Are drug companies ‘disease mongering’?

Ethics @ Work: Three news books provide evidence that many psychiatric drugs are over-prescribed, and many illness are over-diagnosed.

Pills 311 (photo credit: Courtesy)
Pills 311
(photo credit: Courtesy)
A recent article in The New York Review of Books draws attention to the ethical issue of “disease mongering.” The review by Marcia Angell examines three new books that provide evidence that many psychiatric drugs are overprescribed, and many psychiatric illnesses are over-diagnosed.
The authors claim that pharmaceutical companies are able to game the diagnosis and prescription process in various ways to give physicians and patients the impression that: 1) they have a disorder; that 2) can be treated by a drug – when both 1 and 2 are doubtful.
How does this process take place, and what are the main ethical issues involved?
One of the main problems is the medical research. Much medical research is carried out, quite appropriately, by drug companies. Research and development take place in nearly every industry, and in the pharmaceutical industry much R&D is publishable medical research. The problem is that in all areas of science there are certain publication biases, and in medicine these tend to aggravate “disease mongering.”
Some scientists may think a lot of people have psychological problems that can be alleviated by drugs, and some may think the opposite. But even if the science on both sides is equally good, a lot more money is likely to be thrown at experiments that try to affirm this proposition than ones that try to discredit it.
Among the experiments that are done, a lot more of the affirming ones will be sent for publication. If a drug company does a study showing that a particular compound is useless or worse, how much incentive do they have to complete the peer review process? This is a serious problem that was even more serious in the past, when many scholars did not even disclose the extent to which their research was funded by business interests.
A parallel problem is advertising. If one scientist thinks a drug is good for you and another thinks it is bad for you, the first scientist will readily find a huge budget to explain the evidence in favor to physicians and patients; the second one will probably have to settle for interviews with journalists and talk-show hosts.
One of the most interesting ethical questions is: What is special about pharmaceuticals? The parallel “skewing” phenomenon pervades the entire world of marketing. After all, no one is going to spend good money to persuade you that perfume is smelly, that movies are boring, that fruit is more nutritious than candy, and so on. Why are we particularly disturbed when we see the same phenomenon in the pharmaceutical industry?
I see two main reasons why “drugs are different.” One is that drugs are ultimately prescribed by physicians, who are considered authority figures and not merely “consumption advisers.” Ultimately there is no coercion involved when I see a movie or buy a candy bar. But when a doctor prescribes an antidepressant, I may feel that I must defer to his or her judgment.
The second reason is the potential for harm. Even when consumer products are useless they are generally harmless. But many pharmaceuticals have severe side effects that can only be justified by a high degree of certainty of their benefits. Such a standard of proof is compromised by the various ways in which marketing considerations skew the decision process.
One antidote to these drugs is simply more awareness – among journal editors, physicians and even patients, who should be empowered to ask the right questions, and not just the ones the ads tell them to ask. But I think ultimately there needs to be more transparency in the scientific process. Whether you are a drug company or an academic researcher, someone should know about your “failed” experiments as well as your “successful” ones.
Angell reports that one of the researchers she cites had to resort to the Freedom of Information Act to obtain the data from the “failed” experiments, which of course succeeded in casting doubt on the veracity of the “successful” ones. The whole process has too much data-mining (looking for preconceived notions in the data) built in.
Transparency in publication should also include giving a descriptive account of experiments that were conducted and that are not being published, together with access to the relevant data.
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Asher Meir is research director at the Business Ethics Center of Jerusalem, an independent institute in the Jerusalem College of Technology (Machon Lev).