DOI: https://doi.org/10.20529/IJME.2010.082
Pharmaceutical companies use a variety of strategies, including gifts, to influence physicians. In December 2009, the Medical Council of India amended the Code of Medical Ethics to ban medical professionals from accepting gifts from pharmaceutical companies. In view of this ban, it is important to find out the magnitude and contours of the problem amongst Indian medical professionals. We aimed to study, through an e-mail based survey, the attitudes and practices of young resident doctors and interns from two medical colleges of New Delhi regarding acceptance of gifts from the pharmaceutical industry. We e-mailed the questionnaire to 150 fresh graduates. We found that the majority of graduates agreed with existing guidelines: they accepted low cost gifts but considered expensive gifts unrelated to patient welfare unethical. Despite the low response rate, this study is important because data from India on attitudes and practices of medical professionals regarding gifts from the pharmaceutical industry are virtually non-existent.
Pharmaceutical companies and physicians have an interdependent relation. This interaction has attracted a lot of attention in recent times, primarily because the fundamental ethical duty of the physician is to provide the most effective treatment to patients and the key motive of pharmaceutical companies is to extract the maximum possible profit out of their dealings.
While the pharmaceutical industry has often been blamed for bribing doctors, the blame cannot be entirely apportioned to them as doctors do not necessarily view acceptance of gifts as unethical (1). However, among various forms of interaction, acceptance of gifts by physicians from companies and their representatives has been an issue of concern as it leads to conflict of interest between patients and physicians. Four basic principles of medical ethics are autonomy (to respect the patient’s decisions and promote informed choice), beneficence (to act in the best interest of the patient), non-maleficence (to protect the patient from any harm), and justice (to promote equity in the healthcare provided) (2). When physicians accept gifts from a drug company, there may be a conflict of interest between their duty to prescribe effective and affordable treatment to the patient and any obligation that they may feel to prescribe that company’s drugs.
A variety of strategies are used by companies to influence physicians (3). These include gifting materials of daily use, like pens; gifting professional educational and teaching materials; and funding research, conferences and travel. Public concern about these practices led to the development of various guidelines but these guidelines do not impose restrictions on physicians. However, in December, 2009, the Medical Council of India (MCI) amended the Code of Medical Ethics which now recommends strict measures against medical professionals benefitting from pharmaceutical industries (4).
Studies in recent times have documented the increasing influence of the pharmaceutical industry on healthcare (5). Most of these studies have been done on patients and in foreign settings. To the best of our knowledge no study has addressed the issue in the Indian context. The present study is important for two reasons. First, data from India on attitudes and practices of medical professionals regarding gifts from the pharmaceutical industry are virtually non-existent. Second, in view of the recent guidelines by the MCI, it is important to know the magnitude and contours of the problem amongst Indian medical professionals.
We aimed to study the attitudes and practices of young resident doctors and interns regarding acceptance of gifts from pharmaceutical companies.
After reviewing literature obtained from the Pubmed search database using index words like ‘doctors, pharmaceutical industries and gifts’ and ‘doctors, gifts and ethical issues’, we prepared a questionnaire asking what the respondents felt about gifts from pharmaceutical companies and whether they had received any such gifts. The questionnaire was e-mailed to graduates who had completed their internship from two medical colleges in New Delhi — University College of Medical Sciences and All India Institute of Medical Sciences — in the last two years. The questionnaire was also e-mailed to postgraduates, faculty and private practitioners. We sent a reminder e-mail after one week and then waited for another week. We recorded the results available two weeks after the questionnaire was e-mailed. All the participants were assured that their opinions and the information that they shared in this study would be kept confidential.
Out of the 150 fresh graduates contacted, 80 replied, giving a response rate of 53.33%. The response rate by postgraduates, faculty and private practitioners was too low (<10%) to be considered for analysis. Out of the 80 graduates who replied 67 (83.75%) were males and 13 (16.25%) were females. The average age was 23.81 years with a range from 22 to 26 years. 63 (78.75%) of them were working in India, 15 (18.75%) in the United States and 2 were currently not working.
The kind of gifts commonly accepted were pens and pads by 66 (82.5%); books by 23 (28.75%), sponsorship to an academic event/conference by 15 (18.75%), passes/tickets to non-academic events like movies and exhibitions by 7 (8.75%), direct cash by 2 (2.5%), money to conduct research by 2 (2.5%), railway/airline tickets or money for travel by 1 (1.25%) and other stationery materials by 1 (1.25%).
Out of 80 respondents, 62 (77.5%) stated that they had never actively sought a gift or service from a medical representative or a pharmaceutical company. Of 18 graduates who actively sought gifts, the most common gifts were drug samples by 11 (13.75%), pads and pens by 7 (8.75%), sponsorship to an academic event by 6 (7.5%) and subscriptions for books and/or journals by 6 (7.5%). Funding for research by 2 (2.5%) and travel fare by only 1 of them were other less commonly sought gifts.
When asked about the reason for accepting the gifts 59 (73.75%) respondents stated that it was human nature to accept free gifts, 12 (15%) stated that they accepted a gift because they did not want to say no. For 11 (13.75%) respondents, the gift helped them remember the products. 8 (10%) stated that salaries of doctors were inadequate. Other less cited reasons, by 1 person each (1.25%), were that any kind of perks are always welcome and since they are there in every profession, why not in the medical field; that it gave them a feeling of importance; that gifts were too lucrative for them to resist, and that small gifts did not matter when they were already using the same brand and liked it.
