Running head: ETHICAL CONSIDERATIONS BETWEEN DOCTORS AND PHARMACEUTICAL AGENTS Amanda Fox MPH 560 Dr. Toland June 20, 2014 Fox 1 Ethical Considerations Between Doctors and Pharmaceutical Agents Fox 2 Prescription medications have many purposes; mainly to cure and alleviate diseases, as well as reduce pain. There is a great history of medication use dating back to Egyptian Civilizations around 3000 BC. "Egyptian doctors used a huge range of drugs obtained from herbs and minerals. They were drunk with wine or beer or sometimes mixed with dough to form a 'pill'. Egyptian doctors also used ointments for wounds and they treated chest complaints by getting the patient to inhale steam" (Lambert, 2014). Much progress has been made in the making and distribution of medicine since ancient times. The biggest jump of progress occurred in the 19th and 20th centuries. Some of these advancements included the first non-direct blood transfusion, first use of insulin, creation and use of the EEG machine, and the discovery of antibiotics and many other drugs (Lambert, 2014). Prescription drugs play a major role in society today. In order for an individual to receive a prescription medication, it must be prescribed by a medical professional including doctors, psychiatrists, dentists, and nurses. With that being said, there is a relationship between these health professionals and pharmaceutical agents. This correlation involves billions of dollars of prescription medications being prescribed annually. Many prescription drugs are prescribed daily, the question is are all these drugs necessary? Ethically, are doctors and pharmaceutical companies in the wrong for prescribing prescription medication without informing their patients of a natural way of taking care of their health issue? Every year, the amount of prescription medications that are prescribed to individuals continue to increase. America is known as the nation of pill poppers due to the amount of prescription medications that are taken daily. In 2010, nearly thirteen prescriptions were prescribed per man, woman, and child (Global Research, 2014). "We’re one of only two countries in the world which allows direct-to-consumer Rx advertising; and Rx have slowly Ethical Considerations Between Doctors and Pharmaceutical Agents Fox 3 grown to be the third highest medical cost" (Global Research, 2014, pg. 1). In 1980, prescription medication usage was a $12 billion industry. In 2010, this industry has grown to costing around $275.6 billion. This is a significant jump in the past few decades, just showing the amount of growth this particular field has had. In 2010, there were around 4.02 billion prescriptions filled, which cost the average American around $898 in prescription spending (Global Research, 2014). America's prescription costs drastically outweigh prescription costs around the world. In developing countries, the average citizen will pay around $609 per year by 2016, and in emerging countries, the average citizen will pay around $99 per year by 2016 (Global Research, 2014). Currently, in the United States, prescriptions are the fastest growing sector in healthcare costs. The only two healthcare costs that are ahead, for just a short period of time longer, are hospital care and clinical services (Global Research, 2014). The highest money making medications include Antidepressants, Attention Deficit Hyper Disorder drugs, and sleeping medications. Almost every age group takes prescription medication. Prescription medication use tends to increase with age, although a large amount of children are taking medications. "In 2007-2008, 1 out of every 5 children and 9 out of 10 older Americans reported using at least one prescription drug in the past month" (CDC, 2010, pg. 1). As stated above, there is a variance in prescription medication use due to age. In 2008, less than 10% of children under the age of twelve used two or more prescription drugs, and 1% used five or more (CDC, 2010). Of older American's aged 60 and above, 76% of them used two or more prescription drugs and 37% used five or more (CDC, 2010). As far as ethnic backgrounds, "the non-Hispanic white population had the highest prescription drug use and the Mexican-American population had the lowest" (CDC, 2010, pg. 1). Ethical Considerations Between Doctors and Pharmaceutical Agents Fox 4 Who is prescribing all these prescription medications being consumed in the United States? Health care professionals such as doctors, dentists, psychiatrists, nurses, etc. prescribe medications out to patients for many reasons. These health care professionals work alongside pharmaceutical companies and pharmacists to get and prescribe the right medications to their patients. "When it comes to medication safety, the doctor, the pharmacist and the individual need to work together as a team. It’s the doctor’s responsibility to prescribe the most appropriate medication for and individual, and it’s the pharmacist’s responsibility to accurately fill the prescription as it is written" (Richards, 2014). Although these health care professionals are meant to help the overall health of each patient, new questions have risen on the true relationship between pharmaceutical companies and health care professionals. The health care industry consists of many different professionals. One particular group of people whom play a vital role are pharmaceutical sales representatives. The overall