Literature Review

2.0: Introduction

This chapter provides theoretical review of empirical studies conducted by scholars and other researchers on the role of ethics in pharmaceutical sales. Purposely, the literature focuses on the benefits and disadvantages of ethical codes, impacts of unethical behavior of pharmaceutical representatives on the public, and lastly on the implications of increasing awareness of stakeholders.

2.1: Theoretical Review

2.1.1: Pharmaceutical Companies Marketing and Ethic Codes

The World Health Organization defines pharmaceutical sales and promotion as persuasive and informative activities carried out by pharmaceutical dealers and manufacturers in order to market the drugs. These parties will attempt to influence supply prescriptions, purchases, and the use of the medical drug so as to meet demand.

According to Spiller & Wymer 2001, manufacturing companies who are inhibitors of ethical codes in UK play two streams of marketing. The companies use push stream to target the decision makers such as physicians who do drug sampling, write journal articles, advertise research grants, and sponsor medical education programs among other activities. On the other hand, pull streams are extended to consumers who receive drug samples and free medication. The pull and push marketing strategies aim at exerting satisfaction of physicians and customers whereby some medical practitioners have been found to give medical prescription favoring pharmaceutical companies instead of patients request, hence a breach in code of ethics .

According to Hensel & William in 1991, pharmaceutical companies created pharmaceutical promotional push and pull elements to improve commercial and other non-commercial medical drugs distribution channels. Clinical researchers and the UK government observe the channels unregistered as dangerous to health of people. The companies have been breaching medical ethic codes through these channels by providing fake drug samples, gift premiums, making misleading advertisement, and sending wrong mails to patients. Government and public health critics have been in front line as ethical code enables to protect explorations of patients. However, pharmaceutical representatives perceive ethical codes as a stumbling block to high sales volume. Academic physicians, such as Rod & Saunder in 2009, criticized non-commercial channels used to contribute immensely to fake drug prescriptions and samples in the market. They called the UK government to impose strict medical and pharmaceutical regulatory framework to curb all poor medical marketing strategies.

2.1.2: The Current principles of biomedical sales ethics

Principles of biomedical ethics developed by Beauchamp & Childress (1994) have widely helped the advocates of medical drug sale ethics to force pharmaceutical companies and distributers to care for customers. These principles include the obligation of pharmaceutical companies to exercise and respect autonomy of customers in selecting drugs, non-malfeasance of customers (no harm), providing benefits and welfare to patients and, lastly, fairness in distribution of benefits risks and costs. Academic physicians claim that these four principles are sufficient to control arrogance of pharmaceutical representatives and inhibitors of medical ethics from exploiting the customers.

However, the inhibitors of pharmaceutical codes of ethics claimed that the principles were rigid, conflicting at times, and thus they requested the UK government to make some adjustments. They suggested the principles to be replaced with coherentists’ approaches that allow for specification and full balancing of sales principles to all stakeholders. The weakness cited above about the principles was revealed by Rawls in 1979. According to his concept of reflective equilibrium, Rawl suggests that inhibitors’ desire to make profits should be considered by appealing to more formal pharmaceutical rules and general ethics that advocate consistency and coherency. Rawl states that equilibrium in pharmaceutical ethical senses can be fully achieved when the whole iterative activity involves revaluation and proper reference to all ethical theories and patients beliefs. However, the whole process must rely on the principles set within the plurality of patients and other medical drug users’ beliefs.

As argued by Rawl, we can critically say that no attempt has been made to evaluate normative based approaches to ensure ethical justification. The purpose of the principle was rather to illustrate that there exists some manifestation of possible ethical policies in the sector that community pharmacists and medical practitioners should adhere to. Secondly, it is possible to say that the UK government uses the principles to make pharmacists respect customers’ autonomy, beneficence justice, and in this way solve all medical problems.

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2.1.3: Ethical problems linked with pharmaceutical marketing to the public

Currently, a lot of public debates surround pharmaceutical marketing activities in the UK. Most of medical services stakeholders, such as physicians and patients, question the influence of pharmaceutical representatives on pharmaceutical services provision on publics. A critic suggests that some marketing strategies used by the pharmacists have negative effects on the public, and thus should be banned. Two competing opinions have dominated the debate on the matter. The first opinion reflects the views of public based policy organization and consumers autonomy groups, who generally form target marketing groups. Activists from public sectors claim that various pharmaceutical promotional activities carried out in the country have negatively impacted patients’ welfare through fake drug samples. Secondly, they accused pharmaceutical sales representatives of inflating the drug prices and making public health services provision costly.

