Doctors, drug companies and medical ethics: A Sri Lankan perspective
G N Malavige
Pharmaceutical companies and doctors have an interdependent relationship throughout the world. This relationship is even stronger in developing countries such as Sri Lanka, and may lead to adverse outcomes especially for the consumer. Not only do drug companies play a vital role in sponsoring continued professional development (CPD) programmes, they are also at times 'nice enough' to grant personal favours to their 'best prescribers'.
Doctors who are frequently in contact with drug representatives are more willing to prescribe newer drugs. Such doctors do not like ending consultations with advice only, and are more likely to prescribe a drug that is not clinically indicated (1). The situation is worse in developing countries where doctors are seen as 'Gods' by most patients who rarely question their doctors. Therefore, the doctor may prescribe expensive drugs of their favourite pharmaceutical company with scant regard for the expense borne by the patient. For instance, the price of a 10 mg tablet of simvastatin ranges from Sri Lankan Rs 15 (US$ 0.16) to Sri Lankan Rs 128 (US$1.35). Other reasons for doctors to prescribe expensive brands is the presence of substandard drugs in the market (2). The doctors' dilemma is: should they prescribe more expensive brands of reputed companies of which the quality is assured, or low-priced brands of unknown quality? However, strictly controlling drug sales by legislation may help in addressing this problem.
The essential drug concept, introduced by the WHO to help developed countries select appropriate drugs, also provides a basis for drug regulation. This influenced the registration of pharmaceuticals in Sri Lanka (3) but has no control over the price of drugs. Moreover, writing generic prescriptions does not prevent private retail pharmacies from dispensing higher-priced alternatives for a bigger commission (4). The market is poorly controlled and has no ceiling for prices or the number of preparations (of the same drug) that can be imported (4). Prices can be controlled if the government-owned State Pharmaceutical Corporation, which sells high-quality generic drugs at cheap rates, opens up an island-wide network of retail outlets.
Another role that drug companies play is in 'educating' doctors. Continued professional development is an essential component of a good healthcare system and will soon be required for re-validation of doctors in Sri Lanka. However, such events, at present, are unviable without sponsorship. Moreover, few doctors can afford to attend international meetings at their own expenses. Therefore, doctors have no alternative but to rely on the pharmaceutical trade to sponsor them. As the drug companies aim to market their products, one will speculate on the validity and quality of CPD programmes conducted solely by them, and the knowledge doctors gain from such programmes.
Codes of ethics have been laid down by various organisations including the World Medical Association (5) regarding the conduct of doctors with regard to their relationship with pharmaceutical companies. However, such codes of ethics laid down by local medical organisations are not available in Sri Lanka. Most doctors may be unaware of the fact that drug companies influence their prescribing behaviour. Although many have suggested that doctors should distance themselves from drug companies, it is easier said than done in poor countries such as Sri Lanka due to the reasons given above. What needs to be done is to educate medical students about the marketing strategies of pharmaceutical companies. Doctors should be encouraged to practice evidence-based medicine rather than depend on the drug company's representative. Lastly, professional associations should strive to generate funds so that they can conduct their own CPD programmes. These programmes should target non-postgraduates and those in remote outposts, as they are most susceptible to the biased opinions of drug companies.
- Watkins C, Moore L, Harvey I, Carthy P, Robinson E, Brawn R. Characteristics of general practitioners who frequently see drug industry representatives: national cross sectional survey. BMJ 2003;326:1178-9.
- Jayasena K. Drugs-registration and marketing practices in the Third World. Development Dialogue 1985;2:38-47.
- Weerasuriya K. Essential drugs and registration of pharmaceuticals: the Sri Lankan experience. Bulletin of the World Health Organization 1993;71:229-35.
- Jayasinghe S, Jayasinghe S, de Silva P. State can make drugs available cheaply to poor people. BMJ 2003;326:553.
- Wager E. How to dance with porcupines: rules and guidelines on doctors' relations with drug companies. BMJ 2003;326:1196-8.