Biomedical ethics

COMMENTARY

A Social Science Perspective on Gifts to Physicians From Industry Jason Dana, MS George Loewenstein, PhD

A CONFLICT OF INTEREST EXISTS WHEN A PRIMARY ETHI- cal or professional interest clashes with financial self-interest, a situation that arises commonly in medical practice. When physicians are remuner-

ated for performing specific tests and procedures, they face a conflict of interest when they also recommend those same tests and procedures. When they are paid for referrals to clini- cal trials, physicians are in the conflicted position of decid- ing whether their patients are appropriate for the studies. Performing industry-supported research, physicians face an implicit demand for a positive finding to obtain further fi- nancial support. And, when pharmaceutical companies court high-volume prescribers, writing prescriptions becomes an act not only with financial and health consequences for pa- tients, but also with financial consequences for the physi- cian. This last source of conflict of interest is the central fo- cus of this commentary.

In discussions of gifts from industry, whether in medical journals, the media, or in political debates, it is possible to glimpse a common perspective. The biasing effect of ac- cepting gifts is treated as a matter of deliberate choice. The conventional perspective on accepting gifts implies that phy- sicians who are biased by the prospect of personal gains are deciding to do something unethical. Undoubtedly, this per- spective contributes to the indignation with which many phy- sicians respond when it is suggested that gifts create bias. Because the bias is seen as intentional, an allegation of bias is an implicit accusation of impropriety.

Many policies dealing with conflict of interest seem premised on this understanding of bias. For example, con- sider policies on gift size. The recent guidelines for indus- try put forth by the Pharmaceutical Research and Manufac- turers of America1 and the recommendations of the Office of Inspector General of Health and Human Services2 define gifts of “more than nominal value” as inappropriate, while small gifts may not be. Surveys reveal that physicians also view small gifts as ethically more acceptable than large gifts,3,4

and letters to medical journals assert that small gifts do not affect physician judgment toward a product.5 These poli- cies, surveys, and letters reveal a belief that small gifts are not tempting enough to influence physicians’ prescrip-

tion choices, as if physicians are making a deliberate trade- off between the cost of bias and the benefit of the reward.

This deliberate choice view is inconsistent with social sci- ence research, which shows that even when individuals try to be objective, their judgments are subject to an uncon- scious and unintentional self-serving bias. When individu- als have a stake in reaching a particular conclusion, they weigh arguments in a biased fashion that favors a specific conclusion. Returning to the example of gift size, by subtly affecting the way the receiver evaluates claims made by the gift giver, small gifts may be surprisingly influential. Fur- thermore, individuals are generally unaware of the bias, so they do not make efforts to correct for it or to avoid con- flicts of interest in the first place.

We review basic social science research, which shows how financial motives distort judgment, demonstrate its paral- lels to medical research on gifts to physicians from indus- try, and draw out policy implications. A proper policy re- sponse to the issue of gifts from pharmaceutical companies critically depends on a realistic understanding of the psy- chology of conflict of interest. Policies that make sense if bias is interpreted as a matter of deliberate choice (eg, lim- iting gift size, educational initiatives, and mandatory dis- closure of interests) are unlikely to be effective if bias is in fact unintentional and unconscious. We focus on the prob- lem of gift giving from industry because it serves as a con- venient example with which to demonstrate our basic points. However, the implications of the social science findings ap- ply more broadly to policies dealing with virtually all con- flicts of interest in the medical and health care fields, and to conflicts of interest in areas outside of medicine.

Gifts From Industry: A Problem for Policy Makers Gifts from the pharmaceutical industry contribute to the rap- idly increasing cost of medical care, and more specifically, to the increase in expenditures on prescription drugs. Re- tail spending on prescriptions has increased rapidly, more than doubling from $64.7 billion to $132 billion in the years 1995-2000.6 Drug spending increased another 17% to $154.5 billion in 2001, with an estimated one quarter of this in-

Author Affiliation: Department of Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, Pa. Corresponding Author: Jason Dana, MS, Department of Social and Decision Sci- ences, 208 Porter Hall, Carnegie Mellon University, Pittsburgh, PA 15213 (e-mail: [email protected]).

