Hostname: page-component-848d4c4894-8kt4b Total loading time: 0 Render date: 2024-06-29T08:01:40.292Z Has data issue: false hasContentIssue false
  • English
  • Français

Advertising Policies of Medical Journals: Conflicts of Interest for Journal Editors and Professional Societies

Published online by Cambridge University Press:  01 January 2021

David Orentlicher  and
Michael K. Hehir II
Get access Rights & Permissions [Opens in a new window]

Extract

As the medical profession becomes more and more of a commercial enterprise, commentators are subjecting conflicts of interest in medicine to increasing scrutiny. However, one critical area of conflict has largely escaped discussion—the conflicts of interest raised by the advertising policies of medical journals. Moreover, when these conflicts are discussed, they are examined almost exclusively in terms of the concerns that they pose for journal editors. Yet, there is a second critical concern with journal advertising policies. The policies also create serious conflicts of interest for the professional societies that own medical journals.

In this article, we will discuss the conflicts of interest that are raised for journal editors and professional societies by journal advertising policies, and we will conclude that the policies are exactly backward. Currently, medical journals rely on advertisements from pharmaceutical companies and other health-related businesses and avoid—indeed exclude—advertisements from consumer-oriented companies, like producers of automobiles, golf equipment, or jewelry. We submit that the medical journals, the medical profession, and the public would be better served if consumeroriented advertisement were preferred over health-related advertising.

Type
Article
Information
Journal of Law, Medicine & Ethics , Volume 27 , Issue 2 , Summer 1999 , pp. 113 - 121
Copyright
Copyright © American Society of Law, Medicine and Ethics 1999

