Abstract and Introduction
A few months ago, my fellow interns and I attended a resident education session on the influence of drug companies in medicine. All went more or less predictably until we arrived at the issue of drug sampling. Suddenly, the usual dichotomy between overbearing moralists and business-minded realists reversed itself. Previously dispassionate colleagues accused each other of callous disregard for patient needs. Unexpected advocates for the uninsured emerged, and the more demure of both industry skeptics and supporters had questions: drugs are so expensive now, why not give them to people who can't afford them? Maybe sampling was a rare, exploitable weakness in an industry that strong-arms both patients and doctors. Or maybe it was a solitary act of compassion from normally self-interested corporations.
In the last fifteen years, news agencies, physicians' professional organizations, and the general public have begun to wonder whether this very widespread practice is appropriate. Several high-profile newspapers have published stories headlining the influence of samples on prescribing practices, health risks to patients, and health care costs to society. The American Medical Association, American College of Physicians, and Association of American Medical Colleges have issued guidelines that either suggest regulating or discourage the use of samples, and growing numbers of academic medical centers have banned their use. Yet drug sampling remains very common. Why?
The answer has to do with gift-giving. Drug samples are the fundamental element in a three-party gift exchange—from pharma reps to physicians, and from physicians to patients—that both creates and disguises a conflict of interest.
The exchange originates with the drug companies when representatives visit doctors' offices and leave samples behind. Drug samples are valuable gifts to physicians for many reasons: their branded status, their potential to cure patients, their convenience, and their appeal to doctors for personal or family use. But the value of drug samples is also related to their function as a future gift to patients. Because the act of giving a gift is a profoundly meaningful act of human exchange, pharmaceutical companies impart the "gift" of allowing physicians to assume the role of gift-giver themselves.
Thus, the second part of the three-party gift exchange—the physicians' gift of samples to patients—is a critical part of the conflict of interest. Remarkably, because physicians believe pharma reps intend samples as a useful gift to patients (and not a marketing ploy aimed at doctors), the drug's advertising function is disguised. Physicians believe they are participating in an altruistic act. Even when they realize the conflict of interest, they still feel that the samples help patients. If everyone benefits in the short term, then no one is eager to point out the long-term problems.
The gift-giving creates moral ties of generosity, respect, and honor that constitute an ingenious psychological marketing scheme. In the highly regulated patient-physician relationship, samples ostensibly offer a rare opportunity for physicians to cut through the ethos of market rationality with a gift for their patients. In this way, sampling preys on physicians' best qualities. Giving tickets to a sporting event or paying for a meal exploits physicians' self-interests to the eventual benefit of the pharmaceutical company. But sampling exploits physicians' altruistic impulses, and on the surface, the benefit seems to redound to the patient.
When physicians subconsciously feel obligated to reciprocate the drug company's "gift" by altering their prescribing behaviors, the insidious psychology behind samples generates tremendous profits for industry. With sampling's conflict of interest so well disguised as generosity, the pricey prescription rate has been the only aspect of this marketing scheme to attract much regulatory attention.
Cloaked in the pretense of praiseworthy practice, we allow samples to continue to distort physician judgment and endanger patient safety. At the intersection of free-market capitalism and professional ethics, where individuals' good intentions can fall victim to temptation, evidence-based and culturally informed policy development is the only way to protect patients' health and safety. The national trend among academic medical centers toward prohibiting drug samples is the only practical way of combating this insidious attack on physician judgment.
The Hastings Center Report. 2012;42(2) © 2012 The Hastings Center