The Case for Medical Paternalism

by Henry on January 25, 2005

Matt Yglesias mentioned a few days ago that he didn’t see anything that was morally wrong with paternalism, with the implication that paternalist policies ought to be evaluated on purely pragmatic grounds. The Washington Post has an interesting test case today for those who might disagree with him. It describes how “aggressive direct-to-consumer advertising campaigns” for Celebrex and Vioxx persuaded consumers to take these drugs, even though they would predictably have been better off if they had taken other non-prescription drugs instead. As the article says, the US is highly unusual in allowing direct-to-consumer marketing of drugs – Western European countries typically only allow these drugs to be marketed to doctors through specialist publications etc.

None of this is to say that the European system is perfect – drug companies pour an awful lot of money into “seminars” in nice places, golf excursions etc where they try to persuade doctors to prescribe their drugs. But there is a strong pragmatic case to be made that doctors are going to be better informed as a rule than their patients over the benefits and drawbacks of particular courses of treatment (otherwise why use them in the first place?). Thus, they’ll be better able, most of the time, to figure out when pharmaceutical companies are trying to con them into prescribing expensive and potentially dangerous medications where off-the-shelf drugs would work as well or better. Of course, this is not to say that consumers shouldn’t be able to get their hands on relevant information (doctors aren’t infallible) – but it’s surely a bit of a stretch to argue that aggressive TV advertising campaigns provide such information. Thus, I’m pretty well convinced of the case for banning direct marketing of drugs to consumers – it’s a relatively mild form of paternalism, which seems to me to have quite substantial payoffs. Any dissenters out there?

Update: via Bill Gardner, I see that James Surowiecki is similarly critical of the marketing of Vioxx:

But companies like Merck, which spend hundreds of millions on ads targeting consumers, have themselves to blame, too. Instead of getting people to think about drugs in terms of costs and benefits, these ads encourage people to think of medicine in the same way they think of other consumer goods. It would be one thing if Merck had marketed Vioxx only to people who really needed it—people who couldn’t take ibuprofen or aspirin safely. Instead, the company marketed it aggressively to everyone, so that some twenty million Americans had Vioxx prescriptions. That’s why the potential damages against Merck are so vast. If juries have a hard time accepting a risk-benefit trade-off when it comes to drugs, it’s in part because the drug companies have convinced them that no such trade-off has to be made.

{ 24 comments }

1

asg 01.25.05 at 9:12 pm

Why is a ban needed when the damages against Merck could be so high? It seems redundant to allow the tort system to punish Merck for its aggressive advertising, and then also regulate its ability to do so away. Unless you are adopting a Richard Epstein type of view that companies who adhere to FDA regulations ought to receive immunity from product-liability suits, of course.

More broadly, I fail to see how a ban on a certain sort of speech (for that is what marketing is) is “mild” paternalism. Sure, we have a well-established, if spurious, commercial-speech doctrine, but we’re talking about paternalism here, and it amounts to saying that people are too stupid to deal with a certain sort of speech. That may be true, but I hesitate to put that sort of power in the hands of a bureaucrat.

2

JRoth 01.25.05 at 9:34 pm

asg-

Perform any surgery lately? Design any skyscrapers? Wire any buildings?

Why not? Are you too stupid to deal with simple textbooks on these subjects? I’m just glad that there’s no bureaucrat making the decision that only people who know what the fuck they’re doing should be in charge of these life and death decisions.

Yes, a doctor can always refuse to prescribe a less-than-optimal drug to a patient who requests it, but there’s always another doctor, and as long as the requested drug has no clear counterindications, there’s little incentive for a doctor to refuse a patient’s request.

3

Bill Gardner 01.25.05 at 9:49 pm

“[Doctors will] be better able [than patients], most of the time, to figure out when pharmaceutical companies are trying to con them into prescribing expensive and potentially dangerous medications where off-the-shelf drugs would work as well or better.”

Maybe… but do not overestimate what the doctor is likely to know. Often doctors have little idea whether a heavily promoted drug is more effective than a competitor. Often the relevant research hasn’t been done, or the physician hasn’t accessed it. In addition, doctors frequently do not know whether a given medication will be expensive for *this* patient (i.e., will her insurance pay for it). A more effective but expensive drug is not cost-effective for a patient who can’t or won’t purchase it. Finally, if doctors really did know this, I would have fewer concerns about direct-to-consumer advertising — doctors would be better able to screen the patient from inappropriate drugs.

