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Profits Before People?Review - Profits Before People?
Ethical Standards And the Marketing of Prescription Drugs
by Leonard J. Weber
Indiana University Press, 2006
Review by David M. Wolf, M.A.
Jan 15th 2008 (Volume 12, Issue 3)

This thoughtful book of business ethics knows its purposes: "an effort to understand the proper place of commercial interests in marketing prescription drugs" (p 4) and "to consider the kinds of concerns and standards and marketing-related practices that the public can legitimately demand" (of the pharmaceutical industry) (p. 8). Medical professionals, in particular, will want to read this book; so too will people worried about the effects of big pharmaceutical companies on health care for Americans. Ideally, that should include just about everybody, but as a practical matter perhaps, particularly students in business or medicine, policy makers and legislators, those in advertising and media, and people working for pharmaceutical manufacturers.

It is clear from the statement of those purposes that their purview is broadly conceived, and accordingly, Weber's treatment is suitably detailed, even at times complex. The book contains a great deal; think of it as a textbook despite a concise treatment in 197 pages with notes, plus index.

The author alludes to an increasingly critical climate in which big pharmaceuticals market their products to medical practitioners and to the public. Weber says most Americans are persuaded that profits, not the health and welfare of people, is the prime concern of prescription-drug manufacturers. The case for this is more assumed than demonstrated, held as part of our common experience. The ethical focus of the book is meant to answer the following general questions: What are the harms, and what can be done to mitigate the harms of commercial marketing of prescription drugs?

The book's structure has three parts: I-- "Limits of Commercial Interests" about ethics in profit-making business and the various "stakeholders" of the big pharmaceuticals; II-- "Marketing to Healthcare Professionals"; and III-- Marketing to the Public" which is mostly concerned with "DTC," direct-to-consumer advertising.  The topics themselves actually press with increasing urgency as the focus moves from initially esoteric ethical analysis to the real effects of television ads on consumers.

The first part "provides a framework" to understand the ethical responsibilities of pharmaceutical companies. Much of that framework is laying a basis for ethics itself as inherent in profitable enterprise. "Business ethics" is not an oxymoron, Weber shows. Ethics is not only good for business it is good business. The tattered adage, "The business of business is business," has been falsified by experience and today's "business philosophy" (p. 13). Furthermore, the ethics of business is not about individuals or their charity so much as it requires the commitments of entire organizations. These responsibilities must be lawful but necessarily go beyond the law to encompass "higher" ethical standards, those in which harms to all stakeholders are avoided or minimized.

Meeting these higher ethical demands while also preserving profits is how the conflicts and difficulties arise; Weber makes the kinds of philosophical distinctions needed to chart these domains. The most important distinction is simply to recognize that prescription drugs are not like other commodities, because they are prescribed, not freely chosen by consumers.

Another important distinction in Part I. is "stakeholder" a metaphor displaced from "shareholder" and a new locution widely used and accepted now in business parlance. Without this named category, Weber's analysis wouldn't be possible. His essay on "stakeholders" is a good one, but he defines "stakeholder" quite broadly, even including "those who have not voluntarily associated themselves" with the pharmaceutical company "at all."  Later, he fully supports this when it becomes clear how much prescription drug marketing penetrates the lives of us all, even without our informed consent.

Weber cites a set of ethical principles, "The Clarkson Principles" promulgated by a group of scholars in 1999. These provide a firm foundation for his case concerning the ethical responsibilities of the pharmaceutical industry. There are seven principles and they apply to the range of stakeholders by and through the actions of managers. Weber interprets and expands upon these principles, supporting and proscribing various approaches and methods of management.

It's not surprising that Weber's analysis is plainly based in the rich possibilities inherent in this recent distinction "stakeholder." The latter is somewhat dominant in recent years as a way of seeing the corporate reality, that is, it provides in itself a meta-map or a new way to divide up the domain of any enterprise and its supporting environment: hence, the prominent place of the Clarkson Principles in Weber's volume.

 This reviewer did find in reading his Introduction and Part I a characteristic caution, or perhaps hesitation, in the language Weber uses. He writes "may be" and "should be" where a declaring verb belongs.  Other times, he is needlessly but intentionally repetitious when he wants to give emphasis to important points. In such instances, he would have been better served by stating enthymematic propositions, that is, making stronger, better inferences. There is also a recurring vagueness about the use of some terms, such as "common" and even the prime distinction "stakeholder." If this is Weber's chosen way of proceeding, it nonetheless gives an initial impression of fear--the sense he is treading too lightly among controversies, sees them more as a mine field than fields worth mining for ore.

Whatever the source of these reserves of assertion, Weber finds his feet with increasing sureness in Part II and Part III. Part II is about the impact of big pharmaceuticals on scientific integrity and medical professionalism. The ways in which prescription drugs are marketed to physicians, leads to conflicts of interest for medical professionals, researchers, and others involved. Weber sorts out how to resolve or at least minimize these conflicts.

The really important idea Weber brings to light has to do with a fateful flaw in the industry's code of ethics and conduct. That error is a reliance on a distinction between gifts to professionals for their own use--disallowed by the code--and gifts of benefit to patients, mostly permitted (with qualifications). Weber makes a cogent case that the distinction breaks down and that in practice the code is failing to create a climate of ethical conduct. The entire medical profession is affected adversely, research is compromised, and drugs are sold using outright manipulation, nor rational persuasion.

Chief among the gifts permitted, both in terms of influence and dollar value, are the massive quantities of "free samples," that is, expensive new drugs without charge, given doctors. Weber reports that in 2001 the industry distributed a colossal $12 Billion of these drug samples. The unethical implications of this feigned largesse are not easily apparent, but Weber outlines them effectively and in detail. He lays out an agenda for action and identifies eleven sets of practices that need attention. What is at stake is the integrity of medical practice itself and the quality of care provided to the nation. Weber promotes higher ethical standards as the primary means by which to protect both. He then concludes Part II with standards to protect, as well, the scientific integrity of clinical trials, an area systematically distorted by industry exploitation and chicanery.

Part III is most readable and its analysis most laudable. "Marketing to the Public" makes it clear why the US is now ranked 22nd among the 23 industrial nations of the earth in life expectancy (just ahead of Czech Republic). The healthcare system is "by far the most expensive" (p. 143), and no small portion of these high (and increasing) costs is prescription drugs. The fundamental ethical consideration is that consuming medications is not like buying and using other products and services. The essential distinction derives from the fact that prescription drugs are not often free choices by consumers: they result from doctor's choices, and increasingly, from confusing interactions between marketers, endless TV ads, drug companies, researchers and the FDA. The public needs access to clear and reliable information, but pharmaceutical companies thwart this need in their quest for larger profits. Yet, profits must be accommodated, says Weber. How these conflicts are resolved has everything to do with the "higher ethical codes" whose need and outlines he articulates.

© 2008 David M. Wolf

David M. Wolf, M.A. has been leading a Philosophy Evening twice- monthly for the past year at Yoga Bookstore & Cafe in Honesdale, PA. He is the author of Philosophy That Works, a book about the foundations of knowledge, truth, and philosophy; you can read sections at Google Book Search or Chapter One at http://www.xlibris.com/philosophythatworks. David is presently working on a new novel, and a growing collection of sonnets, and other works.

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