Medicine is, at its centre, a moral enterprise grounded in a covenant of trust. — Crawshaw et al, 1995

GLOBALLY, concern is growing over the influence of the pharmaceutical industry on the prescribing habits of physicians.

Pharmaceutical companies are under intense pressure to garner and retain market share, leading the World Health Organisation (WHO) to refer to “an inherent conflict of interest between the legitimate business goals of manufacturers and the social, medical and economic needs of providers and the public to select and use drugs in the most rational way”. In the United States the pharmaceutical industry spends an estimated $25bn to $30bn every year peddling prescription drugs, and much of that money goes to physicians in the form of free samples, meals, conference fees, air fares and continuing medical education activities.

The pharmaceutical industry is adamant that these gifts have no influence on which drugs physicians prescribe to their patients. But a growing body of evidence shows that the drug companies' generosity may in fact be guiding the pen across the prescription pad.

According to Dr Sidney Wolfe, director of the Public Citizen's Health Research Group, USA, “The drug industry doesn't spend $20 or $30bn a year on advertising prescription drugs unless they believe it has an impact on doctors prescribing”.

Alarmed by the influence of 'big pharma' on physicians, many US states have instituted laws requiring pharmaceutical companies to disclose all gifts to physicians in excess of $50. Many top US academic medical centres have placed various restrictions on their faculty vis-à-vis interaction with the pharmaceutical industry. Now a bill, the Physician Payment Sunshine Act, has been introduced in the US Senate that requires disclosure of all financial ties between physicians and pharmaceutical/medical device companies.

This is to ensure greater transparency in an area that has become increasingly murky.

These steps have become necessary because of the inherent conflict of interest issues involved when physicians interact with the pharmaceutical industry. Pharmaceutical companies operate in a world of high stakes with potentially high returns on their investments. Recouping the money they have invested in drug research and development means using marketing techniques that will ensure increased sales. With billions of dollars at stake, companies do everything to get as big a share of the market as possible. The physician therefore becomes a crucial player in the process.

Unlike consumer products where the customer makes an independent, informed decision about a certain product, in the case of medicines the physician is the decision-maker for the patient. What influences a physician to prescribe a certain brand of drug depends on a number of factors, the critical one being his or her interaction with drug companies.

Numerous studies have shown that the more contact physicians have with drug companies the more likely they are to prescribe medicines produced by those firms as well as prescribe them inappropriately. Pharmaceutical companies know this and exploit it to the fullest. Today drug company representatives are highly skilled sales professionals whose training is generally company-specific and more oriented to the art of selling than to therapeutics.

In Pakistan, inducements range from items like diaries, calendars and ballpoint pens to more expensive gifts like briefcases, laptops, air conditioners and even cars. In addition there are drug launches in foreign countries, conference sponsorships and funding of private functions like weddings, etc. Many companies do this under the guise of 'academic' activities. Every interaction between physicians and pharmas is to one and one end only to establish a relationship with physicians and use it to manipulate them to prescribe more of their drugs. There is no other motive.

On the other hand, a physician's primary responsibility is to the patient. The doctor-patient relationship is a unique but unequal one. The former possesses the power, control and knowledge while the latter is in a vulnerable state due to his or her compromised health. This relationship is based on core features like trust, objectivity, impartiality and keeping the patient's interest paramount at all times. The relationship must be free from all external influences.

When a physician prescribes a certain brand of drug to a patient, the patient believes the physician has done so keeping his or her best interests in mind. What patients do not know (and have no way of knowing) is what inducements a physician may have received from companies that may be influencing his prescribing habits.

All inducements from pharmaceutical companies to physicians are legalised bribery. Physicians must be aware of this and not fool themselves into believing they are not influenced by gifts or company-sponsored trips. Even small gifts like coffee mugs, diaries and ballpoint pens have a cumulative effect over time and influence prescribing habits.

Today, the profession of medicine in Pakistan is suffering from a serious crisis of integrity. The health system of the country is in shambles. Millions of Pakistanis continue to be devoid of healthcare and countless others suffer the indignity of being treated in poorly resourced public hospitals and subjected to unregulated medical practice, without any recourse to complaint. There is no authority where patients can take their complaints. Against this background the onus on physicians to conduct themselves ethically becomes paramount.

Physicians must stop taking the easy option of approaching pharmaceuticals for funding their activities, be it attending or arranging conferences or getting something for their units like a water cooler. For many companies Corporate Social Responsibility (CSR) has become a euphemism for this kind of bribery. They promote CSR because of the huge profits they make by bribing doctors to prescribe their medicines.

In Pakistan, patients pay out of their own pocket for drugs. So every time a physician is sent on a foreign trip or a foreign speaker is brought to Pakistan by a pharmaceutical company, patients are funding these activities.

Physicians must remember that interacting with pharmaceutical companies causes serious conflict of interest and has the potential to compromise patient care. Hence they should think carefully about seeing medical reps, accepting gifts, going to conferences or organising seminars with pharma money. Unless physicians take this ethical stance, the exploitation of one by the other will continue. And patients will ultimately pay the price.

Above all, there is a need to get away from the culture of greed and profit that has pervaded the medical profession, particularly in Pakistan. Physicians need to take a deep, hard look at themselves and ask why they have been so willing to bargain their integrity for a few thousand rupees. While most things in life are relative, some are absolute. The physician-patient relationship is an example of the absolute variety.

Its sanctity must be maintained at all costs.

The writer is a consultant psychiatrist.

muradmk@gmail.com