Monday, 30 December 2013

The ethics of medical marketing

Is it ethical to sell medicines in the same way as you sell soap ? A trivially put , but troubling question. Consider the arguments for and against.

The problem in the medical industry is that the consumer, in most cases, is absolutely ignorant and is completely reliant on a doctor's opinion. But it is not the doctor who is paying - it is the consumer. At the time of consumption, the consumer is usually also not in a frame of mind to make rational , sensible choices. He is at his most vulnerable and therefore it can be argued that freedom of choice, a basic underpinning of capitalisim is, by definition, a contradiction in terms when it comes to a medical product

The basics of the medical industry is predicated on a few facts
  • New discoveries are extremely costly - be it a drug or a medical device.
  • Most nations grant a patent for a new discovery which enables the inventor to enjoy a monopoly for a fairly long time
  • Once the patent expires, the product is subject to the same pressures of competition, demand and supply as any other product in any other industry. 
  • There is very little product differentiation that is possible - formulations being legally regulated. Consequently, distribution and selling become the primary marketing tool for companies.
The industry is also peculiar in that the consumer is forced to consume - if it were possible, the consumer would prefer not to consume any medical product at all.  Given that it is the doctor who "forces" the consumer to consume, the backlash of customer dissatisfaction is also on the doctor - at the very least a virulent negative opinion against the doctor and more likely in the US for example, a lawsuit.

If that is so, is it correct for aggressive sales practices, usually found in most industries, to flourish in the medical industry as well ?  Most of the aggression on sales is towards doctors which raises even more ethical questions - should the doctors be influenced so heavily in their decision making. Every major drug company has been caught in questionable sales practices.  GlaxoSmithKline has been accused of bribery of medical professionals in China. Eli Lilly was charged with the same thing in Brazil. Pfizer sponsored incentive trips for Bulgarian doctors - euphemism for holidaying in Greece. Glaxo again took US medical professionals for "conferences" in Hawaii. Amgen offered discounts to  doctors to shift from competing products but allowed them a way to claim full price from health insurers.  Johnson & Johnson has been fined a colossal $2.2 billion for marketing practices stretching over 10 years in the US. Is anybody still left  who hasn't been fined ?

Almost every patient who sees a doctor in India complains of over testing and over prescription. Aggressive sales practices of medical companies and hospitals have certainly contributed to this "disease". One doctor I know, quit a hospital, because he was given a target for generating revenues through tests and prescriptions, regardless of whether the patient needed it or not.

While it would be easy to condemn all sales practices, these are a fundamental and essential part of the capitalist system. We would not bat an eyelid on any of them in other industries like telecom or clothing, or whatever. Its because the industry is the medical industry that there is unease. Although die hard loony leftists will argue against this, it is undeniable that capitalism and free markets have made incredible medical advances possible. If you simply ban all selling , and therefore dampen the means of achieving the profit motive, the industry would inevitably stagnate and then decline.

So where should the line be drawn. What is the difference between educating a doctor on a new drug or the effectiveness of an existing drug  and pushing him to prescribe it. We would, of course,  encourage a "soft sell" but would frown on a "hard sell" - the difficulty is to determine what is "soft" and what is "hard". These are extremely tough issues on which there isn't an easy answer. Doesn't mean that we shouldn't grapple with, or debate about, them.


Sriram Khé said...

Ok, I will not quote Sainath in this comment (again, what exactly are your feelings about Sainath? hehehe) or any other from the loony left that gives you the nightmares ;)

I work (yes, I do work!) in an "industry" that is very similar to the issue in healthcare that you are thinking about here. The higher education industry engages in all kinds of similar schemes, including aggressively selling education and the campus, because, as with health care, in higher education too it is captive consumers we are talking about. As much as patients and their families will try to do everything possible, including all the fancy-shmancy procedures that might not even be needed other than to suck their wallets dry, students and their families shudder at the road not taken of no college, or education at less expensive but not well known colleges.

In both healthcare and higher ed, all we know for certain is that the parties have crossed the metaphorical rubicon. But, we don't have the constructive debates and discussions needed in order to engage in the appropriate corrections ... As we have learnt from the Wall Street debacles, "ethical practices" do not come innately and are oxymorons, it seems.

BTW, a couple months ago, I met with the new dean of the college. (the chores of a department head!) During the briefing about what we do, I told her that none of us in the department cares much for actively selling geography and recruiting students. To which her response was, and I am literally quoting here, "that's not what a dean likes to hear."

