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Abstract
Although the adverse implications of physician advertising are the subject of a fierce and sustained debate, there is almost no scholarly discussion on the ethical repercussions of physician advertising bans. The present paper draws attention to these repercussions as they exist today in most of the world, with particular focus on three serious implications for the public: (a) uncertainty about the physician's interests, namely, that patients must trust the physician to put patient wellbeing ahead of possible gains when taking medical decisions; (b) uncertainty about alternative treatments, namely, that patients must trust in the physician's treatment decisions; and (c) uncertainty about the exclusive patient–physician relationship, namely, that patients must develop and maintain a good relationship with one physician. Physician advertising bans continue to tell the public in most of the modern world that these are irrelevant or inappropriate issues, meaning that they are effectively left to the public to resolve.
- Patient perspective
- Business
- Journalism/Mass media
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The neglected repercussions of a physician advertising ban
Physician advertising is generally met with considerable scepticism. For instance, many survey studies have shown that, with few exceptions, physicians are clearly negatively disposed towards advertising their services.1 Opposing opinions on physician advertising also dominate the scholarly debate. A contribution by Tomycz,2 for example, ‘lamented’ physician advertising—and this is only one of very many contributions to the scholarly literature that are at least as unenthusiastic about physician advertising (eg, refs. 3–5). Contrary to the fierce and sustained debate on the repercussions of physician advertising, there has been almost no discussion on the ethical repercussions of a physician advertising ban. The present paper addresses this void.
Before presenting our argument, we should like to emphasise our awareness that addressing the repercussions of a physician advertising ban is a controversial, if not taboo, topic in some circles. The issue's potential for controversy became particularly evident during the 1970s in the USA when the Federal Trade Commission charged the American Medical Association (AMA) with unlawfully restraining trade by banning physician advertising. The AMA was forced to lift the ban, and the arguments that had become polarised during the controversy have not waned over time.6 It is important in this respect to note that our discussion is not a plea in favour of physician advertising. However, physician advertising bans continue to exist in many regions of the world, including most of Europe, Asia and South America, and we believe that these bans should be subject to as much discussion as physician advertising.
Without in any way denying the vast differences in medical settings across regions, countries and continents, the present paper discusses the above issue with a particular focus on three serious repercussions of physician advertising bans, namely, uncertainty about (a) the physician's interests, (b) alternative treatments and (c) the exclusive patient-physician relationship. The concluding section discusses whether and, if so, how these repercussions can be reconciled with existing practices of physician advertising bans.
The repercussions of advertising or not advertising
In 2007, the São Paulo municipal government banned outdoor advertising. One commentator hailed the ban as ‘a rare victory of the public interest over private, of order over disorder, of aesthetics over ugliness, of cleanliness over trash’.7 Advertising is generally considered one of the ‘ugly faces’ of modern times and is frequently associated with a range of adverse societal phenomena such as materialism, social competition, loss of creativity, medicalisation and sexual preoccupation.8–10 At the same time, advertising is a global, multibillion-dollar industry and an omnipresent reality in nearly all modern societies, and it is used to promote products, services and entities as diverse as toothpaste, hairdressing, holidays, cities, political parties and virtually every other commodity one can think of.
The above two advertising facts illustrate the dilemma faced by probably all product or service providers when deciding whether to advertise: on the one hand, there are the ethical dimensions—which seem mostly to discourage advertising—and on the other hand, there are the economic dimensions, which would seem to make advertising a sheer necessity.11 The ethical dimensions cover a range of concerns about the adverse social and cultural effects of advertising, such as materialism, dishonesty and loss of authenticity. They also include concerns about the potential loss of the dignity of the trade. The economic dimensions, on the other hand, reflect the interests of economic growth, innovation, and a trade's promotion and competition in a market-driven environment. The actuality of this dilemma for professionals, clearly showed in a meta-analysis of attitudes towards advertising by physicians, accountants and attorneys,1 but is also commonly found in the decision to advertise for a range of other professionals, such as psychologists, dentists, veterinaries and architects.12 The pertinent dilemma for the medical profession was expressed by Scheirton (ref. 13, p.96) as follows:
There would seem to be a genuine incompatibility between treating the provider–patient relationship in economic terms and viewing it primarily as a moral relationship. Traditionally, the medical profession has eschewed advertising. The ethical conflict is between a health provider's right to advertise for commercial gain and the right of the largely naive public to protection.
The dimensions of the decision not to advertise are much less discussed than the dimensions of professional advertising. We, however, contend that the decision not to advertise also has ethical dimensions. That is, we believe that refraining from advertising amidst a myriad of advertising messages from nearly all parts of modern society is not, and cannot be, an act to which the public will attach no meaning. It is, in other words, a marked condition that can be assumed to contribute to the perceived character of the product or service concerned and thereby the public's position in relation to that product or service.