job of a pharmaceutical sales representative includes educating health care professionals on their employers products, offering insights into new types of therapy, helping these professionals to provide quality care to their patients, and helping patients maintain good health (Abbot, 2013). The problem that arises with pharmaceutical sales representatives is whether or not they are more interested in making a sale, or actually educating health care professionals on specific products. With that being said, for the past few years, these sales representatives were more-so known as salespeople, interested mainly in meeting sales goals. In order to reach their target sales goals, these representatives would get doctors and other health care professionals to buy into intricate gifts they offered. "From giving doctors elaborate gifts and experiences to recommending off-label uses for drugs, the pharmaceutical industry had a reputation for playing fast and loose with ethics in the name of the sale" (Abbot, Ethical Considerations Between Doctors and Pharmaceutical Agents Fox 5 2013, pg. 1). Pharmaceutical company's would hand out pens, notepads, stress balls, mouse pads, etc. that could be found in most doctors and health care professionals offices. "On any given day, these representatives may be spotted carrying in bags of takeout food for the office staff, all in an effort to gain a few moments of a busy doctor’s time to pitch the latest and greatest drugs offered by their company " (Abbot, 2013, pg. 1). As stated above, the purpose of pharmaceutical reps included educational events to inform doctors of their products. These educational events would involve a short pitch on the prescription drugs, and would then be followed by a fancy meal, sports outing, or show experience. The doctors and health officials would get the "best of the best" during these outings, such as front row seats at a sporting event. These components were all done in order to persuade doctors to listen, and of course choose that particular product over others. The issue arises because health care and prescription medications are not something to be compromised with. Pharmaceutical sales reps are to fully present the benefits, risks, and side effects of the medications, in order to help health care professionals make the best choice when it comes to choosing a medication (Abbot, 2013). When it comes to the elaborate gifts, doctors were more-so being bribed than informed on the product: The competition inherent in the pharmaceutical industry — companies spend millions developing, researching and marketing their products — puts undue pressure on sales and marketing teams to make sales. And due to doctors’ busy schedules (few are willing to sacrifice patient care time to meet with salespeople) and the fact the drug company’s bottom line is riding on sales, some representatives resorted to these less-than-ethical means to sell (Abbot, 2013, pg. 1). Ethical Considerations Between Doctors and Pharmaceutical Agents Fox 6 As aforementioned, doctors were being bribed on products. They were not taking the time to fully understand the product they were purchasing, but looking at the best perks that would walk into their office. From an ethical standpoint, this is wrong for patients going into these doctors offices and being prescribed these drugs that the doctors were just bribed to purchase. Another ethical consideration to take a look at with doctors and patients, in particular, are the amounts of medications being prescribed. Because doctors offices and pharmaceutical companies have a relationship with each other, a viscous cycle takes place as far as doctors continuously prescribing medication, which in turn allows them to receive many gifts, and finally leads to paying the pharmaceutical companies. "The aggressive marketing strategies by the companies just act as tools of information for them. But the prescribing behavior of a vast majority of the medical community is palpably influenced by pharmaceutical companies" (Bansal & Das, 2005, pg. 40). When a physician sees a pharmaceutical rep, they ultimately believe that these interactions will involve some type of educational value, while also having a beneficial component to their patients. Physicians see this as an opportunity to kept up-to-date on current prescriptions and therapeutic agents, and also allowing those patients who could not afford some prescriptions, free drug samples which are given out by different companies (Bansal & Das, 2005). With that being said, a new consensus is occurring that doctors are prescribing more expensive brands of medication because of "quality." It is an open secret that the professional associations depend solely on pharmaceutical companies to sponsor their medical programmes viz., CME's, Conferences, Annual Meeting, Workshops etc. Many junior as well as senior physicians seek sponsorships or financial aids from these companies to attend national as well as International Conferences" (Bansal & Das, 2005). As stated above, even pleasure trips are planned for doctors and immediate family members that are arranged by pharmaceutical Ethical Considerations Between Doctors and Pharmaceutical Agents Fox 7 companies. When doctors are offered all of this, they tend to reciprocate the favor by purchasing and prescribing the medical drugs from those particular companies (Bansal & Das, 2005). This then leads to