Drug Company Representatives and Psychiatrists

To the Editor: At last year's Institute on Psychiatric Services we attendeda debate between Michael Silver, M.D., and Charles Goldman, M.D.,on the ethics of psychiatrists' interactions with pharmaceutical company representatives (1). Dr. Silver notedthat the exorbitant costs of psychotropic medications prevent uninsured patients from freely obtaining these agents. He reasoned that if he had to be a captive audience to asales representative for five or ten minutes to acquire needed medications for his most vulnerable patients, then so be it.

Dr. Goldman, on the other hand,argued that the profession should be skeptical of inducementsoffered by drug representatives, because these representatives' primary motive is profit and the achievement of "face time" with the psychiatrist.His argument appeared to be grounded not on consequences buton the need for psychiatrists to maintain their personal and professional integrity. Thus accepting samples, seminars, and suppers in exchange for listening to a drug representative "detail" a product is an act of compromise and a capitulation to an industry whose motives are exclusively profit driven.

One argued from consequences, while the other offered a counter position based on concerns of compromising personal and professional character. We offer a middle ground between these two counter moral arguments. Most psychiatrists, in their dealings with drug companies, can assume a "blended"ethical approach that includes dynamic aspects of the two polarized positions.

Ideally, we hope that most clinicians who interact with marketing representatives—and, in the real world, how can this be avoided?—weigh and assess the consequences of their choices while balancing the impact of their actions on their character. For example, a strong ethical argument can be made for a psychiatrist's accepting samples on the basis of the adverse consequences that might accrue to patients who are unable to pay for these agents.At the same time, it can be argued that a physician's personalcommitment to the moral virtues of honesty, trustworthiness, and professional obligations remains intact, because the intent is to promotethe welfare of the patient while treating pharmaceutical representatives with the respect they have a right to claim.

On the other hand, it may be somewhat more difficult for a psychiatrist to justify interactions with marketing representatives if the consequences are primarily self-serving or the overall effects run counter to personal values and professional moral standards. Some examples that warrant serious ethical scrutiny are expensive drug company-sponsored dinners, paid "round table discussions," and some"industry sponsored" research and symposia. It appears to be far more challenging to ethically reconcile these involvements with drug companies and their personnel on the basis of balancingconsequences with commitments to moral character.

Clearly,pharmaceutical companies are in the business of selling a product. And psychiatrists, like other physicians,have extensive opportunities to interact with the individuals and events that drug companies employ to promote their sales. Whether these interactions are right or wrong are ethical judgments involving issues ofboth moral consequences and character,not just one or the other. Although polarized moral positions may make for interesting debates, on this complex professional issue they will likely provide somewhat narrow ethical guidance.

Dr. Christensen is associate professor and director of the community psychiatry program and Dr. Garces is chief resident in the department of psychiatry of the University of Florida College of Medicine in Jacksonville.