Thesis Chapter 4 - 5 on Ethics in Pharmaceutical Industry
PRESENTATION, ANALYSIS AND INTERPRETATION OF DATA
This part of the study shall provide discussions based on the available literature collected by the researcher regarding the ethics of pharmaceutical sales representatives. The discussions in this chapter intend to address the problem statement discussed in the earlier chapters of this study.
The Ethical Practices of Sales Representatives
Recent studies, such as that done by Wazana (2000), states that the marketing strategies provided by pharmaceutical sales representatives have a significant impact in the professional activities of a physician. Moreover, the study further stated that there is an independent association between meetings with pharmaceutical representatives and formulary addition requests for the drug of the representative's company, both with respect to control physicians who did not meet representatives and with respect to requests for other companies' drugs. Thus, interactions with pharmaceutical representatives were also found to impact the prescribing practice of residents and physicians in terms of prescribing cost, non-rational prescribing, awareness, preference and rapid prescribing of new drugs, and decreased prescribing of generic drugs. Likewise, exposure to pharmaceutical representatives was highly associated with a perception of the benefits of such an interaction and the appropriateness of other interactions.
Nonetheless, the pharmaceutical companies are stern that what their respective sales representatives engage on is simply a way to get in the door so they can present more detailed information on the drugs. (Appleby 2001) Moreover, resident doctors and physicians have similar attitudes about pharmaceutical representatives. They believe that representatives provide accurate information about their drugs and are resolute in their beliefs that representatives could provide accurate information on established or alternative drugs.
In addition, Wazana (2000) provided a categorization of what the interaction between the medical professional and the sales representative. He also provided the established effects of the said interaction. The first item of discussion is the provision of gifts. Receiving a gift, and the number of gifts received, correlated with the belief that pharmaceutical representatives have no impact on the prescribing behavior of the medical professional. Moreover, receiving gifts of high relevance to practice was also associated with a positive attitude. Another issue is the provision of samples. Predominantly, accepting samples is associated with awareness, preference and rapid prescription of a new drug. Thus this furnishes a positive attitude toward the pharmaceutical representative. Another item of discussion is the industry-paid meals provided by the sales representative. This is the more prevalent method used by pharmaceutical industries and the most encouraged. (Lishctein, turner and O’Brien, 1992) Aside from the said items, pharmaceutical industries, through their medical representatives, endow the medical doctors with a funding for travel or lodging to attend educational symposia. In addition, accepting funding to attend a symposium was independently associated with increased formulary addition requests for the sponsor's drug. Another is the distribution of a continuing medical education (CME) sponsorship provided by the pharmaceutical company. In this light, the sponsor's drug has always preferentially highlighted, although the same drugs were discussed in each event. Studies found out that changes in prescribing practice in favor of the sponsor's drug. And lastly, the pharmaceutical agencies also seek the loyalty of the medical doctor by providing them with honoraria, research funding, and employment. Accepting a drug company honorarium to present data on a new therapy and receiving research support were independently associated with a formulary addition request for the sponsor's drug and any other drug.
Gray Areas on the Ethical Practices of Pharmaceutical Sales Representatives
Relationships between medical practitioners and the pharmaceutical industry raise serious concerns and controversy within the medical profession and the general community. This relationship includes both apparently desirable aspects such as drug samples to low-income patients and research funding and less clearly ethically justifiable ones such as the acceptance of lavish gifts and allowances for travel. The relationship between medical practitioners and the pharmaceutical industry involves a lot more than just giving of gifts. This relationship involves interactions in a variety of different areas that are involved within the day-to-day tasks of a medical practitioner. These include research funding, advertising in magazines and journals, surgery visits for drug presentations, gift giving, subsidized travel and accommodation to conferences and sponsorship of continuing medical education events and activities.
Furthermore, doctors and pharmaceutical companies do share a number of common interests such as encouraging the effective and responsible use of existing drugs as well as innovative research into developing new ones. This is especially important as drug companies currently fund 70% of drug research and development costs (Komersaroff, Kerridge, 2002), which is a $6 billion, a year industry. Much of this research would not go ahead with out this funding. In addition, heavy funding of both leading university and research laboratories by Pharmaceutical companies brings about the possibility of a conflict of interest. De Angelis (2000), on the other hand, highlights this point in the fact that over half the advisers to the Food & Drug Administration in the US, who are in charge of approving drugs for public use, have financial ties to pharmaceutical companies. Also that investigators doing research in an area related to their sponsors are more likely to favor their sponsors and produce research of lower quality.