the over-prescribing of medications. A lot of the prescription usage could be eliminated if doctors informed and educated patients on how to eat healthy and exercise. This is not a regular practice in doctor's offices, though. As health care officials go through school, nutrition and exercise are touched on, but a main area of education goes to pharmacology and the understanding of prescription medications, as well as the impact the medication has on the body. As seen above in current statistics, the pharmaceutical company is almost the top spending area in health care costs. These companies have a lot of power within the United States. Some professionals may see this as a downfall, because these companies are not interested in the actual health of individuals, rather making money off of the medications being sold. This then ties into doctors, because of the incentives doctors are receiving to give out certain pharmaceutical companies products. Contrary to prescription use, are many new studies being done in the past few decades to get a thorough understanding of chronic diseases, and diseases in general, in which many individuals are spending tons of money on prescription medications to treat. Chronic diseases are the leading cause of death in the United States. These diseases consist of heart disease, stroke, cancer, diabetes, obesity, and arthritis. Billions of dollars are spent on prescription medication and treatment approaches to treat these diseases. In 2012, around half of the adult population had one or more of these chronic conditions (CDC, 2014). Heart disease and cancer accounted for around 48% of all deaths in 2010 (CDC, 2014). " Health risk behaviors are unhealthy behaviors you can change. Four of these health risk behaviors—lack of exercise or physical activity, poor nutrition, tobacco use, and drinking too much alcohol—cause much of the Ethical Considerations Between Doctors and Pharmaceutical Agents Fox 8 illness, suffering, and early death related to chronic diseases and conditions" (CDC, 2014, pg. 1). Studies done in 2011 found that more than half of adults aged 18 and over did not meet the recommendations for physical activity, particularly with aerobic exercise, and more than 76% of these individuals did not meet the requirements for strength training (CDC, 2014). " In 2011, more than one-third (36%) of adolescents said they ate fruit less than once a day, and 38% said they ate vegetables less than once a day. In addition, 38% of adults said they ate fruit less than once a day, and 23% said they ate vegetables less than once a day" (CDC, 2014). Two other components that play into these chronic health diseases, which are preventable, are cigarette smoking and alcohol consumption. In 2012, around 42 million adults, one out of every five, currently smoked (CDC, 2014). The current statistics show that cigarette smoking is responsible for around 480,000 deaths per year. "Each day, more than 3,200 youth aged 18 years or younger smoke their first cigarette, and another 2,100 youth and young adults who smoke every now and then become daily smokers" (CDC, 2014, pg. 1). As aforementioned, alcohol consumption also correlates to chronic diseases and death. Alcohol is responsible for around 88,000 deaths per year, and half of which are due to binge drinking (CDC, 2014). "About 38 million US adults report binge drinking an average of 4 times a month, and have an average of 8 drinks per binge, yet most binge drinkers are not alcohol dependent" (CDC, 2014, pg. 1). All of these behaviors are costing America billions in health care costs, which correlates to prescription costs and use. Some of these costs in 2010, according to the Center for Disease Control, included $315.4 billion for heart disease and stroke, $157 billion for cancer, $245 billion for diabetes, $128 billion for arthritis, $289 billion for smoking, and $223.5 billion for drinking (2010). All of these diseases and health risks can be prevented and eliminated with the Ethical Considerations Between Doctors and Pharmaceutical Agents Fox 9 incorporation of healthier lifestyle habits. Again, many doctors and health care providers do not provide their patients this type of information while they are sitting in their offices. Many studies have shown that eating a high nutrient-dense diet, along with exercise drastically reduce the risk of chronic diseases. Many individuals believe that genetically they are prone to these particular diseases as they age, and then go on prescription medications until they end up dying from a chronic illness. Doctors go along with this line of thinking, and never inform patients about the importance of a nutritious diet and exercise. The specific way a person lives and their choices with nutrition and exercise outweighs genetics, for the most part. "Nutrition, exercise and environment simply overwhelm genetics. For example, those living in rural China have less than 2% heart disease risk, but when they move to America their children have the same dismal statistics as other Americans" (Fuhrman, 2014). With nutrition, American's eat processed and packaged foods because of the convenience. These particular foods do not contain the right nutrients the body needs to fight off diseases. Recently, scientists have discovered the importance of two specific nutrients that are vital to have in the daily diet; phytochemicals and antioxidants. Around 12,000 new