In September 1998 the Dutch Ministry of Health together with the Dutch Society of General Practitioners (LHV), the Royal Dutch Society of Pharmacists (KNMP), and the Dutch Patient and Consumer Federation (NPCF) published a pamphlet entitled: The same medicine in a different coat. Drugs without a trademark, equally effective, but cheaper. Patients could obtain a copy at the local pharmacy or in the waiting room of their general practitioner. It deals with the question whether the name of the patent drug should be written on the prescription or only the active (generic) component. This is important because, according to the authors, the costs of health care can be reduced without reducing the quality of the care if the doctor prescribes the generic form. It is also mentioned that another advantage of prescribing the generic form is that, contrary to the patent drug, it is known under the same name in all countries. This enables pharmacists and doctors everywhere to establish directly which drug the patient is taking. As a precaution it is also stated that, in some special cases, it remains necessary to administer the patent drug, for instance, if the right dose is not available in the generic form.

On 19 July 2003 there appeared in the national newspaper, Trouw, an advertisement, which contained a very different message. This time an association of leading pharmaceutical companies in the Netherlands, Nefarma, had replaced the Ministry of Health and the pharmacists (KNMP) as coauthors. In large print the readers were informed as follows: “Save money? Not at the expense of your health. Do not accept another medicine, another composition or dose. The government wants to save money, for instance, on the costs of drugs. Of course this should never be at the expense of your health. Especially for the elderly and the chronically ill patients, who regularly need medicines, such a policy would have great consequences. Also the health insurance companies are involved and are of the opinion that the lower the costs of medicines, the better. It is quite likely that in this tumult you, as a patient, can no longer determine what should be done. Without the doctor’s and your permission, the pharmacist may not deviate from the medicine, written on the prescription”. The advertisement includes a number of drawings: in one of these the doctor gives the patient a prescription for drug A and in another the pharmacist has exchanged this for drug B, which the patient refuses to accept.

I believe that such an advertisement is unethical. The patient is made afraid that his treatment is interfered with in a detrimental way by the pharmacist. Recently de Visser, the director of Nefarma, published an article in a Dutch medical journal¹ in which he clarified his opinion on this matter. De Visser makes it clear that it is illegal for pharmacists to deliver to the patient a generic drug if the doctor has written on the prescription a different (patent) medicine. He also stresses that only the physician knows the disease from which the patient suffers and that he is therefore the only one who can determine which medicine the patient needs. In this article the director of the Dutch Society of General Practitioners, H van Baasbank, reports that the society has: “received signals that without approval of their GP, patients have received from pharmacists an undesirable replacement of patent drugs by generic drugs”. A member of the board of the Royal Dutch Society of Pharmacists (KNMP) presents his case in the same paper. He affirms that the pharmacist knows the regulations on what to do when there is a choice between generic and patent medicines. His motives are based on the price of the drug as long as the effect is the same. He reproaches Nefarma for creating this animosity between the parties solely because it fears loss of profit if more generic drugs are prescribed. It is clear that patients, who are, in general, not aware of the background of this power struggle, are bewildered. In my opinion the advertisement should never have appeared in the newspaper. The sooner the conflict is resolved by discussion between the parties, the better it will be for all concerned.