A New Standard of Professional Integrity

In this issue of Family Medicine, we feature an article by Toby Keys, MPH, and colleagues concerning the exposure of premedical students to pharmaceutical marketing.1 Their study found that 71% of 911 newly enrolled students from 14 medical schools had either received or witnessed someone receiving gifts, food, samples, or scientific articles from drug companies before matriculation. Most of these encounters occurred when students were employed or shadowing in medical practices. The study did not examine how these gifts were explained to the students or what the students’ reactions were to these practices. Nor did it explore student exposure to pharmaceutical marketing directed at the general public. On the face of it, there is hardly anything new or surprising about this study. Marketing is ubiquitous in our culture and pharmaceutical marketing in particular has been the subject of extensive debate for decades. Thirty billion dollars are spent annually on marketing by the pharmaceutical industry. Two-thirds of this effort is directed at health professionals, including $5.6 billion for prescriber detailing, $13.5 billion for “free” samples, and $979 million for direct payments to physicians such as free meals and speaker fees in 2016.2 Within our own discipline, conflicts of interest arising from physicians’ relationships with drug companies have been extensively criticized, and recent evidence suggests that a growing percentage of our residencies have placed restrictions on them.3 Some of us demonstrate our disapproval by boycotting all interactions with drug company sales representatives or by eschewing drug samples in our offices. We design curricula in professionalism to inform students and residents about this problem, but our own professional organizations fall short of openly condemning these practices and continue to accept gifts and grants from some of the industry’s worst offenders. Furthermore, attitudes about this vary widely among the medical specialties, so the approach of medicine as a whole is far from uniform, and abuses continue.

Perhaps of greater concern, one cannot watch television or use the internet without encountering sales pitches from drug and medical device companies focused directly on the public. How many of us have found ourselves explaining erectile dysfunction or irritable bowel syndrome to our children or grandchild while watching television? We generally accept that direct-to-consumer pharmaceutical advertising is with us to stay because our culture has come to regard sales as a form of free speech, but this has not always been the case. Prior to 1985 when the Food and Drug Administration lifted a moratorium on the practice, direct-to-consumer marketing of pharmaceuticals was considered unethical, and most countries still prohibit or severely restrict it.4

Pharmaceutical advertising is really a small part of a larger problem. We have somehow managed to restrict marketing of tobacco products and some alcoholic beverages, but sophisticated marketing strategies abound in our culture. Expensive athletic shoes produced in third-world countries and cosmetics are sold using celebrity endorsements. Nutritional supplements and weight-loss products make dubious claims of benefit with impunity. Perhaps marketing health care is not really different from marketing other services and products in our economy. Supporters of America’s marketing culture claim that these efforts are educational and are designed to teach people about options, thereby empowering consumer choice. But marketing is not education at all. Education is about informing; marketing is about persuading. Education serves the needs of the learner; marketing serves the needs of the seller. American business spends a lot on marketing because doing so increases profits and attracts investors. Whether or not these products benefit the public is at most an afterthought. In many industries, marketing and branding have become more important than product quality or customer service in making businesses successful. Furthermore, while marketing appeals were once simply broadcast to a general audience, they can now be targeted to individual people based on personal data from smartphones, social media platforms, and credit card usage. Our personal data now allow marketing to be weaponized in ways never before possible.

In America today, marketing principles have been adapted to sell ideas as well as products and services and some of these ideas are direct threats to public safety and to democracy itself. On social media, persuasive marketing techniques are used to instill fear of immunizations and distrust of immigrants and ethnic minorities as a way to influence the attitudes and votes of those who are not equipped to see these efforts for what they are. The line between marketing and political propaganda is disappearing. Our ability to effectively persuade has outstripped any sense of moral standard or ethical boundary. In this larger context, the selling of pharmaceuticals and medical devices seems like a pretty small problem. As physicians, educators, and citizens, we struggle with how to mitigate this process while still respecting freedom of speech in the marketplace of ideas. So, the problem gets worse. We all know this is true and we mostly seem to accept there is little that can be done about it.

On the other hand, maybe there are very specific things we can do. The readers of this journal are all health professionals or academicians and this ranks us among the most highly educated people in our respective communities. If our fellow citizens are the targets of unscrupulous commercial and political propaganda, we have a personal and professional responsibility to do something about it. It is fine to refuse gifts from drug companies, but that hardly seems enough in the world we now live in. We immunize our patients against infectious diseases; we now need to consider how to effectively immunize them against a threat that could be even more dangerous. This begins with expanding our efforts to teach medical students and residents about how to avoid breaches in professional integrity, but it also requires us to define the moral responsibilities of health care professionals more broadly. We need to show students how marketing and propaganda work and how to speak out as effective community leaders at a time when civic leadership is more important than ever. The best way to teach this is through our own conduct. Integrity is built by individual acts of moral rectitude and is spread by example. Students and residents need to learn how to respond in real time to unscrupulous efforts to persuade the gullible and uninformed. This will require a moral vocabulary that goes far beyond refusing gifts from drug companies. Students today are looking for our leadership; they learn by watching what we do more than by listening to what we say. This is not about what drug companies or political candidates do; it is about what we do in response.