Moreover, in a study by Morris and Banks (1990), it stated that new trends in drug promotion reflect the industry's success in finding loopholes in existing regulations to control drug promotion. In their 1990 article, US FDA officials, listed five main techniques companies use to get around US FDA regulations, which they call the five advertising end-runs which they specified as the use of industry-sponsored scientific and educational activities; basing claims for products on inadequate scientific evidence, for example open-label studies are used to support efficacy claims; the use of press releases and materials produced by public relations firms; direct-to-consumer advertising; and asking the FDA to pre-approve promotion but then changing the promotional material that is disseminated to the medical profession or the public. Morris and Banks' article is unusual in that it provides a glimpse of a regulatory agency's frustration over company strategies commonly used to bypass controls. These are among the large gaps in the regulation of drug promotion within national borders and beyond. Some have become apparent because of the recent flourishing of unregulated promotion in new media such as the Internet. Others are longstanding problem areas.
Notions on the Relationship of Medical Doctors and the Pharmaceutical Industry
The relationship of the medical doctor and the pharmaceutical industry, through the intervention of the medical representatives, also establishes a distinct impression on the medical environment. This impression reflects the idea of a layperson in furnishing the image of medical representatives’ practices whether it is ethical or not. In a study made by Wirth and Scherer (2001) it sought to measure the perception of the patients in the affairs of the pharmaceutical industry and the medical professionals, through the intervention of the medical representative.
When the respondents of the study were asked how many times, as they perceive, do doctors receive gifts valued less than $25 from pharmaceutical companies, they responded as follows:
Figure 1.Patients’ Perception of Gifts Below $25 Given to Medical Doctors
Almost half of the respondents stated that they think that doctors receive gifts below twenty-five dollars while 22% stated that they think that the doctors receive gifts at least once a week. Moreover, 10% of the respondents stated that they presume that doctors acquire gifts at least once a year. This data affirms the fact that the information that the patients are aware of the transactions between the doctor and the medical representative. However, what the patients perceive is rather disturbing considering they claim that the medical doctors are the process of gift giving from the pharmaceutical industry is a regularity in the professional life of a physician.
In order to verify the responses of the patients, the study also provided the answers of the doctors regarding the actual frequency of the gifts they acquire from the pharmaceutical industry. The doctors’ responses are summarized below.
Figure 2. Doctor’s Response on the Gift Giving Issue
The data above summarized the responses of the medical practitioners. The figure shows that sixty percent of the respondent doctors stated that they only receive an actual item from the pharmaceutical company through the medical representatives for at least once a month. On the other hand, forty percent of the said respondents stated that they only receive gifts from the company at least once a year. The above findings of Wirth and Scherer (2001) assert the notion of the patients of doctors receiving gifts regularly for at least once a month.
On the other hand, when the study asked perception of the patients with regards to the frequency of receiving gifts more than $25, one-third stated that doctors receive gifts for at least once a year. Another one-third perceived that they think they receive gifts at least once a month. Moreover, 17% of them assumed that they don’t ever receive any handouts from pharmaceutical agencies costing more than twenty-five dollars. The data is summarized below.
Figure 3. Perception of Patients Regarding Doctors Receiving Gifts Worth More than $25
However, the responses above is refuted by the respondent doctors when they were asked to fill-in a questionnaire having the same question, an astounding 80% of them stated that they only receive gifts amounting to more than $25 only once a year. On the other hand, 20% of them stated that they still are unable to experience the provision of gifts costing more that a quarter of a hundred bucks.
Figure 4. Doctors’ Response on the Frequency of Receiving Gifts Worth More than $25.
Moreover, the study of Wirth and Scherer (2001) stated that eighteen percent of patients were not happy for their doctors to accept them when offered by pharmaceutical companies and thirty percent did not think companies should be allowed to offer them in general whereas the majority was more tolerant about doctors receiving gifts. However, sixty percent of patient respondents thought they should be better informed about the nature of the doctor-pharmaceutical company relationship. Of those who responded that they were no happy about doctors receiving gifts, eighty percent agreed that patients should be better informed.
