American College of Physicians: Internal Medicine — Doctors for Adults ®

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Consumer ads: How should you handle the pressure?

From the March 2000 ACP–ASIM Observer, copyright © 2000 by the American College of Physicians–American Society of Internal Medicine.

  • Previously published ethics case studies are available online.
  • For additional ethics resources, visit the College's Center for Ethics and Professionalism

This is the 24th in a series of case studies with commentaries by ACP­ASIM's Ethics and Human Rights Committee and Center for Ethics and Professionalism. The series uses hypothetical cases to elaborate on controversial or subtle aspects of issues not addressed in detail in the College's "Ethics Manual" or other position statements.

Case history

Thomas Suit, a 38-year-old attorney with a family history of premature coronary artery disease, is talking with his wife at the dinner table. "You know, honey" she says, "with your dad recently dying of a heart attack and all the stress you're under at work, you really should have a checkup. I've heard a radio ad about a new, painless heart scan where they can tell you whether or not you have heart disease with one quick, easy test."

That week, when Tom sees an ad for a cholesterol medicine, he remembers his wife talking about the radio commercial for the heart scan. The exam is offered at a hospital a few blocks from his office. He decides to have the exam done, if only to make his wife happy. When Tom finds out his insurance won't cover the test, he is aggravated, but he pays for the procedure out of pocket. A few days later, he is confused and frightened when he finds out his test results are "abnormal." He is told to follow up with his private physician.

Tom calls a local internist he has never seen and asks for an immediate appointment to discuss medicines and heart surgery. He is desperate to avoid the fate that befell his father. The physician, however, has no new patient office visits available for two weeks.

"If the doctor can't see me today, can I at least get started on that heart medicine that I read prevents first heart attacks?" Tom asks the receptionist. "My law partner takes that one."

When the receptionist tells Tom he needs to see the doctor first, he insists that he needs the medicine right away. "Can the doctor at least call it into my pharmacy since I have to wait so long to have an appointment with him?" he asks. Finally, the receptionist agrees to squeeze Tom in for an appointment.

Commentary

The case study illustrates an increasingly common scenario in today's medical practice: patients who suggest their own diagnosis or therapeutic course based on information they cull from print advertisements and television commercials.

Advertising for pharmaceutical products and medical technologies such as ultra fast CT heart scans and new forms of eye surgery are plentiful. The United States is the only industrialized nation that allows prescription drugs to be advertised to consumers through television and print advertisements.1 In 1999, the pharmaceutical industry was expected to spend $1.8 billion on consumer-focused advertising in this country.

While direct-to-consumer advertising has become commonplace, the practice still raises many questions.2 Can consumers understand advertised medical information and apply it to their own conditions? Can advertising be considered a form of education? Does the "information" presented in ads change patient expectations of the medical encounter and treatment for the better or for the worse? Does it appropriately influence the prescribing habits of physicians?

Supporters have suggested that consumer advertising offers a number of advantages. They say that it can help educate patients about diseases and identify or treat conditions that might otherwise go undetected. They also point out that because consumer advertising delivers information directly to consumers, it gives them greater autonomy in weighing treatment options. With the information gained from consumer advertising, supporters say, individuals can initiate discussions with their doctors, potentially enhancing the patient-physician relationship. (Approximately 55 million people are said to have talked with physicians in 1998 about prescription drugs they saw advertised.1) Finally, some supporters argue that consumer advertising can increase competition among pharmaceutical companies, lowering drug costs and increasing access to consumers.

Opponents of consumer advertising, however, point to numerous downsides. Because advertisements and commercials are promotional, critics charge, they may encourage increased consumption beyond actual need. In addition, ads and commercials are typically so brief that many critics worry that they may not give enough information about risks and benefits, comparable options and drug interactions.

Consumer advertising can also place undue pressure on physicians to compromise their medical judgment in providing advertised drugs to patients who demand them. One study found that "doctors wrote prescriptions 84% of the time they were asked."1 If physicians choose to deny a patient's request, they must spend valuable time correcting patient misconceptions and misinformation. A final disadvantage of direct-to-consumer advertising, opponents say, is that drugmakers may ultimately increase drug prices to cover advertising costs.

