please ignore the word “mohamed_ald” in the topic. the real topic is marketing and prices. i need four slides from the attachments and should include references in the fifth slide.2:34
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μισε. Παννεντι, μινιυιιυιι νι για KCC ULICA youus
and in particular, the use of gifts to do so – has been seen
as a special case that raises serious ethical issues. The
rely that the evidence shows that all
ties influence prescribing behaviour
otestations of many physicians): the
sources devoted to them shows that
this must be the case. What is of concern is the possible
impact of this influence on both the form and content of
healthcare delivery.
There are three major areas of ethical concern in rela-
tion to gift-giving. First, there is the kind of impact gifts
may have on clinical deliberations. Prescribing decisions
should be based on careful analyses of the circumstances
of individual patients in light of available evidence and the
doctors’ professional knowledge and experience. Gifts,
however, are not directed at rational prescribing prin-
ciples, but instead seek to persuade doctors by appealing to
them in a personal or emotional way. It is possible that
through such a mechanism receipt of gifts may lead to
outcomes that are not in the patient’s best interests.
Second, there is a possible negative impact on the public
standing of doctors and medicine as a whole. Acceptance
of gifts by doctors may create a public perception that the
latter are not independent advocates for the welfare of
their patients, but rather representatives or functionaries
of business or other organizations, thereby undermining
PROVITIES, Watogus arvumu varu TCALCU 1 an
factual knowledge about current circumstances, common
behaviours and implications for both individual patients
and society. If the attitudes and behaviours of doctors fail
to show a sensitive appreciation of the ethical issues, or if
they are shown to be seriously at odds with the interests of
the community, action on the part of either government or
the professional associations may become necessary.
The article by Macneill et al. in this issue makes a useful
contribution to this debate. The authors conducted a
survey of medical specialists and the general public in the
Hunter River region of New South Wales. This survey
inquired into attitudes about the appropriateness’ of
particular kinds of gifts that may be offered to doctors
by industry representatives. The authors concede that
response rates were suboptimal, raising the possibility
of response bias, and they provide no breakdown of
responses from practitioners in different specialities,
despite different cultures and different approaches
adopted by the various specialist colleges. In addition, the
criteria for appropriateness’ are left open, making the
basis for the respondents’ judgements uncertain. In spite
of these limitations, the results are of considerable inter-
est and raise useful questions. They suggest four main
conclusions: (i) that there is considerable variability in
opinion about the appropriateness of certain gifts,
among both specialists and the general public; (ii) that
2010 The Author
Journal compilation © 2010 Royal Australasian College of Physicians
321
Editorial
profit sector. Even if the arguments and the evidence
suggest that doctors should refuse gifts from industry – as
they evidently do – we need to convince doctors, not
force them, to do so.
Received 28 February 2010; accepted 1 March 2010.
doi:10.1111/j.1445-5994.2010.02215.x
P. A. Komesaroff
Monash Centre for Ethics in Medicine and Society,
The Alfred Hospital, Melbourne, Victoria, Australia
References
although both groups accept gift-giving in some circum-
stances, both also feel that there are limits to what is
acceptable; (iii) that most specialists are aware of pub-
lished guidelines with respect to relationships with indus-
try and, in general, specialists’ views about what is
acceptable are consistent with current guidelines; and
(iv) that the views of the public are somewhat more
permissive than those of the practitioners. The last con-
clusion is contrary to what appears from the limited evi-
dence to be the case overseas 5-7 and in addition, the
specialists appear to be more critical of pharmaceutical
gifts than their overseas colleagues.8,9
These conclusions might give some encouragement to
those working to develop guidelines that seek to promote
critical attitudes among doctors to their relationships
with industry. They also pose the question of what, if any,
implications they have for the substantive content of
such guidelines or for public policy. After all, while it may
be true that there is a strong ethical case against receiving
gifts from pharmaceutical companies, this does not in
itself justify mandatory measures to prevent doctors from
accepting gifts.
Surveys of attitudes do not solve ethical problems.
However, they may give some clues about the nature of
the social context within which ethical decision-making
is taking place and practices that may need to be sub-
jected to critical questioning. As in many other areas in
medical ethics, with respect to relations with industry
there are frequent calls for mandatory systems to control
doctors’ behaviours,10,11 It is true that such systems may
be the only way to curtail industry practices that are
potentially contrary to the public interest – a judgement
that is perhaps implicit in the recent decision of the peak
industry association in Australia to introduce strict limi-
tations on the use of gifts in pharmaceutical promotion. “2
However, in relation to the behaviour of clinicians, man-
datory regulation may actually be counter-productive.