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Journal advertising creates other ethical concerns in addition to the conflicts of interest concerns that we discuss. For example, expenditures on advertising arguably raise the costs of drugs to patients, creating hardship for poor patients. These other ethical concerns, while important, are beyond our scope.Google Scholar
Indeed, at times, journal editors forthrightly confront the concerns raised by journal advertising. The Annals of Internal Medicine published an article critical of advertising content. See Wilkes, M.S. Doblin, B.H. Shapiro, M.F., “Pharmaceutical Advertisements in Leading Medical Journals: Experts' Assessments,” Annals of Internal Medicine, 116 (1992): 912–19. Similarly, the New England Journal of Medicine and the Journal of the American Medical Association (JAMA) have published articles questioning the influence of advertising on the journal editorial process. See Bero, L.A. Galbraith, A. Rennie, D., “The Publication of Sponsored Symposiums in Medical Journals,” N. Engl. J. Med., 327 (1992): 1135–40; and Rochon, EA. et al., “Evaluating the Quality of Articles Published in Journal Supplements Compared with the Quality of Those Published in the Parent Journal,” JAMA, 272 (1994): 108–13. Still, one cannot conclude that, because journal editors sometimes resist a conflict of interest, they always do so.Google Scholar
A striking example of the subconscious influence of a conflict of interest is the commonly observed phenomenon in law that respected attorneys on both sides of a case tend to become truly convinced of the merit of their clients' positions.Google Scholar
See “Index to advertisers,” JAMA, 281 (1999): 2259.Google Scholar
In the “Advertising Policy of Annals of Internal Medicine,” the journal lists several examples of “Unacceptable Advertising.” Among the examples are “ads for products and services not directly relevant to the practice of medicine.” For the New England Journal of Medicine, “all advertising must be clearly germane to the practice of medicine.”Google Scholar
See JAMA, 278 (1997): 696a; and JAMA, 278 (1997): 1472a.Google Scholar
See JAMA, 277 (1997): 688e; JAMA, 277 (1997): 770t; and JAMA, 277 (1997): 792i.Google Scholar
See personal communication with Stuart Williams, H., Director of Advertising Sales, Journal of the American Medical Association (Sept. 29, 1998, and June 24, 1999).Google Scholar
See Bero, Galbraith, Rennie, supra note 2.Google Scholar
See Rochon, et al., supra note 2.Google Scholar
See Chren, M. Landefeld, C.S. Murray, T.H., “Doctors, Drug Companies, and Gifts,” JAMA, 262 (1989): 3448–51.CrossRefGoogle Scholar
See Clifton, J.A. Huth, E.J., “Old Friends Among Our Advertisers,” Annals of Internal Medicine, 87 (1977): 115.CrossRefGoogle Scholar
We have presented a hypothetical example in the text, but a recent real example illustrates the possible influence of an editor's personal interests on editorial judgment. Earlier in 1999, during the impeachment proceedings of President Clinton, JAMA published an article reporting the views of college students about oral sex. See Sanders, S.A. Reinisch, J.M., “Would You Say You ‘Had Sex’ If … ?,” JAMA, 281 (1999): 275–77. The article seemed to support President Clinton's claim that he did not lie when he denied having sexual relations with Monica Lewinsky, even though she had performed oral sex on him. Many people felt that the article should not have been published because of its political orientation and the fact that the data came from one university survey conducted eight years earlier. See Kolata, G., “Editor of A.M.A. Journal Is Dismissed Over Sex Paper,” New York Times, Jan. 16, 1999, at A10. One could easily conclude that those considerations would have led a journal editor who disliked President Clinton to reject the article.Google Scholar
See Note, “Facial Discrimination: Extending Handicap Law to Employment Discrimination on the Basis of Physical Appearance,” Harvard Law Review, 100 (1987): 2035–73; Kramer, K.M. Mayerson, A.B., “Obesity Discrimination in the Workplace: Protection Through a Perceived Disability Claim Under the Rehabilitation Act and the Americans with Disabilities Act,” California Western Law Review, 31 (1994): 41–72; Wadden, T.A. Stunkard, A.J., “Psychological Consequences of Obesity and Dieting: Research and Clinical Findings,” in Stunkard, A.J. Wadden, T.A., eds., Obesity: Theory and Therapy (New York: Raven Press, 2nd ed., 1993): 163–77.Google Scholar
See Hemenway, D. et al., “Physicians' Responses to Financial Incentives: Evidence from a For-profit Ambulatory Care Center,” N. Engl. J. Med., 322 (1990): 1059–63.Google Scholar
See Rennie, D., “Editors and Advertisements: What Responsibility Do Editors Have for the Advertisements in Their Journals?,” JAMA, 265 (1991): 2394–96; and Fontanarosa, P.B. Glass, R.M. Murphy, P.J., Letter, “Bioequivalence of Levothyroxine Preparations: Issues of Science, Publication, and Advertising,” JAMA, 278 (1997): 899–900.Google Scholar
Dong, B. J. et al., “Bioequivalence of Generic and Brand-Name Levothyroxine Products in the Treatment of Hypothyroidism,” JAMA, 277 (1997): 1205–13.Google Scholar
See JAMA, 277 (1997): Flyleaf between 1178h & 1178o; flyleaf between 1246 & 1247; and Lankin, K.M., Letter, “Bioequivalence of Levothyroxine Preparations: Issues of Science, Publication, and Advertising,” JAMA, 278 (1997): 897.CrossRefGoogle Scholar
