Today more than six lakh medical representatives slog it out in India, peddling more than one lakh pharma products. Over the last century, the global pharmaceutical industry has refined and fine-tuned its strategies to increase its penetration into the market. Their ‘soft sell’ now includes leaving behind gifts to doctors, dropping free product samples, invitations to dinners, sponsoring holiday at exotic locations and foreign jaunts. Companies also manage to put up a highly visible presence at medical conferences and other professional events. However, there is no such thing as a free lunch. All these freebies come for a price, and it can only be surmised that there is an invisible quid pro quo arrangement in place, which will promptly get reflected on the doctor’s prescription pad.

How far is it ethical and healthy to accept favors from the trade? Let us examine the issues before we come to a conclusion.

As a profession, medical science has always operated from under the cloak of modesty. As our services directly affect the health and well-being of the community, trust is the bedrock of the profession. Due to this reason, any form of trivializing and vulgarizing of professional practice is frowned upon. Advertising and marketing activities being commercial in nature negate the selfless motive that the profession expects from its practitioners. The highly competitive nature of mass marketing makes it an undesirable medium for pharmaceutical industry to engage in, more so because their products are not meant to be used without a doctor’s prescription. These factors have ensured that both medical practitioners and pharmaceutical companies refrain from advertising and marketing as a matter of professional ethics.

With the business-to-consumer (B2C) route thus closed, industries adopt B2B option and approach doctors and hospitals to promote their products. The typical interaction between the two would include introducing the products and their features, clarifying doubts and occasionally handing over drug samples for free distribution to the patients. This is considered acceptable and even essential for the doctor due to the educational value of the interaction.

At some point in the course of time, this process went a step further and the pharmaceutical companies began to distribute gifts to the doctors. Writing pads and pens, table diary, wall clock, paper clips and the like would be given for the doctor’s personal use in the clinic. The gifts would bear prominent display of the company name or product name, and were designed to trigger instant brand recall to the doctor while writing prescriptions. When this too became commonplace, the more expensive gifts followed. Personal utility items, subscriptions to clinical reference books and journals, and sponsoring visit to conferences and personal holidays are some of the persuasive tools employed by the companies to make doctors favor their products while writing prescriptions.

Simultaneously, pharmaceutical companies also aggressively pursue their business promotion agenda with professional bodies. Sponsoring medical conferences, organizing evening parties during conference days, and distribution of freebies during professional conclaves are some of the ways in which the industry makes its presence felt. These practices have raised many eyebrows in recent years, and there is mounting criticism both among the public and within the medical fraternity regarding the ethical dimensions of such practices. A serious charge that this issue has brought up is of drug company-doctor nexus, and there is a genuine fear that doctors thus obligated may indulge in prescription spree while compromising patient well-being.

There is also the economic fallout as the manufacturers are bound to recover the high cost of business promotion by hiking the retail price of branded medicines, which is a burden the patient will have to needlessly bear. It is estimated that the pharmaceutical industry of USA spends upward of 24 billion US dollars on promotional activities, which is a mind-boggling amount by any stretch of imagination. Though no such figures are available for Indian pharmaceuticals, it would be reasonable to assume that amount would be of corresponding value in proportion to the size of our economy.

Today the simmering issue of inducements by pharmaceutical companies is the elephant in the room that no one wants to acknowledge. The rewards are so tempting and compelling that we have come to accept them as one of the perks of the profession without really giving a deep enough thought to the damage it is causing to our integrity, credibility and public standing. When confronted with such uncomfortable questions, we choose to bury our heads in the sand like the proverbial ostrich. But the outside world is not blind to our follies, and governments all over the world are drafting regulations to control certain practices. The Medical Council of India Guidelines clearly draw the line regarding accepting freebies [1]. On another level, the government has drafted Uniform Code for Pharmaceutical Marketing Practices (UCPMP) for the pharmaceutical industry for voluntary implementation [2]. As per this code, the government has fixed a cap of Rs. 1000 as the maximum value of gifts the companies can give to a doctor, and it should serve some clinical purpose. A sample set of guidelines had been issued to pharmaceutical industry some time back to be tried out for six months for the purpose of gaining feedback. Such guidelines have been made applicable only to individual practitioners; professional bodies are allowed to engage with pharma sponsors. Being pediatricians, we are also bound to follow the government regulations stipulated under the Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulations, Supply and Distribution) Act 1992 as amended in 2003 (IMS Act) [3].

