'Free samples from pharmas may bias others, not me'
Doctors say samples ethical, but can bias prescribing
Doctors tend to agree that accepting free samples from pharmaceutical companies is acceptable; but, while they suspect such incentives create bias among their peers, they don't think they are susceptible to being biased themselves.
"The generally held view that accepting modest incentive items, such as drug samples, is appropriate and primarily of benefit to patients needs to be reconsidered, both by doctors and by policy makers," says Maria Morgan, PhD, lead author of a study appearing in the British Journal of Medical Ethics.
Morgan and her colleagues surveyed almost 400 members of the American College of Obstetricians and Gynecologists (ACOG) in 2003 about their relationships with the pharmaceutical industry.
One in three doctors agreed that, in general, free drug samples influence prescribing. But they also think that other doctors are more likely to be influenced by incentives than they are.
Morgan says the survey showed that, overwhelmingly, those asked believe it is ethical to accept free samples from a pharmaceutical company. Many — more than half of those who were asked — said they think accepting a lucrative consultancy with a company that produces a drug that the physician prescribes often is also ethical.
One in three say their prescribing practices would be influenced by accepting free samples. But no matter what the incentive, the doctors who participated in the ACOG study thought others would be more likely to accept the incentive than they would themselves, and also more apt to be influenced by the freebies.
"The findings were not too surprising for me," Morgan says. "Had we asked the physicians directly, 'Is your prescribing influenced by accepting free drug samples?' I suspect there would have been fewer affirmative responses."
Instead, the hypothetical format of the questions (framed as "Imagine that you were in the position of this physician...) might have allowed for the expression of a less-conscious bias, Morgan adds.
MDs aware of guidelines, don't want more
The possibility that drug companies are exerting too powerful an influence on clinical decision making has led to an increase in the number of federal and professional agencies establishing guidelines for appropriate interactions, including ACOG, the American Medical Association, and the Pharmaceutical Research and Manufacturers of America (PhRMA), Morgan points out. Almost two thirds of the respondents in the ACOG study were aware of professional guidelines on the relationship between the pharma industry and the medical profession, and only one-third indicated they thought the relationship should be more tightly regulated. Almost half felt that it should not be restricted further.
But physicians' intent in accepting and distributing incentives was based in the best interest of patients, the respondents indicated.
"I cannot speak as to what motivates the physicians, [but] my personal opinion, having worked with the data and made myself familiar with the literature, is that yes, the physicians are acting in what they perceive to be the best interest of the patient," says Morgan. "Whether distributing free samples is what ultimately is best for the patient is still up for debate."
Physicians cited financial need and convenience as common factors for supporting free samples from pharma companies. Most of those who distributed samples said they did so because of the patient's financial need (93.5%), the availability of the samples (89.1%), and for the patient's convenience (76.1%). Less than two-thirds (62.7%) selected ''knowledge of the efficacy of the sample product'' as a reason for distributing free samples and 59.7% distributed samples to build a good relationship with the patient.
"What makes the distribution of free drug samples so acceptable despite evidence of their influence on prescribing practices? Is it their ubiquity? Is it the seemingly insignificant value of each sample?" Morgan asks. "Perhaps the perceived need for patients to have inexpensive and immediate access to drugs outweighs the concern that samples influence which drug doctors prescribe. As incentives go, samples provide the most direct benefit to the patient and the least tangible benefit to the doctor."
Morgan and her co-authors write that their findings mirror those of other studies.
The conclusion the authors reach is that whether one believes incentive items bias physicians in favor of the sample products or not, the appropriateness and benefit to patients is an issue that deserves continued attention from doctors and policy makers.
Resources
For more information:
- Morgan MA, Dana J, Loewenstein G, et al. Interactions of doctors with the pharmaceutical industry. J Med Ethics 2006; 32:559-563.
- Maria Morgan, PhD, Research Department, American College of Obstetricians and Gynecologists, Washington, DC. Phone: (202) 863-4998.
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