Doctors Drugs Although the Affordable Health Care Act represents a step in the right direction towards encouraging all Americans to avail themselves of medical services, the bill fails to address the root causes of problems in the system. The American health care system is flawed because it is a for-profit model that places profits far ahead of patients. When profits come ahead of patients, the result is an inability to fulfill the ethical duties of being a health care worker. A progressive transformation of the American health care system would systematically undo the nefarious link between corporate interests and the interests of health care.

The relationship between doctors and drug companies has been well established and well documented. Major news media resources like The Atlantic, as well as professional peer-reviewed journals like the New England Journal of Medicine cover stories addressing the potential ethical conundrums inherent in a cozy connection between physicians and pharmaceutical companies. Shaywitz (2013) has described the problem as "a bunch of nefarious pushers who pay off vulnerable doctors to prescribe their latest expensive, mediocre product," while still defending the special relationship that has developed between doctors and pharmaceutical companies (p. 1). Shaywitz's (2013) argument is based on opinion on conjecture only. Most established professional journals imply that collusion between doctors and drug companies leads to a range of problems that potentially harm patients. Writing for the British Medical Journal, Moynihan (2003) locates actual empirical evidence showing that doctors' prescribing habits changes measurably after the skillful marketing techniques used by pharmaceutical industry representatives: techniques ranging from free dinners to gifts. For example, doctors' prescribing habits are "less appropriate" after exposure to the marketing, including "a rise in both prescription expenditures and irrational and incautious prescribing, according to a recent analysis of the ethics of gift giving," (Moynihan, 2003, p. 1189).

What's even more disturbing is that doctors seem to be unaware that their behaviors change as a result of the marketing. Shaywitz's (2013) ridiculously laudatory comments underscore the problem of blissful ignorance among medical professionals. Moynihan (2003) found that doctors "deny their influence despite considerable evidence to the contrary," (p. 1189). Campell (2007) also concludes, "physicians vehemently deny that their industry relationships have any of these negative effect," but are ironically suspicious of their colleagues' ethical practices related to pharmaceutical company payoffs. Often the denial reaches epic proportions, as with the Shaywitz (2013) piece for The Atlantic, in which the author claims, "it's often these experts who are the smartest scientists or the most experienced clinicians -- that's why companies seek them out." This assessment is false. Drug companies seek out physicians who are amenable to working with them and susceptible to their style of direct marketing. The pharmaceutical manufacturers are in it for the money, and they would not invest in physicians with integrity.

It makes it much harder to influence public policy related to this problem when doctors deny that a problem exist, especially because doctors represent a high social status position in society and wield considerable clout politically. Currently, it is perfectly legal for doctors to be able to accept gifts -- essentially bribes -- from pharmaceutical representatives. A recent law attempts to at least inject some added transparency into the laws by forcing manufacturers to disclose the amounts of money they give to physicians, including free dinners and gifts (Campbell, 2007). The so-called Sunshine Law is actually bundled with the Affordable Health Care Act. However, the disclosure laws only apply to companies with revenues of over $100 million. They do not apply to the delivery of free samples to doctors, which is a large portion of their marketing. Because many pharmaceutical giants have subsidiaries, it is unlikely this law will have any impact on practices and behaviors. Moreover, disclosure of information does nothing to stop the practice. As an article in The Economist points out, the Sunshine Law might actually play right into the pharmaceutical companies' desire for financial growth at all costs, by providing them with a publically available (and therefore cost-free) method of marketing data and marketing research ("Let the Sunshine In," 2013). Pharmaceutical companies will be able to track their per-doctor expenditures with their per-patient prescription data, to reveal causal connections between marketing methods and sales. Removing the veil of secrecy from the practice is a step in the right direction in terms of the ethics of transparency, but it is as halfhearted a measure as the rest of the Affordable Health Care Act.

The only way to stop unethical conflicts of interest like those signified by the...

For example, the Boston University School of Medicine and Boston Medical Center recently banned conflicts of interest entirely: "prohibiting their clinicians from accepting gifts from manufacturers of pharmaceuticals and medical devices, banishing industry-funded meals from campus, and requiring physicians who serve on the hospital's drug-selection committees to be free of financial ties to companies that stand to gain from committee decisions," (Campbell, 2007).
No health care decision should be made based on marketing. Marketing works, which is why pharmaceutical companies invest as much money as they do on cultivating doctor complicity. Carollo (2010) cites a ProPublica report revealing that 17,000 doctors and nurses in the United States alone received $250 million in one year. A small percentage of the doctors who receive funds from pharmaceutical companies speak at "professional" conferences, seminars, and similar events sponsored by the corporations and earn payments of $100,000 or more in consultation fees (Carollo, 2010). Interestingly, 250 doctors in 18 states have been disciplined by their state medical boards for misconduct (Carollo, 2010). Up to 95% of doctors regularly see drug company representatives, according to Moynihan (2003). The numbers are astounding, because pharmaceutical companies receive a return on their investments. To think that marketing is not having an impact on doctor decisions related to patient care is not only naive; it is outright wrong based on the numbers of sales of the branded medications to which the doctors were exposed (Moynihan, 2003). As Campbell (2007) puts it, "After all, if these relationships didn't affect physician behavior in such a way as to increase sales, companies wouldn't spend $19 billion each year establishing and maintaining them," (p. 1796). Typical bribes, and they can appropriately be called that, given to doctors include free food and beverages (83%), drug samples (78%), "continuing medical education" fees (35%), and payments for speaking at seminars and related events (28%) (Campbell, 2007). The extent of the corruption runs deep, into academia as well as the professional sector. Boston University School of Medicine and Boston Medical Center is a unique bulwark against corruption. The rest of the nation's medical schools continue to cultivate corrupt and conflicted relationships with pharmaceutical companies, which fund research on medications. "In 2011 drug and device companies sponsored nearly a third of the medical training tracked by the Accreditation Council for Continuing Medical Education," ("Let the Sunshine In," 2013). If empirical studies cannot be trusted, than no patient is safe.

Arguments in favor of tight links between doctor and pharmaceutical companies are spurious, although they attempt to capture an interest in patient care. Common claims are that doctors need to be exposed to "under prescribed" medications to provide best quality of care (Campbell, 2007). Yet professional journals exist so that physicians can keep up-to-date on the latest breakthroughs in the pharmaceutical industry. "There is no reason why an educational activity needs to be accompanied by an expensive meal or a trip to a tropical resort," (Campbell, 2007). Some drug companies claim that they learn from physician feedback to create products that better serve patient needs (Campbell, 2007; Shaywitz, 2013). Of course, pharmaceutical companies are learning from the feedback. They are learning from the feedback not so that patients will receive improved quality of care, but so that their stakeholders receive maximum profits. Pharmaceutical companies are following every law in the books for effective marketing strategies, but none of the laws of bioethics.

Real risks to patient care cause harm, violating the strictest of all medical ethical tenets of "doing no harm." Physicians who are eager to prescribe a new drug, or an existing drug for new reasons, can "pose risks" and cause "serious health problems for patients," (Campbell, 2007). Therefore, immediate action must be taken to reduce the prevalence of the problem. The most effective means of intervening is to design new, tougher legislation banning conflicts of interest entirely. Working with the teams at Boston Medical and Boston University could help federal lawmakers come up with a similar strategy. All parties with vested interests will complain, and many will decry government intervention in business. However, health care is not just another business. Peoples' lives and quality of life is at stake. Patients are the bottom line and primary stakeholder in health care, not pharmaceutical companies.