On a similar study by Gibbons and company (1995), it allowed the participants, doctors and their respective patients, rated 10 pharmaceutical gifts on whether they were appropriate for physicians to accept and whether they were likely to influence prescribing. Patients found gifts less appropriate and more influential than did their physicians. About half of the patients were aware of such gifts; of those unaware, 24% responded that this knowledge altered their perception of the medical profession. Asked whether they thought their own physician-accepted gifts, 27% said yes, 20% no, and 53% were unsure. For patients, feeling that gifts were inappropriate was best predicted by a belief that gifts might influence prescribing, while for physicians, the best predictor was knowledge of guidelines. A summary of the said survey is provided in the figure below.
Figure 5. Awareness of Patients Regarding the Transactions of Medical Doctors and Medical Representatives
The figure shows that the patients feel pharmaceutical gifts are more influential and less appropriate than do their physicians. Physicians may want to consider this in deciding whether to accept particular gifts. Broader dissemination of guidelines may be one means of changing physician behavior. At the same time, future guidelines should further consider the potentially different viewpoints of patients and physicians.
Existing Legislation on the Ethical Practices in the Pharmaceutical Industry
As of the present, the existence of concrete guidelines for the proper ethics on the interaction of the medical profession and the pharmaceutical industry is still indistinguishable. Nonetheless, an international body took on the challenge of providing one, the World Health Organization. As one element in the implementation of its 1985 Revised Drug Strategy, WHO developed a set of Ethical Criteria for Medicinal Drug Promotion. These criteria were adopted by the 1988 World Health Assembly and were the result of consensus discussion involving health workers, drug regulatory agencies, consumers and the industry. (WHO, 1988) The WHO Ethical Criteria states that promotion of prescription and over-the-counter drugs should be consistent with national health policies, contain reliable claims, without misleading or unverifiable statements, contain no omissions which could lead to health risks, and should not be designed so as to disguise its real nature, for example as educational or scientific activities. Moreover, the Ethical Criteria also include general guidelines for advertisements to the medical profession and the public, conduct of sales representatives, free samples, symposia and scientific meetings, post-marketing studies, packaging and labeling, patient information and promotion of exported drugs.
Although some areas of drug promotion are inadequately covered by the Ethical Criteria, their guiding principle, to support and encourage the improvement of health care through the rational use of drugs, remains a universally applicable standard. However, the Ethical Criteria are neither well known nor well used by regulators, health professionals, industry staff or the public. Collier and Fox (1993) commented that it is sad to say that the clear and straightforward criteria have been much neglected. Moreover, they reported on a meeting hosted by WHO and the Council for International Organizations of Medical Science (CIOMS) to explore ways to implement the Ethical Criteria. The meeting recommendations included monitoring, developing performance indicators, remedial measures if promotion is inadequately controlled, periodical review of the Criteria, a framework for national capacity building, and development and dissemination of educational materials on the Ethical Criteria. These recommendations remain valid today. Preliminary results of a multi-country study on the implementation of the Ethical Criteria reported in 1996 indicated, "very little awareness of the Ethical Criteria, national regulations or industry codes among doctors, pharmacists, health workers or industry sales representatives, as well as inadequate government regulation of all aspects of promotion, but especially sales representatives, symposia and post-marketing studies, weak monitoring, and a lack of sanctions.
Furthermore, the other operating international standard is the International Federation of Pharmaceutical Manufacturers' Association (IFPMA) Code of Pharmaceutical Marketing Practices developed in 1981 and revised in 1994. It describes itself as defining universally applicable baseline standards of marketing practice. (IFPMA, 1994) However, this voluntary industry self-regulatory code lacks any mechanisms for active monitoring, effective sanctions, or clear procedures to correct misleading information. Without enforcement, it remains "more show than substance," as Andrew Herxheimer, author of several studies of industry self-regulation, has commented that the spirit of the code is usually disregarded. The same companies repeat their transgressions again and again. (Chetley, 1994) Although the IFPMA code states that it is a minimum global standard for drug promotion, both the 1981 and 1994 versions also allow for precedence of national laws and regulations in all matters of application, interpretation and enforcement...compliance with national laws, regulations and regulatory decisions and requirements will take precedence. (IFPMA, 1994)
Moreover, national drug regulatory agencies are responsible for approval and licensing of drugs that are marketed within their country as well as other regulatory decisions, including approval of the information, which accompanies drugs and governs their use. Multinational companies market their drugs in many countries and must therefore make many separate applications for marketing licenses for each product. At the same time, national drug regulatory agencies are often swamped with drug applications. One of the problems is who has been left out of the decision-making process and priority-setting for international harmonization of drug regulation: consumers, health professionals, regulators from developing countries and transitional economies, domestic industry from these regions and generic manufacturers. It is no wonder that rapid registration of new drugs is taking precedence over a broader public health perspective.
