Ethical Considerations Of Pharmaceutical Sales In The Primary Care Arena

The conflict of interest between pharmaceutical sales and the ethical practice of medicine has long existed. While pharmaceutical companies have lost much of their ability to financially incentivize clinicians, they continue to have undue influence over prescribing practice by means of "detailing." In an attempt to gain large market shares, these companies exploit this mode of medical information dissemination, creating enormous endorsement bias, and ultimately placing patients at the mercy of these manipulation tactics. Jonsen et al. have established the four topic method of ethical discourse which includes medical indications, patient preferences, quality of life, and contextual features. These topics allow for an intelligent discussion concerning the ethics of pharmaceutical business practices. The integrity of evidence-based medicine as well as the safety and welfare of patients are at risk. How clinicians respond to these pressures will have positive or negative impact on this medical ethics dilemma.

Introduction

The conflict of interest between pharmaceutical sales and the ethical practice of medicine has long existed. Since the 1950s, educators, administrators, researchers, and clinicians have fought for corrective action (Podolsky & Greene, 2008). Pharmaceutical companies have spent approximately $21 billion dollars on marketing while 90% of this budget has gone toward directly influencing physician practice (Brennan et al., 2006). Physicians and other health care practitioners have a fiduciary duty to act in the best interest of their patients. Jonsen, Siegler, and Winslade (2006) define this duty as, "[owing] undivided loyalty to clients and [working] for their benefit" (p. 163). Furthermore, according to these authors, it is especially important that fiduciaries avoid financial conflicts of interest that "prejudice their clients' interest" (p. 163).

Now that pharmaceutical companies have lost much of their ability to financially persuade practitioners with large monetary gifts, the focus on ethics behind their influence has shifted more toward the issue of "detailing" (Huddle, 2008). "Detailing" is loosely defined as the process of face to face contact between a medical provider and drug company representative ("drug rep") for the purposes of educating the medical provider on all of the details of a particular drug, service, or device. Many argue that a conflict of interest still exists for patients, despite a cap on monetary incentives (Brennan et al., 2006; Higgins, 2007; Spurling & Mansfield, 2007). They contend that any gift, large or small, may still influence the decision making process of a medical provider, and thus conflict with the better interest of the patient. They often site social science research which has demonstrated the powerful impulse to reciprocate for even small gifts (Brennan et al., 2006). Indeed, from their standpoint, pens and lunches strongly count toward that influence. For those who seem to believe that little influence can be generated from such small gifts, the persuasion is thought to stem from the dissemination of biased information (Huddle, 2008). These conflicting viewpoints have stirred an ongoing battle between the unbiased better interest of patient care and the financial self-interest of multibillion dollar pharmaceutical companies. The integrity of evidence-based medicine and ultimately the safety and welfare of patients hang in the balance as the battle wages on.

Through the litmus of Jonsen et al. four topic method, the far reaching implications of this subject will be explored.

Medical Indications

Medical indications are defined as "the facts, opinions, and interpretations about the patient's physical and/or psychological condition that provide a reasonable justification for diagnostic and therapeutic interventions." (Jonsen et al., 2006, p. 14) The concepts of beneficence and nonmaleficence must be considered regarding what is medically indicated for patients. These concepts define what is necessary to create maximum benefit and avoid harm to the patient. The conflict of interest caused within the drug rep/provider relationship, through the use of detailing and gifting providers, sheds suspicion on what is truly medically indicated for patients. Clinicians often have enormous choices when it comes to what medicine or device they may chose for a patient. Unfortunately, many providers succumb to the pressures placed upon them by drug or device representatives when it comes to patient care. This may not be in the patient's best interest.

Evidence-based practice has emerged as the new standard of patient care. As such, many higher educational institutions have begun to shun pharmaceutical influence in the way they provide care for their patients. For example, Yale, Stanford, and the University of Pennsylvania have limited relationships between member healthcare providers and pharmaceutical companies (Higgins, 2007). Yet other institutions embrace these types of symbiotic relationships. At the forefront of this practice is the Weill Medical College of Cornell University, who recently opened the Clinique Skin Wellness Center (Higgins, 2007). Created mostly from a $4.75 million dollar grant from Clinique, the center justifies its existence through the education of skin cancer prevention. While this is a noble effort, physicians in this setting will find it difficult to convince patients the care they are receiving is unbiased (Higgins, 2007). In other words, providers in this setting might find it difficult to provide medically indicated and evidence-based care when that evidence points away from the use of Clinique products. What are the plans in case of therapeutic failure should Clinique products and educational materials bring detriment to patients? The probabilities of success of Clinique products should have been weighed against the larger body of evidence based medicine before this relationship of biased synergy was struck.