So, yes, pharma companies hype and sell. Hospital admins hype and sell. Doctors hype and sell. Deans hype and sell. Professors hype and sell. At this rate, the ones who don't are fools. As I proclaimed in one new year greeting card a few years ago, I am the global village idiot ;)

Prats said...

This indeed is a very tough question. I some how feel that there is no correct way to achieve this. If one were to believe the mission statements of the so called pharma companies it seems in the ideal world every one would become healthy and they would be out of business.

I strongly feel that it should be made mandatory for the doctors need to prescribe the chemical composition instead of a drug name/brand. The chemist to provide options like when you are out to buy a soap and like any other commoditized product the medicines are sold on basis of price and the overall brand value of the pharma company.

Ramesh said...

@Sriram - Yes, there are many parallels with the education industry. But I feel the position in the medical industry is even more delicate. The key difference is that there is no freedom of choice - in education at least you can decide which college to go to. You can't decide which drug to take - that is "ordered" to you and you do not have the expertise to question that.

@Prats - Its an interesting thought - prescribe only the generic drug and allow the brand choice to the consumer. It will certainly work in quite some cases - in fact something like that already happens. The consumer asks the pharmacist to give a cheaper alternative often.

The question of whether a drug or a procedure is needed at all remains. That is a question of doctor's ethics, but there too aggressive selling plays a part. We must debate these issues.

Ravi Rajagopalan said...

@Ramesh: One should not ignore the fact that the doctor violates the Hippocratic oath when he over-prescribes. A few extra tests cost money, that is wrong, but no permanent damage is done. But when wierd combinations of drugs are licensed by a corrupt drug controller and the doctor prescribes them in response to blandishments, there is a violation of oath. While this does not answer your question, one should not ignore it.

The NHS in the UK solves this problem to a great extent by limiting what can be prescribed - for example, any GP in India would ask you to take a range of antibiotics for a cold. Azithral is a particular favourite because the usual dose is 3x500mg. You cannot do that in the UK. THe most you will get for a cold is aspirin.

Ramesh said...

@Ravi - Yes, of course, the doctor is violating the Hippocratic oath. But then when he is subject to such commercial pressures, he is also human. And accepting a junket from the makers of Calpol in order for him to prescribe it instead of Crocin doesn't violate the oath, but certainly is at the borderline of ethics.

You are in love with the NHS ??????????

Anonymous said...

Mostly hospital & hospital owners are violating ethics. A good hospital will deny medical reps to meet doctor, a hospital in my village asks medical reps to leave their product details in printed format at reception, it’s a good example. As a patient we are the consumer for doctors & he is obliged to consumer, drug companies have no contact with patients. Doctors are deviated from service to profit motive from education level itself, education industry that is forcing all professionals towards return for their spending. Medical collage must run at free of cost, land for hospital must be provided by government at cheaper price, medical equipment available at lower cost, if all this happens then we can expect the industry to do ethical practice.
It’s unfair to single out medical industry on ethical business. Every business is driving towards crazy profit motive. it’s impossible to say one industry to be perfect.

Ramesh said...

@Anon- Thanks for visiting and leaving a comment. Maybe you are a medical professional yourself.

Your idea of not allowing doctor salesman contact is an interesting one. Has been proposed before but the counter argument has been that the pharma industry is one of the important sources of new knowledge dissemination and banning this outright may be counter productive.

Being a staunch capitalist, I have no problems with the profit motive. Indeed the medical professionals must earn handsome profits - why not ? My stand has often been that the consultation fees paid to doctors is grossly inadequate. But profit making should not be at the expense of an exploitation of the vulnerability of the consumer. The medical industry is unique that its consumers are at their most vulnerable and unable to choose. Hence it must be extra careful as compared to other industries.

Anonymous said...

In the era of internet i don't think medical REP need to educated doctors. even if i buy that logic we need to recoganise that universities and medical association, senior doctors are failing to educate doctors. Company can put thier product details in website or by mail. 25%of cost on drug will come down if marketing expenses cut down. (i am not from medical industry and has no connection with it)

Ramesh said...

@Anon - Yes; surely medical reps are not best placed to educate doctors. But what about medical conferences the industry organises where research findings are presented and discussed. The medical industry is a key part of research. The problem with such conferences is also that they become junkets for doctors - maybe the solution there is to organise them not in Hawaii or Tahiti, but only in Gobichettypalayam :)

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