Objectives - To
analyse the explicit or implicit claims embodied in the proprietary names of pharmaceutical
products.
Design - Linguistic and ethical analysis of proprietary names of
pharmaceutical products marketed in the UK and in Denmark.
Results and
conclusions - A number of drugs have names that allude to their indication or actions.
Such names may be problematic, however, because they often promise more than the drug can
deliver. Taking into account, firstly, the type of allusion and its degree of
sophistication, and, secondly, the seriousness of the indication may help in identifying the
most problematic drug names.
Introduction
"What's in a name? That which we
call a rose by
any other name Would smell as sweet."
Romeo and Juliet II, ii, 43
We all know that names matter. The names of ordinary consumer products are often
extensively field tested before a new product is brought on to the market. From such a
perspective, Shakespeare's greater attention to the object itself than to its name may be
admirable-but it is not of much use to the marketing men, whose motto was better (though
unintentionally) captured in Matthew Prior's ode:
"The merchant, to secure his treasure,
conveys it in a borrowed name...."
The naming of pharmaceutical products is an area that
has been neglected in medical ethics. It is not, however, neglected by the marketing
departments of pharmaceutical companies. There are rules of thumb for choosing these
names-for example, keep them short with a first letter near the beginning of the
alphabet-and some pharmaceutical firms also develop their own traditions-for example,
Glaxo Wellcome seems to like names beginning with "Z" or "X".(1) (2)
Published papers about the naming of such products have mainly been concerned with either
how to choose a good name and avoid a bad one,(1) (2) with simple safety issues
such as prohibiting names that are too similar to each other,(3) (4) or with
identifying cases where the same name is used for products with different
constituents.(5) We have, however, been unable to find any papers looking at the
ethical aspects of the naming of pharmaceutical products.
Many contemporary product names
rely on associations with either popular or scientific conceptions of pathology and
therapeutic action. But these same modern scientific conceptions invite us to be sceptical
of the merely "declaratory" therapeutic action of carefully chosen product names.
Pharmaceutical marketing is, of course, correct to affirm the psychological power of names.
However, that psychological power does not confer therapeutic power, and it should not be
used to invite unfounded beliefs in the likely efficacy of pharmaceutical products. In this
paper we look at the connection between the names of drugs, the indications for their use,
and their proved effects; and we point to some morally troubling types of naming.
The
meaning of the name
So long as the name of a drug has only a strictly conventional
relation to the effect of the drug-that is, so long as it does not involve a tacit claim
about the drug's effect-then no moral problems arise. If, however, the name in some way
makes suggestions about either the indications for the drug's use or the drug's action or
effect then the name embodies a claim. The claim has a (tacit) meaning for either the
patient, or the doctor, or both; and since we are talking about the result of marketing
activities it would be na|fkve to suppose the meaning were not fully intended by the
manufacturers.
In maintaining that a rose would smell as sweet by any other name,
Shakespeare may have been observing that there is a purely conventional relation between the
name "rose" and plants of the genus Rosa. That relation is devoid of implicit or
explicit meaning (at least so far as it concerns the "therapeutic action" of being sweet
smelling; the separate connection between the name and the colour is, of course, falsified
in most actual roses).
However, it is important to remember that even if "rose" had
meant "sweet smelling" Shakespeare's point would nevertheless have stood. The class of
sweet smelling objects is not restricted to those whose names mean "sweet smelling," and
this in itself arouses no moral interest. Moral interest is legitimately aroused, however,
by the reverse question-that is, the question of whether the class of objects which are
named "sweet smelling" is restricted to those which really are sweet smelling; and the
same is true for other names embodying value terms. It is then straightforwardly of moral
importance whether a claim about a valued action or effect is true.
Names and
indications
We looked through the British National Formulary(6) and the
Danish equivalent, the Laegeforeningens Medicinfortegnelse,(7) and constructed
the following initial classification of pharmaceutical trade names:
- The opaque (no
meaning, conventional or otherwise; they are simply proper names)
- The chemical or
pseudochemical
- Names referring to the producer of the product
- Names
referring to indications for use
- Names referring to the actions of the drug.
This classification has some similarities to the classification proposed by Jack
and Soppitt,(2) but ours is based primarily on the implicit or explicit message in the
name.
In many cases it is difficult to locate a name uniquely in one or other of the
categories. We do not therefore claim that this initial classification is exclusive or
exhaustive, and we are presenting here only a selection of interesting names in order to
illustrate our discussion. We will see below that a further subclassification is possible
which helps in assessing the moral importance of problems associated with the use of
specific names.