Don't mess with old ladies

An older lady gets pulled over for speeding...

Older Woman: Is there a problem, Officer?

Officer: Ma'am, you were speeding.

Older Woman: Oh, I see.

Officer: Can I see your license please?

Older Woman: I'd give it to you but I don't have one.

Officer: Don't have one?

Older Woman: Lost it, 4 years ago for drunk driving.

Officer: I see...Can I see your vehicle registration papers please.

Older Woman: I can't do that.

Officer: Why not?

Older Woman: I stole this car.

Officer: Stole it?

Older Woman: Yes, and I killed and hacked up the owner.

Officer: You what?

Older Woman: His body parts are in plastic bags in the trunk if you want to see

The Officer looks at the woman and slowly backs away to his car and calls for back up. Within minutes 5 police cars circle the car. A senior officer slowly approaches the car, clasping his half drawn gun.

Officer 2: Ma'am, could you step out of your vehicle please! The woman steps out of her vehicle.

Older woman: Is there a problem sir?

Officer 2: One of my officers told me that you have stolen this car and murdered the owne r.

Older Woman: Murdered the ! owner?

Officer 2: Yes, could you please open the trunk of your car, please.

The woman opens the trunk, revealing nothing but an empty trunk.

Officer 2: Is this your car, ma'am?

Older Woman: Yes, here are the registration papers. The offi cer is quite stunned.

Officer 2: One of my officers claims that you do not have a driving license..

The woman digs into her handbag and pulls out a clutch purse and hands it to the officer.

The officer examines the license. He looks quite puzzled.

Officer 2: Thank you ma'am, one of my officers told me you didn't have a license, that you stole this car, and that you murdered and hacked up the owner.

Older Woman: Bet the liar told you I was speeding, too.

Never Be Late!

A priest was being honored at his retirement dinner after 25 years in the parish. A leading local politician and member of the congregation was chosen to make the presentation and give a little speech at the dinner.

However, he was delayed, so the priest decided to say his own few words while they waited:
'I got my first impression of the parish from the first confession I heard here. I thought I had been assigned to a terrible place. The very first person who entered my confessional told me he had stolen a television set and, when questioned by the police, was able to lie his way out of it. He had stolen money from his parents, embezzled from his employer, had an affair with his boss's wife, taken illegal drugs, and gave VD to his sister. I was appalled.

But as the days went on I learned that my people were not all like that and I had, indeed, come to a fine parish full of good and loving people.'...

Just as the priest finished his talk, the politician arrived full of apologies at being late. He immediately began to make the presentation and gave his talk:

'I'll never forget the first day our parish priest arrived,' said the politician. 'In fact, I had the honor of being the first person to go to him for confession.'

School friend

1 day I was in history (with a renowned dragon of a teacher) sitting next to my best mate. I was just out of hospital mentioned before, with crutches & leg in plaster so was allowed out 5 mins early to get down the stairs before the seething herd.

This one day my best friend KEEPS on releasing God awful silent farts while his guts keep rumbling LOUDLY like a school of whales. I kept berating him for the stench every 5 minutes.

I'm allowed to go, leave my things on the desk for him to bring and start hop-a-hopping down the steps. I get about 5 steps down when I clearly hear a MASSIVE ripping FART from the room and a chorus of "UUUUUURGGGGGHHHH!" (some people claim the windows rattled).

Said friend RUSHES past me, briefly stopping to say "I've been sick!". "No shit" I think as he has chunks plus liquid on his chin which weren't usually there. He rushes off in panic to the nearest loo.

Apparently he just stood up, involuntarily let loose a fantastic ripper, vomited all over the desks and shat himself LOL! (Well, not sure if he actually shat through to the public side of his trousers, but it sounds good, right? ;-) )

Other mean friends were not helpful in retrieving my things on account of them now being under a thin layer of instant soup substitute. I had spaghetti bolgnese for dinner that day which was somehow not as enticing as normal.