See Fontanarosa, Glass, Murphy, supra note 16.Google Scholar
See Bramblett, M.T., Letter, “Bioequivalence of Levothyroxine Preparations: Issues of Science, Publication, and Advertising,” JAMA, 278 (1997): 899.Google Scholar
See DiPaola, R.S. et al., “Clinical and Biologic Activity of an Estrogenic Herbal Combination (PC-SPES) in Prostate Cancer,” N. Engl. J. Med., 339 (1998): 785–91; and Slifman, N.R. et al., “Contamination of Botanical Dietary Supplements by digitalis lanata,” N. Engl. J. Med., 339 (1998): 806–11.Google Scholar
See Coppes, M.J. et al., Letter, “Alternative Therapies for the Treatment of Childhood Cancer,” N. Engl. J. Med., 339 (1998): 846–47; Ko, R.J., Letter, “Adulterants in Asian Patent Medicines,” N. Engl. J. Med., 339 (1998): 847; and LoVecchio, F. Curry, S.C. Bagnasco, T., Letter, “Butyrolactone-Induced Central Nervous System Depression after Ingestion of RenewTrient, a ‘Dietary Supplement’,” N. Engl. J. Med., 339 (1998): 847–48.Google Scholar
See Angell, M. Kassirer, J.P., Editorial, “Alternative Medicine—The Risks of Untested and Unregulated Remedies,” N. Engl. J. Med., 339 (1998): 839–41.CrossRefGoogle Scholar
See Gorton, C., Letter, “Butyrolactone-Induced Central Nervous System Depression after Ingestion of RenewTrient, a ‘Dietary Supplement’,” N. Engl. J. Med., 339 (1998): 848.Google Scholar
See Siegel, R. Wertheimer, L., “Alternative Medicine,” All Things Considered (National Public Radio broadcast, Sept. 16, 1998) (Transcript No. 98091613–212).Google Scholar
See Hazlet, T.K. Sullivan, S.D., “Professional Organizations and Healthcare Industry Support: Ethical Conflict?,” Cambridge Quarterly Healthcare Ethics, 3 (1994): 236–56; and Leffler, K., “Persuasion or Information? The Economics of Prescription Drug Advertising,” Journal of Law & Economics, 24 (1981): 45–74.CrossRefGoogle Scholar
See Avorn, J. Chen, M. Hartley, R., “Scientific Versus Commercial Sources of Influence on the Prescribing Behavior of Physicians,” American Journal of Medicine, 264 (1990): 2409–15.Google Scholar
See Wilkes, Doblin, Shapiro, supra note 2.Google Scholar
Some would argue that, instead of curtailing health care advertising, we should turn to better education of physicians to ensure that they appropriately weigh the informational value of journal advertisements. It is not clear how successful better education would be at addressing the influence of advertising on physicians' practices. Physicians may come to rely on advertising not because they do not know better, but because it is more time consuming and expensive to seek out more reliable sources of information. In any event, better education is a long-term strategy that cannot address the problems created in the short term by medical journal advertising.Google Scholar
See Kennett, R.L. Liebman, M., “Too Tight a Focus in Micromarketing?,” Medical Marketing & Media, 29, no. 7 (1994): 66. In fact, however, physicians might be influenced more by other sources of information, including the views of trusted colleagues. See Orentlicher, D., “The Influence of a Professional Organization on Physician Behavior,” Albany Law Review, 57 (1994): 583–605.Google Scholar
Material in Drug Evaluations was developed as follows: Chapters initially are prepared by the professional staff of the AMA Division of Drugs and Toxicology on the basis of the current scientific literature. Chapter drafts then are reviewed by distinguished expert consultants (more than 800 participate for the entire text) and by the medical staffs of the pharmaceutical manufacturers whose products are evaluated. Division of Drugs and Toxicology, American Medical Association, Drug Evaluations: Annual 1995 (Chicago: American Medical Association, 1995): at iii [hereinafter Drug Evaluations].Google Scholar
For example, in creating its legal standard for evaluating claims of discrimination on the basis of disability, the U.S. Supreme Court adopted a standard proposed by the American Medical Association (AMA) in its amicus curiae brief. See School Board of Nassau County v. Arline, 480 U.S. 273, 288 (1987). Similarly, at oral argument in Patrick v. Burget, 486 U.S. 94 (1988), Justice O'Connor asked Dr. Timothy Patrick's lawyer what he thought of the standard proposed for the state action doctrine by the AMA.Google Scholar
For example, in its discussion of drugs for chronic heart failure in May 1993 and January 1999, The Medical Letter advised that patients with heart failure due to left ventricular dysfunction take an angiotensin-converting enzyme inhibitor drug, plus a digoxin and diuretic or plus a beta-blocker. See Medical Letter, 35 (1993): at 42 (advising use of a digoxin and diuretic); and Medical Letter, 41 (1999): 14 (advising use of a beta-blocker). In contrast, Drug Evaluations advised in 1995 that a combination of different drugs is usually required, but did not endorse one particular combination. See Drug Evaluations, supra note 31, at 687.Google Scholar
See Fletcher, R.H. Fletcher, S.W., “Pharmaceutical Advertisements in Medical Journals,” Annals of Internal Medicine, 116 (1992): 951–52.Google Scholar
See Brown, C., “Callaway is Prepared to Fight Any Ban on Clubs,” New York Times, May 23, 1998, at C6.Google Scholar
