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Another Malpractice

Friday, January 7, 2005; Page A18

RECENT REVELATIONS about the side effects of popular medicines -- painkillers that may increase the risk of heart disease, antidepressants that cause suicidal thoughts in children -- have fueled a discussion about the marketing of drugs. Pharmaceutical companies spend millions on advertising that may cause consumers to badger their doctors for certain medicines, which might in turn be overprescribed. On the other hand, it's hard to object to advertising that informs patients about their options, so long as doctors advise them on whether the latest cure is suitable. The real question is whether that advice is reliable -- despite the attempts of the drug firms to influence it.

Both the American Medical Association and the drugmakers' trade association have voluntary codes of conduct to guide the relationship between doctors and drug firms. These are full of sensible principles: It's okay for a drug company representative to buy lunch for a doctor, for example, but not to invite the doctor's spouse. These guidelines are helpful, but the economics of the drug market make it difficult to prevent abuse. It costs billions to invent a drug but little to produce it, so there's a huge incentive to pump up sales volumes; this creates a temptation to push the ethical boundaries. Moreover, the medical market presents a classic case of informational asymmetry. Patients generally don't know enough to second-guess doctors, so doctors can get away with overprescribing medicines.

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How far such overprescription occurs is hard to know. Most physicians chose their line of work because they care about health; they do not want to harm people. But it isn't reassuring that a former sales director of the biotechnology company Serono International S.A. pleaded guilty recently to offering free trips to France to doctors who wrote more prescriptions for his firm's AIDS drug. Nor is it wonderful that doctors routinely accept free drug samples from sales representatives.

One level up in the food chain, the corruption of pharmaceutical studies is even more disturbing. Medical researchers whose opinions are likely to influence other physicians routinely accept speaking and consulting fees from the firms whose drugs they pronounce on. In July, for example, a much-publicized report called for more aggressive prescription of cholesterol-lowering drugs; it turned out that all but one of the report's authors had financial ties to the drugmakers. Again, it's possible that the report was based on nothing but pure science, but how can anybody be confident?

The flap over drug side effects has revealed how much we don't know about the pills we take, and some of this knowledge gap may be unbridgeable. Clinical trials that yield preliminary indications of health risks tend to be shut down, so it's often hard to establish how seriously these risks should be taken. All the more reason to demand that the medical research that does get done should be demonstrably unbiased.

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