When faced with issues raised by consumer advertising, physicians need to balance two principles of bioethics, namely, beneficence--the duty to promote and act in the best interests of patients and the public health--and respect for autonomy--the duty to protect and foster the patient's free, uncoerced choices.3 In addition, the autonomy principle requires us to adhere to the rules of truth-telling and disclosure.4

While these principles are generally accepted as normative for physicians, they could be equally applied to pharmaceutical and other health-related enterprises whose consumer advertisements directly impact potential patients. Thus, one could argue that only those ads that can be considered in the best interest of the potential patient--those that fully disclose the potential benefits and harms of the advertised product or service and those that ensure consumers' informed choice of all available options--should be published or broadcast. The information provided in these ads should be data-based, unbiased and specific to patients' needs. Educating those in need, rather than creating a need, should be the primary purpose and outcome of consumer advertising.

Federal regulations and College policy

In response to the growth of direct-to-consumer advertising, the FDA has created guidelines for direct marketing of prescription drugs to consumers. The guidelines specify the type of information consumer advertising should include and how the information should be presented.

The federal regulations do not, however, authorize the FDA to pre-screen advertising messages. While pharmaceutical companies may voluntarily submit advertising for pre-clearance, the FDA is authorized to regulate advertising only after it is published.

The College's "Ethics Manual" states that advertising by physicians and health care institutions is unethical "when it contains statements that are unsubstantiated, false, deceptive, or misleading, including statements that mislead by omitting necessary information."4 This principle can be applied to health care advertising more broadly.

The College does not favor promotional messages such as advertising as a way to educate patients.5 Some critics question whether consumer advertising by for-profit drug companies is ever in the best interest of patients or the public. Because consumer advertising is currently allowed in the consumer market, the College "supports strong regulations and strict guidelines to make such advertising as honest and useful as possible."5

Specifically, the College supports mandatory pre-release screening of all pharmaceutical advertising to ensure clarity and truthfulness. It furthermore suggests that physicians and pharmaceutical companies work jointly to create consumer advertising. It believes that the following statement should be a mandatory part of any consumer advertising for prescription drugs: "This medication is not appropriate for everyone. Consult your doctor about appropriateness for you."5

Physician considerations

The case study presents a situation in which consumer advertising indirectly results in pressure on the physician. As the case also demonstrates, consumer advertising can play a positive role in alerting consumers to medical procedures or drugs with which they might not be familiar. Ultimately, however, a physician must intervene to determine whether the medical procedure and/or drug is appropriate for the patient.

The fact that Mr. Suit has "predetermined" which medication he should take before a diagnosis has been made will undoubtedly make the physician's job more difficult. But instead of becoming frustrated or discouraged, physicians should use this type of opportunity to educate patients and further develop the patient-doctor relationship. Given the time pressures in today's practice, figuring out how to do so will be a challenge.

Physicians have a duty, both individually and collectively, to advocate that everyone in the health care community adhere to the principles of beneficence and respect for autonomy. Physicians need to keep informed about current consumer advertising so they can counsel patients knowledgeably and effectively, improve patient-physician communication and enhance informed consent by patients. Physicians should also plan workups carefully, discuss them openly and avoid unnecessary medications.4

Physicians must deal with a new generation of "self-informed" patients by refusing to compromise their medical judgment in the face of commercially induced pressures and by educating their patients while remaining attentive to their concerns. Moreover, physicians individually and as a group can push for the creation of local, state and national policies relating to consumer advertising, and they can monitor advertising and report inappropriate ads to relevant agencies such as the FDA. As individuals and as a profession, physicians must always be committed to the best interests of their patients and of society.

Acknowledgments: The Ethics and Human Rights Committee would like to thank Richard J. Carroll, ACP­ASIM Member, and Lois Snyder, JD, authors of the case history and commentary, and Peter Poon, JD, co-author of the commentary.

References

1. USA Today, Americans Pay More for Medicine, Nov. 10, 1999.

2. Kessler DA, Pines, WL. The federal regulation of prescription drug advertising and promotion. JAMA. 1990;264:2409-15.

3. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. Fourth ed. New York: Oxford Univ Press; 1994.

4. American College of Physicians Ethics Manual, fourth ed, Ann Intern Med. 1998;128:576-59.

5. Direct to Consumer Advertising for Prescription Drugs, ACP­ASIM position paper, October 1998 (www.acponline.org/hpp/pospaper/dtcads.htm).

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