Moreover, the report released by Mizik & Jacobson in 2004 revealed that pharmaceutical representatives introduced some unnecessary promotions that significantly contributed to physicians prescribing expensive branded drug services rather than giving cheap medical drugs.

Secondly, the next opinion is about industrial groups and pharmaceutical companies found to be inhibitors of pharmaceutical codes of ethics. In their views, companies are carrying out pharmaceutical promotions to increase drug awareness among the public. However, they admit that on some occasions, the advertisements influence physicians’ perceptions and behaviors negatively. They stated further that a physician needs medical drug information and educational advices, which can only be provided by promotion practices. The companies suggest that in manufacturing process, pharmacists and physicians were excluded and thus they need the information to give rational prescriptions.

The views of medical service critics and those of public healthcare advocates differ from the companies’ views. They critically suggest that the issue is not about creating awareness among the public or providing information to the physician to the doctors. Rather, the government should institute strict codes of ethics to protect the public from price and fake sample exploitation. They accuse promotional activities of influencing physicians’ behaviors in prescribing wrong drugs to patients. Inappropriate prescriptions can endanger patients’ health, hence the activities must be carried out in a well planned manner.

A research by Manchanda & Honka in 2005 studied and analyzed ethical perceptions about pharmaceutical promotion among medical representatives and physicians. Some differences arise in the promotional efforts where manufacturers give out gifts so that physicians would favor their drugs. The ethical dilemma surrounds pharmaceutical promotional practices as it is believed that these gifts influence physician’s attitudes and perceptions related to prescription. Thus, the advocates require the ethic codes designed under UK pharmacy Acts to consider opinions of physicians as reflecting the manufacturers’ and pharmaceutical representatives’ opinions and not those of the public.

It is possible to say that the literature indicates that physicians have negative attitude instead of being neutral towards the public. They are influenced by the mere gifts and other details when they prescribe medical services and are inclined to support opinions of pharmaceutical representative. Furthermore, physicians trust the informational and educational sources provided by pharmaceutical companies instead of their own research about the drugs. They should partially doubt representatives’ opinions as manufacturing does not mean expertise. In most cases, pharmaceutical sales practices are biased and subjective towards correct drug prescriptions. Secondly, it is possible to suggest that the codes of ethics provided should clearly cover samples and other promotional items provided as they can negatively impact health of the patients. In most cases, pharmacists provide them to patients instead of physicians. This totally contradicts the UK standards and principles outlined under the code of ethics in medical and pharmaceutical profession. If the gifts provision practices are not reciprocated, behavioral discomforts among pharmaceutical representatives will continue to harm patients.

A research conducted by Roughead et al in 1998 disclosed that the UK government must do something to the unethical behavior of medical practitioners of providing gifts to physicians such as pens, mugs, and other stationeries found to influence their attitudes in drug prescriptions. The government can only achieve it through revising pharmaceutical marketing policies under medical code of ethics.

2.2: Empirical Review

2.2.1: Managerial and pharmaceutical policy implications

Ethical practices pushed by pharmaceutical enabler such as the government and public healthcare advocate aim to ensure better management of interaction among patients and physicians. Moreover, codes of ethics aim at ensuring that companies are socially responsible in marketing strategies campaigns. Most of the empirical research states that pharmaceutical companies are too much driven by profits instead of medical drugs objectives. The UK pharmaceutical code of ethics requires companies to carry out marketing process in informative and educational ways instead of commercial ones. The policies require them to hold and sponsor educational campaigns such as CMEs and drug use conferences. Moreover, the companies should produce pharmaceutical journals and books purposely to educate physicians and patients about the drugs. Moreover, they should attach company drug manuals that clearly state that the drugs meet international ethical standards. These activities can help pharmaceutical companies improve their image, increase their market share and make the society perceive them as responsible in contributing to medical professions and better healthcare.