252 JAMA, July 9, 2003—Vol 290, No. 2 (Reprinted) ©2003 American Medical Association. All rights reserved.

at STANFORD Univ Med Center on March 15, 2011jama.ama-assn.orgDownloaded from

crease resulting from a shift to the prescribing of more ex- pensive drugs. Pharmaceutical companies employ repre- sentatives who meet with physicians with apparent success to aggressively promote newer and typically more expen- sive drugs. A positive correlation has been found between the cost of physicians’ treatment choices and their amount of contact with pharmaceutical company representa- tives.7,8 Wazana9 concluded on the basis of a review of 29 empirical articles that physician interactions with pharma- ceutical companies led to increased prescription costs and nonrational prescribing. This increase is problematic, given the prevalence of new, expensive drugs of questionable in- cremental value. From 1989 to 2000, the US Food and Drug Administration judged 76% of all approved new drugs to be no more than moderate innovations over existing treat- ments, with many being a modification to an older product with the same ingredient.10 In 2000, the average price of these standard-rated new drugs was nearly twice the average price of existing drugs prescribed for the same indications.10

Social Science Research on Conflict of Interest A line of research with important implications for financial conflict of interest examines the “self-serving bias”11 in per- ceptions of fairness: individuals’ judgments of what is fair are typically biased in favor of their self-interests. In early experiments by Messick et al,12 individuals performing a task were given pay for themselves and another individual per- forming the same task and asked to divide it as they saw fit. They were told that (1) the other individual worked twice as long at the task; (2) completed twice as much work; (3) both; or (4) neither. Individuals kept more than half if they either worked longer or completed more of the task, but felt that an equal division was appropriate when both dimen- sions were unfavorable to them.

This behavior helps to illuminate the psychological mecha- nisms underlying financial conflicts of interest. In many situ- ations, there are multiple interpretations of what is consid- ered fair. Actions that do not fall under any of these interpretations are usually considered unfair with little dis- agreement, but when there are multiple notions of fair- ness, individuals tend to default to those notions that favor their own interests. In the study by Messick et al,12 there were 2 competing notions of fairness: equality of payoffs and pay based on effort. When individuals responsible for dis- tributing the pay worked shorter hours and produced less output, they tended to view equality as fair, but when they worked longer or produced more, they viewed pay based on effort as fair and believed that whichever measure of ef- fort favored them was more important.

In a series of experiments that examined the causes and consequences of self-serving bias,13-16 bargaining experi- ments were conducted in which individuals were pre- sented with case materials (depositions, police reports, etc) from an actual lawsuit, were randomly assigned to the role of either plaintiff or defendant, and attempted to negotiate

a settlement in the form of a payment from defendant to plain- tiff. At the outset, the defendant was given a monetary en- dowment to finance the settlement. Both parties were pe- nalized as a function of how long it took them to reach a settlement, and, if they failed to settle, the defendant’s pay- ment to plaintiff was determined by a neutral judge who had been given the same case materials.

Before negotiating, individuals were asked to predict the judge’s ruling and were paid for their accuracy. Plaintiffs’ pre- dictions of the judge’s award amount were substantially higher than those of defendants, despite the fact that they had no bearing on the case, and the larger the discrepancy, the lower was the likelihood of settlement and hence the individuals’ payoffs. This suggests that individuals are often unable to avoid bias, even when it is in their best interest to do so.

In subsequent experiments using the same paradigm, in- dividuals were asked to rate the importance of 8 arguments favoring the side they had been assigned (plaintiff or de- fendant) and 8 arguments favoring the other position, as per- ceived by a neutral third party.14 The results showed a strong tendency to view arguments supporting an individual’s own position as more convincing than those supporting the other position, further illustrating the difficulty that individuals have in taking a neutral, objective perspective when they have a personal interest in arriving at a specific conclusion. Moreover, when individuals were assigned roles only after reading the transcripts, thus removing any motivation to fa- vor one side when the materials were evaluated, bias was reduced and settlement rates increased markedly. All of these findings suggest that self-interest distorts the way that in- dividuals weigh arguments.

In later studies, the same researchers attempted to re- duce bias by educating individuals, describing these behav- ioral regularities in detail, and testing to make sure they were understood.17 This intervention was successful insofar as in- dividuals became convinced that their negotiating oppo- nent would be biased, but the individuals themselves be- lieved they would not be. Moreover, when individuals did concede that they might be somewhat biased, they tended to drastically underestimate how strong their bias would be.

