Map of life expectancy at birth from Global Education Project.

Wednesday, March 14, 2007

Parlancheq asks:

Seriously, though, I don't advocate a ban on DTC ads. Why does Pharma not get to advertise if other businesses do? If you say it's because you have to go through a doc to get an Rx or because people are not smart enough to understand the relevant medicine/science, it's almost like saying 'doctor knows best' or that people can not be savvy healthcare consumers. If you say it's because Pharma should be spending money on R&D instead of advertising, it suggests they are not autonomous businesses that can spend money however they see fit. mean, sure the ads are basically crap, but why not just tune them out along with all the annoying ads for cars and whatnot?

There are a couple of issues in there that I'll have to tease apart in order to respond. The first is the criticism of medicine as paternalistic, the traditional "expert model" in which patients are completely passive consumers. Would a ban on prescription drug advertising suggest that we don't think consumers are capable of processing messages skeptically, winnowing out the wheat from the chaff, and participating effectively in decisions about their own treatment?

The second is the question of why pharmaceutical products should be treated any differently from cars or men's cologne or cosmetics or junk food. Most advertising is largely bullshit, so what else is new?

I agree that we should do our best to be informed consumers of health care and to participate in decisions about our own treatment. I would say that in the real world, we more often need to resist our doctors' efforts to give us drugs than to encourage them. But that's an empirical question. The problem with advertising is that it is not neutral information (see above paragraph), it is intended to manipulate our behavior, not to inform us. Barbara Mintzes and colleagues compared physician visits in Sacramento and Vancouver, Canada, where patients had less exposure to prescription drug advertising. (It wasn't a perfect choice of site since people in Vancouver can see U.S. TV.) They conclude:

Patients who requested DTCA drugs were much more likely to receive 1 or more new prescriptions (for requested drugs or alternatives) than those who did not request DTCA drugs (OR 16.9, 95% CI 7.5–38.2). Physicians judged 50.0% of new prescriptions for requested DTCA drugs to be only "possible" or "unlikely" choices for other similar patients, as compared with 12.4% of new prescriptions not requested by patients (p < 0.001).

Interpretation: Our results suggest that more advertising leads to more requests for advertised medicines, and more prescriptions. If DTCA opens a conversation between patients and physicians, that conversation is highly likely to end with a prescription, often despite physician ambivalence about treatment choice.

So, when patients come in "empowered" by DTCA, doctors are likely to go along with their requests, even though half the time, the doctors don't actually think it's a good idea. If the patients had gotten their information from a neutral source, perhaps their requests would be more likely to be appropriate; and, since the requests would be based on rational analysis rather than Pavlovian behavior modification, the patients would be more easily talked out of it if the prescription wasn't really appropriate after all.

As for the question of why prescription drugs should be treated differently from other products, there is precedent, of course. Tobacco ads are banned from television - by a voluntary agreement, to be sure, but the agreement was an alternative to legislation that surely would have ensued without it. Distilled spirits similarly are not advertised on TV, and there are restrictions (not so you'd know it) on wine and beer advertising.

While drugs obviously can benefit people, all drugs are also poisons. They have risks as well as benefits, and if used by the wrong people in the wrong way, are more likely to be harmful than helpful. That's why many drugs are available by prescription only, precisely because the question of whether any individual ought to take them is complex and requires expert knowledge and judgment. I wish we could all know as much as our doctors but the reason why we go to doctors is that we don't. What we are buying (whether out of pocket or through insurance) is their expertise. If we knew as much as they did, they wouldn't exist. To me, the concept of the informed consumer does not mean that we should try to replace the physician's expertise with our own research, but rather that we should be able to process the physician's technical expertise in light of our own goals, tolerance for discomfort, risk aversion, and values.

That doesn't mean doctors are Godlike or infallible. Indeed, they too are manipulated by drug companies that send attractive young people in flattering clothing around to their offices, buy them fancy meals, and even golf vacations, as well as giving them trinkets and free drugs for their needy patients. Drug ads in medical journals use imagery and emotional manipulation as well as providing information. I think all that should be banned as well. (The free samples have a minor social benefit as long as we have uninsured people, but if they are supposed to be a public service, they should be allocated according to need and delivered without a sales pitch.)

Nevertheless if we don't ascribe expertise to doctors we have a much mre profound problem than DTCA to worry about. Anyway, most current proposals in the U.S. don't call for banning DTCA, but for restrictions, such as not allowing advertising of drugs within 2 years of initial approval, before substantial knowledge about safety and effectiveness in the general population has been acquired; or requiring that they consist only of information presented in a neutral, non-manipulative manner.

Thanks to the Internet, consumers who want to be informed about prescription drugs have much better alternatives than watching drug ads on TV. You can get all the downside news here, from Public Citizen's "Worst Pills" site. They list some drugs, including some which are heavily advertised, that they don't think anybody should take. (Now there's a second opinion for you.) You can get a fair and balanced assessment from the National Library of Medicine here. There are a lot of other sites that offer prescription drug info, but they are mostly supported by advertising, so I'm a little leery.

Anyhow, that's what I think. I'll be happy to hear from dissenters.

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