On Pharmaceuticals and Marketing

Kalman Applbaum has a wonderful post over at Somatosphere entitled The Colonization of Pharmaceutical Science by Marketing.  While readers of MH Blog might be forgiven for thinking this is the same old COI material I am constantly dredging up, there are some excellent points raised by Applbaum that I'd like to highlight.

Applbaum begins by noting the obvious, that pharmaceutical science is often affected by marketing agendas, but goes on to observe that

the process by which this corruption occurs isn’t straightforward . . . Intention and collective agency often don’t coincide. Conspiracies are rare. Institutions and professions instead develop normative trajectories that seem to work independently of the wills and intentions of individual member actors. Self-evidence and other forms of implicit knowledge mediate the interface between individual managers and the institution, and this disposition enables and even drives the reproduction of existing practices.

This is important stuff.  Because American political culture is so focused (obsessed?) with individual agency, the discourse over COIs often devolves, IMO, to an emphasis on what the individual investigator or researcher does or does not do.  In contrast, comparitively little attention is paid to the ways in which social and cultural norms, habits, and practices are subtly constructed and reinforced on a collective, institutional level, and on the ways in which these norms are socialized into the behavior and practices of individuals. 

Applbaum continues,

To address the problem of the colonization of pharmaceutical science by marketing, we’ll have to confront the conundrum of where collective agency ends and individual responsibility begins.

I agree with this, but the conundrum is even thornier, IMO, then is suggested here, because, in point of fact, institutions are legal actors in and of themselves (not to mention social and cultural actors).  Institutions face challenges, choices, and exercise powers that are undreamt of on the individual level, but nevertheless may have profound effects on individuals within or related to the institution.  This is to say nothing of the well-known puzzle of the corporate veil, in which corporations and institutions achieve legal personhood even while their activities are obviously the product of collective decision-making by a group of individuals.

Applbaum also admonishes lawyers and bioethicists, arguing that they

tend to focus on individual action and intention rather than on how social norms and processes are implicated in the growth of harmful systems. Social scientists, by contrast, study phenomena at a level of collective abstraction at which individual agency and intention disappear.

I enthusiastically agree with this critique, although I do want to note that one does not need to be a social scientist per se, to study phenomena from a collective level.  One could, indeed, be a medical humanist . . .

Finally, Applbaum also links to a wonderful article I had not seen by Alastair Matheson, so do, as they say, read the whole thing.

Comments

[btparts]

Intersting post, I touched on this the other week:

"What do the US and New Zealand have in common (besides goalposts)?

Yesterday brought Americans together for the 43rd annual viewing of the Superbowl. Both teams put on a show worthy of any football enthusiast, but for those more interested in pork rinds than pigskins, the commercials in between the action are their own form of entertainment. Despite well-publicized hard times, a wealth of companies still lined up to pay fantastic sums of money to air their thirty-second statement telling us why we should have what they peddle.

Television commercials demonstrate a subtle artistry that is intended to entice our demand, despite necessity. This dance between industry and consumers has been refined and mastered by American staple brands for decades, however this country has also granted consumer-courting rights to an industry locked out of advertising privileges in all other world nations (except New Zealand) – the pharmaceutical industry.

There is no secret (see Know the Facts) about the vast sums of money that are being made by the pharmaceutical industry. It is however less known that Americans are the ones contributing the most. Our people, our businesses and our government are paying half of the drug industry’s worldwide profits. All the while drug costs to our healthcare system are anywhere from 50% to 70% higher than in other countries. With such a statistic one cannot help but point to the distinguishing aspect of our drug market and theirs - the ability to advertise.

Estimates by one study in the New England Journal of Medicine put overall annual marketing expenditures at nearly $30 billion in 2005, up from $11.4 billion in 1996. Direct consumer advertising increased by 330% over the same period, but such promotions only account for around 15% of drug companies’ marketing expenditures. Rather, the majority of promotional costs are for visits by sales representatives to doctors and hospitals.

The sheer cost of actively lobbying the American consumer and their healthcare providers is passed right back to Americans in the higher costs for their drugs. Therefore this practice does not only lead to our drugs costing more, it also means we get more of them. With the intention of advertising being to create demand regardless of necessity, drug advertising just may have something to do with unnecessary prescriptions in what many call our over-medicated society.

One survey found that 71% of doctors surveyed said advertising would put pressure on their colleagues to give drugs to patients that they would normally not prescribe, which of course adds cost to the system and profits to the drug companies. Drug companies, whose most noble endeavor is to research and develop life saving compounds, walk an ethical tightrope when advertising costs begin to reach parity with research costs and when selling quantities of drugs takes priority over their quality. Another recent study found even actually found that:

“…based on the systematic collection of data directly from the industry and doctors during 2004… the U.S. pharmaceutical industry spent 24.4% of sales dollars on promotion, versus 13.4% for research and development as a percentage of US domestic sales of $235.4 billion.”

In 2000 alone, Merck & Co. spent $161 million on the advertising their arthritis medication Vioxx. But by 2004, Merck withdrew Vioxx from the market after the FDA estimated that the drug caused between 88,000 and 139,000 heart attacks in the 5 years of its availability. It is one thing to try and convince people that they have complications and that they need your product, it is another for your product to have a hand in causing it."