Doctors and Drug Companies
http://www.100md.com
《新英格兰医药杂志》
To the Editor: Blumenthal's article (Oct. 28 issue)1 about the complex and controversial relationships between doctors and drug companies should provoke soul-searching on the part of all physicians who rationalize accepting gifts from the pharmaceutical industry. In this thoughtful and scholarly review, the author invokes the social-science literature to illustrate how even the smallest gifts can be influential.2 But he need not look so far afield. Despite the confidence expressed by many physicians that they are not influenced by the marketing efforts of pharmaceutical companies,3 an obvious indictment of their vulnerability is the annual $12 billion to $15 billion pharmaceutical marketing budget.2 Doctors and drug companies justify these relationships by insisting that they benefit patients by means of physician education. In their defense, Blumenthal himself rationalizes that physician education by the pharmaceutical industry may lead to increased dispensing of drugs that are currently underprescribed, thereby correcting "major adverse consequences for public health."1 If the honest objective of these relationships is to benefit patients, then why are gifts from pharmaceutical companies necessary for physicians to do the right thing?
Laura A. Lambert, M.D.
University of Texas M.D. Anderson Cancer Center
Houston, TX 77030
lalambert@mdanderson.org
References
Blumenthal D. Doctors and drug companies. N Engl J Med 2004;351:1885-1890.
Katz D, Caplan AL, Merz JF. All gifts large and small: toward an understanding of the ethics of pharmaceutical industry gift-giving. Am J Bioeth 2003;3:39-46.
Chren M. Interactions between physicians and drug company representatives. Am J Med 1999;107:182-183.
To the Editor: That physicians increasingly function as financially interested middlemen is the result of policies and perceptions that have permitted health care to be subsumed by the health care industry. To the extent that individual health care products have been treated as entitlements, the government has guaranteed a market and tacitly promoted the health care industry. The public, narrowly equating heath care with products of the health care industry, greedily clamors for more access to those commodities perceived as unequivocally beneficial. With patients as consumers, the public perception that access to individual products constitutes health care, and a health care industry motivated by profit, is it any surprise that physicians are no less market-driven?
Absent from the public's perception of health care is an appreciation of the critical role of the public health infrastructure, surveillance activities, regulatory agencies, and public health policies as significant determinants of health. Perhaps our intolerance of greed on the part of physicians should be matched by a commensurate recognition of the misguided selfish interests that dominate the current health care debate.
Elizabeth R. Jenny-Avital, M.D.
Jacobi Medical Center
Bronx, NY 10461
elizabeth.jenny-avital@nbhn.net
Dr. Jenny-Avital reports having received honoraria from Bristol-Myers Squibb, Abbott Laboratories, and GlaxoSmithKline and lecture fees from GlaxoSmithKline.
Dr. Blumenthal replies: These letters raise fundamental and intractable issues related to our health care system. Lambert asks why physicians don't dispense helpful drugs in optimal amounts simply "to do the right thing." The answers are complex, including physicians' failure to master the burgeoning scientific literature, oversights in the care of patients, inadequate time to manage complex chronic illness in daily practice, and more. Whatever the reason, physicians have consistently failed to give patients the full benefit of available medications. Therefore, efforts by drug companies to promote the appropriate use of pharmaceuticals may have public health benefits. Of course, those benefits must be weighed against associated costs, which result not only from the expense of the drugs themselves but also from inappropriate use stimulated by company marketing.
Jenny-Avital makes the case that the health care industry has commercialized health services and promoted excessive use of medical care but that public health has been neglected. Public health has certainly been undersupported in the United States, though that problem predates the burgeoning of the medical–industrial complex. There is something about personal health services that captures the public imagination more than the collective goods provided by public health authorities. Fortunately, people such as Dr. Jenny-Avital continue to advocate for public health programs.
David Blumenthal, M.D., M.P.P.
Massachusetts General Hospital
Boston, MA 02114
Laura A. Lambert, M.D.
University of Texas M.D. Anderson Cancer Center
Houston, TX 77030
lalambert@mdanderson.org
References
Blumenthal D. Doctors and drug companies. N Engl J Med 2004;351:1885-1890.
Katz D, Caplan AL, Merz JF. All gifts large and small: toward an understanding of the ethics of pharmaceutical industry gift-giving. Am J Bioeth 2003;3:39-46.
Chren M. Interactions between physicians and drug company representatives. Am J Med 1999;107:182-183.
To the Editor: That physicians increasingly function as financially interested middlemen is the result of policies and perceptions that have permitted health care to be subsumed by the health care industry. To the extent that individual health care products have been treated as entitlements, the government has guaranteed a market and tacitly promoted the health care industry. The public, narrowly equating heath care with products of the health care industry, greedily clamors for more access to those commodities perceived as unequivocally beneficial. With patients as consumers, the public perception that access to individual products constitutes health care, and a health care industry motivated by profit, is it any surprise that physicians are no less market-driven?
Absent from the public's perception of health care is an appreciation of the critical role of the public health infrastructure, surveillance activities, regulatory agencies, and public health policies as significant determinants of health. Perhaps our intolerance of greed on the part of physicians should be matched by a commensurate recognition of the misguided selfish interests that dominate the current health care debate.
Elizabeth R. Jenny-Avital, M.D.
Jacobi Medical Center
Bronx, NY 10461
elizabeth.jenny-avital@nbhn.net
Dr. Jenny-Avital reports having received honoraria from Bristol-Myers Squibb, Abbott Laboratories, and GlaxoSmithKline and lecture fees from GlaxoSmithKline.
Dr. Blumenthal replies: These letters raise fundamental and intractable issues related to our health care system. Lambert asks why physicians don't dispense helpful drugs in optimal amounts simply "to do the right thing." The answers are complex, including physicians' failure to master the burgeoning scientific literature, oversights in the care of patients, inadequate time to manage complex chronic illness in daily practice, and more. Whatever the reason, physicians have consistently failed to give patients the full benefit of available medications. Therefore, efforts by drug companies to promote the appropriate use of pharmaceuticals may have public health benefits. Of course, those benefits must be weighed against associated costs, which result not only from the expense of the drugs themselves but also from inappropriate use stimulated by company marketing.
Jenny-Avital makes the case that the health care industry has commercialized health services and promoted excessive use of medical care but that public health has been neglected. Public health has certainly been undersupported in the United States, though that problem predates the burgeoning of the medical–industrial complex. There is something about personal health services that captures the public imagination more than the collective goods provided by public health authorities. Fortunately, people such as Dr. Jenny-Avital continue to advocate for public health programs.
David Blumenthal, M.D., M.P.P.
Massachusetts General Hospital
Boston, MA 02114