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| Journal of the New Zealand Medical Association,
22-August-2003, Vol 116 No 1180
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Direct-to-consumer advertising – where does the public
interest lie?
Barrie Saunders
In debating the merits of direct-to-consumer advertising
(DTCA), the key questions to ask are:
Before
dealing with these questions I will make some general observations. Whether DTCA
should be banned or more tightly regulated is not an issue to be determined by
opinion polls of doctors, medical academics or the public, or by policies
adopted by other countries.
Governments are elected to make wise decisions having regard
for the interests and views of its constituents – not simply respond to
interest groups, no matter how important or vocal.
Thus, the fact that a significant number of doctors
(probably a minority) want DTCA banned, and, depending on the questions asked,
that the public appears to have a degree of ambivalence, does not remotely make
a case for banning DTCA.
DTCA is not a privilege. The right to freedom of expression
is protected by the New Zealand Bill of Rights Act 1990, and should only be
constrained when there is a compelling case, based on a rigorous analysis of the
public interest. While there may be good reason to update the regulations, the
case for a ban on DTCA is very weak.
The report by Professor Toop et al to the Minister of Health
is a contribution to the debate about DTCA but it should not be seen as an
academic exercise just because four professors of medicine authored
it.1 This conclusion was also reached by
Professor Donald Evans (Director, Bioethics Centre, University of Otago) who
investigated a complaint about the research methods used by Toop. He concluded
‘that this proposed report did not convey the impression the survey was a
research project but rather clearly demonstrated that it was an explicit
gathering of evidence to support a protest to Government about
DTCA.’2
Other issues raised by the Toop paper are dealt with in my
report sent to the Government on behalf of the Advertising Standards
Authority.3
Does DTCA have a negative
or positive effect on health funding?
It has been claimed that DTCA leads to
‘unnecessary’ doctor visits, an increase in dispensing, and switches
to expensive medicines that are not much more effective than lower-cost
alternatives.
Whether a visit is ‘unnecessary’ or not is very
much in the eyes of the beholder. If the result is a patient reassured that
nothing is wrong, they may consider that result worth the time and cost. If it
leads to a prescription, one must assume that this is necessary because doctors
would be acting unprofessionally to prescribe otherwise.
No doubt some visits to GPs could be classified as
‘unnecessary’ for many reasons, not just DTCA. However, there are
likely to be far more occasions when a visit is appropriate and does not take
place. This is an area where the medical fraternity might focus some of its
energies, because the anecdotal evidence is that far too many New Zealanders
ignore symptoms until there is a serious problem.
The claim that DTCA can lead to pressure to switch to more
expensive medicines would be a serious one if it were not for the fact that
PHARMAC wields enormous power, and that doctors are professional about decisions
relating to different medicines.
I asked Wayne McNee, CEO of PHARMAC for evidence the about
impact of DTCA on the pharmacy budget and the issue of patients switching to
more expensive medicines. The response arrived after (30 April 2003) my report
was completed. DTCA gives them some concerns, but the letter said that PHARMAC
manages the financial risks though negotiations with pharmaceutical companies
about price and quantity, and through its education programmes for health
professionals. As a consequence, prescription numbers involving DTCA medicines
usually increase at a faster rate than costs to PHARMAC.
Of interest is PHARMAC’s 2002 annual review, which
shows that since 1993 the pharmacy vote has been held to an average annual
increase of less than 3% compared with 14% in Australia over the same
period.4 Through its tendering system PHARMAC
has been able to lower the cost of medicines thereby widening their
availability. PHARMAC’s achievement is remarkable considering the
population increase and the arrival of new medicines during that time.
The most significant comment in the PHARMAC report is the
statement that less than half the population ‘with proven cardiovascular
disease are on a statin’. This suggests there is a good case for more
public funding of the availability of non-publicly advertised medicines, such as
statins, to deal with real health problems. This is a far more important area of
debate than DTCA.
The PriceWaterhouse Coopers report to the Researched
Medicines Industry provides a framework for thinking about the allocation of the
health budget.5 It shows that in some areas the
health vote will achieve better overall results if there is greater expenditure
on medicines at the early stage of a problem.