Opaque names - The names of drugs in the opaque group
seldom give rise to moral problems. If the name is devoid of meaning it cannot misrepresent
the product.
Names referring to chemicals or manufacturers - Chemical
or pseudochemical names, as well as those that refer to pharmaceutical companies themselves,
are also in most cases ethically unproblematical, partly because they are effectively opaque
to the lay person. Names like Aramine, Colestid, or Hydrocortistab seem no more likely to
entice anyone to impute specific actions to the drugs bearing them than do metaraminol,
colestipol hydrochloride, or hydrocortisone acetate-the respective generic names from which
the proprietary names are derived. In the same way, the over the counter paracetamol
formulations Panodil, Pamol, or Setamol seem innocuous in a way that Alleve and Remedeine
cannot be. Turning to company names, Duphaston (produced by Duphar), Dysport (Porton), and
Sandostatin (Sandoz) seem not to have tacit meanings. There might be a problem with
Wellferon and Sanomigran, which appear to imply certain benefits, but these only exemplify
the more general problem of the associations of the names of certain pharmaceutical
companies (Wellcome, Sanofi).
Names referring to indications or
actions - The possibility of misrepresentation is much more apparent when the
names refer to the drugs' indications or actions. Even in these groups most names are
innocuous-like Sotacor for the beta blocking agent sotalol, or Cerviprost for a
prostaglandin used for cervical maturation. By contrast, one can ask whether the
gonadotrophin releasing hormone Fertiral should even implicitly promise restored fertility,
whether the indomethacin preparation Mobilan should suggest improved mobility by overcoming
joint pain, or whether the intended success of prochlorperazine in counteracting vertigo
should be telegraphed in advance through the brand name Vertigon. Again, does Serevent
really ensure the peaceful resolution of the asthmatic's breathing difficulties, and is
Selexid as selective and deadly towards its target bacteria as the name implies?
Dangerous Liaisons
The foregoing are single examples from some of the larger
therapeutic groups; in some specific groups the dangerous liaisons between names and implied
effects are more widespread. The group of anorectic agents are known to have a limited
effect unless combined with rigorous diet regimens, but nevertheless we find names promising
a lot more, including Mirapront (both miraculous and prompt?) and the Danish drug Letigen
(literally "light again").
Exactly the same problem can be found in more important
therapeutic groups. The hypnotics and anxiolytics include names like Librium (promising
freedom), Serepax (peace and serenity), Euhypnos, Welldorm, and Stilnoct (all three offering
a good night's sleep, with the last having useful if unintended echoes of the old carol
Stille Nacht), Equanil (following which life may be faced with equanimity), and
Tranxene (offering tranquillity). Given what is known about the long term effects of such
drugs, it is to say the least morally problematic to name them in such a way as to imply
only the desired effects. (It is possible that Stilnoct offers an exception on the
alternative interpretation that the implied effects are actually those on the clinical
carers after administering the drug liberally to their patients.)
Even more problematic
are the relations between the names and effects of certain drugs in the neuroleptic and
antidepressant groups. The first neuroleptic ever marketed was named variously Largactil or
Largactif (according to country of sale) and evidently promises large amounts of an
unspecified action. Later names have been more inventive, with a widely varying degree of
specialised knowledge presumed in the allusion, which can be medical, literary, or even
musical. For instance, it is unlikely that Sordinol worked as gently on the psychotic mind
as did the sordini (mutes or dampers) on a stringed instrument, just as it is unlikely that
Serenace really brings serenity.
Similar misplaced imagination can be found in the naming
of antidepressants, where we find names like Allegron, Aurorix, Concordin, Lustral, Optimax,
and Surmontil. Are we really to believe that these chemical substances can help the
depressed patient, respectively, to get back up to full speed, see the light, achieve inner
harmony, brighten up, reach the summit, or surmount his or her problems? None of the implied
actions would ever be allowed to enter a serious list of indications for use, and it is
accordingly strange that they should be allowed in the names.
A survey of drug names
A more thorough study than is possible here would perhaps
reveal more precisely where the marketing departments have concentrated their creative
efforts. It would be important to establish this if, for example, there were a correlation
between the marketers' tendency to imply indications for use and a clinical area in which
prescribing habits are particularly fluid, or where no really effective treatments are
available. The relative sophistication of the allusion might also suggest whether the drug
is aimed at a more or less sophisticated target audience; and this could imply beliefs on
the part of the pharmaceutical marketers about connections between specific illness groups
and specific social groups. An analysis of allusive sophistication may, however, be
problematic in some cases because a name with many layers of allusions will be more likely
to appeal to both prescribers and patients (the so called "milles feuilles" phenomenon).
