Is their integrity on the line when doctors pitch products?

Paid endorsements pose conflicts, some physicians and ethicists say.

By — Posted March 24, 2008

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When revelers rang in the New Year, Robert Jarvik, MD, was the star of a massive Pfizer Inc. advertising campaign for Lipitor (atorvastatin). By the end of February, Pfizer had ended the campaign, under the pressure of a U.S. House Energy and Commerce Committee probe.

The committee's chair, Rep. John Dingell (D, Mich.), charged that the ads misled the public because they created the impression that Dr. Jarvik is a practicing physician, when he is a biomedical engineer not licensed to practice medicine. The committee disclosed that Dr. Jarvik received $1.35 million under a two-year contract set to expire this month, according to media reports.

Dr. Jarvik, who had helped develop the Jarvik-7 artificial heart, defended his role as a physician spokesman, adding in a statement that his "credibility as a heart expert is fully justified and is fairly represented" in the ads.

But the controversy has sparked a broader conversation about the ethical ramifications of physicians serving as commercial endorsers. While the Lipitor campaign is the most prominent use of a paid physician spokesperson, it is not the only one.

Pfizer also has featured former CBS News medical correspondent Howard Torman, MD, in ads for Viagra (sildenafil citrate). Some physicians even have appeared endorsing direct-to-consumer products such as herbal supplements or cosmetics in late-night infomercials.

To some experts, the issue of what is appropriate is open and shut.

"What is a doctor doing putting money in his or her pocket, shilling for a product?" asked Howard Brody, MD, PhD, director of the University of Texas Medical Branch Institute for the Medical Humanities. "Show me where in the Hippocratic oath you'll find how we're serving mankind by doing that. It's called greed. It's called commercialism. There is no positive reason why a doctor should do such a thing."

Steven Miles, MD, professor of medicine and bioethics at the University of Minnesota Medical School, was equally adamant in opposing paid physician endorsements.

"Doctors should not do product endorsements," he said. "It is either self-dealing or self-enriching. In either case, it is corrupt because it is not being tailored to an individual patient's interest."

Dr. Miles said a physician who believes in a product should promote it through professional channels such as peer-reviewed medical journals.

Conflicting interests

Getting paid to endorse drugs or medical devices "presents major conflicts of interest with physicians' major interests and values," said Roy M. Poses, MD, clinical associate professor of medicine at Brown Medical School, Providence, R.I.

For the practicing doctor, he said, physician endorsement could induce bias in favor of the product when it is not in a patient's best interest. Academic research could be compromised by the influence of payments.

"I wouldn't do it," Dr. Poses said.

The AMA has policy discouraging the use of physicians or other health care professionals to endorse drugs or devices in direct-to-consumer advertising. If doctors appear in such ads, any compensation should be noted in a "clearly visible disclaimer."

Arthur L. Caplan, PhD, director of the University of Pennsylvania Center for Bioethics, said he is not categorically opposed to physicians endorsing products.

"I might urge somebody to think twice about it, but I can understand they may choose to do it," he said.

In that case, he added, physicians should have expertise in the relevant area of medicine, use or prescribe the product and have a preexisting preference for the product not motivated by the promise of compensation for an endorsement.

Stephen Barrett, MD, has been the bane of snake-oil salesmen for four decades as a consumer advocate and founder of Quackwatch Inc. But although he has seen his share of shady doctors-for-hire -- "scoundrels," he calls them -- he is not against every physician endorsement.

"The most important thing is whether the product is properly represented and deserves the endorsement," said Dr. Barrett, a retired psychiatrist in Chapel Hill, N.C.

But he said he is not sure why Food and Drug Administration-approved drugs and devices would need physicians' help.

"There is no logical reason to endorse a prescription drug unless there's some special reason why it's so much better than the rest and nobody knows it," Dr. Barrett said. "It doesn't make sense."

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Guidelines for advertising physician services

The American Medical Association does not have policy on whether, or under what circumstances, it is ethically permissible for physicians to endorse products or services. However, the AMA has ethical guidelines that it says doctors should heed when advertising their services. The general rule is that physicians are free to promote their services to the public in whatever form they see fit, so long as they do not mislead or deceive.

When advertising, doctors should:

  • Avoid aggressive, high-pressure tactics.
  • Abide by federal regulatory standards that apply to commercial advertising.
  • Refrain from using testimonials that do not reflect typical patient outcomes.
  • Make only objective, factually supportable claims about experience, competence and quality.
  • Be careful when claiming to have treated a particular ailment successfully in a large number of cases, because this can imply a certainty of result or create unjustified patient expectations.
  • Eschew claims of unique medical skill unless it is true for a particular geographic area.

Source: AMA Code of Medical Ethics, Opinion 5.02

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