Mark Hall pointed out to us that, in the past, medical journals may have thought there were tax reasons to accept only health-related advertising and to justify such a policy on educational grounds. See Personal Communication with Mark Hall, Professor, Wake Forest University (June 4, 1999). In 1967, the U.S. Treasury adopted a regulation that subjected to taxation the commercial ventures of tax-exempt organizations that were not substantially related to the purposes of their tax exemption. A medical journal might have concluded that it could escape taxation for its advertising if the advertisements were health related. That interpretation was finally foreclosed by the U.S. Supreme Court in 1986. See U.S. v. American College of Physicians, 475 U.S. 834 (1986). Tax incentives are not the entire story, however. The nearly exclusive use of health-related advertising can be found in issues of leading medical journals even in the years predating the influence of tax regulations. See, for example, “Index to Advertisers,” JAMA, 191 (1965): 222. Also, medical journals that are run by for-profit companies have the same advertising policies as journals run by nonprofit professional societies.Google Scholar
See American College of Physicians, 475 U.S. at 847–50.Google Scholar
See id. at 849.Google Scholar
If medical journals mix health-related and nonhealth-related advertisements, advertising revenue might decline rather than increase. Health-related companies are willing to pay higher fees than other companies will pay, and journals may not be able to sustain a two-tiered fee structure. As a result, the journals might have to lower their fees for health-related advertisements. In addition, health care companies apparently prefer not to advertise in medical journals if nonhealth care advertising is also present, possibly because the other advertising diverts the attention of readers. If health care companies cannot escape competition with nonhealth care companies by advertising in medical journals, they may have an even stronger interest in advertising directly to consumers in lay journals, where nonhealth care advertising already exists. As to whether a drop in revenues from mixing health-related and nonhealth-related advertising justifies a policy of accepting only health-related advertisements, see the discussion below regarding the potential drop in revenues from excluding all health-related advertisements.Google Scholar
See Goldstein, J.F., “Of Mugs and Marketing,” JAMA, 265 (1991): 2391–92.Google Scholar
When similar conflicts of interest arise with industry funding, it is often the case that the benefits of the funding outweigh the risks of harm. For example, pharmaceutical companies are a leading source of funding for biomedical research, and the funding creates a conflict of interest for the recipients who conduct the research. Safeguards have developed to limit the risk (including disclosures of the conflicts), and it is generally believed that the public would be worse off if the funding were cut off entirely. Still, each conflict of interest raised by industry funding must be considered on its own terms. The balance of benefits and risks will play out differently in different cases, with benefits sometimes outweighing risks and vice versa.Google Scholar
One might argue that it is better to err on the side of too many journals because journal editors will sometimes mistakenly reject a good article. Editorial judgment is not perfect. Having fewer journals will increase the likelihood of a good article being rejected, and patients could lose out on an improvement in therapy. On the other hand, it may be worse to publish a bad article than not to publish a good article. Bad information can lead to dangerous therapies being used and harm being caused to patients. Having fewer journals will decrease the likelihood of a bad article being published, and patients may end up better overall.Google Scholar
In other words, the conflict of interest is primarily a conflict for professors reading the journals, whose gratitude for the advertising dollars could influence their choice of textbooks for courses. The difference in advertising for academic journals in other fields probably reflects the fact that they do not have the same opportunities for industry funding as do medical journals. Nevertheless, the important point is that these other fields seemingly are able to publish enough of their fields' research without relying on the same kind of industry funding as received by medical journals.Google Scholar
See Kassirer, J.P., Letter, “Pharmaceutical Advertising in the Journal,” N. Engl. J. Med., 327 (1992): 1689.Google Scholar
See id.Google Scholar
See Zuger, A., “After Bad Year for A.M.A., Doctors Debate Its Prognosis,” New York Times, Dec. 2, 1997, at F3.Google Scholar
See Starr, P., The Social Transformation of American Medicine (New York: Basic Books, 1982): at 299–310, 367–70.Google Scholar
See Editorial, “The A.M.A.—Deja Vu, Again,” New York Times, May 29, 1994, 4–10.Google Scholar
See Pear, R., “Inquiry Criticizes A.M.A. Backing of Abortion Procedure Ban,” New York Times, Dec. 4, 1998, at A27.Google Scholar
See Collins, G., “A.M.A. Seeks to Dismantle Sunbeam Deal,” New York Times, Aug. 22, 1997, at D2.Google Scholar
See American Medical Association, SmokeLess States Tobacco Use Prevention Program (visited July 7, 1999) <http://www.ama-assn.org/special/aos/tobacco/main.htm>..>Google Scholar