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10 Am. J. Bioethics 1 (2010)

handle is hein.journals/ajbio10 and id is 1 raw text is: The American Journal of Bioethics, 10(1): 1-8, 2010 Copyright c Taylor & Francis Group, LLC ISSN: 1526-5161 print / 1536-0075 online DOI: 10.1080/15265160903440998 The Pitfalls of Deducing Ethics From Behavioral Economics: Why the Association of American Medical Colleges Is Wrong About Pharmaceutical Detailing Thomas S. Huddle, University of Alabama School of Medicine The Association of American Medical Colleges (AAMC) is urging academic medical centers to ban pharmaceutical detailing. This policy followed from a consideration of behavioral and neuroeconomics research. I argue that this research did not warrant the conclusions drawn from it. Pharmaceutical detailing carries risks of cognitive error for physicians, as do other forms of information exchange. Physicians may overcome such risks; those determined to do so may ethically engage in pharmaceutical detailing. Whether or not they should do so is a prudential judgment about which reasonable people may disagree. The AAMC's ethical condemnation of detailing is unwarranted and will subvert efforts to maintain a realm of physician discretion in clinical work that is increasingly threatened in our present practice environment. Keywords: academic medicine, behavioral economics, medical ethics, medical professionalism, pharmaceutical detailing, pharmaceutical industry Medicine's relations with industry have long been a topic of controversy within academic medicine, and direct phar- maceutical advertising to physicians, also known as phar- maceutical detailing, has been a special target of criticism. Criticism of detailing intensified with the turn of the new century, and recently critics have begun to make progress at the organizational level. In 2006 a call for an academic ban on detailing appeared in the Journal of the American Medi- cal Association (Brennan et al. 2006), and the Association of American Medical Colleges (AAMC) charged a task force that took up this and other aspects of academic medicine's relations with industry. In the past 2 years a number of academic medical centers have banned detailing (Rothman and Chimonas 2008). The AAMC task force issued a re- port in 2008 that condemned detailing practices as unethical (Association of American Medical Colleges, 2008a). Shortly thereafter, the report was unanimously approved by the Association's Executive Council (Association of American Medical Colleges 2008b), and the AAMC is now encour- aging medical schools that have not yet implemented the report's recommendations to do so. Until recent years the academic case against detailing has depended upon studies examining bias in industry ad- vertising and its effects on physicians. As summarized by Wazana in a widely quoted meta-analysis (Wazana 2000), this literature suggests that detailing induces physicians to prescribe new drugs too rapidly, to request the addition to formularies of drugs that offer no advantage over existing drugs, and to prescribe fewer generic drugs. Such conclu- sions have a good deal of face validity for many physicians, who, whether or not they participate in detailing, agree that information from drug representatives is inevitably biased (Manchanda and Honka 2005; Prosser and Walley 2003). Skepticism about detailing is also fueled by well-publicized detailing misconduct by pharmaceutical companies, such as Parke-Davis's improper promotion of gabapentin for off- label uses in the late 1990s (Steimnan et al. 2007), as well as by what appears to have been over-zealous industry pro- motion of drugs that did not live up their promise, such as the Cox-2 inhibitors. The AAMC did not particularly rely upon the Wazana studies in formulating its recommendations on medicine- industry relations. It turned instead to a new line of criticism of detailing that has emerged in the past 10 years or so: so- cial science in the form of behavioral and neuroeconomics. Rather than focusing on conscious corruption occurring through conflict of interest, critics informed by behavioral economics suggest that unconscious influence exerted by advertising and promotional gifts on physician decision making inevitably bias physician decisions-and that the necessary remedy is avoidance of the gifts and the adver- tising (Dana and Loewenstein 2003; Katz et al. 2003). I argue that the behavioral economists have over- generalized from their data in drawing conclusions about ajob 1 Address correspondence to Thomas S. Huddle, Division of General Internal Medicine, UAB School of Medicine, 1530 3rd Avenue South, FOT 720, Birmingham, AL 35294, USA. E-mail: thuddle@uab.edu

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