70 (87.5%) out of 80 respondents felt that accepting cash was unethical. 58 (72.5%) considered accepting household items to be unethical. Other gifts considered unethical were other material gifts such as watches, shirts and bags, by 55 (68.75%) respondents, funding for a non-academic event by 52 (65%), travel fare or tickets by 49 (61.25%), sponsorship to a conference or academic event by 23 (28.75%), books or journal subscriptions by 19 (23.75%), pads and pens by 7 (8.75%), drug samples by 4 (5%), and any gifts which are not used for patient welfare by 1 (1.25%). 6 (7.5%) stated that that it was not unethical to accept any of the above gifts. A majority of respondents, 54 (70%) believed that receiving gifts did not affect their prescribing practices.
44 (55%) out of 80 respondents stated that the government should prohibit pharmaceutical companies from giving gifts to doctors. 26(32.5%) were against such a ban and 10 (12.5%) were not sure regarding this. 41 (51.25%) of 80 respondents agreed that the government should frame laws to prohibit medical practitioners from accepting gifts from pharmaceutical companies, whereas 31 (38.75%) were against such a law and 8 (10%) were not sure. 45 (56.25%) believed that the amendment in the MCI code of ethics was justified but 24 (30%) disagreed with it and another 11 (13.75%) were not sure regarding this.
Our study has some limitations. With a response rate of just 53.33%, we could not rule out response bias.In any case the participants are not representative of the population at large as the study population comprised only young medical graduates and interns. Also, the possibility that participants who were already in a ‘symbiotic’ relationship with some companies were more inclined to respond cannot be ruled out. Since the study was based on self reporting, we cannot be sure that the answers given by them truly reflect their attitudes and practices.
Our study found that most doctors do accept gifts from pharmaceutical companies. The gifts reported to be accepted most frequently were of relatively lower cost like pens and pads. Certain gifts like direct cash and passes or tickets to non academic events were accepted by very few of them and were considered unethical by most young graduates. A clear majority of participants in the study stated that it was human nature to accept gifts, and this was the reason for their practice of accepting gifts. Their justification was that very few of them actually sought a gift from representatives and even the gifts most sought after were usually directly related to patient care. A subset of graduates also found it difficult to say no to gifts.
These results in the Indian population are similar to findings of earlier studies done in Australian (6, 7) and American (8, 9) patients and physicians that revealed that gifts of relatively low monetary value and related directly to patient care were more acceptable and not considered unethical by both patients and physicians. However, a small percentage of graduates in our study did not believe it was unethical to accept gifts. This is a matter of concern since they are more likely to be affected by the gifts from pharmaceutical companies.
Most graduates believed that gifts did not affect their prescription practices, but studies in the past have shown that even small insignificant gifts can influence the behaviour of physicians. A pharmacy that used a keychain as a gift noted a 17% increase in sales (10). A randomised controlled trial by Grande et al showed that even exposure to small promotional items influenced the attitude of medical students towards a company’s products (11). This may be because even trivial gifts impart a sense of gratitude that modifies physicians’ attitudes regarding their choice of prescription, which may conflict with their primary duty towards their patients. A physician receiving gift may subconsciously recommend products made by the gift giver without due consideration of other cheaper or more effective options.
The majority of graduates in our study agreed that policies should be framed by the government to formulate laws to control and prevent the influence of pharmaceutical companies on physician’s choice of medication. Most of them also supported the recent amendments made by the MCI in its code of ethics to control such interactions. A number of ethical codes and guidelines have been issued by various medical organisations in an attempt to avoid this conflict of interest in imparting the most appropriate patient care. However, these serve more as guidance than rules that impose restrictions.
In the United States, the American Medical Student Association has issued one of the strictest guidelines asking trainees to avoid all promotional items, including even trivial pens and notepads, and calling for a cessation of all pharmaceutical company-sponsored meals (12). The new code by the Pharmaceutical Research and Manufacturers of America eliminated small gifts to physicians such as pens and mugs. However, it does not prohibit sponsorship of hospital-based meals and continuing medical education events (13). The American Medical Association’s (AMA) guidelines consider gifts to physicians to be acceptable as long as they are “of minimal value”, defined as $100 or less, and are considered beneficial to the patients (14). The Department of Veterans Affairs (DVA) restricts gifts to a value of less than $20 per occurrence and less than $50 in aggregate value over a year from a single source (15), and the American College of Physicians (ACP) (16) and Association of American Medical Colleges (AAMC) (17) guidelines recommend that context and intentionality of interaction are better criteria than monetary value (16). The AAMC’s statement emphasises that all interactions having even the appearance of conflict of interest should be avoided (17). Further, all organisations recommend that the gifts must be contributory to patient education and welfare.
The guidelines and code of ethics issued by MCI are significantly different from others in that they specifically ban (18)all gifts worth above Rs 1,000. The recommended minimum punishment for accepting gifts up to a value of Rs 5,000 is censure and above that is suspension from the medical register for various durations (2). Thus, the majority of graduates in our study were more in line with the guidelines advocated by various organisations like AMA, DVA, ACP, AAMC with the majority accepting low cost gifts and considering high cost gifts not related to patient welfare unethical.