Advertising Research Paper Example

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Abstract

Advertising in the etymological sense refers to the action of drawing attention to a product, in order to accomplish the goal of selling it. Advertising of health-related services or products can be done in an open or a disguised form. When advertised openly, health-related products can be directed to the ﬁnal consumer, or the health professional, being the former the most frequent target of such strategy. When the advertising occurs in a disguised form, it is usually camouﬂaged as education, and, in this case, the health professional is the preferred target. Although any form of advertising of health-related products may represent ethical problems, it is the advertising disguised as education the most dangerous threat to the global community, because it is not recognized as advertising or marketing, and it is responsible for a great part of the social burden that the cost of pharmaceutical products represent. The bioethical approach of principlism may be used to put advertising in perspective. All four principles (respect for autonomy, beneﬁcence, non-maleﬁcence, and justice) are hurt by advertising, both open and disguised. However, it is intervention bioethics that is the most appropriate approach to take action against the consequences of advertising of health-related products, because of its more political nature. It is not enough to disclose conﬂicts of interest. All disguised advertising should be banned.

Introduction

Advertising is a term whose etymology goes back to “draw attention to something,” which is appropriate, since what it does in fact is to try to show people that a particular point of view about a particular product or service is worth their attention. A positive point of view, evidently. In this sense, it keeps close relationship to the advertising and marketing terms, since it is important to make public and, therefore, sell the product or service.

Considered in its original, neutral sense, advertising has apparently nothing to do with bioethics. However, as bioethics deals with the well-being of the creatures of the planet, the traditionally permissive form accepted for advertising in other areas becomes harmful when it comes to matters related to the health of these creatures, particularly humans. In other words, if two different brands of pencil are equally safe for children to use, little or nothing matters if the advertisement of one is more appealing than the other and therefore sells more. A pencil that costs twice as much as another but still sells better because its advertising team is more creative does not represent great risk to society. The same cannot be said about the brand of drugs and equipment used for health-related purposes. A pharmaceutical laboratory that invests millions in a drug that does the same thing as another already available (“me too” drugs) may carry out ethically lax clinical trials, in addition to a massive investment in marketing, both to the patient and the health professional, trying to convince them that their new drug adds something worth switching to it. This does not come without a cost.

There are different ways in which advertising can be used in healthcare. Health professionals, hospitals, clinics, and laboratories may use advertising in order to sell their services. Medical equipment makers advertise their products to health professionals. The pharmaceutical industry invests in advertising for its products directly to the consumer (the patient) or to health professionals.

Advertising of the health professional services usually has restrictions that will vary according to the deontological codes of each profession and country. Generally, the rules that are expected to the other types of advertising will be similar for the services of health professionals, the most common being to not allow them to broadcast a misleading message to consumers (in this case, patients). But the advertising can also be subliminal, not assuming the classical form of a paid commercial. It may assume the form of an interview or quote in newspaper columns, for example. These ways of bypassing rules and restrictions are not entirely free of the constraints of professional codes and must also comply with the general ethical precepts of not transmitting misleading messages. However, they are more difﬁcult to be scrutinized, and, more importantly, their efﬁcacy is bigger, because they seem to be absorbed by the public as more reliable than pure advertisements.

Although advertising of professional services may represent true ethical problems, it is the advertising of healthcare-related products that imposes the greatest challenge to global bioethics, since it involves heavy economic interests and potentially great risks to all countries, particularly the developing and underdeveloped nations (World Health Organization 2015). Such a practice can occur directly to the consumer, or directed to the health professional, who will prescribe the medication. The direct to consumer advertising, although it is growing recently, is still far less signiﬁcant than the advertising for the health professional, especially doctors (Donohue et al. 2007).

The importance that drug companies give to the marketing of their products is evident by the impressive numbers: approximately one-third of its sales is directed to marketing, which is double the amount they spend on research and development (Angell 2005). Add to this a tricky question: what is meant exactly by “research and development”? Is the declared spending on research, in fact spent on research?