These studies help to explain specifically how self-interest affects decision making. First, individuals are unable to re- main objective, even when they are motivated to be impar- tial, demonstrating that self-serving bias is unintentional. Sec- ond, individuals deny and succumb to bias even when explicitly instructed about it, which suggests that self- serving bias is unconscious. Third, the studies show that self- interest affects choices indirectly, changing the way individu- als seek out and weigh the information on which they later base their choices when they have a stake in the outcomes.

Evidence in Medicine The medical literature dealing with conflict of interest bears similarities to the social science literature reviewed herein. Like the participants in the studies who did not view them-

COMMENTARY

©2003 American Medical Association. All rights reserved. (Reprinted) JAMA, July 9, 2003—Vol 290, No. 2 253

at STANFORD Univ Med Center on March 15, 2011jama.ama-assn.orgDownloaded from

selves as biased, physicians typically report that they are not biased by financial arrangements with pharmaceutical com- panies, although a large body of research suggests that they are.18-23 For instance, one retrospective study24 tracked house staff who attended a grand rounds given by a pharmaceu- tical company speaker and found them more likely to in- dicate that company’s drug as a treatment than did their col- leagues. However, many of the house staff did not recall what company sponsored the grand rounds.

Although most physicians do not perceive themselves as biased, they do admit that conflicts of interest might com- promise other physicians’ decisions.25 A recent study of medi- cal residents26 found that 61% reported that “promotions don’t influence my practice,” while only 16% believed the same about other physician’s practices. Clearly, it cannot both be true that most physicians are unbiased and that most other physicians are biased. Furthermore, medical stu- dents recognize gifts as more problematic for other profes- sions than they are for medicine.27 This finding is analo- gous to that from the social science research showing that bias is recognizable, but only in others.

Like other self-serving biases, bias in prescription prac- tices appears to be unintentional. Orlowski and Wateska28

tracked the pharmacy inventory usage reports of 2 drugs after 20 physicians at their institution were sponsored to at- tend continuing medical education seminars sponsored by the companies producing the drugs. Usage of the drugs de- scribed at these seminars increased, both in time series at the institution and compared with the national average dur- ing the same period. However, all but one physician de- nied that the seminars would influence their behavior prior to attending. Being asked about bias should make physi- cians more aware of the potential of bias entering into the seminar, yet this did not prevent the seminar from appar- ently having an impact on the physicians’ decisions.

Patients, while somewhat more concerned about the pos- sible biasing effects of gifts than physicians, seem to be vi- cariously self-serving in their perceptions, believing that other individuals’ physicians are more likely to be biased by gifts than their own physicians.29 An implicit embrace of the model of deliberate choice probably colors patients’ views of their physicians. Because most patients cannot imagine that their physicians would intentionally put their own monetary in- terests above those of their patients, they cannot imagine their physicians being biased.

Policy Implications A research-informed understanding of conflict of interest has important implications for policy. Specifically, the in- terventions mentioned earlier—limiting gift size, educa- tional initiatives, and mandatory disclosure—are unlikely to eliminate bias because they rest on a faulty model of hu- man behavior. The finding that individuals are not aware of their bias, even when taught about it, suggests that the problem cannot be dealt with effectively through training.

For example, even if ethical conduct is clearly illustrated through case studies, few conflict of interest situations that the physician will actually encounter are likely to replicate these cases so closely as to preclude potential mitigating cir- cumstances, thus opening the door for a self-serving inter- pretation of whether one’s own behavior is improper.

The finding that the bias is strong, even in studies with small stakes, suggests that a policy of limiting gift size is un- likely to eliminate bias. Because even small gifts can subtly bias how arguments are evaluated, they can be surprisingly influential. The sheer ubiquity of trinkets given by phar- maceutical companies is evidence of their effectiveness; why else would profit-minded companies continue to provide them? Thus, policies against gifts should not be limited to large gifts.

Finally, the general misconceptions about conflict of in- terest weigh in against the effectiveness of disclosure as an antidote to bias. Disclosure can only be effective if those in- formed can rationally update their beliefs—discount the ad- vice they receive from physicians who disclose conflicts of interest—in light of the disclosure. However, most pa- tients would have little idea about, for example, how much to discount their physician’s recommendation to partici- pate in a clinical trial if they were informed that their phy- sician would benefit financially from their participation.

