Have you ever found yourself sitting in front of your television wondering, “Good gawd, how many of these drug commercials am I going to have to watch?” Well, wonder no longer. The answer, according to a new JAMA analysis, is 663,000. Yes, 663,000. That’s how many drug commercials aired in the U.S. in 2016. Add in print and digital advertising and the number grows to whopping 4.6 million ads for a grand total of $30 billion in spending. That’s a lot of money. And a lot of ads. It’s high time we start talking about the ethics of pharmaceutical marketing to physicians.
Let’s begin with the obvious: Physicians are powerful. Almost nothing in the health care ecosystem happens without them. Physicians order diagnostic tests (an estimated $50 billion industry), they admit patients to hospitals (a $979 billion industry), and they prescribe medications ($328 billion). For all this power – indeed because of this power – physicians are at the top of every “target audience” list in health care marketing plans everywhere.
Pharmaceutical marketing is ethically different
To be fair, spending $30 billion in marketing isn’t all that uncommon in the U.S. The automotive industry, for example, spends about $35 billion each year on marketing. “But,” you say, “Pharmaceutical marketing is different!” Yes, it is, and there are two big reasons why.
The first reason involves what is being marketed. No one strictly needs a high-definition television or a fancy watch to live. So when someone wants to make a lot of money selling diamond encrusted watches, we all shrug. Access to medications, however, is often a matter of life and death. So when someone wants to make a lot of money off of HIV medication, we get really, really angry. Human life carries more ethical weight than a convenience does.
The second reason involves who the marketing targets. Most marketing targets consumers who make direct purchases. Drug companies don’t do that. They don’t target the people who use their products. It may seem like they do, but those ads urging you to “talk to your doctor” instead of “Xanax is on sale now” is a big clue. They are trying to convince you to convince your doctor to do something. The ads are indirectly targeting doctors.
How it works. Or, two roads diverged in a wood and both were plastered in marketing
Marketing to physicians typically follows two paths. One is direct marketing. Here, we find the beautiful pharmaceutical sales representatives who meet one-on-one with physicians to talk about the latest discoveries. The rep might also give presentations to a group of doctors during lunch meetings. It is common practice for pharmaceutical companies to pay for these lunches and/or provide drug samples and other branded merchandise like pens, mugs, and writing pads to physicians.
These small gifts may seem like harmless perks, but research shows that providing free meals and gifts results in higher rates of prescriptions for “name brand” drugs. Scholars out of the University of Pennsylvania also found that these small gifts create “networks of obligation” in which physicians feel compelled to reciprocate, and that they make physicians more receptive to the drug company’s information.
Down the second path are the commercials we all know and loathe. Advocates for these “direct to consumer” ads argue that they help educate patients and encourage more open dialogue with physicians. On this point, studies have indeed shown that the ads get patients to talk to their doctors. But it’s not always a happy conversation. Doctors reported that they spend a lot of time explaining why the medication is not needed or negotiating the benefits of a different treatment. Yet, despite all the hassle for doctors, pharmaceutical companies know it’s worth the investment. A recent study found that a 10% increase in advertising exposure increased the number of prescriptions by 5%.
Physicians know better, right? Right?
The big question in all of this is whether physicians aware of the influence marketing is having on them. And the answer is pretty surprising: Physicians believe they are immune to it. In fact, physicians are so sure of their independence that when presented with information to the contrary they tend to deny their own naivete. They choose instead to believe their colleagues are more susceptible to marketing than they are.
Physicians also tend to believe that the free drug samples they get from sales representatives are the best way to help their poorest patients. They argue that indigent patients can’t afford expensive, name brand drugs and these samples are the only way they can access needed medications. Yet, here again the data does not support the belief that poor patients benefit from free samples. Studies instead show that the free samples are more often given to wealthier patients with better insurance.
But is it wrong?
If a medication is proven to work, then prescribing it helps the patient. This, in turn, upholds the healing role of the physician. And the pharmaceutical company earns revenue that can be used to develop more life saving drugs. It’s a win-win-win, right?
Maybe. In deciding what is ethical, we often want to look at values. One value that is important here is trust. Both the trust that patients have in their doctors, and the trust that doctors have in the pharmaceutical company’s claims.
Patient trust: If a gift as menial as a pen or a sandwich can induce a physician to prescribe a brand name medication when a lower cost generic will do, a patient may legitimately question the allegiances of their physician. The good news is that there is currently no evidence to suggest that all this marketing had led to negative clinical outcomes. The bad news is that there can be negative financial outcomes for patients who needlessly incur higher out-of-pocket costs for name brand drugs.
Physician trust: Let’s say a drug company knows that the competition’s drug works better and is less expensive. What incentive do they have to inform doctors of this? None. None at all. In fact, sales representatives often downplay the negative effects of the drugs they’re promoting. Physicians do tend to rely on the information that the drug representatives give them, and that information isn’t always trustworthy.
An ethical path forward
Physicians are under a great deal of pressure, and they often face conflicting moral responsibilities. On the one hand, they need to know about latest advances in medicine, including drug therapies. Educational sessions offered by pharmaceutical representatives are a convenient and cost-effective way to stay informed. On the other hand, physicians have to maintain their objectivity. Can there be a way to meet both obligations without compromising the physician’s integrity? I believe there can.
- Shift to unbiased information. The practice of offering small gifts, lunches, and free drug samples in exchange for a few minutes of the physician’s time ought to be abandoned. It may be cost-effective for the pharmaceutical company and convenient for doctors, but it corrodes the trust required for modern medicine to be effective. Instead, the American Medical Association can work collaboratively with the Pharmaceutical Research and Manufacturers of America to make evidence-based, unbiased information available to physicians either in person or online.
- Reward for value. The incentives for prescribing pharmaceuticals need to be adjusted. Programs such as bundled payments, which reward caregivers for following evidence-based protocols, should be expanded to medication use. Reimbursements should be tied to the value and effectiveness of the overall treatment.
- Physicians need to lead. They are the linchpin in all of this, and they can and should be part of the solution. Physician-led models for care delivery, including prescribing practices, can transform the way that medicines are prescribed and developed. Physicians locally and nationally should agree to stop accepting gifts from pharmaceutical representatives, seek information from unbiased, trusted sources, and prescribe medications based on the efficacy of the drug.