“I’m pretty well convinced of the case for banning direct marketing of drugs to consumers – it’s a relatively mild form of paternalism, which seems to me to have quite substantial payoff.”

I’m not so sure. It is surprisingly hard to change physician behavior (or, I expect, any other professional’s behavior; this is just the literature I happen to know). Sometimes the new drug is better, but it isn’t prescribed as often as it should be. Getting the patient to come in and ask about the new drug is an effective way to influence the physician. Consider also that there are often many persons who suffer from treatable conditions, but who do not seek treatment for them. It is also possible that direct-to-consumer advertising may prompt some of those persons to come in for care.

I’m not arguing *for* direct-to-consumer advertising. My point is that there are plausible benefits along with the apparent risks, and I want to see more data.

By the way, I think the lesson from Vioxx is that we need more federally-funded post-marketing research on the safety and effectiveness of drugs in real clinical practice. The randomized clinical trials used to evaluate drugs for iniitial FDA approval provide necessary but not sufficient information.

4

spd 01.25.05 at 9:49 pm

“even though they would predictably have been better off if they had taken other non-prescription drugs instead”

In order for the ban you suggest to have a positive effect, we must assume that the level of consumption of drugs will remain constant without advertising, and consumers/patients will simply switch to the cheaper drugs. I’m not sure this assumption is supported (or even considered) by the study.

If these ads are banned, certainly some percentage of consumers that would have otherwise sought treatment will remain ignorant and not pursue medication. These consumers are likely worse off than they would have been had they taken overpriced medication.

My point is not that an ad-ban will necessarily harm more people than it helps. However, the ban is certainly not “harmless” from a purely pragmatic perspective. Scientific studies can shed light on the balance of good/harm, but we must acknowledge the negative effects as well as the positive ones.

5

Kieran Healy 01.25.05 at 9:53 pm

Thus, they’ll be better able, most of the time, to figure out when pharmaceutical companies are trying to con them into prescribing expensive and potentially dangerous medications where off-the-shelf drugs would work as well or better.

Off the top of my head, I think that there are some classic papers in medical sociology (one by Jim Coleman, I think) showing that doctors were aware that drug companies were trying push drugs on them, were convinced of their ability to resist the blandishments on offer, and were nevertheless much more likely to prescribe the drugs that the companies were pushing.

6

weboy 01.25.05 at 10:32 pm

The argument against DTC is that it isn’t working – drug companies still get more bang from promoting to doctors than advertising in most categories. DTC has mostly led to heartache – from Wyeth and Premarin to Vioxx with a number of high profile disasters in between. Greater awareness has led to increased scrutiny and often to investigations of sloppy science in bringing drugs to market. It may seem paternalistic (and I too don’t see what’s wrong with that), but when the stakes are as high as loss of life, perhaps there is a heavier than normal expectation that the government should step in.

7

spd 01.25.05 at 10:58 pm

weboy –

I may be misreading your post, but I don’t follow your logic. You seem to say:

1) DTC has increased awareness and scrutiny [of drugs]
2) DTC has led to re-evaluation of the science behind the drugs and their approval.
3) Therefore DTC should be banned to save lives

Is this what you meant to say? Points 1 and 2 are very strong arguments supporting DTC if they’re true. Do you think that banning DTC will improve the “sloppy science in bringing drugs to market”?

8

weboy 01.25.05 at 11:14 pm

The point of DTC is to sell more drugs. I agree points one and two may be valuable from a public safety standpoint, but they are the ancillary effects of what is, in fact, DTC backfiring a succesful strategy for pharma companies. If we want increased scrutiny and slowing down the rush of drugs to market (which I am all for), then do that up front with increased funding and regulatory power for the FDA, not by allowing drug companies to run glossy ads making dubious claims with only minimal warnings regarding efficacy and safety.

9

spd 01.25.05 at 11:41 pm

weboy-
I am no expert on the pharma industry. However, my understanding is that no drug can be brought to market without FDA approval. The FDA requires proof (yrs of study) showing both safety and efficacy of a drug. It has 100% veto power over drugs. What more regulatory power could the FDA need besides the power to keep a drug completely off the market? What more scrutiny is there besides requiring proof of safety and efficacy?

