From Lydia Pinkham to Bob Dole: what the changing face of direct-to-consumer drug advertising reveals about the professionalism of medicine

From its founding in 1847, the AMA divided drugs into "ethical" and "unethical" preparations. Those that were ethical had a known composition and were advertised only to the profession. Other, patent medicines (technically proprietary drugs, whose trademarks were protected by copyright), were sold directly to the public. In spite of the AMA's efforts to ban the advertising and sale of those nostrums, proprietary drugs flourished during the nineteenth century. Starting in 1900, however, three major societal trends combined to bolster the AMA's campaign, and by 1920 almost all advertising was directed to physicians, who would then prescribe medications to their patients. This ban on advertising pharmaceuticals directly to the public remained virtually unchanged until approximately 1980. Since then, it has slowly eroded and, as recently as 1997, the FDA created guidelines for pharmaceutical companies to advertise on television. What does this change say about the profession of medicine, the role of the physician in society, and the doctor-patient relationship? Using a comparative historical approach, this paper examines these issues.     

Prescribing Psychologists in Integrated Primary Care: Introduction to the Special Section

The authority to prescribe could differentiate psychologists from other non-physicians in primary care, achieving a significant step for the growth of our profession. Psychologists are currently prescribing in primary care settings in a number of public service venues, as well as medical school training facilities. In this Special Section of the Journal of Clinical Psychology in Medical Settings, results of a survey of physicians working with a prescribing psychologist indicate that the psychologist is highly valued and seen as a competent prescriber. A series of papers providing case examples demonstrate how psychologists are evolving in these new clinical roles, as well as participating in behavioral and psychopharmacology training of primary care physicians.     

Professional Autonomy and the Normative Structure of Medical Practice

Professional autonomy is often described as a claim of professionalsthat has to serve primarily their own interests. However, it can also beseen as an element of a professional ideal that can function as astandard for professional, i.e. medical practice. This normativeunderstanding of the medical profession and professional autonomy facesthree threats today. 1) Internal erosion of professional autonomy due toa lack of internal quality control by the medical profession; 2)the increasing upward pressure on health care expenses that calls for ahealth care policy that could imply limitations for the professionalautonomy of physicians; 3) a distorted understanding of theprofession as being based on a formal type of knowledge and relatedtechnology, in which other normative dimensions of medical practice areneglected and which frustrates meaningful communication betweenphysicians and patients. To answer these threats a normative structureanalysis of medical practice is presented, that indicates whichprinciples and norms are constitutive for medical practice. It isconcluded that professional autonomy, normatively understood, should bemaintained to avoid the lure of the technological imperative and toprotect patients against third parties' pressure to undertreatment.However, this professional autonomy can only be maintained if members ofthe profession subject their activities and decisions to a criticalevaluation by other members of the profession and by patients and ifthey continue to critically reflect on the values that regulate today'smedicine.     

Ethical evaluation of "retainer fee" medical practice

This article examines the reasons that some physicians have recently opted to reduce the size of their practice rosters to allow more time for each patient in exchange for a retainer fee from patients. These physicians also offer supplementary, nonmedical amenities to patients as part of their service. Because physicians have reduced the size of their practice rosters and have increased the price tag for their services, some patients have lost access to their care. We have tried to assess the ethical propriety of such a change in the design of medical practices by weighing plausible, ethically relevant arguments favoring and opposing RFMP. Physicians are ethically obligated first and foremost to promote and protect the health of their patients. RFMP fulfills this duty directly by ensuring prompt and ample professional time for the care of patients. It does so indirectly by allowing time for physicians' continuing education, which in turn should upgrade the quality of care. It also advances the ethical goals of autonomy as it allows patients to choose their own physicians and to spend their money as they please. On the other hand, these ethical positives are offset by the cost of retainer fees that may exclude access of patients to their physicians' care. Even if ethical tradition obligates physicians primarily to patients under their specific care, as professionals and as private citizens, they also have a responsibility to support the health of the entire community. RFMP does little to advance this cause, except that by optimizing the conditions under which their own private patients receive healthcare, they call attention to shortcomings in prevailing public healthcare policies, which by comparison fall short of that standard. An assumption that health is not properly a market commodity, and that all people should receive healthcare on equal terms, would expose RFMP to moral reproof. From an ethical perspective, we find sufficient cause for concern and caution in this innovative style of practice. Nevertheless, the weight of arguments presented here does not seem to justify unequivocal moral condemnation of RFMP. As neither pro nor con views seem to have settled the ethical question, definitive moral judgment on RFMP will probably depend on the outcome of future experience and ongoing evaluation. The implications of RFMP for any future healthcare system are not clear, at least to us.     

