Can drug companies have it both ways?
CMAJ 1997;156:982
The articles by Drs. Joel Lexchin ("Enforcement of codes governing pharmaceutical promotion: What happens when companies breach advertising guidelines?" CMAJ 1997;156:351-6 [abstract / résumé]), Martin F. Shapiro ("Regulating pharmaceutical advertising: What will work?" 359-61 [abstract / résumé]) and Jean G. Desjardins ("The PMAC Code of Marketing Practices: Time for improvement?" 363-4 [abstract / résumé]) are timely and provocative, and pose some fundamental questions.
For instance, can pharmaceutical companies have it both ways? They wish to be known as "partners in the health care team" (or some similar bromide) but they do not wish to be subject to the same degree of self-regulation, bolstered by considerable government interference, that is now enjoyed by the established self-regulated professions.
A second issue is the complaints process. It is inadequate to depend on complaints from professionals, who are mostly but not exclusively physicians, because it is well known that physicians often do not complain. This is not due to a conspiracy of silence but to simple inertia and heavy involvement with other matters. In the same vein, it seems ridiculous to accept complaints about a company from a rival company: the various companies would simply abuse the regulatory process for personal gain whenever possible. This is human nature, and pharmaceutical companies are run by humans.
A third issue is "direct-to-consumer" advertising, which appears to be here to stay but points to a total lack of consistency. Certain drugs are available only by prescription because it has been decided that a professional is needed to make appropriate recommendations about them. In direct-to-consumer advertising, how-
ever, patients are persuaded to override the professional's opinion. If it is truly in the public interest to promote a specific drug directly to consumers, then that drug is perhaps safe enough to be available without prescription.
The final issue concerns access to drugs. If Canadians were told that a patient with apparent appendicitis may have access to the surgeon's opinion but must pay for the surgery, there would be a revolution; in psychiatry the patient is entitled to be diagnosed "for free" but often cannot afford the treatment. And with the emergence of admittedly superior antidepressant and antipsychotic drugs, this problem is making a mockery of medicare. Yet pharmaceutical firms can appropriate from their profits the amount of money it would cost to set this right and spend it on advertising, much of which is suspect. The point of all this: How can one of the "partners in health care" abrogate responsibility for delivering the health care whereas the others would be jailed if they acted in the same way?
I close by praising all 3 authors. Desjardins' brief explication was pointed and balanced and Lexchin's careful accumulation of evidence was up to his usual standards. However, Shapiro was correct to suggest that Lexchin's suggestions for reform are not sufficiently radical. That was not my opinion 5 years ago, but that is progress.
Morton S. Rapp, MD
North York, Ont.
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