Drug Samples Create Ethical Divide


TUCSON, ARIZ. — Physicians are divided over whether it is ethical to use free sample medications in their primary care practices, Dr. Nancy Sohler, Ph.D., and Dr. Diane McKee reported at the annual meeting of the North American Primary Care Research Group.

Accepting samples was viewed either as being ethically questionable or as a useful way of helping provide health care to low-income patients, according to findings from a study of 24 family medicine and general internal medicine physicians, nurses, and administrators in practices affiliated with a large urban medical center serving low- and middle-income patients in New York.

Interactions with pharmaceutical representatives were viewed as a direct conflict of interest, an influence that could be controlled, or a source of useful information that helped keep the practice up to date on new medications.

Of the total, 10 respondents felt that they could control the influence of drug firm representatives by keeping them away from residents, by setting limits on what gifts or favors could be accepted, or by always being mindful that representatives are selling a product, Dr. Sohler said in an interview.

For the respondents who drew a hard ethical line, “It wasn't that they thought giving out samples [to patients] was unethical, but that it wasn't good practice,” she said. “They understood why others did it, but they worried about conflicts of interest with their interactions with the reps.”

Those who accepted samples said inadequacies in the health care system forced them to rely on gifts to care for their most needy patients.

All the respondents evaluated marketing practices from the perspective of protecting and serving their patients, said Dr. Sohler, professor of community health and social medicine, City University of New York, New York. No one was concerned that physicians were ignoring clinical symptoms to prescribe the “right drugs,” he said.

The study included in-depth, qualitative interviews and was prompted by an administrative decision at the medical center to ban samples and pharmaceutical representatives from the community practices.

That decision left many providers uncertain about how to care for patients without adequate health care coverage. Others suggested that the policy was changed because the administration did not want physicians taking the time to talk to sales representatives, didn't trust that staff would avoid entering into agreements with pharmaceutical firms, and did want a single policy, because teaching sites had a “no-rep” policy and other sites didn't need samples.

Dr. Sohler said further study would be needed to determine whether samples help poor patients more than they harm them, and whether representatives influence prescribing practices in mostly helpful or harmful ways.

“The empirical, quantitative evidence isn't good on whether free medications help or harm our patients,” Dr. Sohler said. “We realize that all marketing has an influence, but we don't know if it harms our patients.

“People are drawing on their different values and perspectives to make a decision. We need hard evidence to make a policy, but in the meantime, we should keep these perspectives in mind as the data come in.”

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