DTC: The Pill-Pushing Debate
What do Nexium, Lunesta, Vytorin, Crestor, and Advair have in common? They are the five drugs with the highest direct-to-consumer advertising in the United States.1 Although their brand-name recognition does not rival that of Coca-Cola, their names are familiar to consumers across the nation. As the flag bearers of the direct-to-consumer (DTC) advertising efforts of the pharmaceutical industry, they are at the forefront of the DTC debate. A recent AC Nielsen study found that 17 percent of new prescriptions filled were the result of DTC advertising.2 Furthermore, patients were significantly more likely to refill a prescription that arose from DTC advertising.3
Why debate DTC advertising? In his testimony before the Senate Commerce Subcommittee on Consumer Affairs, Dr. Sidney Wolfe, director of Public Citizen’s Health Research Group, expressed the following concern: “There is little doubt that false and misleading advertising to patients and physicians can result in prescriptions being written for drugs that are more dangerous and/or less effective than perceived by either the doctor or the patient. This can then lead to a subsequent toll of deaths and injuries that would not have occurred had safer, more effective drugs been prescribed.”4 Dr. Wolfe cites the following findings from medical studies as cause for concern:
1. Consumers rate drugs significantly more positively when ads have incomplete risk statements.
2. Consumers believe that there is prior scrutiny of DTC ads by the FTC and that DTC ads are held to a higher standard than other ads. Both of those beliefs are wrong.
3. DTC ads provide only a minimal amount of educational information.
4. When a study asked what patients would do if a doctor refused to prescribe a drug that a patient wanted because of a DTC ad, 25 percent said they would seek a prescription elsewhere; 15 percent said they would terminate their relationship with the physician.5 Another concern relates to opportunity costs and the danger that DTC advertising will siphon funds from other more important purposes. A 2006 report from the United States Government Accountability Office (GAO) found that money spent on DTC advertising “increased twice as fast from 1997 through 2005 as spending on promotion to physicians or on research and development.”6 As of 2007, the United States and New Zealand remained the only two developed countries to allow the practice of DTC advertising.7
Consumer groups claim that one cause of the increase in health care costs is the explosion of DTC ads and the unnecessary medication that results. The advertising seems to work. The sales of the heavily advertised drugs increased by 32 percent compared to 14 percent for other drugs. However, proponents of DTC ads argue that they help patients. Dr. Richard Dolinar, an endocrinologist, says that the ads empower consumers: “Direct-to-consumer advertising is getting patients with diabetes into my office sooner so they can be treated.”8 Most physicians disagree with Dr. Dolinar: 64 percent believe there should be some sort of moratorium on DTC advertising in the United States, 44 percent would approve a moratorium of two years or more, and 27 percent believe that DTC ads should be banned completely.9 Doctors claim it makes it very difficult to prescribe the appropriate medication when a patient comes to the office already committed to the drug he or she wants the doctor to prescribe. This takes much of the diagnosis and prescribing freedom and authority out of the hands of the professionals who should be making these judgments. Dr. Kurt Stange, editor of the Annals of Family Medicine, described the effect of DTC ads on the patient– doctor relationship in an editorial calling for a ban of DTC ads:10 DTC ads manipulate the patient’s agenda and steal precious time away from an evidencebased primary care clinician agenda that is attempting to promote healthy behavior, screen for early-stage treatable disease, and address mental health. The negative consequences of this manipulation of the public, the patient, the clinician, and their relationship are subtle but pervasive. An insidious adverse effect occurs in what is not done during the limited time of a visit. Discussing why the advertised drug is not the best option for a particular patient may mean that a mammogram is not ordered, an important health behavior is not discussed, a family matter is not brought up, a deeper patient concern is never articulated, a diagnosis for which there is no drug ad is not made. The clinician is put in the role of gatekeeper for the advertised commodity rather than a gateway for prioritizing health care based on the concerns of patients and the science-based recommendations for preventive, chronic disease, mental health, and family care.
Questions for Discussion
1. What are the ethical issues in this case?
2. Should DTC advertising be judged by the same criteria as other advertising? If not, how should it be judged differently?
3. What public policy changes would you advocate regarding DTC? Should the United States and/or New Zealand ban them?