The physician and social renewal: Julius B. Richmond as role model

We live in an age of “high tech” medicine which affects both health care recipients and physicians who are taught its many wonders and uses. It is easy in this atmosphere of specialization for clinicians, professors and medical students to become isolated and to ignore social issues which affect health care in its broadest sense. Individuals who are committed to the “common good” are the ones historically who have been effective change agents. It would be tragic simply to stand back and allow the cynical and greedy to dominate any profession which deals with the poor, the uninsured and the homeless. It is imperative for physicians to take a broad view of today's problems in health care delivery systems, for they can have an enormous impact on the kind of world our children will inherit. It is essential for physicians to become involved in social concerns, and in improving health care delivery, at all levels in their practice. Given their power and prestige, it is crucial for physicians and aspiring physicians to have positive role models. Dr. Julius B. Richmond provides an admirable example of a physician who cares about his profession, his patients and his nation. Through his research, his public service and his teaching, Dr. Richmond has demonstrated the difference a single individual can make in improving the quality of life for all Americans.     

"Doctor, would you prescribe a pill to help me … ?" a national survey of physicians on using medicine for human enhancement

Using medical advances to enhance human athletic, aesthetic, and cognitive performance, rather than to treat disease, has been controversial. Little is known about physicians' experiences, views, and attitudes in this regard. We surveyed a national sample of physicians to determine how often they prescribe enhancements, their views on using medicine for enhancement, and whether they would be willing to prescribe a series of potential interventions that might be considered enhancements. We find that many physicians occasionally prescribe enhancements, but doctors hold nuanced and ambiguous views of these issues. Most express concerns about the potential effects of enhancements on social equity, yet many also believe specific enhancements that are safe and effective should be available but not covered by insurance. These apparently contradictory views might reflect inherent tensions between the values of equity and liberty, which could make crafting coherent social policies on medical enhancements challenging.     

Sex differences in the professional orientation of first-year medical students

This article, presenting the findings from a 1975 survey of first-year medical students in the state of North Carolina, explores the relationship between students' sex and professional orientations considered relevant to current health care problems. The professional orientations concern four problem areas: (1) physicians' relationships with patients, (2) political and economic change in the medical profession, (3) the treatment of women physicians and women patients, and (4) geographic and specialty mal-distribution of physicians. Substantial sex differences are found for some professional orientations. As hypothesized, women orient more highly than men to humanizing physician-patient relationships, political and economic change in medicine, the problems facing women physicians and patients, and expecting an inner-city practice. Implications of the findings for health care and medical education are discussed.This report is based on the author's doctoral dissertation, Boys and Girls in White: Professional Orientation of the Student Physician Department of Sociology, Duke University, 1976. The author would like to express appreciation to Jim House for his continued guidance and encouragement as dissertation advisor.     

Foucault's "fearless speech" and the transformation and mentoring of medical students

In his six 1983 lectures published under the title, Fearless Speech (2001), Michel Foucault developed the theme of free speech and its relation to frankness, truth-telling, criticism, and duty. Derived from the ancient Greek word parrhesia, Foucault's analysis of free speech is relevant to the mentoring of medical students. This is especially true given the educational and social need to transform future physicians into able citizens who practice a fearless freedom of expression on behalf of their patients, the public, the medical profession, and themselves in the public and political arena. In this paper, we argue that Foucault's understanding of free speech, or parrhesia, should be read as an ethical response to the American Medical Association's recent educational effort, Initiative to Transform Medical Education (ITME): Recommendations for change in the system of medical education (2007). In this document, the American Medical Association identifies gaps in medical education, emphasizing the need to enhance health system safety and quality, to improve education in training institutions, and to address the inadequacy of physician preparedness in new content areas. These gaps, and their relationship to the ITME goal of promoting excellence in patient care by implementing reform in the US system of medical education, call for a serious consideration and use of Foucault's parrhesia in the way that medical students are trained and mentored.     