Moreover, doctors are also mandated to follow what they called a clinical practice guideline (CPGs), which includes the ethical guidelines and code of conduct of a good doctor of medicine. In a study of Choudhry (2002), it stated that there has been a reported increasing contact between physicians and the pharmaceutical industry, although no data exist in the literature regarding potential financial conflicts of interest for authors of clinical practice guidelines. These interactions may be particularly relevant since CPGs are designed to influence the practice of a large number of physicians. The study found out that eighty-seven percent of authors had some form of interaction with the pharmaceutical industry. Fifty-eight percent had received financial support to perform research and 42% had served as employees or consultants for a pharmaceutical company. This data is illustrated below. On average, CPG authors interacted with 10.5 different companies. Overall, an average of 81% (95% confidence interval, 70%-92%) of authors per CPG had interactions. Similarly, all of the CPGs for 7 of the 10 diseases included in our study had at least 1 author who had some interaction. Fifty-nine percent had relationships with companies whose drugs were considered in the guideline they authored, and of these authors, 96% had relationships that predated the guideline creation process. Fifty-five percent of respondents indicated that the guideline process with which they were involved had no formal process for declaring these relationships. In published versions of the CPGs, specific declarations regarding the personal financial interactions of individual authors with the pharmaceutical industry were made in only 2 cases. Seven percent thought that their own relationships with the pharmaceutical industry influenced the recommendations and 19% thought that their co-authors' recommendations were influenced by their relationships.
Figure 6. Interaction of Clinical Practice Guidelines Authors With Pharmaceutical Agencies
The Illustration shows that there appears to be considerable interaction between CPG authors and the pharmaceutical industry. Our study highlights the need for appropriate disclosure of financial conflicts of interest for authors of CPGs and a formal process for discussing these conflicts prior to CPG development.
Likewise, Mazza and Russell (2000) confirms the above findings by conducting a study that investigated aspects of general practitioners' current use of clinical practice guidelines (CPGs) in daily general practice. The study found out that each GP interviewed was able to name at least one 'guideline' that they knew about. The most commonly used was a therapeutic guideline with 'prescribing' being the most common reason for accessing a guideline. Most GPs stored guidelines in their consulting room, reading them when they felt they needed to. Some also used them during the consultation and showed them to patients. General practitioners used CPGs to assist in making therapeutic decisions more frequently than when deciding when and whether to implement preventive measures. The study concluded that the main finding from this study is that GPs are not in the main following, or accessing, the CPGs that have been developed. Strategies are required to create a culture in which evidence based guidelines are used and valued within general practice. Such a culture in which the processes of development, dissemination, implementation and evaluation of CPGs are well established, may take 5-10 years to achieve.
With the discussion above, one could posit that the medical practitioners have no regard on the provision of ethical guidelines. Moreover, it depends on the respective morals of individual doctors of medicine to distinctly measure his/her propensity to give in to the provisions of the pharmaceutical industry.
Relations of the Medical Doctor and the Pharmaceutical Industry Based Studies
In a study by Lexchin (1993) which sought to determine the effect of three types of interaction between physicians and the pharmaceutical industry--company-funded clinical trials, company-sponsored continuing medical education (CME) and information for physicians supplied by pharmaceutical detailers--on orientation and quality of clinical trials, content of CME courses and physicians' prescribing behavior, it took A total of 227 papers from the MEDLINE and HEALTH searches and about 2000 items from the author's library were initially reviewed. The following selection criteria were used: studies conducted in Australia, Canada, New Zealand, Britain and the United States; studies conducted after 1977; quantitative surveys containing details of the survey methods; studies on the orientation and quality of company-funded clinical trials and on the content of CME courses giving explicit criteria used in the evaluation; and reports on the outcome of interactions stating how the outcomes were assessed. Thirty-six studies met these criteria. The study found out that although most physicians participate only occasionally in company-sponsored clinical trials, most see detailers and attend company-sponsored CME courses. However, physicians do not have a very high opinion of the information from detailers or of company-sponsored CME events. Many doctors regard pharmaceutical companies as an important source of funding for clinical trials, but they also have concerns about accepting money from this source. Company funding of clinical trials may affect the quality of the trials and the types of research that physicians undertake. Company-sponsored CME courses may have a commercial bias even if conducted under guidelines designed to ensure the independence of the event. All three types of interactions affect physicians' prescribing behavior and, in the case of obtaining information from detailers, physicians' prescribing practices are less appropriate as a result of the interaction. Moreover, it concluded that Physicians are affected by their interactions with the pharmaceutical industry. Further research needs to be done in most cases to determine whether such interactions lead to more or less appropriate prescribing practices. The CMA's guidelines on this topic should be evaluated to see whether they are effective in controlling physician-industry interactions. Further measures may be necessary if the guidelines fail to prevent negative effects on prescribing practices.
