Bribes for Doctors: A Gift for Bioethicsts?

Research, teaching, and debate about gifts from drug companies to doctors might give bioethicists the greatest opportunity to help improve healthcare during the twenty-first century. My organization, Healthy Skepticism, has been campaigning for 20 years to improve health by reducing harm from misleading promotion (see http://www.healthyskepticism.com). We have identified gifts as a key factor in the widespread dependence of doctors on information from drug companies. That information is often misleading. Consequently the article by Dana Katz, Arthur Caplan, and Jon Merz (2003) about gifts is extremely important. They have produced an excellent summary of the evidence that all gifts, both large and small, are a major cause of harm. One of the many strengths of their article is the use of insights from psychology to understand how the use of conscious and subconscious reciprocal obligation can manipulate doctors. I will provide four additional considerations and then speculate about how medical students and doctors think about gifts. Finally I will attempt some constructive suggestions about how bioethicists can help advance this issue.

Four Additional Considerations

1. Katz, Caplan, and Merz correctly point out that the term gift is misleading, but their only suggestion for a replacement is "promotional wares." Another option is to recognize that gifts are bribes. According to Merriam-Webster's Collegiate Dictionary, a bribe is "1: money or favor given or promised in order to influence the judgment or conduct of a person in a position of trust; 2: something that serves to induce or influence." The term bribe has the advantage of accuracy but the disadvantage of eliciting defensive reactions. Consequently there are strategic reasons for continuing to call bribes "gifts."
2. Katz, Caplan, and Merz did disclose that they received funding from a drug company, but they did not discuss the implications. That gift puts them in a difficult position because they cannot make a strong call against gift-taking without appearing inconsistent. It would be better to be inconsistent than to be consistently wrong. The path my colleagues and I have taken out of this trap is to admit that we have taken gifts in the past but to now recognize that doing so was a mistake that we do not intend to repeat.
3. Katz, Caplan, and Merz's main conclusion that small gifts are as harmful as large ones is well-justified, and their speculation that government regulation of small gifts might have adverse effects is reasonable. However, they give little attention to the possibility that the benefits of regulation could exceed the adverse effects. As with new drugs we don't know until after a fair trial. More important, it is worthwhile to consider combining regulation with education and/or promotion. For example, drunk driving was once regarded as socially acceptable in Australia. However, a combination of regulation, including random breath testing, and promotional messages such as "If you drink and drive, you're a bloody idiot" has reduced road death rates (Job 1990). Driving under the influence of alcohol and prescribing under the influence of gifts raise similar ethical and psychological issues, so a similar multi-intervention strategy deserves a fair trial.
4. Katz, Caplan, and Merz don't mention the drug- company side of these ethical issues. The choices of drug-company staff are locked by golden handcuffs. They have little choice but to do whatever works for increasing profits or risk losing well-paid jobs. Drug-company staff have told me that they resent having to pay bribes. They would prefer to live in a world where medical care for their families depended on the merits of therapies rather than the power of bribes.

Why Do Good Doctors Do Bad Things?

I will now speculate about why so many doctors take gifts. Medical students are introduced to gift-taking during a process of socialization in which they increasingly set aside their own sense of self so they can act like doctors until people treat them...