The development and manufacture of pharmaceutical drugs have enabled modern doctors to cure infectious diseases, manage chronic illnesses, and alleviate acute and terminal pain. However, the relationship between the pharmaceutical industry and physicians is an uneasy alliance because of the need to balance marketing practices and patient welfare.

Gifts to physicians run the gamut from those that may benefit patients, underwriting legitimate educational events, for example, to obviously improper perks, such as all-expense-paid trips to exotic locations for "educational" conferences that are merely marketing junkets.

In 1990 the AMA established guidelines to assist physicians in judging whether or not to accept gifts from the pharmaceutical, device, and medical equipment industries.1 While not meant to be all encompassing, the guidelines do provide basic criteria. For example, gifts should entail a benefit to patients or be related to a physician's work. Their value should be modest, about $100 or less, and no strings should be attached. The guidelines would prohibit Dr. Goodenough from accepting the cruise tickets, although the gifts provided to Dr. Doright would probably be allowed.

A review of studies and editorials since the AMA guidelines were released shows wide variance in thinking and practice among physicians and trainees. A 1993 study of emergency medicine faculty and residents found that while the former had more concerns than the latter about the appropriateness of gifts and their own susceptibility to be influenced in prescription practices, few programs provided formal policy or guidance regarding promotional activities and gifts.2 Additionally, while most educational directors expressed concern about the potential for gifts to create real or perceived conflicts of interest that could compromise patient care, almost all accepted funding from the industry for their programs. These results were similar to those obtained in studies of internal and family medicine departments.

In contrast to the graduated provisions of the AMA guidelines and the ambivalence of their colleagues, other physicians have maintained that acceptance of any gift violates physicians' ethical obligations to do no harm, put patients' interests first, and treat patients fairly. A 1991 editorial in Pediatrics criticized the AMA guidelines and posited that there is no such thing as a free gift: acceptance requires some response from the recipient.3

This reasoning would require Dr. Doright to ask whether the aggregate effect of individual inexpensive gifts has created a sense of obligation or heightened awareness of particular products. Since manufacturers are increasingly marketing their goods directly to consumers, he should also consider whether he is, albeit unintentionally, advertising to patients when he uses nominally valued office supplies with company logos and brand names. There is the additional possibility that some patients might lose trust in Dr. Doright if they believe, rightly or wrongly, that he profits in some way from using company merchandise.

An editorial published earlier this year acknowledged the potential for doctors to be unduly influenced by gifts from pharmaceutical companies.4 However, the physician author also noted that free samples provide opportunities to try alternatives thought to be more effective without incurring additional costs. For proponents of the "no gifts" perspective, "free" samples are erroneous since their cost is ultimately charged back to patients in the marketplace.

For the same reason, "no gifters" would be particularly concerned about Dr. Doright's occasional meals with drug company reps and the provision of journal club lunches, since these gifts are actually subsidized by patients and redound solely to physicians' personal enjoyment. They would argue that a meal costing at or below the AMA suggested value of $100 is an unfair allocation of resources to physicians at the expense of patients—many of whom cannot afford such food for themselves.

The AMA recently announced an educational initiative to increase compliance with its guidelines among physicians, trainees, and sales representatives. While there is general agreement that the program is needed, participation by Bayer, Glaxo, Merck, and other pharmaceutical companies as sponsors has been controversial. Critics have questioned whether the goal of stemming improper alliances with pharmaceutical companies is undermined by the presence of those companies as funders. The AMA holds that maintaining high ethical standards is both good medicine and good business.5