Mistakes Were Made - Carol Tavris [25]
The Gift that Keeps on Giving
Physicians, like scientists, want to believe their integrity cannot be compromised. Yet every time physicians accept a fee or other incentive for performing certain tests and procedures, for channeling some of their patients into clinical trials, or for prescribing a new, expensive drug that is not better or safer than an older one, they are balancing their patients’ welfare against their own financial concerns. Their blind spot helps them tip the balance in their own favor, and then justify it: “If a pharmaceutical company wants to give us pens, notepads, calendars, lunches, honoraria, or small consulting fees, why not? We can’t be bought by trinkets and pizzas.” According to surveys, physicians regard small gifts as being ethically more acceptable than large gifts. The American Medical Association agrees, approving of gift-taking from pharmaceutical representatives as long as no single gift is worth much more than $100. The evidence shows, however, that most physicians are influenced even more by small gifts than by big ones. 20 Drug companies know this, which might have something to do with their increased spending on marketing to physicians, from $12.1 billion in 1999 to $22 billion in 2003. That’s a lot of trinkets.
The reason Big Pharma spends so much on small gifts is well known to marketers, lobbyists, and social psychologists: Being given a gift evokes an implicit desire to reciprocate. The Fuller Brush salespeople understood this principle decades ago, when they pioneered the foot-in-the-door technique: Give a housewife a little brush as a gift, and she won’t slam the door in your face. And once she hasn’t slammed the door in your face, she will be more inclined to invite you in, and eventually to buy your expensive brushes. Robert Cialdini, who has spent many years studying influence and persuasion techniques, systematically observed Hare Krishna advocates raise money at airports.21 Asking weary travelers for a donation wasn’t working; the Krishnas just made the travelers mad at them. And so the Krishnas came up with a better idea: They would approach target travelers and press a flower into their hands or pin the flower to their jackets. If the target refused the flower and tried to give it back, the Krishna would demur and say, “It is our gift to you.” Only then did the Krishna ask for a donation. This time the request was likely to be accepted, because the gift of the flower had established a feeling of indebtedness and obligation in the traveler. How to repay the gift? With a small donation … and perhaps the purchase of a charming, overpriced edition of the Bhagavad Gita.
Were the travelers aware of the power of reciprocity to affect their behavior? Not at all. But once reciprocity kicks in, self-justification will follow: “I’ve always wanted a copy of the Bhagavad Gita; what is it, exactly?” The power of the flower is unconscious. “It’s only a flower,” the traveler says. “It’s only a pizza,” the medical resident says. “It’s only a small donation that we need to have this educational symposium,” the physician says. Yet the power of the flower is one reason that the amount of contact doctors have with pharmaceutical representatives is positively correlated with the cost of the drugs the doctors later prescribe. “That rep has been awfully persuasive about that new drug; I might as well try it; my patients might do well on it.” Once you take the gift, no matter how small, the process starts. You will feel the urge to give something back, even if it’s only, at first, your attention, your willingness to listen, your sympathy for the giver. Eventually, you will become more willing to give your prescription, your ruling, your vote. Your behavior changes, but, thanks to blind spots and self-justification, your view of your intellectual and professional integrity remains the same.
Carl Elliott, a bioethicist and philosopher who also has an MD, has written extensively about the ways that small gifts