The socioeconomic impact of business strategies of big pharmaceutical companies worldwide, particularly in developing and underdeveloped countries, will be greater in the proportion of the effectiveness of its forms of advertising.

Philosophical Background

If we admit a broad sense to the term advertising, from a philosophical perspective, we found plenty of materials in classical writings that expose ways to get success by calling the attention only to what matters. For example, in book II of Plato’s Republic (Plato 2001, 359d–e, 360a–b), Glaucon tells the story of the ring of Gyges to illustrate his point of view about justice. Gyges was a shepherd who found a ring and discovered that, when turned inside bezel, he became invisible. Empowered by this, he invaded the castle, seduced the Queen, and took power. At ﬁrst glance, this story has nothing to do with advertising. But Glaucon goes ahead, defending the thesis that, once assured that nothing will happen to them, human beings will do anything to get what they desire, and they will succeed, as long as they are successful in keeping a facade of fairness and honesty. The important thing is not to be, but to appear to be.

In the sixteenth century, Niccolo Machiavelli developed a similar thesis for advising the prince how to succeed. The important thing is not to have, in fact, good qualities (morally speaking) but to seem to have them, because “men in general judge more by the eyes than by the hands, for every one can see, but very few have to feel. Everybody sees what you appear to be, few feel what you are (.. .)” (Machiavelli 1984, p. 113).

It is important to emphasize that the examples given so far do not relate to a justiﬁcation of advertising in the strict sense. However, they provide important keys to understand the mechanisms through which the pharmaceutical industry can draw the attention of consumers and health professionals. To draw attention to the qualities of a product does not necessarily mean to lie. But it can mean omitting important information and/or potential bias of reasoning for an adequate decision-making. In this process, it will be all too common that there is participation and even complicity of health professionals. This characterizes a great ethical problem, not always fully revealed or perceived. That is the real point of interest to bioethics.

There are basically two types of advertising of products related to healthcare:

– Direct to consumer advertising

– Advertising to health professionals

Direct To Consumer Advertising

The direct to consumer advertising of drugs has restrictions depending on the laws of each country. Rules applicable to advertising in general will also apply to the case of advertising of drugs, such as the basic rule to tell the truth, which in the case of drugs means to present only the information for which there is solid evidence, so as not to hide adverse effects.

Regulatory agencies such as the FDA in the United States and ANVISA in Brazil, for example, develop rules that basically follow the local legislation, without a prior censorship of each advertisement. Advertising is allowed, as long as it meets certain requirements, such as presenting risks with equal prominence given to the beneﬁts and not using language that misleads consumers.

Regulations of possible excesses of advertising drugs directly to consumers are undeniably important but insufﬁcient to avoid the potential damage that such practice may represent to the population. Even when they are created strictly by the rules, without using language that leads to false conclusions, and showing the adverse effects, the advertisements can cause damage to the individual and the society.

The individual damage would be a consequence of an artiﬁcially created demand upon vulnerable individuals. The wrongful induction does not necessarily depend on inappropriate language. A useful analogy, though somewhat cruel, would be if a pasta dish was presented to someone who has dietary restrictions, it would be pointless not to call it “delicious,” for the visual appeal has already done the damage. The social damage is potentially enormous, since demand can be created for “me too” drugs which are more expensive than the original and become popular just because they are new and are contemplated with a more efﬁcient advertising (Angell 2005). This can happen without strictly breaking any rules.

On the other hand, the argument for advertising of “me too” drugs is not entirely invalid: it considers the possibility of individual differences in response among patients, for which the existence of similar but not identical drugs is a positive factor. More importantly, the advertising of a cheaper “me too” drug draws attention to its existence, allowing patients to question their doctors about the possibility of using cheaper similar drugs. However, unfortunately, the massive investment in “me too” drugs strangely does not signiﬁcantly reduce drug prices. That brings us back to the point – why advertise “me too” drugs just because they are new? Not infrequently, this drug will be more expensive than the original one, without adding much improvement, or none at all.

