appears impossible to legislate this behavior out of existence. It is worthy of note that in clinical investigations, while overly generous remuneration to participants in research studies is disallowed, no one has advocated abolishing payments to subjects for their time and effort. Second, disallowing small gifts from pharmaceutical companies to doctors is likely to represent a law that the medical community could not abide and therefore would ignore. There is a well-known dictum in Jewish law that a court should not and cannot issue a decree that the people will be unable to comply with (Tractate Avodah Zara). In view of the regular contact between physicians and representatives of the pharmaceutical industry, it is inconceivable that these two groups would not interact and exchange services and favors. Prohibiting gifts would require behavior that neither group could honor and would lead to wholesale disregard of the law.

Third, using Prohibition as a model, it is likely that were the American Medical Association or Congress to pass a law against even small gift-giving by representatives of the drug company to doctors, gift-giving would go underground and assume forms that would be more detrimental to the sound ethical practice of medicine. Fourth, the authors assert that research has shown that even small gifts can influence the recipient's behavior toward the donor. However, even if one concedes this point, one must question whether this is a subject that can be reliably studied by social scientists. Can the veracity of the doctor or the drug company benefactor be trusted under these circumstances? Fifth, in the grand scheme of pharmaceutical transgressions, is this a battle in which the medical profession wants to expend...