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The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Three Reasons to Ban Advertising for Health Care Services Candice Delmas
a
a
Clemson University Published online: 04 Mar 2014.
Click for updates To cite this article: Candice Delmas (2014) Three Reasons to Ban Advertising for Health Care Services, The American Journal of Bioethics, 14:3, 51-52, DOI: 10.1080/15265161.2013.879958 To link to this article: http://dx.doi.org/10.1080/15265161.2013.879958
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
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Advertising for Health Care Services
reducing vulnerability to marketing practices with questionable ethics. However, this model does not solve every issue inherent in health care advertising. One problem mentioned by Schenker and colleagues is that it is difficult for consumers to assess prices of health care services. Given the nature of the health care system and the presence of a third-party payer, this issue would be difficult to resolve with this committee alone. Furthermore, ensuring that a committee is comprised of appropriate stakeholders who are free from bias is difficult, as well as mobilizing all of these people on a regular basis. Because this is a theoretical model, there is no indication as to how many rounds would be required to reach a mutually agreed upon result. Qualitative and quantitative research would give insight into the effectiveness of this regulatory model. Overall, through use of community engagement, health care advertising can be changed from a persuasive technique used to encourage people to procure services they may not need, to an informational outreach giving agency to the community and building trust between provider and patient. By respecting the autonomy of the patient and providing only treatments needed to improve the health of the patient, health care institutions can adhere to the special moral obligations to which they hold themselves. With the formation of committees that involve the community,
the risks inherent in advertising can be mitigated and hold health care institutions to a higher standard. REFERENCES Clinical and Translational Science Awards Consortium; Community Engagement Key Function Committee Task Force on the Principles of Community Engagement. 2011. Principles of community engagement, 2nd ed. June. NIH publication no. 11-7782. Available at: http://www.atsdr.cdc.gov/communityengagement Department of Labor, Bureau of Labor Statistics. 2013. Current population survey (321). Available at: http://www.bls.gov/ emp/ep chart 001.htm Donohue, J. M., M. Cevasco, and M. B. Rosenthal. 2007. A decade of direct-to-consumer advertising of prescription drugs. New England Journal of Medicine‘357: 673–681. doi:10.1056/NEJMsa 070502 McCune, J. 2013. Health empires. Pittsburgh Post-Gazette, December 9. Available at: http://www.post-gazette.com/opinion/ letters/2013/12/09/Health-empires.html Schenker, Y., R. M. Arnold, and A. London. 2014. The ethics of advertising for health care services. American Journal of Bioethics 14(3): 34–43. Ventola, C. L. 2011. Direct-to-consumer pharmaceutical advertising. Pharmacy and Therapeutics 36(10): 669–674, 681–684.
Three Reasons to Ban Advertising for Health Care Services Candice Delmas, Clemson University In “The Ethics of Advertising for Health Care Services,” Yael Schenker, Robert M. Arnold, and Alex John London (2014) argue that the mechanisms that are currently in place to regulate advertising for prescription pharmaceuticals should apply more broadly to advertisements for health care services. In this commentary, I argue that advertising for health care services should be banned. Three reasons support such ban: Advertising for health care services (1) threatens the fiduciary relationships on which health care depends; (2) imposes significant externalities on physicians and the public at large; and (3) corrupts the good of health care. I First, Schenker, Arnold, and London (2014) correctly identify the features that distinguish decisions about pursuing health care services from decisions about consumer goods, namely, informational asymmetries, high stakes, and patient vulnerabilities. Given these features, patients’ desires
and understanding of health care services can easily be manipulated through the use of common advertising techniques. For instance, associating certain treatments with indirect benefits such as celebrity and wealth can lead patients to seek unnecessary services; and presenting individual success stories without background probabilities can induce in patients unrealistic expectations about what treatments can achieve. As the authors show, these pernicious effects of advertisements exercise serious strains on the fiduciary responsibilities of health care institutions. The authors conclude that advertising for health care services ought to be strictly regulated so as to protect the patient’s interests. Regulation might be warranted if advertising for health care services provided some significant benefits. But what good does advertising serve? Champions stress that it informs the public about the existence of new treatments. As the authors note, however, whereas advertisements for consumer goods generally provide useful
Address correspondence to Candice Delmas, Clemson University, Department of Philosophy and Religion, 403 Calhoun Dr., Hardin Hall, Clemson, SC 29634, USA. E-mail: [email protected]
March, Volume 14, Number 3, 2014
ajob 51
The American Journal of Bioethics
information—especially regarding the price and quality of the product advertised—advertisements for health care services do not convey such information. They further fail to present crucial features of the treatment such as its indication, success rate, and risks. Even if regulations were in place to mandate disclosure of important facts like these, advertisements would still fall short of promoting patients’ interests, given their use of manipulative advertising techniques. These considerations weigh in favor of banning, rather than regulating advertising for health care services.