In this case, the marketing effort will be enormous, but it generally pays back. Companies will invest in direct to consumer advertising, as well as “education,” showing health professionals that the new one is better and should be preferred. They count on Machiavelli’s assertion – ordinary people judge by the surface, not bothering to try and look deep inside.

Patients questioning their doctors for cheaper options of treatment as a positive point of direct to consumer advertising leads us to another issue, which is the advertising to health professionals. Although there is a considerable growth of the pharmaceutical industry’s investment in direct to consumer advertising in recent years, this is not the biggest slice of the budget dedicated to promote their products. Their real target is the health professional, particularly doctors, responsible for most of the pharmaceutical companies’ investment in advertising, though not tagged as “advertising” (Angell 2005; Donohue et al. 2007).

Advertising To Health Professionals

The pharmaceutical companies’ proportion of the investment corresponding to the advertising to health professionals is much larger than the direct to consumer advertising, but its exact size is difﬁcult to be determined. One of the reasons is because pharmaceutical companies often declare as investment on advertising only direct to consumer advertising, sales pitches to doctors in their ofﬁces, free samples for doctors, and advertising in medical journals (Angell 2005). An important component of the advertising of their products is deﬁned as “education,” by means of which they escape the scrutiny to which the advertising is usually submitted. This last point is the one that presents the greatest challenge in bioethics.

Free samples and sales pitches for doctors tend to come together, and its clear goal is to inﬂuence their prescriptions. It is intriguing to observe how a signiﬁcant number of professionals fully trust the advertising materials provided by the companies’ representatives (Fagundes et al. 2007). Such uncritical attitude is worrisome, as it exposes patients to risks by not using the best available scientiﬁc evidence, as well as the ﬁnancial damage, with the possibility of cheaper and equally effective drugs not being used.

The interaction between representatives of the pharmaceutical industry and health professionals starts as early as during college years (Bellin et al. 2004). Intensifying and improving as the experience and, consequently, the potential inﬂuence of the professional increases. This is a relevant fact, as these professionals are exposed to apparent harmless situations, but which can exert great interference in their attitudes. Very early students and residents get used to free samples, small gifts, and educational materials provided by the representatives, who do not infrequently become their friends. This calls our attention to the potential danger of deﬁning as moral that which is habitual, customary. If it is normal or correct that with which we are accustomed, it will be acceptable to live with such practices, which are old, harmless, and “everyone does.” This kind of mistake may lead to disastrous consequences, such as the profoundly unethical Tuskegee study.

However, there is a kind of advertising which is even more ethically questionable that goes way beyond free samples of medications. These are gifts, reimbursements, and payments to healthcare professionals. The higher the rank of the professional, the better the gift. Snacks and small gifts are distributed more widely, while reimbursements for trips to conferences and payments for “consulting,” more selectively. Male doctors in teaching hospitals and certain specialties (e.g., cardiology) have more chances to receive more and better incentives from the pharmaceutical industry (Campbell et al. 2007).

Although advertising in medical journals ﬁts in the category of “education” and is admitted as advertising by pharmaceutical companies, their participation in their total spent is small. This is indeed a complicated issue, because journals rely on this source of ﬁnancing, but on the other hand their inﬂuence in the readers, i.e., health professionals, can be harmful. A study in high-impact journals from Canada, the USA, and Great Britain, for example, identiﬁed a proportion of almost 1:1 of editorial content and advertising in some of these journals (Gettings et al. 2014).

However, this is not the biggest ethical problem created by advertising in the category “education.” Just as what happened with the ring of Gyges in book II of Plato’s Republic (or of the Nibelung, or the Lord of the Rings), the ability to become invisible to act with freedom gives true strength and effectiveness to advertising camouﬂaged as education.

