THE ROLE OF MEDICALIZATION
The impact of DTCA on American culture is complex. More specifically, DTCA has contributed to increasing
medicalization, a term that refers to labeling more and more human experience and behavior as a medical problem or illness for which the medical profession has treatment.4 As DTCA creates excitement and interest, the media increase medicalization through further reporting/coverage. For example, many advertisements for anxiolytics describe anxiety disorders as an "anxious feeling" or "nerves around people." This type of anxiety is often part of a normal life course and does not necessarily reflect pathology. People viewing the advertisement may identify with the actors' portrayal, thereby expanding the scope of medicine to include stressful social situations.
Medicalization arises on at least three levels: conceptual, interactional, and institutional.4 Each level has a presence in the relationship between DTCA and medicalization. For example, the pressures that can push PAs to prescribe, such as increasingly busy schedules and the economics of clinical practice, are amplified when patient requests stem from DTCA and, in turn, engender medicalization at the interactional level. By conceding to patient prescription demands, clinicians may be affirming the presence of an illness that requires treatment, thereby validating the purpose of DTCA. This can pose a violation of beneficence and nonmaleficence.
A hallmark of ethical clinical practice is maintaining patient autonomy. This affords the patient the possibility of making medical decisions that fit his or her personal wishes, taking into account the many facets of a patient's life (culture, economy, and logistics). Autonomy incorporates knowledge of the issues surrounding a medical decision and the capacity to thoughtfully evaluate them. Advocates of DTCA suggest that DTCA can provide some of this knowledge. Opponents challenge the value of this education and feel it produces more emotional sentiment than enlightenment.5
The pervasiveness of advertising and the emotive storylines it carries make people identify with the products and conditions. Common human experiences, such as baldness, menstruation, and stress, have been turned into diseases that can be treated.2 High volumes of advertisements that show these types of conditions in a distressing or negative way can change how a person views his or her own experience with these conditions. This may threaten a patient's ability to make an informed decision and suggests other educational sources are needed to preserve patient autonomy.
IS DTCA PROVIDING NEEDED INFORMATION?
In 2005, the Journal of Bioethical Inquiry featured two papers that looked at the issue of DTCA from opposing perspectives. Both sides of the argument regarding the allowance of DTCA present interesting theories as to why their position best represents the health and welfare of our society.6
DTCA supporters cite an increased understanding of disease and treatment options as a positive attribute.7,8 They also attempt to demonstrate several mechanisms through which increased patient involvement can bring about improved health outcomes, including better medication adherence.8,9 Support for DTCA is summarized as, "Those who support DTCA counter-argue that the ads are in principle no different to other forms of advertising, that they inform the population, and reassure individuals they are not alone with their problem and that help is available. They are also said to encourage people to initiate discussions with their doctor."6
From the opposite perspective, a rationale for a total ban of DTCA is described this way: Drug promotion should be evaluated according to its impact on health, access to information, informed consent, and wealth. Drug promotion currently does more harm than good to each of these objectives because it is usually misleading. This is a systemic problem. Whilst improved regulation and education will address it to some degree, major reforms to payment systems for drug companies and doctors are also required. Until all these systemic reforms can be put in place, the best policy option is to ban the promotion of drugs to doctors and the public.10
Other negative aspects of DTCA include concerns about the emotion stimulated through advertisements, as well as their questionable educational value.5 DTCA critics cite the economic and time costs these ads bring into the clinic, touching on the issue of distributive justice.
In addition, advertising has an inherent bias, which is the clear intent to generate sales and profit. The pharmaceutical company has a responsibility toward its employees and investors. The clinician's allegiance is a bit different. The fiduciary duty of a clinician is to communicate the most reliable and effective clinical information. These two responsibilities can be in conflict.
DTCA will continue to be an issue that impacts clinicians in both private and academic practice. The conversation surrounding the cost and benefit of this allowance is complex and includes the intersection of autonomy, nonmaleficence, beneficence, and distributive justice. PAs can prepare themselves for DTCA-driven patient encounters by framing such encounters in related bioethical principles and knowledge of the history of DTCA. JAAPA
Kevin O'Hara practices in internal and HIV medicine in New York, New York, and is a graduate student with the Department of Sociomedical Sciences at Columbia University, also in New York. He has indicated no relationships to disclose relating to the content of this article.
REFERENCES
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