Although government regulation is not a perfect solution, the medical profession and pharmaceutical industry have fallen short in reducing the influences of gifts through self-regulation. Payments and gifts from the pharmaceutical industry to physicians are ubiquitous despite ample evidence demonstrating their influence on prescribing preferences and decisions. It is possible that market forces and evolving regulatory policies that increase generic competition, expand the role of prescription drug formularies, or reduce profit margins in other ways could decrease the importance of detailing and gifts over time. However, it does not diminish the significance of addressing this issue. In addition, how diminished profit margins might affect marketing decisions by pharmaceutical firms or investments in research and development has not been well described.
Gifts associated with pharmaceutical detailing are motivated by a single goal - to increase the sales of a company’s products. There is no ethical basis for allowing these types of financial exchanges to continue. In this case, the government should assert its regulatory role by banning all gifts. Given the evidence that gifts of any value influence the recipient20
, states should follow the leadership of Massachusetts and avoid setting financial thresholds that would define the permissibility of gifts. However, they should go further by banning all gifts rather than exempting some such as office-based meals.
Disclosure as a remedy to financial conflicts of interest has its flaws. Financial relationships with the sole purpose of influencing prescribing should not be disclosed, but prohibited. However, as a supplement to gift bans, disclosure can play a valuable role in monitoring more complicated relationships such as consulting arrangements. If combined with a gift ban, a payment reporting threshold of $25 (as in Vermont) would likely capture most financial relationships. Disclosure would contribute information to the public record to ensure that policymakers, the media and consumer advocacy groups can monitor and scrutinize physician-industry relationships.
Independent of policy discussions concerning pharmaceutical promotion, public sector support of academic detailing programs makes sense to promote evidence-based prescribing. The pharmaceutical industry has mastered the art of influence - using these same techniques to encourage quality improvement could benefit patients and is worthy of public investment.
Even with these government approaches, self-regulation remains important and is not at odds with government regulation. Government regulations will contain loopholes and the pharmaceutical industry will find new ways to promote its products. Professional ethics and strong professional norms can better respond to complex and changing relationships and promote a stronger ethical foundation to enhance social trust.
What will it take for the medical profession to begin to clean its own house of ethically problematic industry relationships? The AMA guidelines do not seem to be a meaningful driver of professional change. Perhaps it is time for medical organizations to develop professional enforcement or reward mechanisms for compliance with ethical standards. For example, physician practices achieving a level of compliance could receive special professional recognition that would be on display to the public. In addition, professional medical societies could begin to provide leadership by weaning themselves of industry dependence as called for in a recent JAMA editorial52
While governmental regulatory actions are needed, the medical profession needs to reclaim its professional independence from industry. Current relationships are eroding public respect for medical professionals; further loss of social trust threatens to undermine the profession’s future. Regulation alone can’t fully address the negative influences of marketing. In the end, government should play an important role but physicians themselves need to cleanse the profession of undue commercial influence.