I feel that as professionals, each of us should take a call of conscience as far as accepting gifts is concerned. Gifts by pharmaceutical companies largely fall into two categories: educational handouts and recreational freebies. Studies done in other parts of the world indicate that the practice of accepting gifts has become so deeply entrenched over the decades, that even seasoned senior doctors harbor ambivalent attitudes regarding the issue [4]. Most of them look upon the practice of low value gifts, educational handouts and free samples as passé. It is only on the matter of recreational gifts like conference sponsorship and free holidays that some discomfort is felt, and that too only when the obligation to reciprocate is very overt or expressly stated.

This brings us to the question: Is it okay to accept low value gifts, such as note pads and pens? While these gifts appear harmless – and they might indeed be so – an in-depth study made on the subject indicates that the human instinct for reciprocity is innate and any favor that we receive, however small, triggers in us a desire to give back in kind and balance the equation [5]. We must also not forget that the art of advertising and marketing has attained such heights of sophistication that even subtle messaging designed for brand recall can seriously subvert our independent choice in decision-making.

In our field, it is almost inevitable that we need to entertain medical representatives in order to keep ourselves abreast of the latest developments in the industry. It might seem acceptable to the average practitioner to accept inexpensive educational handouts from them too. But I am sure all will agree that it is downright repulsive to sell oneself to the pharmaceutical companies at the altar of expensive joy rides. Professional bodies might not mind allowing corporates to sponsor educational sessions during conferences as it is for the common good of all, while obligating no one in particular. But it is obscene to see delegates standing in long queues to lay their hands on a freebie during such conferences, while the main halls, where educational activities are going on, run empty for illustrious speakers who have worked hard to prepare their presentations.

And while I am on it, let me also highlight yet another malady. While the issue of gifts largely arises out of the initiative of the corporates themselves, there are also some among us who seek to exploit the subservience of the pharmaceutical representatives. It is not infrequently that we hear of so and so who employs pharmaceutical representatives to run petty errands for them. There are reports that during the days of demonetization, quite a few hapless young men were forced to stand in long queues at the ATM booths to exchange old currency notes for new on the demand of the clinician. It goes without saying that such unprofessional behavior only degrades us and takes the doctor-industry relationship to a new low.

Indeed we are living in a world of contradictions galore and it is agonizing to make sense of it all. In the final reckoning, one can only say that it is left to the individual to decide where to draw the line. The choice is between self-respect and greed, professional autonomy and obligation, patient well-being and self-gratification. Choosing the formers has the power to elevate you, falling prey to the latter ones can potentially destroy you. May wisdom prevail in every decision you make.

Disclaimer: This article presents a general perspective on the issue compiled with the help of information freely available in the public domain, and any references made herein may not be construed as concerning any individual member of the profession known to me or otherwise.

1. Doctors who take gifts from pharma firms to be punished: MCI guidelines. The Indian Express 2016 February 06. Available from: https://indianexpress.com/article/india/india-news-india/doctors-who-take-gifts-from-pharma-firms-to-be-punished-mci-guidelines. Accessed July 18, 2018.

2. Government set to put Rs 1,000 cap on pharma companies’ gift. The Times of India 2017 February 26. Available from:http://timesofindia.indiatimes.com/articleshow/5735 1341.cms?utm_source=contentofinterest&utm_medium =text&utm_campaign=cppst. Accessed July 18, 2018.

3. Tiwari S, Bharadva K, Yadav B, Malik S, Gangal P, Banapurmath CR, et al. Infant and Young Child Feeding Guidelines, 2016. Indian Pediatr. 2016;53:703-13.

4. Brett AS, Burr W, Moloo J. Are gifts from pharmaceutical companies ethically problematic? A survey of physicians. Arch Intern Med. 2003;163:2213-8.