In summary, the pharmacy budget in total is not being
threatened by DTCA, nor is there any evidence that growth in prescriptions of
some medicines as a result of DTCA has led to reduced allocations for others. It
should be noted that there can be significant variations from year to year in
PHARMAC’s expenditure on different classes of medicines, regardless of
DTCA. Whether the overall impact on the health funding is positive or negative
cannot be determined on the basis of the evidence available, but is likely to be
small, and could even be positive.
Does DTCA compromise or
improve patient health?
Clearly, DTCA leads to some patients visiting doctors who
would not otherwise have done so and some are issued with prescriptions. There
is no evidence, however, that doctors typically write prescriptions for people
who do not need them. Thus, it follows that the people who now have
prescriptions as a result of the advertising stimulus have in fact improved
their health prospects.
Research from Massey University shows that some doctors use
the opportunity created by such a visit to discuss other health areas and
lifestyle issues the patient might address. In this sense, DTCA has a positive
effect.
There is no evidence presented by Toop or the Massey
University researchers that a significant proportion of visits to doctors are as
a result of anxieties created by DTCA that are not justified by reality. It is
true that some patients will have illusions about what medicines may achieve in
areas such as obesity. However, their visits provide doctors with the
opportunity to deliver a reality check, which is better than them not having had
that opportunity.
On balance, DTCA is therefore likely to be positive for the
health of patients.
Does DTCA have a negative
or positive effect upon the patient–clinician
relationship?
Like all other professionals, doctors will be subject to
pressures from their clients/patients. This is for them to manage while
maintaining their professionalism. Denying patient’s possible knowledge
through a ban on DTCA is an implicit admission on the part of doctors that they
lack the skills to manage patient relationships. If some doctors are struggling,
they should seek guidance from their professional organisation.
In reality, whether or not there is a real health problem is
a question that can only be answered by both doctors and their patients. In some
cases, DTCA will be positive in that it opens up a new subject for discussion.
It is conceivable that in some individual doctor–patient cases the answers
may not be the same. It is almost certainly true that there will be cases where
a doctor has rejected a patient’s request for a DTCA medicine, and some
strain on the relationship results. None of the evidence available suggests this
problem exists with anything more than a tiny proportion of patients.
What should medical
organisations and the Government do?
DTCA is subject to specific and generic laws and
regulations. It is also subject to the Advertising Standards Authority
Advertising Codes of Practice, and the Researched Medicines Industry Code of
Practice.6,7
Instead of seeking government intervention, the medical
fraternity should engage directly with the RMI and the ASA to see if any further
refinements are necessary to either their codes or the way they are managed.
Industry regulation can be more responsive and effective than that determined by
government.
Only after exhausting these options should they consider
promoting changes to existing regulations. Any proposals to the Government
should be based on better evidence than has been advanced so far by Toop and
others.
For its part, the Government is equally well advised to
explore further with industry ways in which its voluntary codes are designed and
being administered. Only if these are unproductive, and there is clear and
quantifiable evidence of public harm, should it consider making changes to
existing regulations or statutes.
Finally, the fact that most Western countries effectively
ban DTCA does not constitute a case for us following them. There are many
policies followed by other countries that New Zealand has not adopted. Freedom
of speech is a precious right that must only be compromised when there is
compelling evidence to do so, which at present does not exist. There are serious
health issues such as cholesterol, obesity and diabetes, which dwarf DTCA, that
should receive more attention because the returns to society will be so much
greater.
Author information:
Barrie Saunders, Public Policy Consultant, Saunders Unsworth Limited,
Wellington
Correspondence: Mr
Barrie Saunders, Saunders Unsworth Limited, P O Box 10-200, Wellington. Fax:
(04) 914 1760; email: barrie@sul.co.nz
References:
ResponseWe are comfortable to let the reader
judge the strength of the arguments and assertions put forward in this
editorial. We do note, however, that Mr Saunders has used the word
‘evidence’ 11 times. In his critique of our report to the Minister
he used the same word 35 times. In both pieces it is used mainly in the context
of his thesis that there is no
evidence to support our arguments for a
ban on DTCA.
Figure 1. Number of supporting references listed in
documents for and against a ban of DTCA in NZ
 *June 2003 update of GP academics’ report,
including comments on Saunders’ and other pro-DTCA reports, is available
from www.chmeds.ac.nz/report4.htm
QED.
Les Toop
Dee Richards
Department of General Practice Christchurch School of Medicine and Health Sciences, Christchurch |
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