If the FDA is certifying unsafe drugs as safe and we blame DTC for all the problems, we’re ignoring the elephant in the room.

10

Xavier 01.25.05 at 11:57 pm

How about this for a compromise: DTC marketing is banned, but all drugs are available over the counter. That way consumers will be able to make decisions about the drugs they take without undue influence from the industry, but they won’t be limited by FDA restrictions or the need to consult a doctor.

11

Alison 01.26.05 at 12:05 am

spd said

In order for the ban you suggest to have a positive effect, we must assume that the level of consumption of drugs will remain constant without advertising

I think the level of drug use would fall, and this would be a good thing. Americans take a lot more prescription drugs than anyone else on Earth, and this is surely linked to the aggressive marketing that goes on in your country.

(‘More than 40 percent of the population is taking at least one prescription drug, and about 16 percent take three or more’ as of Dec 2004.) These are high levels of medication. And it’s not as if you see lower mortality rates compared to countries with more moderate drug use.

12

weboy 01.26.05 at 12:56 am

Because of the protests from people with AIDS (remember ACT UP?), the time to approval for drugs has been sharply reduced – it was felt that some drugs can show compelling need to be in market with large scale, but short term, safety and efficacy studies. In fact, some side effects take longer to be seen, or to be seen so that significance can be fully understood – like heart problems.

DTC doesn’t cause the problems, it exacerbates them. By making drugs that have received fast track approval widely used in a short period of time (which is the goal of DTC – fast, early adoption of a drug treatment), drug companies are, in effect, conducting their long term longitudinal studies in market. Slowing down the approval process to complete and analyze longer term results would help improve safety and efficacy. The dilemma is that some very useful drugs would be waiting to go in-market when they could be saving larger numbers of lives. The dilemma is very real, but one can argue that we have gone too far in the direction of letting not quite ready for market drugs into the system.

13

nick 01.26.05 at 1:19 am

I first visited the US in 1998, when DTC advertising (on television, at least) was still quite highly restricted. Now I live here, and we have ads for stiffy-pills in prime time. (Remember, a four-hour erection requires immediate medical attention.)

My wife has also told me that doctors actually ask her if she wants to be put on the latest-and-greatest beneficiaries of pharmaceutical marketing. Add in the fact that she works in the mental health sector, and sees psychiatrists regularly given meals, deductible junkets and truckloads of tchotchkes to prescribe brand-name medicines for Medicaid recipients with schizophrenia, and it’s all very depressing.

14

asg 01.26.05 at 1:41 am

jroth,

My mistake; I must have missed where Congress passed a law removing the discretion over whether to have surgery from a patient’s hands. There’s a difference between speech, which is what advertising is, and brain surgery.

15

Anna in Cairo 01.26.05 at 12:52 pm

The suggestion that you ban drug consumer oriented advertising and make all drugs available without a prescription is exactly the situation ehre in Egypt, whree you can walk into a pharmacy and get virtually any drug you want including antibiotics, Tegretol, Prozak and Viagra without any prescription whatsoever. However, there is no drug advertising allowed in the country. Doctors tend to overprescribe because drug companies give them incentives and because they are undereducated and often don’t take the time to do a careful diagnosis but just throw tons of antibiotics at anyone who comes in complaining of cold-like symptoms. But what is the real danger of a system like this is that people tell each other “well I took this really good antibiotic for my flu last week, I think you should take it for your stomach ailment” and then go out and buy this stuff on each other’s advice. It’s a totally insane system. Not to mention that there’s no consumer-oriented language in the pharmaceuticals’ packaging, so non-doctors really don’t understand what it says. For all these reasons I think that idea is insane and will exacerbate the situation you’ve got in the U.S.

16

jet 01.26.05 at 1:39 pm

weboy,

Why wouldn’t the most obvious solution be to limit marketing of fast tracked drugs? That seems the most effective compromise possible.

17

mw 01.26.05 at 2:21 pm

Aaach. These are prescription drugs which means not only have they been FDA approved but that people who see DTC ads can’t buy the drugs unless their physicians agree that they’re appropriate and write a prescription.

That’s plenty of paternalism as it is–we don’t need to ‘help’ people even more by keeping them in the dark as to new developments in medicine.

What’s more — as blog readers should be well aware — trying to keep information the exclusive property of experts and prevent it from reaching the general public is not really feasible any more.