The primary responsibility of clinicians is to make deci-
sions in the interests of their patients, taking into account
the manifold complexity of the latter’s personal and
social circumstances. This requires a high level of ethical
competence, including an ability to engage in open criti-
cal dialogue about one’s own personal values and profes-
sional role. If one is simply following a rule or obeying a
law, one is not making an ethical judgement: the risk of
increasingly elaborated and directive codes of conduct is
that they may erode such competence and undermine
the fecundity of the dialogical process on which the clini-
cal encounter is based.13
The article by Macneill et al. contributes to the ongoing
ferment about dealings between physicians and industry
and it may add to the broader debate about the nature of
the relationship between clinical practice and the for-
1 Gagnon MA, Lexchin J. The cost of pushing pills: a new
estimate of pharmaceutical promotion expenditures in
the United States. PLoS Med 2008; 5: el.
2 Wazana A. Physicians and the pharmaceutical industry:
is a gift ever just a gift? JAMA 2000; 283: 373-80.
3 Royal Australasian College of Physicians. Ethical
Guidelines in the Relationships involving Medical Practitioners
and Industry, 3rd edn. Sydney: RACP; 2006.
4 Macneill PU, Kerridge IH, Newby D, Stokes BJ, Doran E,
Henry DA. Attitudes of physicians and public to pharma-
ceutical industry ‘gifts’. Intern Med J 2010; 40: 335–41.
5 Jastifer J, Roberts S. Patients’ awareness of and attitudes
toward gifts from pharmaceutical companies to
physicians. Int J Health Serv 2009; 39: 405-14.
6 Blake RL Jr, Early EK. Patients’ attitudes about gifts to
physicians from pharmaceutical companies. J Am Board
Fam Pract 1995; 8: 457-64.
7 Gibbons RV, Landry FL, Blouch DL, Jones DL,
Williams FK, Lucey KR et al. A comparison of physicians’
and patients’ attitudes toward pharmaceutical industry
gifts. J Gen Intern Med 1998; 13: 151-4.
8 Morgan MA, Dana J, Loewenstein G, Zinberg S,
Schulkin J. Interactions of doctors with the
pharmaceutical industry. J Med Ethics 2006; 32: 559–63.
9 Brett AS, Burr W, Moloo J. Are gifts from
pharmaceutical companies ethically problematic? A
survey of physicians. Arch Intern Med 2003; 163:
2213-18.
10 Grande D. Limiting the influence of pharmaceutical
industry gifts on physicians: self-regulation or
government intervention? J Gen Intern Med 2010; 25:
79-83.
11 Angell M. Relationships with the drug industry: keep at
arm’s length. BMJ 2009; 338: b222.
12 Medicines Australia Code of Conduct (Edition 16),
section 9.12 [cited 2010 Feb 28]: Available from URL:
Code-of-Conduct-Edition-16.pdf
13 Komesaroff PA, Kerridge I, eds. The Australian Medical
Council Draft Code of Professional Conduct. Good
practice or creeping authoritarianism? Med J Aust 2009;
190: 204-5.
322
© 2010 The Author
Journal compilation © 2010 Royal Australasian College of Physicians
2:34
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A onlinelibrary-wiley-com.uaeu.idm.oclc.org
INTERNAL MEDICINE JOURNAL
Internal Medicine Journal 40 (2010) 321-322
EDITORIAL
Ethical issues associated with gifts provided to physicians by
the pharmaceutical industry
It is not known exactly how much money the pharma- the basic, constitutive trust that is at the heart of all clinical
ceutical industry spends on promotional activities. It is, relationships. Finally, there is the potential impact on the
however, clear that it is a very large amount – some health system as a whole. While adding nothing to the
estimates put it at more than $US50 billion per year in value of a product, gifts – like other promotional activities
the USA alone – and that it exceeds industry expenditure – invariably add to the price, which ultimately has to be
on research and development. Promotional activities borne either by individual patients or by the community as
take many forms, including provision of samples, face- a whole. In this manner, gift-giving may redirect scarce
to-face ‘detailing’ meetings between industry representa- health resources away from areas of high need, thereby
tives and prescribers, advertising in print and the acting against the broader pubic interest.
electronic media, and support for meetings and travel. From an ethical point of view, these concerns raise two
One of the activities that has come under closest scrutiny questions: should industry representatives offer gifts to
in recent years is the provision of gifts to physicians, physicians, and if they do, should the latter accept them?