Reframing the dilemma from the ethical versus the economic dimensions of advertising, into a dilemma of advertising versus advertising bans—both of which have their moral concerns—raises the question what the signals are that stem from refraining from advertising. A large share of these can be assumed to originate in common public knowledge of what advertising is and what it is about. Advertising is, of course, about its persuasive content, such as that ‘Brand A's chocolate chip cookies are simply irresistible’. Besides the persuasive intent, however, a range of other signals are related to common assumptions regarding the role and function of advertising in modern society. Among these assumptions is that advertising is a manifestation of an economy of markets where players compete with each other for consumers’ preferences. Hence, advertising is a signal of an interest in promoting the product or service; that is, the public will understand that it is in some way lucrative for the advertiser to try to persuade audiences to use its product or service. Advertising also constitutes an implicit, and sometimes more explicit, claim to variation. In other words, the public understands that alternative products or services supposedly do not possess the same qualities as the advertised product or service. Thus, the signal is that brand A's cookies are not simply as ‘irresistible’ as any other, but allegedly have some unique qualities that make them different from any other cookie. Third, advertising a product or service signals that target audiences can acquire the product or service at some minimal level of non-exclusiveness. After all, if an audience has little or no choice, there is no incentive to attempt to influence its preferences.
If a particular category of products or services is not usually advertised in a modern society, common knowledge of the roles and functions of advertising thus suggests that some or all of these roles and functions do not apply. The products or services may hence be assumed to not have a lucrative character, there may be no basis for believing that the offer is unlike any other or there may be a lack of choice.
As argued in more detail below, each of the aforementioned advertising signals is actually part of the present-day reality of the medical profession in most modern countries. Although this varies a great deal across countries, physicians usually have interests in providing their services, there is ample variation between the services offered by different physicians, and in many countries the physician–patient relationship is in principle not exclusive. Physicians in that respect are regular market players, yet often without the associated advertising routines. The physician advertising ban thereby effectively tells the public that these issues are irrelevant or at least inappropriate. However, that these issues are supposedly not relevant or appropriate does not mean that they do not exist in the eyes of the public. On the contrary, they are effectively left to the public to resolve. The following sections discuss this further, with a particular focus on the ethical repercussions for the public.
The repercussions of uncertainty about the physician's interests, alternative treatments and the exclusive patient-physician relationship
Uncertainty about the physician's interests
Many authors and medical associations voice the opinion that advertising makes physicians’ gains from patient care too palpable. Jones and McCullough (ref. 4, p.214), for instance, state that advertising ‘reduces medical care to a commercial commodity’, while Tomycz (ref. 2, p.27) writes that ‘Although doctors certainly have financial interests in their work, advertising can make this interest so palpable and conspicuous that it may compromise the trust on which doctors and patients rely’. Notably, the reverse argument is used in medical research, where it is now commonly agreed that medical researchers should declare any commercial or other interests they may have in their research findings.14 When it comes to judging one another's work, medical practitioners thus generally agree that any potential gains should be made palpable and conspicuous. When it comes to patients’ care, however, it is commonly believed that it is better to avoid making possible gains palpable.
A serious ethical question surrounding a physician advertising ban is: who is it that benefits from not making a physician's interests palpable? Under a physician advertising ban, the public must disambiguate the delicate question whether physicians gain from the medical decisions they take. Indeed, it would be hard, if not impossible, to deny that financial and other interests sometimes play a role in physicians’ decisions, as has been shown by numerous empirical studies in the USA and a myriad of other countries as diverse as Australia, Central Asia, Eastern Europe, India, the UK, Taiwan and Turkey (eg, refs. 15–17) Under a physician advertising ban, however, a patient can only speculate whether a medical decision was in his or her best interest as well as that of the physician.
We may assume that the patient would in many cases be wrong to assume that the physician's interests take priority. However, even though the patient is likely to be wrong in a public domain where physicians’ gains from patient care are not made palpable, talking with a physician about such motivations constitutes a grave breach of trust that only the most assertive of patients might undertake, and that is definitely a ‘no-go area’ for all others. The physician advertising ban has thus effectively created a public domain in which patients have to trust in the doctor's disinterest in the gains, no matter what the patient's private beliefs are concerning this issue.
Uncertainty about alternative treatments
Some readers will be surprised to learn that many women in the Netherlands undergo childbirth under the supervision of a midwife rather than a physician and without pain medication. Why is this? The Netherlands is an affluent society in which high-level healthcare provisions are readily available. The Dutch, however, do not usually regard childbirth as a medical circumstance that requires pain medication or the presence of a physician, unless special medical conditions apply or unexpected complications arise.18
The above example is a very specific one and should not be taken to mean that Dutch childbirth practices are better or worse than other practices, or that mothers give birth at home against their will. The point is that considerable variation in medical practice is well-documented, and such variation is not ‘merely’ based on inter-country differences, differences between mainstream and alternative medicine, Western versus non-Western perspectives on medicine, and so on. Significant variation in medical practices exists also within modern, mainstream medicine. One may be tempted to say it is a matter of course, because medicine is an academic discipline that is subject to the same principles of knowledge claims and disputes over those claims to which all other disciplines are subject.19 ,20
Under a physician advertising ban, the delicate question whether modern, mainstream medical care is subject to variation is effectively removed from the public domain. Once again, the ethical concern is: who is it that benefits from not making alternatives palpable? The patient is unlikely to be able or willing to discuss medical evidence with the physician, if only because it would once more constitute a grave breach of trust in the doctor's expertise. It is therefore largely up to the public to disambiguate the question whether alternatives are available.