Downloaded by [Imperial College London Library] at 12:34 07 April 2015
II Not only is advertising for health care services not in the patient’s interests, but it also imposes significant burdens on health care practitioners and society at large. This is the second main reason to ban advertising. The authors briefly evoke these costs at the end of their article. For one, because advertisements shape desires and expectations, physicians sometimes have to spend valuable time realigning patient expectations or explaining to disappointed patients why a particular intervention is not an option for them. Furthermore, as Schenker and colleagues observe, “The costs associated with advertising-driven demands . . . may consume scarce health care resources and reduce the pool of funds, drawn from public health plans or private insurance pools, that are available to pay for needed services” (40). Hence advertising appears triply prejudicial: to patients, physicians, and taxpayers. From this perspective, strict regulations would effectively reduce some of the pernicious effects of advertising, but they would not be, on balance, preferable to the absence of advertisement. Indeed, concern for patients, physicians, and the public has led the World Health Organization and many medical professional associations around the world to oppose advertising for prescription drugs and health care services. The authors should have taken their arguments to support not simply regulations, but instead a full ban on advertising for health care services. III The third reason in support of the ban is based not simply on the fiduciary relationships at the heart of health care, or on the externalities of advertising, but on the good of health care itself. Michael Sandel writes in What Money Can’t Buy that people “often assume that markets are inert, that they do not affect the goods they exchange. But this is untrue. Markets leave their mark” (Sandel 2012, 9). Markets in general, and advertisements in particular, “express and promote certain attitudes toward the goods” being exchanged or advertised (Sandel 2012, 9). Through advertising, hospitals and clinics suggest that health care is a mere commodity. Advertising thereby obscures the special moral importance of health care, which, for Norman Daniels, derives from the way health care keeps “people close to normal functioning,” and thereby “preserves [their] abil-
52 ajob
ity to participate in the political, social, and economic life of their society” (Daniels 2001, 3). As Daniels persuasively argues, health care is essential because “it sustains [people] as fully participating citizens—normal collaborators and competitors—in all spheres of social life” (3). Turning health care into a mere commodity through advertisement degrades it and warps the community’s understanding of its special moral importance. Nothing short of a ban on advertising can avoid corrupting the good of health care. Section 19 of the French Public Health Code, which prohibits advertising for prescription drugs and health care services, states: “Medicine shall not be practiced as a commercial transaction. All direct or indirect public advertisement is prohibited, including any physical design or signage giving the establishment the appearance of a commercial function” (Article R.4127-19 du Code de la Sant´e Publique n.d.). France insists that clinics and hospitals should not look like commercial establishments such as hotels and spas, let alone advertise for “V.I.P. treatments” or “World-Class Comfort and Care,” on pain of degrading the good of health care. According to the French National Council of Physicians, “health is not a consumer good”; “the physician does not ‘sell’ prescriptions or treatments”; and patients are neither clients nor consumers (Conseil de l’Ordre National des M´edecins 2012). In other words, health care institutions should not fall within the jurisdiction of the Federal Trade Commission. The landmark decision that ordered the American Medical Association to cease enforcing restraints on advertising was therefore a deplorable one (American Medical Association, Petitioner, v. Federal Trade Commission, 638 F.2d 443: 1980). Proper concern for the patients, the public, and the good of health care demands a full ban on advertising for health care services. REFERENCES 638 F.2d 443: American Medical Association, Petitioner, v. Federal Trade Commission, Respondent. Connecticut State Medical Society and New Haven County Medical Association, Inc., Petitioners, v. Federal Trade Commission, Respondent. 1980. U.S. Court of Appeals SC-Fd, ed; 1980. Code de la Sant´e Publique,. n.d. Available at: http://www. legifrance.gouv.fr (translation by Joseph Mai). Conseil de l’Ordre National des M´edecins. 2012. Commentaires du Code de D´eontologie M´edicale. Available at: http://www.conseilnational.medecin.fr/article/article-19-interdiction-de-la-publicite243 (translation by Candice Delmas). Daniels, N. 2001. Justice, health, and healthcare. American Journal of Bioethics 1(2): 1–16. Sandel, M. J. 2012. What money can’t buy: The moral limits of markets. New York, NY: Farrar, Strauss, and Giroux. Schenker, Y., R. M. Arnold, and A. London. 2014. The ethics of advertising for health care services. American Journal of Bioethics 14(3): 34–43.