In fact, recent social science research involving auditing suggests that disclosure may have perverse effects.30 Indi- viduals were randomly assigned to the role of estimator or advisor. Estimators made money by accurately estimating the value of a jar of coins they viewed from a distance. Ad- visors saw the jars close up, and suggested values to the es- timators, but they were paid according to how high, rather than how accurate, the estimator’s guess was. Half of the advisors were required to disclose their incentives for the estimator to give high estimates. Advisors who disclosed val- ues to the estimators suggested much higher values. The es- timators did not discount the advice they received suffi- ciently and the estimates made with disclosure information were higher than those made by estimators to whom the con- flict of interest was not disclosed. As a result, estimators made less money, and advisors more, when advisors disclosed.

Because bias induced by monetary interests is uncon- scious and unintentional, there is little hope of controlling it when monetary interests exist. The implication for in- dustry gifts is straightforward: they should be prohibited. The American Medical Student Association has already be- gun an initiative urging physicians to refuse gifts from in- dustry,31 but one wonders whether such idealism will be maintained in the face of the inducements they are likely to encounter in their professional careers.

Pharmaceutical companies know that gifts influence phy- sicians, which is why many restrict their own employees from accepting even small gifts.32 Isn’t it time for physicians to adopt similar restrictions on gifts to eliminate their vulner- ability to unconscious bias?

COMMENTARY

254 JAMA, July 9, 2003—Vol 290, No. 2 (Reprinted) ©2003 American Medical Association. All rights reserved.

at STANFORD Univ Med Center on March 15, 2011jama.ama-assn.orgDownloaded from

Other conflicts of interest for physicians may be more dif- ficult or costly to eliminate. For example, requiring differ- ent physicians to recommend and actually perform proce- dures would help to limit physicians’ motivation to recommend unnecessary procedures that they personally benefit from but would limit patient choice and increase costs. Similarly, although many consultancies may serve as a back- door method of providing incentives for prescribing, bar- ring physicians from serving as paid consultants to phar- maceutical companies would hamper the activities of those who do play essential roles in transmitting important data to drug developers. Perhaps this is why recent guidelines by the Pharmaceutical Research and Manufacturers of America and the Office of Inspector General of Health and Human Services permit pharmaceutical companies to hire physicians as consultants, given the somewhat ambiguous proviso that there is “a legitimate need for the services.”33

It would be costly, if not impossible, to eliminate all con- flicts of interest, but some interventions are relatively ob- vious and straightforward. Such measures are required if phy- sicians want to retain the widespread public trust that they still enjoy.

REFERENCES

1. Pharmaceutical Research and Manufacturers of America. PhRMA code on in- teractions with healthcare professionals. Available at: http://www.phrma.org /publications/policy/2002-04-19.391.pdf. Accessibility verified June 12, 2003. 2. Office of Inspector General of Health and Human Services. OIG compliance program guidance for pharmaceutical manufacturers. Available at: http://oig.hhs .gov/fraud/docs/complianceguidance/042803pharmacymfgnonfr.pdf. Accessi- bility verfied June 12, 2003. 3. Steinman MA, Shlipak MG, McPhee SJ. Of principles and pens: attitudes of medicine housestaff toward pharmaceutical industry promotions. Am J Med. 2001; 110:551-557. 4. McKinney W, Schiedermayer D, Lurie N, Simpson D, Goodman J, Rich E. At- titudes of internal medicine faculty and residents toward professional interaction with pharmaceutical sales representatives. JAMA. 1990;264:1693-1697. 5. Hume AL. Doctors, drug companies, and gifts [letter]. JAMA. 1990;263:2177- 2178. 6. National Institutes of Health Care Management Research and Educational Foun- dation. Changing patterns of pharmaceutical innovation. Available at: http://www .nihcm.org/innovations.pdf. Accessibility verified June 12, 2003. 7. Caudill T, Johnson M, Rich E, McKinney P. Physicians, pharmaceutical sales rep- resentatives, and the cost of prescribing. Arch Fam Med. 1996;5:201-206. 8. Bower A, Burkett G. Family physicians and generic drugs: a study of recogni- tion, information sources, prescribing attitudes, and practices. J Fam Pract. 1987; 24:612-616. 9. Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA. 2000;283:373-380.

