Lunch with Lilly: Who Pays?

Dana Katz, Arthur L. Caplan, and Jon F. Merz (2003) argue that even small gifts from drug companies can influence physicians' decisions about the choice of drugs to prescribe, an influence that sometimes works against the interests of patients. Although the authors raise the issue of government regulation of gift-giving by pharmaceutical companies, they appear to reject this approach, based on a concern that "Government regulations might indeed be too crude and too heavy-handed an approach for micromanaging the fine lines between geniality and commercial inducement." It might be claimed that current professional guidelines should be modified to recommend that physicians not accept even small gifts, but the authors do not explicitly call for such changes. Thus, although Katz, Caplan, and Merz should be commended for their discussion, it is somewhat unclear what they think should be done about the problem of drug company gifts, particularly the small gifts that are currently condoned by the medical profession.

Katz, Caplan, and Merz's argument that even small gifts create a sense of obligation in the recipient is not new. For example, Chren, Landefeld, and Murray (1989) discuss the social and psychological dimensions of gift- receiving and its implications in the context of drug company gifts to physicians. They argue that even small gifts can be significant if they create a feeling of obligation in the receiver, and they recommended that all drug company gifts to individual physicians be avoided. I also have argued (2001) that all drug company gifts to individual physicians are ethically unacceptable.

There is persuasive evidence that large gifts are effective in altering physicians' prescribing patterns (Orlowski and Wateska 1992). Although there have been no studies demonstrating that small gifts influence physician behavior, it is reasonable to think that the psychology of gift- receiving, including a sense of indebtedness, is at work when physicians receive such gifts. If prescribing decisions are influenced by small gifts so that a patient receives a drug that is more expensive or less effective than a drug that otherwise would have been prescribed, then the patient's interests suffer and the principle of nonmaleficence is violated.

In addition to these concerns, there are at least three arguments not mentioned by Katz, Caplan, and Merz in support of the view that physicians should not accept small gifts. First, patients' trust in their physicians is undermined when gift-receiving creates the appearance of a conflict of interest. Data relevant to this argument are provided in a study by Blake and Early (1995), who surveyed 486 family-practice patients. Part of their questionnaire asked whether the respondents believed it was acceptable for physicians to receive certain gifts. Forty-eight percent disapproved of physicians receiving free dinners, 28% disapproved of physicians being treated to an ice-cream social, and 17.5% disapproved of physicians being given ballpoint pens. Fifty-four percent believed that drug company gifts sometimes influence physicians' prescribing, and an additional 16% believed that the influence is frequent. Given these results, the concern about patient trust should be taken seriously. Second, even if some gifts are too minor to influence physicians, the problem of distinguishing them from gifts that exert influence would be difficult. A straightforward way to resolve this problem is for physicians not to accept any gifts from drug companies. Third, the cost of gifts is ultimately passed to patients and other buyers of health insurance in the form of higher medicine prices. According to a report of the U.S. Senate Committee on Labor and Human Resources, a survey of 18 major pharmaceutical companies revealed that the firms spent $165 million on symposia and gifts in 1988 (Randall 1991). The report stated that the total spent on marketing by the pharmaceutical industry in 1989 was more than $5 billion. By 2001 that figure had risen to approximately $12 billion a year (Department of Health and Human Services 2001).

These considerations suggest that we should strive to change the culture...