March, Volume 14, Number 3, 2014
The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Three Reasons to Ban Advertising for Health Care Services Candice Delmas
a
a
Clemson University Published online: 04 Mar 2014.
Click for updates To cite this article: Candice Delmas (2014) Three Reasons to Ban Advertising for Health Care Services, The American Journal of Bioethics, 14:3, 51-52, DOI: 10.1080/15265161.2013.879958 To link to this article: http://dx.doi.org/10.1080/15265161.2013.879958
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Downloaded by [Imperial College London Library] at 12:34 07 April 2015
Advertising for Health Care Services
reducing vulnerability to marketing practices with questionable ethics. However, this model does not solve every issue inherent in health care advertising. One problem mentioned by Schenker and colleagues is that it is difficult for consumers to assess prices of health care services. Given the nature of the health care system and the presence of a third-party payer, this issue would be difficult to resolve with this committee alone. Furthermore, ensuring that a committee is comprised of appropriate stakeholders who are free from bias is difficult, as well as mobilizing all of these people on a regular basis. Because this is a theoretical model, there is no indication as to how many rounds would be required to reach a mutually agreed upon result. Qualitative and quantitative research would give insight into the effectiveness of this regulatory model. Overall, through use of community engagement, health care advertising can be changed from a persuasive technique used to encourage people to procure services they may not need, to an informational outreach giving agency to the community and building trust between provider and patient. By respecting the autonomy of the patient and providing only treatments needed to improve the health of the patient, health care institutions can adhere to the special moral obligations to which they hold themselves. With the formation of committees that involve the community,
the risks inherent in advertising can be mitigated and hold health care institutions to a higher standard. REFERENCES Clinical and Translational Science Awards Consortium; Community Engagement Key Function Committee Task Force on the Principles of Community Engagement. 2011. Principles of community engagement, 2nd ed. June. NIH publication no. 11-7782. Available at: http://www.atsdr.cdc.gov/communityengagement Department of Labor, Bureau of Labor Statistics. 2013. Current population survey (321). Available at: http://www.bls.gov/ emp/ep chart 001.htm Donohue, J. M., M. Cevasco, and M. B. Rosenthal. 2007. A decade of direct-to-consumer advertising of prescription drugs. New England Journal of Medicine‘357: 673–681. doi:10.1056/NEJMsa 070502 McCune, J. 2013. Health empires. Pittsburgh Post-Gazette, December 9. Available at: http://www.post-gazette.com/opinion/ letters/2013/12/09/Health-empires.html Schenker, Y., R. M. Arnold, and A. London. 2014. The ethics of advertising for health care services. American Journal of Bioethics 14(3): 34–43. Ventola, C. L. 2011. Direct-to-consumer pharmaceutical advertising. Pharmacy and Therapeutics 36(10): 669–674, 681–684.
Three Reasons to Ban Advertising for Health Care Services Candice Delmas, Clemson University In “The Ethics of Advertising for Health Care Services,” Yael Schenker, Robert M. Arnold, and Alex John London (2014) argue that the mechanisms that are currently in place to regulate advertising for prescription pharmaceuticals should apply more broadly to advertisements for health care services. In this commentary, I argue that advertising for health care services should be banned. Three reasons support such ban: Advertising for health care services (1) threatens the fiduciary relationships on which health care depends; (2) imposes significant externalities on physicians and the public at large; and (3) corrupts the good of health care. I First, Schenker, Arnold, and London (2014) correctly identify the features that distinguish decisions about pursuing health care services from decisions about consumer goods, namely, informational asymmetries, high stakes, and patient vulnerabilities. Given these features, patients’ desires
and understanding of health care services can easily be manipulated through the use of common advertising techniques. For instance, associating certain treatments with indirect benefits such as celebrity and wealth can lead patients to seek unnecessary services; and presenting individual success stories without background probabilities can induce in patients unrealistic expectations about what treatments can achieve. As the authors show, these pernicious effects of advertisements exercise serious strains on the fiduciary responsibilities of health care institutions. The authors conclude that advertising for health care services ought to be strictly regulated so as to protect the patient’s interests. Regulation might be warranted if advertising for health care services provided some significant benefits. But what good does advertising serve? Champions stress that it informs the public about the existence of new treatments. As the authors note, however, whereas advertisements for consumer goods generally provide useful
Address correspondence to Candice Delmas, Clemson University, Department of Philosophy and Religion, 403 Calhoun Dr., Hardin Hall, Clemson, SC 29634, USA. E-mail: [email protected]
March, Volume 14, Number 3, 2014
ajob 51
The American Journal of Bioethics
information—especially regarding the price and quality of the product advertised—advertisements for health care services do not convey such information. They further fail to present crucial features of the treatment such as its indication, success rate, and risks. Even if regulations were in place to mandate disclosure of important facts like these, advertisements would still fall short of promoting patients’ interests, given their use of manipulative advertising techniques. These considerations weigh in favor of banning, rather than regulating advertising for health care services.