phytochemicals have been identified by scientists in the past few decades that has created excitement. "These compounds work synergistically to detoxify cancer-causing compounds, deactivate free radicals, enable DNA repair mechanisms, and play a major role in human immune system defenses" (Fuhrman, 2014, pg. 1). These phytonutrients are only found in fresh fruits, vegetables, beans, and raw nuts. When these types of nutrients are missing from the diet, chronic disease flourishes. The typical American diet consists of high saturated fat and high trans-fat foods. "Americans eat about 40 percent of calories from animal products and 50 percent of calories from processed foods such as oil, sugar and white flour products" (Fuhrman, 2014, pg. 1). Most Ethical Considerations Between Doctors and Pharmaceutical Agents Fox 10 animal products, especially cheese and milk, are high in saturated fat and cholesterol. Saturated fat consumption correlates to cancer, and high cholesterol consumption correlates to heart disease. "Neither animal products nor processed foods contain antioxidants, bioflavonoids, caratenoids, folate, vitamin C, vitamin K or those thousands of phytochemicals that are essential for cellular normalcy" (Fuhrman, 2014, pg. 1). Several animal studies were done to prove this philosophy. Researchers found that when you feed an animal less food, but food that was high in nutrients, it will live much longer. Also, the thinnest animals always outlive the heavier ones. Excess calories are harmful to all animals, as well as humans. When humans consume a high calorie, low nutrient diet, disease flourishes. "When we consume calories without an accompanying nutrient load, it puts a major stress on the body, and promotes cellular aging. The ability of each cell to maintain internal cleanliness and prevent degeneration or aging is dependent on fueling its functions with an assortment of nutrients, including anti-oxidants and phytochemicals" (Fuhrman, 2014, pg. 1). Exercise also promotes health by allowing individuals to maintain a healthy weight, increases the body's efficiency, reduces the risk of disease, and improves the state of mind. Looking at the benefits of nutrition and exercise, and the importance of implementing these two components into daily life, some may question why doctors do not touch on this with higher magnitude. If doctors really started telling their patients about these two components, especially the thorough details, and patients abided by it, pharmaceutical companies would start going out of business. Ethically, doctors should inform their patients of everything, especially if it reduces their disease risk drastically. It is a viscous circle of money and presents between pharmaceutical companies and health care professionals. Not all health care professionals buy into the medication side, but a majority does, and that is why prescriptions are one of the top Ethical Considerations Between Doctors and Pharmaceutical Agents Fox 11 spending items in health care. If more patients knew how to actually take charge of their health, and prevent and reverse disease, many of the chronic illnesses would be eliminated, and prescription drug usage would decrease drastically. The question is, would this ever happen? Again, ethically doctors are supposed to look at their patient on an individual basis, and prescribe the best treatment for the patient. Many believe it is prescribing a prescription medication, and then telling the patient to come back in six months to a year to adjust the medication, if necessary. Most doctors are not informing their patients of how to take charge of their own health, and live a healthy lifestyle. Ethically, the prescription drug companies and doctors are wrong in their thinking and practice. Every individual deserves a right to be educated and informed on every treatment approach, and then make up their own mind on which approach they want to take. The spending in health care could be drastically reduced, if more implemented the approach of nutrition and exercise, over prescription medication. Ethical Considerations Between Doctors and Pharmaceutical Agents Fox 12 Works Cited Abbot, A. (2013). Ethical issues in pharmaceutical sales. Retrieved on June 20, 2014, from http://worldofdtcmarketing.com/ethical-issues-in-pharmaceutical-sales/guest-post/. Bansal, R., & Das, S. (2005). Unethical relationships between doctors and drug companies. Retrieved on June 21, 2014, from http://medind.nic.in/jal/t05/i1/jalt05i1p40.pdf. Center for Disease Control. (2014). Chronic diseases and health promotion. Retrieved on June 22, 2014, from http://www.cdc.gov/chronicdisease/overview/. Center for Disease Control. (2010). Prescription drug use continues to increase. Retrieved on June 22, 2014, from http://www.cdc.gov/nchs/data/databriefs/db42.htm. Fuhrman, J. (2014). Eat to live, the basics. Retrieved on June 22, 2014, from http://mychristiancare.org/eattolivethebasicsarticle.aspx. Global Research. (2014). Pill nation usa; are american's over-medicated? Retrieved on June 22, 2014, from http://www.globalresearch.ca/pill-nation-are-americans-overmedicated/5367349. Lambert, T. (2014). A brief history of medicine. Retrieved on June 22, 2014, from http://www.localhistories.org/medicine.html. Richards, K. (2014). Your doctor, your pharmacist, and you. Retrieved on June 23, 2014, from http://www.healthcentral.com/chronic-pain/doctors-161607-5.html.