which themselves may vary from practice-related items The question about industry poses the problem of the
of trivial value to expensive goods intended for the exclu- power of pharmaceutical companies to set the agenda for
sive personal use of the recipients.
clinical practice and to limit the authority of government
There is nothing untoward about the concept of pro- to make decisions about health resource allocation; that
motion of commercial goods as such. It is, after all, a about physicians raises issues regarding the behaviour of
familiar feature of all modern economies and can provide individual doctors and the kinds of ethical decisions they
a useful means for disseminating information about make on a personal level and in the context of the clinical
available products and, by contributing to a healthy com- encounter. As with all other ethical questions, the answers
petitive market, help stimulate innovation and enter- depend on both an understanding and analysis of the
prise. However, promotion of pharmaceutical goods – problems, dialogues around value-related issues, and
and in particular, the use of gifts to do so – has been seen factual knowledge about current circumstances, common
as a special case that raises serious ethical issues. The behaviours and implications for both individual patients
concern is not merely that the evidence shows that all and society. If the attitudes and behaviours of doctors fail
promotional activities influence prescribing behaviour to show a sensitive appreciation of the ethical issues, or if
(contrary to the protestations of many physicians): the they are shown to be seriously at odds with the interests of
sheer volume of resources devoted to them shows that the community, action on the part of either government or
this must be the case. What is of concern is the possible the professional associations may become necessary.
impact of this influence on both the form and content of The article by Macneill et al. in this issue makes a useful
healthcare delivery.
contribution to this debate. The authors conducted a
There are three major areas of ethical concern in rela- survey of medical specialists and the general public in the
tion to gift-giving. First, there is the kind of impact gifts Hunter River region of New South Wales. This survey
may have on clinical deliberations. Prescribing decisions inquired into attitudes about the appropriateness’ of
should be based on careful analyses of the circumstances particular kinds of gifts that may be offered to doctors
of individual patients in light of available evidence and the by industry representatives. The authors concede that
doctors’ professional knowledge and experience. Gifts, response rates were suboptimal, raising the possibility
however, are not directed at rational prescribing prin- of response bias, and they provide no breakdown of
ciples, but instead seek to persuade doctors by appealing to responses from practitioners in different specialities,
them in a personal or emotional way. It is possible that despite different cultures and different approaches
through such a mechanism receipt of gifts may lead to adopted by the various specialist colleges. In addition, the
outcomes that are not in the patient’s best interests. criteria for ‘appropriateness’ are left open, making the
Second, there is a possible negative impact on the public basis for the respondents’ judgements uncertain. In spite
standing of doctors and medicine as a whole. Acceptance of these limitations, the results are of considerable inter-
of gifts by doctors may create a public perception that the est and raise useful questions. They suggest four main
latter are not independent advocates for the welfare of conclusions: (i) that there is considerable variability in
their patients, but rather representatives or functionaries opinion about the appropriateness’ of certain gifts,
of business or other organizations, thereby undermining among both specialists and the general public; (ii) that
© 2010 The Author
Journal compilation © 2010 Royal Australasian College of Physicians
321
Editorial
profit sector. Even if the arguments and the evidence
suggest that doctors should refuse gifts from industry – as
they evidently do – we need to convince doctors, not
force them, to do so.
Received 28 February 2010; accepted 1 March 2010.
doi:10.1111/j.1445-5994.2010.02215.x
although both groups accept gift-giving in some circum-
stances, both also feel that there are limits to what is
acceptable; (iii) that most specialists are aware of pub-
lished guidelines with respect to relationships with indus-
try and, in general, specialists’ views about what is
acceptable are consistent with current guidelines; and
(iv) that the views of the public are somewhat more
permissive than those of the practitioners. The last con-
clusion is contrary to what appears from the limited evi-
dence to be the case overseas 5-7 and in addition, the
specialists appear to be more critical of pharmaceutical
gifts than their overseas colleagues.8,9
These conclusions might give some encouragement to
those working to develop guidelines that seek to promote
critical attitudes among doctors to their relationships
with industry. They also pose the question of what, if any,
implications they have for the substantive content of
P. A. Komesaroff
Monash Centre for Ethics in Medicine and Society,
The Alfred Hospital, Melbourne, Victoria, Australia
References
1 Gagnon MA, Lexchin J. The cost of pushing pills: a new
estimate of pharmaceutical promotion expenditures in
the United States. PLoS Med 2008; 5: el.
2 Wazana A. Physicians and the pharmaceutical industry:
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