Pens and Other Pharmaceutical Industry Gifts

Recently at a meeting I was sitting next to a colleague, a professor at an academic medical center. I was impressed by his pen and asked to see it. With some pride he showed off its features—both ballpoint and stylus tips plus a built-in laser pointer, all in a slim and handsome brushed-silver case. The case bore the name of a major drug firm. My colleague said that he had picked up this pen while walking past the firm's display at a medical convention.

Out of curiosity (or perhaps envy), I logged onto the Internet and obtained prices for this sort of pen ranging from $17.80 to $29.99.

Here, then, is a case study of the sort of gift discussed by Dana Katz, Arthur L. Caplan, and Jon F. Merz (2003). I wish to call attention to two issues. First, should gifts like this be allowed; and how should they be regulated, if at all? Second, is it of any ethical significance that the authors had grant funding from a major pharmaceutical manufacturer?

Gifts and Relationships

The pharmaceutical industry talks out of both sides of its mouth on the matter of gifts. On one hand, its spokespersons insist that people like me, who allege that these gifts influence physicians' prescribing, are insulting the integrity of the medical profession (Spilker 2002). On the other hand, the amount given away annually in the form of these gifts remains one of the most closely-guarded secrets of the industry. It is relatively easy to obtain reliable estimates of the total marketing budgets of the major drug firms but very difficult to obtain estimates of the specific amount spent on gifts to physicians, of either high or low value. The only sales representatives I am aware of as having spoken of these figures have done so only after being promised anonymity. Why is this such a touchy subject?

The main contribution of Katz, Caplan, and Merz is that they discuss (but perhaps do not sufficiently highlight) how the issue of gifts recedes before the much greater issue of the ongoing relationship between the individual physician and the pharmaceutical industry. Gifts are tokens and tools of this larger relationship and probably mean little outside the context of the relationship, whatever their monetary value. This relationship has two major dimensions.

First, the industry devotes considerable effort to creating an environment, from the first day of medical training, in which seeing and talking with detail people ("reps") is viewed as normal operating procedure for good physicians and gifts from reps become merely an acknowledgment of the entitlement of the soon-to-be physician, who is working long hours, studying hard, and making many sacrifices. The student, will, of course, encounter some Goody-Two-Shoes types who will cluck their tongues over the propriety of such gifts, but the student soon learns that the pharmaceutical industry and the reps totally sympathize—they understand how hard the student works and how difficult it really is. By graduation from residency the environment says "the drug rep is your friend; it would be silly of you to refuse to talk with your friend when he or she comes to visit, and even more stupid to refuse to accept the offered gifts, which you have earned by the sweat of your brow."

Second, the industry works to develop a close relationship with the practitioners who actually write the prescriptions for the company products. What most physicians appear unaware of—and explaining why the industry does not want us to look behind this curtain—is the highly-detailed and specific information that reps readily obtain about the exact prescribing habits of each practitioner and the precise way that contacts with reps and gift values are "dosed" according to the prescription patterns. If you want to get the best freebies, be one of two physicians: either an acknowledged high prescriber of that firm's product...