Direct to consumer advertising of prescription drugsBMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7194.1301 (Published 15 May 1999) Cite this as: BMJ 1999;318:1301
An idea whose time should not come
- Jerome R Hoffman (), Professor of medicine.,
- Michael Wilkes, Associate professor of medicine, Division of Internal Medicine.
Direct to consumer (DTC) advertising of prescription drugs is expanding dramatically in the United States, and there is some sentiment in favour of allowing this practice to come to the United Kingdom.1 Such advertising is a powerful tool, designed to create a demand, in order to maximise profits. Extending the scope of already ubiquitous promotions about “post-nasal drip,” “unsightly rashes,” or “cures” for baldness has little to do with educating patients or relieving suffering. It will, however, inevitably drain healthcare dollars, dramatically increase unnecessary prescribing, and strain patient-doctor relationships.
Typical direct to consumer advertising for prescription drugs in the US consists of glossy promotional materials suggesting that the advertised product represents a major medical advance, accompanied (because of Federal Drug Administration regulations, and over the objections of the pharmaceutical industry) by tiny print “information” presented in medical jargon which virtually no consumers can understand. 1 2 These advertisements—whose “rules for doing DTC right” include “always focus on benefits, not problems”3—are intended not to educate patients, nor to empower them to be more intelligently involved in their own care, but merely to increase physician prescribing, regardless of need. This is hardly surprising since, even when marketing to doctors, pharmaceutical companies provide far less education than jargon and promotion,4 and many claims prove to be inaccurate or misleading. 5 6 Advertisements to consumers are hardly likely to be more reliable.
The industry likes to cite undertreatment of important problems such as hypertension as an argument in favour of advertising, exhorting the public to “Ask your doctor about….”7 But do not expect to see consumers regaled with promotions about inexpensive diuretics or β blockers, any more than about measles, mumps, and rubella vaccination or regular cervical smears. The issue is not whether deficiciencies in doctors' and patients' awareness exist, but whether promotions designed to increase demand, and profits, that focus primarily on “me-too” products in competitive categories 3 4 can really be expected to benefit the public health.
Doctors have a fiduciary responsibility to act in the best interest of their patients, and secondary goals, including increased income or professional stature, must be held subordinate to that primary commitment. For-profit companies, on the other hand, have a primary goal of maximising profits; indeed the responsibility of company executives is first and foremost to owners and shareholders. Though improving the public health may be seen as a desirable byproduct of company activities, concerns about health care cannot take precedence over profits: when the two goals conflict profit must win. 2 8
Similarly, for proprietary companies no healthcare spending, no matter how expensive or inefficacious, is “inappropriate” if it increases profits. It is essentially irrelevant whether a drug unreasonably increases consumer expectations, forces doctors to spend substantial time disabusing patients of misinformation, diminishes the doctor-patient relationship because a doctor refuses to prescribe an advertised drug, or results in poor practice if the doctor capitulates and prescribes an inappropriate agent. Promotions of new and expensive drugs are successful if they increase sales, regardless of these other effects, and even if sales of rival products designed to treat the same diseases are not lessened.9 Ultimately, of course, consumers pay for these promotions, whether it be the fortune spent on promotions to doctors (estimated to be about as much in the United States as is spent for all medical school and residency training combined10) or the potentially even greater spending on direct to consumer advertising.
Direct to consumer advertising of prescription drugs has been described as a “wonder drug” for the drug industry itself, because of its ability to affect patient demands—and in turn doctors' behaviour.11 If they believe that patients want and expect drugs then doctors will prescribe them even when they know they are not indicated,12 even when patients don't specifically ask for them, and even when an individual patient never expected the drug but the doctor thinks he or she did.13 All that is required for direct to consumer advertising to increase product sales dramatically is that some patients ask and that doctors begin to believe that many patients will be dissatisfied without it.
We do not believe that drug companies should be blamed for valuing self interest above the needs of the public. In our society that is how companies are programmed to behave. Nor should doctors expect anyone else to be our ethical watchdogs. It is our responsibility to serve as advocates for our patients and for the public health. Whenever the search for greater profits is allowed to siphon off valuable and scarce resources that would be better used to improve the health of our entire community, we believe it is our obligation to speak out in opposition. We hope readers of the BMJ will join us in opposing the introduction of direct to consumer advertising of prescription medicines to the United Kingdom.