Gift-giving in the pharmaceutical industry and physician ethics

Ethics in Business

Ethical problems faced in the workplace

The ethics of gift-giving in business: A case study of the medical profession

Ethical problem in the workplace

One ethical problem which frequently arises the workplace and in many industries is the question of giving gifts to clients or using free 'perks' to attract business. In the pharmaceutical industry until recently, it was extremely common to give gifts to doctors to encourage physicians to take an interest in prescribing a drug. Although a 'quid pro quo' agreement would have been blatantly unethical, the practice of giving free trips, meals, and office supplies to doctors by corporate entities raises ethical questions about the extent to which this might influence physician's beliefs and attitudes towards a drug. "Companies schedule individual speakers to speak to groups of physicians over dinner at no cost to the physicians, and some companies will pay $100 to each physician who attends the dinner to compensate for the physician's time. It has been reported that a few companies also have given physicians gifts or cash payments for every patient who was started on a particular drug" (Gifts to physicians from industry, 1991, CJEA Report).

Drug companies defend the practice because they say their mission is merely educational and designed to make physicians more aware of the options available for their patients. However, even doctors are only human and after receiving such incentives, "the physician may be more responsive in granting interviews to sales representatives and may, on the basis of the information presented, decide to use a new drug or device on a trial basis with his or her patients" due to the positive feelings fostered by the gift and persuasive abilities of the salesperson, rather than actual evidence about the drug's efficacy (Gifts to physicians from industry, 1991, CJEA Report). Several states, including Minnesota and Massachusetts have set strict legal limits upon the types of gifts physicians can accept. There have been calls for a widespread national ban given that: "gifts associated with pharmaceutical detailing are motivated by a single goal - to increase the sales of a company's products" (Grande 2010). The question of what is an appropriate gift in business, what is a bribe, and what constitutes undue influence often remains relatively fuzzily defined within all industries in practice, although the health consequences regarding gifts in the medical industry and the possible erosion of trust in doctors make such gifts of even greater concern.

Normative ethical theories

From the point-of-view of a salesperson, there is likely to be little ethical conflict in doing all he or she can to influence a physician to listen to a 'pitch' about a particular drug. After all, that is what salespersons are bound to do, according to their job definitions. Salespersons are not professionals who must abide by a specific professional ethical code of conduct as well as merely fulfill their job functions. When a physician acts, he or she is supposed to do so with the benefit of the patient in mind and the honor of his profession is at stake with every decision made. If a physician seems unduly influenced by monetary or other motivations, overall professional credibility is eroded as well as the ethical principle of doing no harm.

As professionals, physicians are expected to take a deontological view of their ethical responsibilities. The classical statement of deontological ethics is Kant's categorical imperative which holds: "act only on that maxim whereby you can at the same time will that it would become a universal law of nature" (Ursery 2002). This is necessary for physicians given that they hold life and death matters in their hands: patients who are prescribed a particular drug must feel confident that the drug was prescribed for medical reasons, not because the physician subconsciously felt beholden to a drug company.

In contrast, sales representatives for pharmaceutical companies are assumed to have a much more utilitarian view of what they are doing: it is assumed that their primary aim is to sell drugs, not necessarily to serve the best interests of patients. "Pharmaceutical sales representatives are not bound by any ethical duty to patients - their primary goal is to increase the number of prescriptions written for their company's product. Aligning this goal with strong [deontological] ethical norms would be challenging" (Grande 2010). Regarding the interests the sales representative is upholding, his or her major ethical obligation is to firm shareholders, to make the company profitable, not ethical principles of medicine. The interests of the many shareholders outweigh the interests of a 'few' patients that might be harmed. But a researcher in the pharmaceutical industry might take a different perspective: as a scientist, he or she might feel ethically obligated to take into consideration the needs of patients when creating a drug and the higher principles of medicine.

For example, creating an antidepressant with many additional side effects than the drugs currently on the market might be considered 'unethical' because it compromised patient's health needlessly when a better available alternative was at hand, even though the drug company wished to compete with a rival organization; similarly creating a new drug that was very similar to an existing cheaper drug that would incur additional costs to patients and to the healthcare industry as a whole would be an unethical endeavor by a researcher. However, from the point-of-view of the salesperson, his or her professional ethics are defined by the motive of enhancing firm profitability, nothing else.

Cognitive analysis

Physicians often believe that they are immune to being unduly influenced by gifts and advertising as educated professionals. However, there is considerable evidence that this is not the case. For example, physicians are required to engage in continuing education to keep their licenses current. Drug companies are often major sponsors of such educational courses as 'gifts,' which they defend as part of their public mission of physician education, even though the education they give through such courses is highly biased in favor of their particular drugs. "In a study of industry funding for continuing medical education (CME), researchers found a relationship between the source of funding and physician prescribing practices….[when] the course topic was directly related to a single class of drugs with at least three drugs in the class, and the drugs were essentially similar in terms of benefits, side effects and costs. While after each course there were increases in the prescribing of all drugs in the class, the greatest effect occurred for the drug whose company was the major financial supporter of the course," indicating the slanted presentation of this course 'given' to the physician merely for educational purposes (Gifts to physicians from industry, 1991, CJEA Report).

Even if physicians are not consciously influenced by hard-sell techniques, subconsciously they may be influenced by such advertising and free 'education.' One survey of internists in the Boston area found that even when "the medical literature was clear" that certain drugs "were neither effective nor offered any advantage over currently available therapy," most physicians who had been exposed to advertising "believed these agents to be effective -- even those who claimed to rely more on scientific, as opposed to commercial, sources" (Goodman 2001: 236). This suggests that even physicians who feel they are being ethical and steeling themselves to 'not believe' advertising can still be highly influenced by it. Ethical actions mean not only trying to act ethically on a case-by-case basis or trying to be a 'good person' consistent with the principles of virtue ethics: it also means creating an environment which supports unbiased and ethical actions within the workplace to minimize such subliminal influences.