10. National Institutes of Health Care Management Research and Educational Foun- dation. Changing patterns of pharmaceutical innovation. Available at: http://www .nihcm.org/innovations.pdf. Accessibility verified June 12, 2003. 11. Messick DM, Sentis KP. Fairness and preference. J Exp Soc Psychol. 1979;15: 418-434. 12. Messick DM, Sentis KP. Fairness, preference, and fairness biases. In: Messick DM, Cook KS, eds. Equity Theory: Psychological and Sociological Perspectives. New York, NY: Praeger; 1983. 13. Loewenstein G, Issacharoff S, Camerer C, Babcock L. Self-serving assess- ments of fairness and pretrial bargaining. J Leg Stud. 1992;12:135-159. 14. Babcock L, Loewenstein G, Issacharoff S, Camerer C. Biased judgments of fair- ness in bargaining. Am Econ Rev. 1995;85:1337-1342. 15. Babcock L, Wang X, Loewenstein G. Choosing the wrong pond: social com- parisons that reflect a self-serving bias. Q J Econ. 1996;111:1-19. 16. Babcock L, Loewenstein G. Explaining bargaining impasse: the role of self- serving biases. J Econ Perspect. 1997;11:109-126. 17. Babcock L, Loewenstein G, Issacharoff S. Creating convergence: debiasing bi- ased litigants. Law Soc Inquiry. 1997;22:401-413. 18. Caudill T, Johnson M, Rich E, McKinney P. Physicians, pharmaceutical sales representatives, and the cost of prescribing. Arch Fam Med. 1996;5:201-206. 19. Orlowski J, Wateska L. The effects of pharmaceutical firm enticements on phy- sician prescribing patterns. Chest. 1992;102:270-273. 20. Lurie N, Rich E, Simpson D, et al. Pharmaceutical representatives in academic medical centers: interaction with faculty and housestaff. J Gen Intern Med. 1990; 5:240-243. 21. Gibbons RV, Landry FJ, Blouch DL, Jones DL, Williams FK, Lucey CR. A com- parison of physicians’ and patients’ attitudes toward pharmaceutical industry gifts. J Gen Intern Med. 1998;13:151-154. 22. Avorn J, Chen M, Hartley R. Scientific versus commercial sources of influence on the prescribing behavior of physicians. Am J Med. 1982;73:4-8. 23. Lexchin J. Interactions between physicians and the pharamaceutical industry: what does the literature say? CMAJ. 1993;149:1401-1406. 24. Spingarn R, Berlin J, Strom B. When pharmaceutical manufacturers’ employ- ees present grand rounds, what do residents remember? Acad Med. 1996;71:86- 88. 25. McKinney W, Schiedermayer D, Lurie N, Simpson D, Goodman J, Rich E. At- titudes of internal medicine faculty and residents toward professional interaction with pharmaceutical sales representatives. JAMA. 1990;264:1693-1697. 26. Steinman MA, Shlipak MG, McPhee SJ. Of principles and pens: attitudes of medicine housestaff toward pharmaceutical industry promotions. Am J Med. 2001; 110:551-557. 27. Palmisano P, Edelstein J. Teaching drug promotion abuses to health profes- sion students. J Med Educ. 1980;55:453-455. 28. Orlowski J, Wateska L. The effects of pharmaceutical firm enticements on phy- sician prescribing patterns. Chest. 1992;102:270-273. 29. Gibbons RV, Landry FJ, Blouch DL, Jones DL, Williams FK, Lucey CR. A com- parison of physicians’ and patients’ attitudes toward pharmaceutical industry gifts. J Gen Intern Med. 1998;13:151-154. 30. Cain D, Moore D, Loewenstein G. The Dirt on Coming Clean: Perverse Ef- fects of Disclosing Conflicts of Interest [working paper]. Pittsburgh, Pa: Graduate School of Industrial Administration, Carnegie Mellon University; 2003. 31. American Medical Student Association. AMSA policy on pharmaceutical pro- motions. Available at: https://www.amsa.org/prof/policy.cfm. 32. Randall T. Ethics of receiving gifts considered. JAMA. 1991;265:442-443. 33. Pharmaceutical Research and Manufacturers of America. PhRMA code on in- teractions with healthcare professionals. Available at: http://www.phrma.org /publications/policy/2002-04-19.391.pdf. and http://oig.hhs.gov/fraud/docs /complianceguidance/042803pharmacymfgnonfr.pdf. Accessibility verfied June 12, 2003.

COMMENTARY

©2003 American Medical Association. All rights reserved. (Reprinted) JAMA, July 9, 2003—Vol 290, No. 2 255

at STANFORD Univ Med Center on March 15, 2011jama.ama-assn.orgDownloaded from