Free Lunches

One of the most common forms of advertising camouﬂaged as education is the popular “free lunches.” These are frequently offered as a stimulus for attending a lecture as part of a scientiﬁc meeting program. In addition, they may be offered to a small group of doctors or residents and become a routine in a clinic or hospital, particularly school hospitals. Sometimes those free lunches may become fancy dinners. An important issue to be considered here is the fact that, when asked, the professionals who participate in these industry-sponsored activities do not consider their practices to be inﬂuenced by this. However, there is plenty of evidence that people in general are inﬂuenced by the most unexpected things. Who would have thought the smell of a fresh cookie has the power of inﬂuencing people’s behavior to the point of being kinder to strangers? (Appiah 2008). Or the reading of words with positive connotation can make us more patients soon after reading? (Appiah 2008) We are a lot less rational, and we have a lot less control of ourselves than we would like to admit (Ariely 2008). If this holds true in general terms, it is especially true in the case of masked advertising tactics inﬂuencing health professionals. A review study conducted by Wazana (2000) reached this troubling conclusion: “Meetings with pharmaceutical representatives were associated with requests by physicians for adding the drugs to the hospital formulary and changes in prescribing practice. Drug company-sponsored continuing medical education (CME) preferentially highlighted the sponsor’s drug (s) compared with other CME programs. Attending sponsored CME events and accepting funding for travel or lodging for educational symposia were associated with increased prescription rates of the sponsor’s medication. Attending presentations given by pharmaceutical representative speakers was also associated with nonrational prescribing” (Wazana 2000, p. 373).

Disclosure Of Conflicts Of Interest

The social cost that the various forms of advertising bring is enormous, both for developed nations and especially the developing and underdeveloped ones. As the saying goes, there is no free lunch; someone always has to pay the bill – in this case, the patients. The cost of the gifts, reimbursements, and kickbacks is passed on to the ﬁnal consumer. And this is no secret. Some strategies have been tried to diminish the ability of pharmaceutical companies to interfere on medical prescriptions. One of them is a limitation on the value of gifts. Limits of 25, 50, or 100 dollars are ﬁxed, without success, because actions classiﬁed as “education” and “consulting” remain untouched.

Since it would be difﬁcult not to count on the pharmaceutical industry funding of scientiﬁc meetings and journals, the solution found was the disclosure of conﬂicts of interests. At ﬁrst glance it seems a good idea, and in fact it is not bad. To be aware of every relevant ﬁnancial links the speakers may have means transparency and that is always welcome. There remain, however, at least two problems. The amount of conﬂicts of interest today is so great, which confuses the audience, giving the impression that, having ties with competing companies, the speaker will be immune to inﬂuences and, consequently, the audience, which is not, in practice, what happens, since even if a speaker has links to competing companies, each lecture will have its ﬁnancier responsible, who is, not infrequently, in charge of preparing the teaching materials used by the speaker. The speaker, in turn, although openly exposing his conﬂict of interest, will not consider it necessary to go into detail about the preparation of his lecture, depriving listeners of important information about the way the educational activity they are attending was prepared.

The common sense imagines a correlation between the kind of the gift and the power of its inﬂuence. By this line of reasoning, a health professional who wins a pen will be less prone to be inﬂuenced than the receiver of a trip to Paris at the expense of a pharmaceutical laboratory. While individually this may be true, in a general and systematic way it may not be. The inﬂuence occurs, whether the gift is big or small. By systematically pampering health professionals, the industry gets the same results as the ones provided by better awards (Katz et al. 2003). Therefore, it is of no use to prohibit only “large gifts.” The prohibition, to reach its goal effectively, must be general.

Some people may fear that such an attitude could have the opposite effect, making professionals feel their freedom threatened and become defensive. In that case, they should be reminded that their profession has similar characteristics of that of judges, who cannot accept gifts from the defendants. An analogy that makes perfect sense, since what are health professionals but judges whose verdict determines what patients will buy and use.