Primary care physicians attitude toward diagnosis and treatment of late-life depression

Underdiagnosis and undertreatment of late-life depression is common, especially in primary care settings. To help assess whether physicians attitude and confidence in diagnosing and managing depression serve as barriers to care, a total of 176 physicians employed in 18 primary care groups were administered surveys to assess attitudes towards diagnosis, treatment, and management of depression in elderly patients, (individuals over 65 years of age). Logistic regression was performed to assess the association of physician characteristics on attitudes. Nearly all of the physicians surveyed felt that depression in the elderly was a primary care problem, and 41% reported late-life depression as the most common problem seen in older patients. Physicians were confident in their ability to diagnose and manage depression, yet 45% had no medical education on depression in the previous three years. Physicians confidence in their ability to diagnose, treat, and manage depression, and their reported adequacy of training, do not appear to correspond to the amount of continuing medical education in depression, suggesting that physician overconfidence may potentially be serving as a barrier to care.     

Commitment Shift during Organizational Upheaval: Physicians' Transitions from Private Practitioner to Employee

This longitudinal study examines the individual transition journeys of physicians as their private medical practices are acquired by a large integrated health care system. We test the proposition that transition patterns (trends in an individual's commitments to organization and profession over time) are a function of individual differences in years in profession and perceived organizational enabling characteristics (change involvement, openness to ideas, and work discretion). Three years of survey data were obtained from a panel of 48 physicians who transitioned through an organizational change process. Results challenge traditional assumptions that tenure reinforces commitment and cast doubt on the effectiveness of current medical school curricula in preparing medical graduates to practice in an administrative environment. In addition, results strongly suggest that enabling characteristics of organizational change are critical for compatibility between the organizational and professional attachments of transitioning physicians.     

Psychological knowledge in a colonial context: theories on the nature of the "native mind" in the former Dutch East Indies

This article analyzes the views of 3 Dutch physicians working in the former Dutch East Indies during the first part of the 20th century. These physicians based ideas about the nature of the normal indigenous psyche on both their analysis of Indonesian individuals suffering from mental illness and on casual observations that represented widely shared cultural stereotypes. On that basis, they advocated a psychological colonial policy, which was to be based on a scientific understanding of the psyche of the Indonesian people. Using these ideas, they advocated political repression, justified inequality and racism, and limited educational opportunities for Indonesians. Representatives of the Indonesian nationalist movement vigorously protested against these ideas.     

Professional Boundary Ethics Attitudes and Awareness Among Nurses and Physicians in a University Hospital in the Kingdom of Saudi Arabia

This study sought to gauge ethical attitudes about professional boundary issues of physicians and nurses in the Kingdom of Saudi Arabia. Respondents scored 10 relevant boundary vignettes as to their ethical acceptability. The group as a whole proved “aware/ ethically conservative,” but with the physicians' score falling on the “less ethically conservative” part of the spectrum compared to nurses. The degree of ethicality was more related to profession than to gender, with nurses being more “ethical” than physicians.     

Limiting the role of the family in discontinuation of life sustaining treatment

In matters of discontinuation of life-sustaining treatment, traditional role of the family to speak on behalf of the incompetent patient is questionable. We explore the reasons why physicians perceive patient autonomy to be transferrable to family members. Principle of patient autonomy may not suffice when futile treatment is demanded and may serve to erode the ethical integrity of medical profession. An enhanced role for bioethics committees is proposed when physicians propose to discontinue life-sustaining treatment against the wishes of the patient or their families.     

