Pharma gifts: Is there a free lunch?

My first boss in community mental health had a favorite saying: “There’s no such thing as a free lunch.” But is that really true? 

For many years pharmacy company representatives have been providing physicians and nurses in our organization catered lunches. I believe our organization has tried to informally ban this practice a few times in the past, but it seems to keep returning as new pharmaceutical company representatives are hired and new medications are  promoted.

First of all I think we can all agree that the selection of medications for prescribing  should be based entirely upon clinical evidence, not promotional gifts. What, however,  is the effect of such gifts and  how should they be dealt with by behavioral healthcare organizations.

Staff members may see free food as a minor benefit that does no harm and believe that management is “machine-gunning butterflies”  in trying to ban or regulate this practice. They may see it as a deserved reward for their hard work and argue that it can help keep them on the job since they don’t have time to go out for lunch, anyway.   

Staff members in other departments, however,  who do not get the food,  may see it as an unfair benefit bestowed upon a select few.  The food (including its delivery, setup, aromas, and disposal)  may  be disruptive and place a burden on other staff  members who must clean up after it.

Of course the biggest objection is based on the ethics of the matter. Does a free lunch create a conflict of interest and can it actually bias prescribing practices. 

David Grande from the University of Pennsylvania has written.  “Gifts associated with pharmaceutical detailing are motivated by a single goal - to increase the sales of a company’s  products. Given the evidence that gifts of any value influence the recipient,  states should follow the leadership of Massachusetts and avoid setting financial thresholds that would define the permissibility of gifts. However, they should go further by banning all gifts rather than exempting some such as office-based meals.”  

Ken Johnson,  former  member of the U.S.  House of Representatives and  spokesman for the Pharmaceutical Research and Manufacturers of America (PhRMA) has said, “U.S. physicians are committed to quality health care. It’s part of the oath they take. So, despite what critics say, it’s insulting to suggest that doctors would prescribe treatments based on who gave them a slice of pizza, a pen, or a medical dictionary.”

In response to this, a commenter named  Nishkant wrote:“It may be insulting, but the truth is often unkind.  …If I do something nice for you, you will want to do something nice for me in return. …  So we can angrily demand to know how dare someone accuse doctors of being influenced by promotional freebies?! But that doesn't negate the fact that doctors are human and the rules of evolution and social interaction apply to them too."

According to Jason Dana and George Loewenstein from Carnegie Mellon University, surveys show that many doctors  consider small gifts as “ethically more acceptable”  than large ones and seems to believe that they  don’t  affect  judgments regarding  products. This assumes that physicians are making deliberate conscious choices, which is inconsistent with research regarding  self-serving biases.

No one actually says to themselves: “That drug company makes one fine damn ink pen, I’m sure their medicine is just as good.”  or “That pizza wasn’t nearly expensive or good enough  to make me want to prescribe the drug 'Expensivexa.'  I would  need some Russian caviar to even consider such an action.”

The influence of small premiums is much more subtle and insidious. While most doctors  and medical students  do not see themselves as being biased by freebies, they  openly admit that colleagues and others are. Dana and Lowenstin  say, “This finding is analogous to that from the social science research showing that bias is recognizable, but only in others."

One  group  of healthcare professionals have banded to oppose the acceptance of any gifts from pharmaceutical companies. At their website  https://nofreelunch.org  they say,  “We are health care providers who believe that pharmaceutical  promotion should not guide clinical practice. Our mission is to encourage health care providers to practice medicine on the basis of scientific evidence rather than on the basis of pharmaceutical promotion. We discourage the acceptance of all gifts from industry by health care providers, trainees, and students. It is time to just say no to drug reps and  their pens, pads, calendars, coffee mugs, and of course, lunch.”

This group is also opposed to the acceptance of sample medications. In addition to ethical, accreditation, and legal risks, they cite several studies showing that the use of samples can lead to inappropriate prescribing practices. The use of sample medications is a whole other can of worms that we won’t pursue at this time.

I have asked some colleagues how they deal with freebies and many ban it altogether, some are quite permissive, and others allow it  only under tight regulation with inclusive  formal presentations  that must be  open to all.

In  their  October 2003 report regarding Veteran Administration (VA)  practices  the National Center for Ethics in Health Care emphasized the importance of avoiding  even  the appearance of a conflict of interest in such situations,  saying ,  “VA health care professionals also cannot accept gifts that result in or appear to involve use of their public office for private gain. For example, if a VA physician were to repeatedly accept a drug manufacturer’s offer to pick up the lunch tab at their regular meetings, it might appear that lunch was being provided in order to reward or encourage that physician to continue recommending the company’s product to VA patients.

Where does your organization stand or should I say dine?