On the other hand, Komesaroff and Kerridge (2002) stated that medical practitioners and the pharmaceutical industry serve interests that sometimes overlap and sometimes conflict. There is strong evidence that associations between industry and doctors influence the behavior of the latter in relation to both clinical decision-making and the conduct of research. In view of the risk of compromising relationships with patients and the integrity of the research process, doctors must exercise care in their dealings with industry. The basic principles underlying the conduct of doctors with respect to pharmaceutical companies should be openness and transparency. Clearly articulated procedures should be developed to deal with specific issues such as travel subsidies, receipt of gifts, sponsorship of conferences and continuing education activities, and dualities of interest arising in clinical and research settings.
SUMMARY AND CONCLUSION
This chapter shall provide an overview and a summation of the study in order to postulate several sound conclusions for the ethical practices of the pharmaceutical sales representatives regarding their interaction with medical doctors.
The study intended to prove if the industry practices of the pharmaceutical industry are ethical and legitimate. Specifically the study sought to describe the manner on which the pharmaceutical industry defined the ethical practices of their medical representatives; the gray areas in the ethical practices of medical representatives in their relationship with the doctors they deal with; and the existing legislation that would check unethical practices in the pharmaceutical industry.
The data were gathered through the use of past and current literature that would be the basis for discussions and conclusions. The researcher wanted to know how these sources classify the practices and interaction between the medical doctor and the medical representative. The legitimacy of the said practices shall be obtained through analysis of the texts and shall be noted in this study’s conclusion.
On the basis of the data gathered in relation to the statement of the problem, the following are the significant findings:
1. The pharmaceutical companies are stern that what their respective sales representatives engage on is simply a way to get in the door so they can present more detailed information on the drugs.
2. Medical Doctors and physicians believe that representatives provide accurate information about their drugs and are equivocal in their beliefs that representatives could provide accurate information on established or alternative drugs. Most believe that representatives prioritize product promotion above patients' welfare and are likely to use unethical practices.
3. The relationship between medical practitioners and the pharmaceutical industry involves a lot more than just giving of gifts. This relationship involves interactions in a variety of different areas that are involved within the day-to-day tasks of a medical practitioner, which includes research funding, advertising in magazines and journals, surgery visits for drug presentations, gift giving, subsidized travel and accommodation to conferences and sponsorship of continuing medical education events and activities.
4. The patients perceive that the medical doctors are the process of gift giving from the pharmaceutical industry is a regularity in the professional life of a physician.
5. The patients feel pharmaceutical gifts are more influential and less appropriate than do their physicians. Physicians may want to consider this in deciding whether to accept particular gifts.
6. Broader dissemination of guidelines may be one means of changing physician behavior. At the same time, future guidelines should further consider the potentially different viewpoints of patients and physicians.
7. One element in the implementation of its 1985 Revised Drug Strategy, the World Health Organization developed a set of Ethical Criteria for Medicinal Drug Promotion. These criteria were adopted by the 1988 World Health Assembly and were the result of consensus discussion involving health workers, drug regulatory agencies, consumers and the industry.
8. Operating international standard is the International Federation of Pharmaceutical Manufacturers' Association (IFPMA) Code of Pharmaceutical Marketing Practices developed in 1981 and revised in 1994. It describes itself as defining universally applicable baseline standards of marketing practice.
9. Doctors are also mandated to follow what they called a clinical practice guideline (CPGs), which includes the ethical guidelines and code of conduct of a good doctor of medicine.
On the basis of the above summary of findings in this study, this research came up with the following conclusions:
The study paid particular concern to many physicians regarding the promotional activities of the pharmaceutical industry. These can take many forms, including overt advertising and the provision of gifts and perquisites to individual doctors or to their employing institutions. It is important to recognise that although physicians are the targets for advertising and promotional activities of pharmaceutical companies, they are not the consumers of the products. Indeed, physicians act as the agents of consumers, who are their patients, and their relationships with the latter are both guided by ethical considerations and subject to laws governing, amongst other things, the prescribing of drugs.