Social ethics,the philosophy of medicine,and professional responsibility

The social ethics of medicine is the study and ethical analysis of social structures which impact on the provision of health care by physicians. There are many such social structures. Not all these structures are responsive to the influence of physicians as health professionals. But some social structures which impact on health care are prompted by or supported by important preconceptions of medical practice. In this article, three such elements of the philosophy of medicine are examined in terms of the negative impact on health care of the social structures to which they contribute. The responsibilities of the medical profession and of individual physicians to work to change these social structures are then examined in the light of a theory of profession.     

Trust in the medical profession and patient attachment style

Attachment style is a person’s approach to interpersonal relationships, which develops from early experiences with primary caregivers and can remain stable into adulthood. Depending on a person’s attachment style, the amount of trust one has in others can vary when forming relationships, and trust is important in formation of the patient–physician relationship. The purpose of this study was to see if there is an association between attachment style and trust in physicians in general. Participants were recruited from an emergency department (ED) and an online university participant pool, and completed short questionnaires assessing attachment style and trust in the medical profession. Results revealed that individuals with a fearful attachment style reported significantly lower levels of trust in the medical profession than those with a secure attachment style. ED participants also reported higher levels of trust in the medical profession in comparison to student participants. This study provides a better understanding of trust in the medical profession, and insight into future care for patients who have low trust.     

The medical profession and the corporatization of the health sector

This article describes the most important determinant of contemporary American medical practice: the corporatization of the health care delivery system. It argues that there is an urgent need for greater reflection by physicians on the values inherent in profit-based health care and on the implications of such a model of care. Other pressures on the medical profession and several available responses are examined. The article then poses a challenge to the profession to assume a more forthright advocacy for social equity in health care provision.     

Palliative sedation: clinical context and ethical questions

Practitioners of palliative medicine frequently encounter patients suffering distress caused by uncontrolled pain or other symptoms. To relieve such distress, palliative medicine clinicians often use measures that result in sedation of the patient. Often such sedation is experienced as a loss by patients and their family members, but sometimes such sedation is sought as the desired outcome. Peace is wanted. Comfort is needed. Sedation appears to bring both. Yet to be sedated is to be cut off existentially from human experience, to be made incapable of engaging self-consciously in any human action. To that extent, it seems that to lose consciousness is to lose something of real value. In this paper, I describe how sedation and the question of intentionally bringing about sedation arise in the care of patients with advanced illness, and I propose heuristics to guide physicians, including Christian physicians, who seek to relieve suffering without contradicting their profession to heal.     

La force normative du contrôle ordinal des contrats conclus par les médecins

Professional contracts concluded by physicians are specific. Indeed, these contracts must be compliant with ethical standards of the profession. As a professional authority, the College of physicians introduces obligations under which professionals have to stipulate several specific clauses and transmit their written contracts to the College, which controls their conformity. However, the normative power of these obligations is weak. To ensure the respect of ethical standards in professional contracts, soft law is more and more used by the College.     

Voluntary Control of Behavior and Responsibility

Malpractice insurance rates have created a crisis in American medicine. Rates are rising and reimbursements are not keeping pace. In response, physicians in the states hardest hit by this crisis are feeling compelled to take political action, and the current action of choice seems to be physician strikes. While the malpractice insurance crisis is acknowledged to be severe, does it justify the extreme action of a physician walkout? Should physicians engage in this type of collective action, and what are the costs to patients and the profession when such action is taken? I will offer three related arguments against physician strikes that constitute a prima facie prohibition against such action: first, strikes are intended to cause harm to patients; second, strikes are an affront to the physician-patient relationship; and, third, strikes risk decreasing the public's respect for the medical profession. As with any prima facie obligation, there are justifying conditions that may override the moral prohibition, but I will argue that the current malpractice crisis does not rise to the level of such a justifying condition. While the malpractice crisis demands and justifies a political response on the part of the nation's physicians, strikes and slow-downs are not an ethically justified means to the legitimate end of controlling insurance costs.