Abstract
The purpose of this paper is to provide a normative model for the assessment of the exercise of power by Big Pharma. By drawing on the work of Steven Lukes, it will be argued that while Big Pharma is overtly highly regulated, so that its power is indeed restricted in the interests of patients and the general public, the industry is still able to exercise what Lukes describes as a third dimension of power. This entails concealing the conflicts of interest and grievances that Big Pharma may have with the health care system, physicians and patients, crucially through rhetorical engagements with Patient Advocacy Groups that seek to shape public opinion, and also by marginalising certain groups, excluding them from debates over health care resource allocation. Three issues will be examined: the construction of a conception of the patient as expert patient or consumer; the phenomenon of disease mongering; the suppression or distortion of debates over resource allocation.
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Notes
It may be argued that Big Pharma is distinctive also in the fact that it produces health care, and thus products that save lives and improve the quality of life of the consumer. Firstly, it is questionable whether this distinction can be drawn clearly. All producers, one assumes, would argue that their products improved at least the quality of life (although perhaps not the quantity of life) of their consumers. In addition, the exact impact that modern medicine has on quality of life and longevity is highly contested, and the phenomenon of iatrogenesis is one motivation for the regulation of the industry. Secondly, even if the output of Big Pharma was of unalloyed benefit, it is not at all clear that this would excuse morally and politically dubious behaviour on the part of the producer.
The basic assumption lying behind this essay is that democratic societies ought to operate as closely as possible to the ideal outlined by Habermas in his early work on the public sphere (see Habermas 1974), and indeed in his more recent works on law (Habermas 1996). At the core of any such account of democracies lies a stress on the formation of public opinion through free and open debate, and the responsiveness of governments to that debate. It will be argued that certain practices of Big Pharma distort the formation of public opinion (although it should not be thought that Big Pharma is unique in doing this, nor that it is the worst corporate offender).
It is assumed that all capitalist industries (and indeed enterprises within those industries) share certain interests, regardless of competition between them. Economy, polity and even culture need to be shaped in such a way as to ward off certain threats to capitalism, be they Marx’s social revolution, economic instability and crisis, or perhaps environmental degradation. While Marx envisaged a capitalist state that only looked to the interests of capital, the modern capitalist state will have to balance the interests of capital against those of its citizens, where the two do not coincide.
A primary purpose of this paper is to explore the usefulness of Lukes’ account of three dimensions of power to the understanding of Big Pharma. There are obviously alternative frameworks that could be adopted, such as those derived from Foucault. There is not space in the essay, as it stands, to debate the merits of different theoretical approaches (merely to suggest the usefulness of Lukes’).
See Jones (2008, pp. 933-4) for indicative data on the nature and scope of this funding. Larger companies, such as Pfizer and SmithKlineGlazo, devoted sums in the region of US$10,000 million to $20,000 million pa to PAG support. (These figures were reported by companies in 2007.) Individual grants might be small (less than $10,000) with only 6% being above $100,000. Jones notes that the ‘[t]ypes of projects supported by industry ranged across sponsorship of conferences, publications, disease awareness campaigns, provision of core grants to cover groups’ running costs, funding specialist nurses and/or research projects’ (p. 934). It is worth noting that, although it will be argued below that Big Pharma benefits from the ability of PAGs to lobby governments and to influence public opinion through PR campaigns, it does not appear that companies explicitly fund this work. The importance of maintaining the PAG’s apparent neutrality and objectivity in such campaigns is overriding.
Some PAGs will indeed refuse pharmaceutical money, precisely because of the threat of their independence being undermined. Others take the money reluctantly, as too substantial a source turn down (Batt 2005, pp. 7–8). The representatives of PAGs interviewed by Buttle and Boldrini stressed the need for the supporting pharmaceutical company to respect the PAG’s independence and integrity, and express fears that the pharmaceutical company’s benevolent motives will be compromised by a commitment to sales (2001 p. 206).
That the term ‘lifestyle’ is used by Buttle and Boldrini is significant. ‘Lifestyle’, with its implications of consumer choice, replaces the more usual ‘quality of life’.
This point again highlights a very important role that Big Pharma could (and at times does) play in the education of patients.
http://www.bbc.co.uk/news/health-11060968 [accessed 1st September 2010].
http://www.bowelcanceruk.org.uk/home/media-centre/latest-news/negative-nice-guidance-re-treatment-beva?s1=avastin [accessed 1st September 2010]. Bowelcancer UK does make a series of worthwhile moral and political points, focussing on the extraordinary value of even short term survival to the patient, and the comparability of UK and European formularies. Cost issues are largely avoided, beyond a general awareness of recessionary pressure on government budgets.
Decisionism is the thesis that value judgements cannot be resolved through rational debate, and so are made on the basis of subjective caprice (Habermas 1976, p. 265).
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Edgar, A. The dominance of big pharma: power. Med Health Care and Philos 16, 295–304 (2013). https://doi.org/10.1007/s11019-012-9385-9
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DOI: https://doi.org/10.1007/s11019-012-9385-9