In November, the pharmaceutical giant Merck launched a series of television ads for Gardasil, the somewhat controversial vaccine designed to prevent Human Papillomavirus (HPV) in young women. The ads are smartly sexless, featuring a series of individual prepubescent girls who stare straight into the camera and spout facts about cervical cancer. For a drug that has provoked more than its share of pushback, the ads have been singularly unobtrusive, disseminating information about the vaccine while forcing it on no one.
Innocuous as they seem, ads like these would be banned if the American Medical Association and certain patient groups got their way. Pharmaceutical companies that appeal directly to the people their products most benefit–patients–are still regarded with suspicion. The Institute of Medicine, a nonprofit that researches biomedical issues, recommended a ban on advertising new classes of drugs in a report commissioned by Congress. Until last week, Senate legislation mandating an overhaul of the FDA approval process would also have given the FDA the power to ban ads for new drugs until two years after approval. Now that the provision has been weakened, interest groups are already calling for separate legislation to cut off communication between manufacturer and consumer.
Public health advocates consider such advertising a threat to consumers, who may be misled into asking for risky pharmaceuticals. "When new drugs are widely advertised to consumers before the risks are known, thousands of those who take them may be harmed," write Judy Norsigian, executive director of the women's health advocacy organization Our Bodies Ourselves, and Diana Zuckerman, president of the National Research Center for Women & Families, in a recent Boston Globe opinion piece.
In boldly asserting that advertised drugs may or may not kill an apparently arbitrary number of people, Zuckerman and Norsigian are indisputably correct. Alas, this does not take us very far. Direct to consumer advertising does seem to work, and to the extent that more patients are requesting (and receiving) specific pharmaceuticals, more patients will be exposed to whatever risks those pharmaceuticals pose. But uninformed patients, unaware of their options, are subject to another kind of risk. Those who would ban the ads need to explain why too many prescriptions are worse than too few. In 2003 the FDA asked physicians how many of their patients who asked for drugs by brand name (and had been prompted to do so by ads) actually had the condition the drug treats. Doctors said their patients suffered from targeted condition 88 percent of the time.
You don't have to believe in the healing power of Merck-sponsored TV spots to oppose an ad ban, because the alternative is likely to be worse. Pharmaceutical companies told they cannot market to consumers will simply redirect marketing dollars to physicians, whose incentives are more complex than those of their patients.
Last week, The New York Times broke two disturbing stories on prescription drugs, both of which implicated the women and men doing the prescribing. The Times found that doctors had much to gain from administering anemia drugs directly to patients. Doctors receive rebates for part of the drug's price from pharmaceutical companies, but charge insurance companies the original price of the medicine with a markup. One group of six doctors received $2.7 million in payments from Amgen for prescribing $9 million worth of its drugs. The report coincides with FDA concerns that the drugs are being prescribed to too many people and in excessive doses
In a separate investigation, the Times found that between 2000 and 2005, drug maker payments to Minnesota psychiatrists jumped sixfold, while prescriptions of antipsychotics for children in the state's Medicaid program increased 9 times over. Physicians who took the most money from makers of the drugs prescribed them the most often. More than a third of Minnesota's licensed psychiatrists have taken money from drug makers, mostly for giving promotional lectures about the drugs.
There is no proof of wrongdoing here, and it's possible that doctors form lucrative relationships with companies because they believe in certain drugs—and are therefore more likely to recommend them. Doctors insist that the gifts they accept have naught to do with the advice they dispense (though many seem to believe that their colleagues are compromised.) But a considerable literature on reciprocity suggests that the will to reciprocate is a deeply ingrained adaptive behavior. People can act on feelings of obligation without being aware of their motives. As Bioethicists Arthur Caplan, Dana Katz, and Jon Merz put it in a 2003 article in The American Journal of Bioethics, "The obligation to directly reciprocate, whether or not the recipient is conscious of it, tends to influence behavior."
Physician-directed marketing has its role; doctors need to learn about new treatments, and much of their education is funded by drug makers. But it is unclear how patients benefit when admen can only compete for physician eyes. Advertising is about conveying information, however incomplete that information may be. And given the proliferation of pharmaceutical choice alongside the growth of physician-directed marketing, patients need all the information they can get.
Kerry Howley is an associate editor of reason.
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