Ban DTC TV ads for new drugs and be prepared for ‘viral’ marketing via email, blogs, web forums, etc to take up the slack.

18

Nicholas Weininger 01.26.05 at 2:27 pm

Doctors are probably more likely to be informed about the general properties of drugs, but a doctor is much less likely to be informed than a patient about the patient’s own values, level of risk tolerance, etc. In a perfect world we might hope that a doctor would give an objective, disinterested explanation to each patient of the tradeoffs involved in various treatment options, and then allow the patient to make up his/her own mind. In the real world, doctors have many biases, some but far from all of which spring from drug company marketing practices, and it is foolish to expect those biases not to have an effect.

So allowing DTC advertising gives patients access to another source of info with which to make decisions about their own bodies. A biased source, to be sure; but it is surely reasonable to expect that adults should be able to recognize it as such and add salt accordingly, and its biases are different from, and thus can potentially serve as a check on, the doctors’ biases.

That’s the consequentialist anti-paternalist argument. The snarkier libertarian argument is, of course, that protecting people from the consequences of their own stupidity is a bug, not a feature– especially when, as in the case of anti-arthritis drugs, their stupid decisions clearly hurt no one but themselves.

19

John Isbell 01.26.05 at 2:29 pm

Clearly the Vioxx marketing campaign is the fault of the trial lawyers. Just listen to the doctors.

20

digamma 01.26.05 at 2:31 pm

But there is a strong pragmatic case to be made that politicians are going to be better informed as a rule than their citizens over the benefits and drawbacks of particular courses of policy (otherwise why use them in the first place?)…. Of course, this is not to say that citizens shouldn’t be able to get their hands on relevant information (politicians aren’t infallible) – but it’s surely a bit of a stretch to argue that aggressive TV advertising campaigns provide such information. Thus, I’m pretty well convinced of the case for banning public political advocacy – it’s a relatively mild form of paternalism, which seems to me to have quite substantial payoffs.

21

Ophelia Benson 01.26.05 at 6:55 pm

But paternalism doesn’t really cover the subject. Most of these comments (in good libertarian style) talk as if decisions about what drugs to take affected only the one person taking the drug. I have only one word to say: antibiotics.

22

Nicholas Weininger 01.26.05 at 7:05 pm

Ophelia: that’s a fair point if limited to antibiotics and other drugs for communicable diseases, but we’re not talking about those (and how often have you seen DTC ads for those anyway?), but about anti-arthritis drugs. Is there any reason to believe that overuse of Vioxx by some will make arthritis treatment less effective for anyone else?

23

nick 01.27.05 at 12:50 am

people who see DTC ads can’t buy the drugs unless their physicians agree that they’re appropriate and write a prescription.

And in a private market, physicians know that if they don’t prescribe drugs that their patients have just seen on TV, they’re likely to lose those patients. So, as long as there aren’t any obvious contraindications, they’ll sign off on the prescription.

And if you deny that, your own knowledge of the American healthcare profession is sadly lacking.

we don’t need to ‘help’ people even more by keeping them in the dark as to new developments in medicine.

Please, tell us the medical knowledge that is gained from watching a Levitra commercial, other than the need to go to the ER to deal with a four-hour erection. DTC dumbs down non-clinicians appreciation of new developments: at worst, it gives them false hopes and misinformation.

Your point was?

24

Bill Gardner 01.27.05 at 5:40 pm

Nick wrote:
“And in a private market, physicians know that if they don’t prescribe drugs that their patients have just seen on TV, they’re likely to lose those patients. So, as long as there aren’t any obvious contraindications, they’ll sign off on the prescription.”

There are two additional variables to consider: does the patient need the medication (a complicated question on its own!) and does the DTC medication cost more (as it frequently does)? DTC is clearly harmful if it encourages prescription in the absence of need or the prescription of more expensive drugs (everything else being equal).

Consider, however, a situation in which the patient needs a drug and there are no obvious contraindications to the DTC drug. I think a doctor might legitimately prefer to prescribe a drug requested by the patient even if it costs more, assuming that the patient knows that it costs more. Over and above her duty to honor the patient’s wishes in the absence of a compelling reason not to, the doctor might prefer to prescribe a drug requested by the patient because he might be more likely to actually take it. It would be interesting to see if DTC affects adherence to prescriptions.

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