Empirical research investigation by Coleman et al in 2003 revealed that 72.2% of physicians prefer non-commercial based sources of medical information instead of commercial ones. Physicians though provided with gifts to motivate them rationally expect the companies to enhance the quality of their non-commercial activities as source of information. Moreover, the study findings revealed that the UK government and all other concerned ministries set weak ethical policies that do not fully protect intellectual property rights within pharmaceutical industry. The companies accuse their rivals of marketing unregistered fake samples and illegal generic drugs hence contributing to unnecessary competition within the market. Foreign investors have been discouraged by these unregistered pharmaceutical companies, whose services are cheap and hence increase opportunities for generic but unregistered drugs. These drugs contribute to deterioration of health among patients. It is crucial for the UK government to enforce strict pharmaceutical codes of ethics over drug manufacturing and application. The government must also attract foreign medical and pharmaceutical investors by enhancing research and development activities, establishing better clinical laboratories for clinical trials, and avoiding unnecessary bureaucratic activities in registration process of manufactured drugs. This will help in empowering the UK-based pharmaceutical industry by ensuring that all local companies comply with international competitions found to improve the drug quality. Moreover, it will act as a major boost in national pharmaceutical production and hence provide affordable pharmaceutical services to poor patients. Moreover, the research work found that pharmaceutical sales and marketing practices focus on advertising expensive and patent drugs, which are costly to patients. Thus to conclude, the ministry of health and other government stakeholders must revise the codes of ethics and pharmaceutical standards that protect patients against national drugs exploitation.

A result from the qualitative and quantitative analysis of the research study found that pharmaceutical companies use gifts and wrong information adverts in promotional articles. The pharmacists provide wrong recommendations to physicians found to contribute to exploitation of patients. This requires the UK government to impose strict policies under the pharmacy acts against such pharmaceutical service practices because they harm patients’ health. Moreover, the study recommends that the government must create national and multinational companies conflict resolution center for solving all price and quality service conflicts between them and patients. It is possible to recommend that the ethical dilemma surrounding the pharmaceutical sales and marketing practices should be solved by imposing strict regulation pharmacy policies and enforcing patent rights protection. Moreover, we recommend that companies should ensure promotional activities so as to reduce black market within the UK pharmaceutical industry. Moreover, further critical analysis shows that it is recommendable for the government to train all policy makers and physicians in training about the need to offer affordable and high quality pharmacy services to the public. Physicians should avoid pharmaceutical marketing practices that offer them gifts.


In summary, various theoretical and empirical studies have researched pharmaceutical enablers and inhibitors roles in adhering to accepted codes of ethics in pharmaceutical industry. The main aim of this study is to study rug promotion activities undertaken by Pajunk pharmaceutical representative in UK. The study will play an instrumental role in filling the gap found by researchers on roles of ethics in pharmaceutical sales. The research study aims to meet various objectives. First, it critically evaluates pharmaceutical representatives’ perceptions of enablers and inhibitors adherence to ethical codes. Secondly, the study helps explore enablers and inhibitors perceptions of negative effects on the public by looking at unethical behaviors of pharmaceutical representatives. Third, the study critically addresses and evaluates the impact of pharmaceutical representatives’ ethical awareness when the first based Association of British Pharmaceutical Industry (ABPI) and the code of conduct.

Researchers need to ask themselves some questions about pharmaceutical sales and the role of ethics to meet the above-mentioned objectives. Some of the questions include: What are the perceptions of pharmaceutical representative of enablers and inhibitors adherence to the ethical code of conduct stated in pharmacy act? Secondly, what are the negative effects of unethical behaviors portrayed by pharmaceutical representatives to the public? The question helps other researchers, the government, and physicians determine implications of fake medical prescriptions from wrongly made pharmaceutical marketing practices. Lastly, the researchers should ask what are the impacts of pharmaceutical representatives’ ethical awareness implemented by the Association of British Pharmaceutical Industry (ABPI) and the code of conduct? The answers obtained from the research work will help reduce the research gap indentified above. Moreover, the research work will help the government, academicians, and physicians understand better the ethical dilemma surrounding pharmaceutical sale and marketing practices. Moreover, it will boost the revision process of pharmaceutical codes of conducts.

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