All roads lead to a total restriction of participation of any kind of pharmaceutical industry funding, whether for free samples, small gifts, lunches with lessons, consulting physicians, reimbursements of expenditure on meetings, and, of course, bonuses for prescribing the drugs. Whereas this has as a consequence increased costs of educational and scientiﬁc activities, as well as a restriction of traditional freedoms, is it ethically justiﬁed? A ﬁrst and simple answer, without even the need to make use of ethical epistemology, is the proposal of Marcia Angell (2005): streamline meetings, which would no longer be the great amusement parks that are today, would be more austere and frugal.

Normative Approaches: What Must Be Done?

From the point of view of the epistemology of ethics, a valuable argument would be that of the German philosopher Immanuel Kant. The Kantian moral categorical imperatives have a distinct characteristic of demanding universality. An action will be morally acceptable if it can be a universal law. For example, lying is unacceptable from a Kantian perspective because it could not be a universal law. If we submit the practice of receiving gifts or money from the same institution that needs us to prescribe their products, this clearly could not be a universal law. The conﬂict of interest is ﬂagrant.

Although utilitarianism is an epistemological opposite of Kant, it also ﬁts as an argument here. Considering that the advertising disguised as education and the gifts, reimbursements, and kickbacks are responsible for the cost of the drugs, those practices are not morally right, because they do not promote the best results for the greater number of people. There are signiﬁcantly more patients than health professionals.

From the perspective of bioethics, considering the traditional principlism of Beauchamp and Childress (2013), one can consider that the pharmaceutical industry advertising hurts all the principles: respect for autonomy, because it introduces a bias in the quality of information that comes to the professional and, consequently, the patient; beneﬁcence and non-maleﬁcence, because it causes a signiﬁcant increase in the chance of not using the best treatment and even causing harm to the patient; and ﬁnally justice, by increasing the cost of treatment, therefore preventing people to have access to them.

Perhaps the most powerful epistemological instrument in bioethics to approach the ethical problems raised by advertising of drugs would be the Intervention Bioethics (Garrafa and Porto 2003), developed in Latin America, in response to an important social and global demand. Unlike principlism, which has a more passive approach, and is completely apolitical, Intervention Bioethics is openly active and interventional. From the perspective of Intervention Bioethics, it makes no sense, for example, to even take into consideration the possibility of nuisance on the part of health professionals for an alleged loss of freedom by depriving them of the gifts and ﬁnancial support from the pharmaceutical industry: ﬁrstly because the freedom that really matters is kept, i.e., the professional maintains its ability to choose the best for their patients, and even with more freedom, without the invisible but very powerful bonds of the bias caused by different forms of advertising of the industry, and, secondly, because the higher price paid by the minority (journals and scientiﬁc meetings becoming more expensive) is socially much less important than the huge price paid by most patients around the world unable to afford the high costs of their treatments.

Conclusion

Advertising of drugs is deﬁnitely a relevant matter, which may pose serious ethical problems. It may present itself in open but also disguised forms. Both are problematic. When advertising is used openly, i.e., as advertising in companies’ budgets, it inﬂuences patients and pushes them to ask for the “new and better” drug to be prescribed by the health professional. This would not be a problem, were these drugs really new or cheaper, which is not often the case. When advertising is disguised as education, it is even more problematic, for it is camouﬂaged as something else than a commercial product, which it really is. As a product, its only purpose is to make money, to raise the already astronomical proﬁts of its manufacturers. This inserts a bias in health professionals’ minds who are not always capable of recognizing it. For this reason, the mere disclosure of conﬂicts of interests is not enough. Advertising disguised as education or research, i.e., the ﬁnancial support of pharmaceutical industries of meetings and journals, as well as artiﬁcial phase IV trials, should be banned. The cost of advertising for the global community has become unacceptable.

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