Uncertainty about the exclusive patient–physician relationship
The medical profession assumes that physicians and patients enjoy close relationships. Physician advertising has therefore been fiercely criticised for the adverse effects it could have on the physician–patient relationship.2 ,4 ,21 However, whether or not most people have close relationships with their physicians is hardly ever questioned. On the one hand, there is ample evidence that a longer relationship with a doctor is significantly related to increased treatment compliance and trust in one's physician, particularly among the more vulnerable such as the elderly and those suffering from chronic conditions.22 ,23 On the other hand, the average person in many Western societies sees a physician around four times a year; most visits are for mundane matters, such as general medical examinations, routine check-ups, or complaints of colds and coughs. Moreover, these averages are heavily influenced by the 10% of people who see a physician 20 or more times a year, whereas up to a quarter of all people do not visit their doctors at all in a year.24 ,25 Whether the majority of people are or need to be in a close relationship with a physician can hence be questioned. In the words of Guthrie and Wyke (ref. 26, p.9), who conducted interviews with Scottish patients about their perceptions of the value of a continued relationship with one general practitioner (GP):
What patients therefore wanted was ‘access to appropriate care’, where what was appropriate depended on the problem to be dealt with. For chronic, complex and psychological problems this was usually consultation with a GP with whom the patient had an on-going relationship [ ]. For minor or episodic problems, or where the problem was perceived as very urgent, then any GP was likely to be appropriate.
A third repercussion of a physician advertising ban is that the issue whether people need to have an exclusive relationship with a physician effectively remains unknown to the general public. This again is a very important ethical concern. There are the relatively minor repercussions, such as the one that patients are dependent for care on one physician's practice hours, waiting lists and location. More major repercussions are that the patient must maintain a good relationship with the physician in order to ensure future quality care. Again, this is not to deny that physicians usually firmly embrace principles of quality and impartiality in patient care. A patient questioning this may hence be wrong. Under a physician advertising ban, the delicate issue of whether a patient necessarily needs to be loyal to one physician, however, is clearly a taboo topic that in effect is left to the patient to disambiguate.
Discussion
Whereas the drawbacks of physician advertising have been extensively discussed (eg, refs. 2–5), the present paper has reframed the dilemma by stressing that both sides (physician advertising vs no physician advertising) have their positive and negative moral dimensions. A particular focus was placed on the signals stemming from the absence of advertising in modern-day consumer societies and the resulting position that the public will assume vis-à-vis this service. This includes uncertainty about the physician's interests, about treatment alternatives and about the exclusive patient–physician relationship.
The abovementioned issues are an undeniable part of the present-day reality of the medical profession, and this has been extensively documented and researched elsewhere for a large variety of modern countries. However, they do not sit well with the professional physician image of benevolence (as opposed to interest in gains), evidence-based practice (as opposed to individual variation) and committed relationships (as opposed to consumerism). A vast number of international empirical studies into physicians’ attitudes towards advertising have shown that the possible adverse effects on the profession's image are among the prime reasons for physicians to oppose advertising (eg, refs. 1,12 and 27). Physicians thus recognise that issues such as those identified in this paper are delicate and could potentially tarnish their professional image. Whereas maintaining their professional image is a prime reason for physicians to oppose advertising, the repercussions of advertising bans for the public are a prime reason for us to critically discuss them.
As mentioned earlier—and this is something that cannot be emphasised enough—the present argument should not be taken to mean that physicians tend to neglect their professional duties. On the contrary, the majority of physicians place their patients’ wellbeing above everything else. Many patients, moreover, learn from experience, word of mouth and the media how to negotiate uncertainty about the physician's interests, about alternative treatments and about exclusive relationships with physicians. This is illustrated by, for instance, the widespread phenomena of informal payments, the sharing of prescription medication, and internet forums discussing ‘what one should say to the doctor’ in order to obtain a desired referral.17 ,28 ,29 However, such practices also underline the existence of a predicament that is supposedly non-existent. The present argument entails that a physician advertising ban effectively tells the public that issues of gains from patient care, variation in medical practice and the necessity of an exclusive doctor–patient relationship are not supposed to exist. That such issues allegedly do not exist does not, however, mean that the potential repercussions are eliminated; instead, they are effectively left to the public to confront.
References
Footnotes
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Contributors The author is solely responsible for the paper, including the drafting of the article and revising it critically for intellectual content.
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Competing interests None.
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Provenance and peer review Not commissioned; externally peer reviewed.
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