Summary and Conclusion
So I do agree that in the past it was a little excessive and there was probably too much influence in a negative way but now I think it’s the other way around—[distrust and regulation of pharmaceutical marketing is] stifling innovations and when I meet, you know I’ll be honest, when I meet doctors who refuse to attend any promotional events they honestly are usually the ones that are the least educated about products in our field.—Interviewed physician (psychiatrist) KOL
Pharmaceutical marketing is centered on the production and distribution of information, mostly forms of medical science. The industry provides roughly half of all funding for clinical trials—often randomized, controlled trials, the most valued form of medical knowledge—and sponsors a majority of the new trials initiated each year. The bulk of that funding goes to CROs, which make no claim on the data they produce, simply handing it over to the companies that hire them to use as they want. Using this and any other available data, the pharmaceutical industry produces a significant portion of the scientific literature on in-patent prescription drugs, with as many as 40% of the articles on recently approved drugs in the more prestigious medical journals having been ghost managed for companies. Publication planners create teams of professionals to create those articles and choose KOLs to serve as authors and journals to which to submit them.
Companies’ interests can thus be expected to influence a myriad of legitimate choices in the design, implementation, analysis, description, and publication of clinical trials. We can reasonably expect, and there is abundant evidence, that companies make those choices to support their commercial interests. Even if companies are not completely coherent actors, they are coherent enough in their goals that choices in all the different stages of research and communication can point in the same direction. The result is still recognizably medical science, and may even be high quality science, but it is science serving particular and clear interests.
This continues with the communication of medical science in the field. The science that sales representatives give to physicians is invariably science that serves their companies’ interests. When they give talks, KOLs contribute to the enormous influence that the pharmaceutical industry has on medical knowledge. The form of CME in which KOLs participate is one thoroughly shaped by the interests of the companies that sponsor it. What is communicated will often be sound medical science, which is why KOLs are willing to communicate it; nevertheless, it will be science chosen to help sell a product.
This chapter is broadly about knowledge, but the specific issues at stake are not especially salient within the traditional philosophical project of epistemology. Epistemology is centrally the study of justification, and in particular the study of the justification of individualized beliefs. Undoubtedly, some of the claims that pharmaceutical companies make and promote are poorly justified, and undoubtedly some are false in egregious ways. On occasion, there are significant scandals involving errors, falsehoods, and gross manipulations circulated by pharmaceutical companies. But by and large, these companies are working within the medical mainstream, producing data of reasonably high quality using the most valued of research tools; they go on to analyze it using standard statistical means and construct articles that pass the scrutiny of peer reviewers at many of the best medical journals. The problems of knowledge in the pharmaceutical industry discussed in this chapter are not primarily problems of justification.
However, seen in terms of political economies of knowledge, there are very large concerns. As this chapter has illustrated, largely unnoticed issues of influence and control permeate important areas of medical knowledge, whether the claims that constitute that knowledge involve issues of justification or not. Individual companies with stakes in specific medical topics have the capability to influence knowledge so significantly that their preferred science becomes dominant. They have the capability to achieve hegemony over understandings of particular diseases, symptoms, treatment options, trajectories and side effects. By virtue of the enormous resources at their disposal, they have dominant positions within the political economy of medical knowledge. This flood of pharmaceutical knowledge is not created for broad human benefit, but to increase profits; at least some of the time those two goals will be very opposed. We might ask not whether this or that piece of pharmaceutical knowledge is justified or true, but note instead that the structures of knowledge that create it concentrate power in very few actors, who in turn have very narrow interests.
We can see an aspect of pharmaceutical companies’ influence in the statement at the head of this section. For the KOL quoted, being an educated physician is closely linked with knowing the material that pharmaceutical companies are communicating. In fact, most of the KOLs interviewed for this project defend their giving promotional talks in related terms: if physicians are “not educated enough, the public will suffer,” says one; “oh, it helps other patients elsewhere, it’s spreading the word—it’s spreading the gospel,” enthuses another. For them, pharmaceutical industry influence has become normalized, to the extent that they see the industry as the source of the most valuable medical information. The industry has achieved a level of hegemony over parts of medical education and thus over what physicians see as treatable diseases and how they should be treated.
Pharmaceutical companies ghost manage the production of the research, they shepherd the KOLs who disseminate the research as both authors and speakers, and finally they orchestrate the delivery of CME courses. In so doing, they attempt to be the ultimate sources of the information physicians rely on to make rational decisions about patient care. In this we can see the importance of the hegemony of knowledge gained through pharmaceutical industry strategy.
Acknowledgment This chapter presents material from a large project on the political economy of pharmaceutical knowledge. That project was funded by a grant from the Social Sciences and Humanities Research Council of Canada (#410-2010-1033). Some additional research was funded by a grant from the Canadian Institutes of Health Research (#2009-11-02). Zdenka Chloubova performed many of the interviews quoted here. Khadija Coxon assisted with other research that made its way into this chapter and helped considerably with the organization of a draft. Apologies are owed to Ernesto Laclau and Chantal Mouffe for the chapter’s title.