Such multilayered names are therefore likely to be chosen by companies, and it may be
difficult to tell whether one has uncovered all the possible allusions. Finally, it seems to
us self evidently important to discover whether or not marketing departments are more
cautious in proportion to the gravity of the clinical conditions at which their products are
aimed.
A selection of the drugs produced by our survey is listed in the box. We
classified them according to their allusive sophistication and the clinical seriousness of
the condition for which the drug is used (table 1). We accept that we could be criticised
for the crudity of our measures as well as for the paucity and unrepresentativeness of our
sample. Moreover, we are making two assumptions. One is the obvious presumption that moral
concern increases with the gravity of the condition. But we also make the more contestable
presumption that concern increases also with the sophistication of the allusion: we suggest
that the less obvious the claim, and the more it relies on a tacit appeal to specialist
knowledge, the more it is likely to slip under the guard of the unwary. On these
assumptions, therefore, the morally most troublesome names are those in the bottom right of
the table.
| Table 1 - Products by seriousness of indication and mode of suggestion |
|
Indication |
| Type of suggestion |
Trivial |
Moderate |
Serious |
| Assertion |
Givitol, Normax, Novaruca, Powerin, Regaine |
Marvelon, Mercilon, Mobilan, Univer |
Motival |
| Crude suggestion |
Miraxid, Pacifene, Propain, Preferid, Securopen, Verrugon |
Fertiral, Flexin, Tensium, Vertigon |
Lustral, Optimax, Securon, Vivalan |
| Suggestion |
Effico, Mildison, Miradol |
Accuretic, Antabuse, Enduron, Harmogen, Migraleve, Rhythmodan, Somnite, Tranxene, Welldorm |
Concordin, Serenace, Surmontil, Tremonil |
| Informed suggestion |
Equagesic |
Atensine, Corgard, Dormonoct, Equanil, Tonocard, Volital |
Allegron, Epilim, Glurenorm, Phasal, Symmetrel |
| Specialist suggestion |
Donobid |
Eudemine |
Alineton, Moditen, Primacor |
A challenge for regulators
It is worth noting that an
alternative analysis of names of prescription drugs might differentiate between the effects
of a given name on a patient, whose psychological reaction concerns the likely appeal of the
single drug already prescribed to him or her, and the effects on a prescribing physician,
whose psychological reaction concerns the relative appeal of the names of the many different
drugs from which he or she has to select.
From moral and regulatory points of view it is
worrying that there are drugs on the market whose names imply indications, actions, or
effects that are different from the drugs' real effects. Patients are likely to remember
drugs more by their proprietary names than by their generic equivalents and typically have a
highly limited understanding of pharmaceutical chemistry and therapeutics. At the same time
most physicians, while enjoying this knowledge, are nevertheless unlikely to be able to
recall the exact list of indications for a given drug. In this somewhat fluid context the
value implications of proprietary drug names can obviously have a disproportionate
influence.
We think it would be reasonable to require that no drug with a misleading name
should be registered for sale. Even given the allusive imagination evidently available to
the pharmaceutical industry, it cannot be an insurmountable task for regulatory agencies to
"shadow" these efforts when checking the names of new products, or reviewing those of
existing ones. Those who dislike regulatory sug-gestions of this kind must recognise
that the alternative is to rely on the pharmaceutical companies' prescribing to their
market-ing departments a daily dose of the promising-but as yet unproved-drug
Ethicaid.
| Key messages |
| Drug names often contain implicit messages
Good ethical reasons exist to question names that imply actions far beyond the known pharmacological actions of a given product |
We gratefully acknowledge helpful comments from Dr David
Greaves and from two anonymous referees for the BMJ.
Department of Medical Philosophy and Clinical
Theory,
University of Copenhagen,
DK-2200,
Copenhagen N,
Denmark
Soren Holm,
senior research fellow
Centre for Philosophy and Health Care,
University of
Wales Swansea,
Swansea SA2 8PP
Martyn Evans,
university fellow
Correspondence to: Dr Holm.
References:
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for Den Norske Laegeforening 1995;115:380-3.
2 Jack D B, Soppitt A J. Give a
drug a bad name. BMJ 1991;303:1606-8.
3 McNulty H, Spurr P. Drug names
that look alike or sound alike. BMJ 1979;ii:836.
4 Faber J, Azzugnuni M, Romana
SD, Vanhaeverbeek M. Fatal confusion between "Losec" and "Lasix." Lancet
1991;337:1286-7.