Downloaded by [Imperial College London Library] at 12:34 07 April 2015
II Not only is advertising for health care services not in the patient’s interests, but it also imposes significant burdens on health care practitioners and society at large. This is the second main reason to ban advertising. The authors briefly evoke these costs at the end of their article. For one, because advertisements shape desires and expectations, physicians sometimes have to spend valuable time realigning patient expectations or explaining to disappointed patients why a particular intervention is not an option for them. Furthermore, as Schenker and colleagues observe, “The costs associated with advertising-driven demands . . . may consume scarce health care resources and reduce the pool of funds, drawn from public health plans or private insurance pools, that are available to pay for needed services” (40). Hence advertising appears triply prejudicial: to patients, physicians, and taxpayers. From this perspective, strict regulations would effectively reduce some of the pernicious effects of advertising, but they would not be, on balance, preferable to the absence of advertisement. Indeed, concern for patients, physicians, and the public has led the World Health Organization and many medical professional associations around the world to oppose advertising for prescription drugs and health care services. The authors should have taken their arguments to support not simply regulations, but instead a full ban on advertising for health care services. III The third reason in support of the ban is based not simply on the fiduciary relationships at the heart of health care, or on the externalities of advertising, but on the good of health care itself. Michael Sandel writes in What Money Can’t Buy that people “often assume that markets are inert, that they do not affect the goods they exchange. But this is untrue. Markets leave their mark” (Sandel 2012, 9). Markets in general, and advertisements in particular, “express and promote certain attitudes toward the goods” being exchanged or advertised (Sandel 2012, 9). Through advertising, hospitals and clinics suggest that health care is a mere commodity. Advertising thereby obscures the special moral importance of health care, which, for Norman Daniels, derives from the way health care keeps “people close to normal functioning,” and thereby “preserves [their] abil-
52 ajob
ity to participate in the political, social, and economic life of their society” (Daniels 2001, 3). As Daniels persuasively argues, health care is essential because “it sustains [people] as fully participating citizens—normal collaborators and competitors—in all spheres of social life” (3). Turning health care into a mere commodity through advertisement degrades it and warps the community’s understanding of its special moral importance. Nothing short of a ban on advertising can avoid corrupting the good of health care. Section 19 of the French Public Health Code, which prohibits advertising for prescription drugs and health care services, states: “Medicine shall not be practiced as a commercial transaction. All direct or indirect public advertisement is prohibited, including any physical design or signage giving the establishment the appearance of a commercial function” (Article R.4127-19 du Code de la Sant´e Publique n.d.). France insists that clinics and hospitals should not look like commercial establishments such as hotels and spas, let alone advertise for “V.I.P. treatments” or “World-Class Comfort and Care,” on pain of degrading the good of health care. According to the French National Council of Physicians, “health is not a consumer good”; “the physician does not ‘sell’ prescriptions or treatments”; and patients are neither clients nor consumers (Conseil de l’Ordre National des M´edecins 2012). In other words, health care institutions should not fall within the jurisdiction of the Federal Trade Commission. The landmark decision that ordered the American Medical Association to cease enforcing restraints on advertising was therefore a deplorable one (American Medical Association, Petitioner, v. Federal Trade Commission, 638 F.2d 443: 1980). Proper concern for the patients, the public, and the good of health care demands a full ban on advertising for health care services. REFERENCES 638 F.2d 443: American Medical Association, Petitioner, v. Federal Trade Commission, Respondent. Connecticut State Medical Society and New Haven County Medical Association, Inc., Petitioners, v. Federal Trade Commission, Respondent. 1980. U.S. Court of Appeals SC-Fd, ed; 1980. Code de la Sant´e Publique,. n.d. Available at: http://www. legifrance.gouv.fr (translation by Joseph Mai). Conseil de l’Ordre National des M´edecins. 2012. Commentaires du Code de D´eontologie M´edicale. Available at: http://www.conseilnational.medecin.fr/article/article-19-interdiction-de-la-publicite243 (translation by Candice Delmas). Daniels, N. 2001. Justice, health, and healthcare. American Journal of Bioethics 1(2): 1–16. Sandel, M. J. 2012. What money can’t buy: The moral limits of markets. New York, NY: Farrar, Strauss, and Giroux. Schenker, Y., R. M. Arnold, and A. London. 2014. The ethics of advertising for health care services. American Journal of Bioethics 14(3): 34–43.
March, Volume 14, Number 3, 2014