As a general rule, arrangements between physicians and pharmaceutical companies should be open and transparent. Where the possibility of a conflict of interest could be raised, either in clinical practice or in research, they should be declared openly to patients and employers. Physicians are mandated to judge for themselves what is and is not acceptable, but should err on the side of rejection of gifts. Service oriented items may on occasions be acceptable, e.g. patient counselling or teaching aids, or monograms for surface area calculations. Non-service oriented items should in general not be accepted. However, there is an obvious gradient of acceptability from, on the one hand, items of trivial value, to, on the other hand, more substantial items, acceptance of which anyone would find objectionable. The appearance of impropriety should be considered before accepting lavish dinners and entertainment, even if accompanied by a scientific presentation. It is recognised that judgment on these matters may sometimes be difficult. In specific cases it may be helpful to discuss issues that arise with colleagues, institutional representatives, or an ethics committee.
Based on several studies from the discussion on previous chapters, it has been established that the prescribing behaviour of the medical doctors are altered by their interaction with the medical representatives. Nonetheless, the situation happens in rarity when one considers the discussions in chapter four regarding the response of the medical doctors concerning the gift they receive costing more than 25 dollars. They stated that they encounter that specific situation for at least once a year, while a notable portion of the respondent doctors stated that they have yet to encounter that situation. The fact still remains that the responsibilities of physicians to their patient in relation to pharmaceuticals are still the main concern of the medical doctor. These responsibilities include the use existing, approved drugs in the most effective and appropriate way as part of treatment and care; monitoring their use and report adverse reactions; participating in post-marketing surveillance of new drugs; keeping up to date with scientific developments in their field, including information about new drugs and changed information about established ones; and to consider the implications of new technologies and pharmaceutical agents for the community as a whole and contribute to discussion about the most appropriate use of resources, and where appropriate, to engage directly in research into new drugs or into new applications of existing ones, or contribute to or support such research.
In addition, recent studies stated that ethical standards provided by the World Health Organization and the International Federation of Pharmaceutical Manufacturers' Association has been created guidelines as early as 1984 and 1994 respectively. This means that both physicians and pharmaceutical companies are also subject to laws and regulations governing the prescription of drugs and in some cases the conduct of research. It is also important to stress the need for openness and transparency in dealings between physicians and pharmaceutical companies. In many cases this will require disclosure of financial or other arrangements to institutions, ethics committees, patients, potential research subjects and others. Such disclosures do not in themselves imply the existence of conflicts of interest, but merely allow public scrutiny of dualities of interest to ensure that such conflicts do not develop.
Furthermore, the pharmaceutical industry is a major contributor to patient care and education, medical research, and postgraduate and continuing medical education as discussed earlier regarding the provision of continuing medical education (CMEs). Moreover, the pharmaceutical industry provides sponsorship both for organising meetings and to physicians for attending them. While this sponsorship is provided with the expressed aim of contributing to continuing education, the manner in which it is provided may leave the reasons for its provision open to the perception that the physician is being unduly influenced by the pharmaceutical industry. It is normal for the industry to provide sponsorship through an independently organised scientific meeting for which the costs of bringing in invited speakers are defrayed by the funds provided by industry; the cost of travel and attending such a meeting is met by physicians because of its value to their continuing education. The regulations of the authorities stated above ensure that the sponsorship is clearly linked to education. It also assures the medical doctor that there is no loss of professional independence through accepting the sponsorship offered. Moreover, the physician is required to have no reservations regarding the sponsorship being publicly scrutinised.
While the discussed activities in this study usually have a clearly defined primary educational aim, they again may be potentially open to the suspicion of unethical interaction between physicians and the pharmaceutical industry. Physicians involved in organising or attending such activities need to have a high level of awareness of this risk. They should ensure they could meet any allegations of unethical behaviour, through avoiding any secrecy regarding the source and extent of sponsorship, and by ensuring that the provision of food or other attractions at these meetings is not on so lavish a scale as to cast doubt on the primary educational purpose of the activity. The position of this study remains that the marketing strategy of the pharmaceutical industry, through their medical representatives, follows a legitimate and ethical procedure that adheres to the guidelines of the medical organizations stated in the discussions above.
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