5 Aronson J K. What's in a brand name? BMJ
1994;308:1140-1.
6 British national formulary. London: British Medical
Association and Royal Pharmaceutical Society of Great Britain, 1995.
7
Laegeforeningens medicinfortegnelse.Copenhagen: Laegeforeningens Forlag, 1995.
Accuretic
- Quinopril/hydrochlorothiazide (hypertension): accurately controls urea concentrations.
Akineton - Biperidon (parkinsonism): tackles your dyskinesias or dystonias.
Allegron - Nortriptyline (antidepressive): gets you back up to full speed again.
Antabuse - Disulfiram (substance dependence): defeats abuse.
Atensine - Diazepam (anxiolytic): no (more) tension.
Concordin - Protriptyline hydrochloride (antidepressive): restores peace and harmony.
Contrapain - Ibuprofen (over the counter analgesics): against pain.
Corgard - Nadolol (|gb blocker): guards your artery walls or your heart.
Donobid - Diflunisal (weak analgesic): give twice a day (dono bis in die).
Effico - Tonic: "most efficacious in every way."
Enduron - Methyclothiazide (oedema, hypertension): the power to keep you going.
Epilim - Sodium valproate (epilepsy): limits epileptic episodes.
Equagesic - Ethoheptazine citrate (non-opioid analgesic): brings you back to an even temperament.
Equanil - Meprobamate (anxiolytic): face life with equanimity.
Flexin - Indomethacin (inflammatory joint pain): Flex those joints.
Givitol - Ferrous fumarate (compound iron preparation): homophone for "give it all." Glurenorm-Gliquidone (diabetes mellitus): glucose restored to normal.
Harmogen - Piperazine oestrone sulphate (hormone replacement therapy): generates harmony. Lustral-Sertraline (antidepressive): Puts a shine on your day.
Marvelon - Combined oral contraceptive: no comment necessary.
Migraleve - Combined non-specific analgesic/antiemetic for migraine: relieves migraine, alleviates migraine
Mildison - Hydrocortisone (inflammatory skin disorder): mild and gentle touch.
Miraxid - Pivampicillin (antibiotic): miraculous in killing.
Mobilan - Indomethacin (joint pain): get mobile again.
Moditen - Fluphenazine hydrochloride (antipsychotic): modifies (or moderates) the patient.
Motival - Compound antidepressant: motivates you.
Normax - Co-danthrusate (laxative): restores you to normal (and does so maximally).
Novaruca - Glutaraldehyde (warts): homophone for "no verruca(s)"
Optimax - Tryptophan (antidepressive): be optimistic about a maximally optimum outcome, or, "Cheer up!"
Phasal - Lithium carbonate (mania, manic/depressive illness): puts you " back in phase"; attends to divergent phases.
Preferid- Budesonide (inflammatory skin disorder): your first choice every time.
Prepulsid - Cisapride (impaired gastric motility): the driving force.
Primacor - Milrinone (congestive heart failure, short term treatment): first class for the heart.
Propain - Paracetamol/codeine/diphenhydramine (over the counter analgesic): take it for pain.
Provera - Medroxyprogesterone acetate (contraceptive) \N proven results
Regaine - Minoxidil (hair stimulation in male pattern baldness): get back what you've lost.
Rhythmodan - Disopyramide (cardiac arrhythmia): restores (modulates) your heart rhythm.
Securopen - Azocillin (infections): Safety first.
Serenace - Haloperidol (antipsychotic): brings serenity.
Somnite - Nitrazepam (insomnia): sleep at night.
Surmontil - Trimipramine (antidepressive): surmount life's hurdles.
Symmetrel - Amantadine hydrochloride (parkinsonism): redresses hemiplegic or other one sided imbalances, restores symmetry.
Tonocard - Tocainide hydrochloride (ventricular arrhythmia): tones your heart.
Trancopal - Chlormezanone (anxiolytic): offers tranquillity.
Tranxene - Clorazepate dipotassium (anxiolytic): again, offers tranquillity.
Tremonil - Methixene hydrochloride (parkinsonism, tremor reduction): get your tremors down to nil.
Univer - Verapamil hydrochloride (vasodilator): to be prescribed everywhere, always, for everything. Verrugon-Salicylic acid (for warts): verrucas gone.
Vertigon - Prochlorperazine (vertigo): vertigo's gone.
Volital - Pemoline (childhood hyperkinesia): brings movement back under voluntary control; improves (controls) willpower.
Welldorm - Chloral hydrate (insomnia): no comment necassary.
