Suppose for a moment that I had just signed a prescription for you. Would you still trust my decision if I had used a pen with the drug's logo printed on it? What if the company's representative had treated my whole firm to dinner the previous evening?

The majority of medical students in the UK will come into contact with pharmaceutical marketing by the end of their training. There is sponsored food at hospital grand rounds and meetings. Junior doctors are offered gifts of textbooks and invited to evenings out. Christian students and doctors need to consider their position: an estimated £10,000 for every doctor is spent each year on pharmaceutical marketing.[1] Yet increasing numbers of doctors are growing uneasy about their involvement with pharmaceutical marketing.[2]

It is difficult to write about the pharmaceutical industry's contribution to medical practice without sounding trite. We have antibiotics, effective treatments for heart attacks, and chemotherapy that works. Without the industry's expertise in developing new drugs and producing them on a large scale, we would not.[3] I am not trying to argue that doctors are good and the industry is bad. However, it is important that we think through a number of matters concerning our interaction with pharmaceutical companies.

Q: Any such thing as a free lunch?

The most immediate question for most of us will be whether it is right to accept gifts or food from drug reps when there is evidence that doctors who do so change their prescribing practices. The innocuous free pen is more powerful than it appears. I might think that I am strong-willed enough to look at a drug logo on my stationery every day, and eat a drug rep's sandwiches without it affecting my freedom in prescribing. However, the influence of gift-giving is subtle. Evidence has shown that companies are getting a good return on their investment: businesses are unlikely to write large cheques for something that doesn't get results. One author put it well: 'food, flattery and friendship are powerful tools of persuasion, particularly when combined.'[4]

Even a small gift, whether or not we acknowledge it, creates a sense of obligation. Meetings of doctors with pharmaceutical representatives have been found to correlate with an increased number of formulary addition requests for the reps' companies' drugs, most of which offered no advantage over drugs already in the formulary, even though most doctors denied that they were influenced. The interactions were also found to influence prescribing in terms of preference for new drugs, reduced prescribing of generic drugs, and non-rational prescribing.[5] GPs who see reps regularly are more likely to prescribe drugs that are not clinically indicated, and more likely to give a script at the end of a consultation.[6]

A: Definitely not!

Uncomfortable doctors and students can investigate the No Free Lunch movement, founded by a New York physician, which now has a UK website.[7] The organisation's main demand is a register of all NHS professionals' contacts and interactions with the pharmaceutical industry. Doctors are invited to take a brief 'Are you a pharma junkie?' questionnaire based on the CAGE alcohol misuse screening tool:

• Have you ever prescribed Celebrex?
• Are you Annoyed by people who complain about drug lunches and free gifts?
• Is there a medication loGo on the pen you're using right now?
• Do you drink your morning Eye-opener out of a Lipitor coffee mug?

Respondents can then print out and sign a pledge not to accept money, gifts or hospitality from the pharmaceutical industry and to seek unbiased sources of information.

Isn't all this a little extreme? Some might argue that doctors need to know about new medicines, and that visits and talks from drug reps serve an important educational function. However, reps are unlikely to give out papers that show that their company's drug is no better than placebo! Even if I turn down glossy reprints of published articles, it may be hard to make sure that my education in therapeutics is not skewed by industry influence on research. Industry-sponsored studies are commonplace, are less likely to be published, and not all studies report unfavourable intention-to-treat data (where participants who drop out before the end of the study are included in the analysis).[8,9]

Seek justice…encourage the oppressed

If you choose to go 'pharm-free', you should be prepared to honour your commitment, unlike the Pharisees, who kept religious rules without fighting against social injustice (the spirit of the law).[10] The issue is pertinent because despite heavy investment in 'me-too' products for 'western world diseases', relatively tiny amounts of money go towards research into conditions prevalent in developing countries. Of $35.3bn invested in research and development in 1999, only 10.1% was for infectious and parasitic diseases, eg malaria, schistosomiasis, river blindness, trachoma, infectious diarrhoeal diseases and TB. Such illnesses account for only 5% of the disease burden in developed countries, but a third of the world's total. 1,393 new drugs were registered between 1975 and 1999; just 13 were for tropical diseases and three for TB. Much of the spending on infectious diseases was accounted for by 20 new antiretroviral drugs – an investment encouraged by politicians and the prospect of healthy returns from Western trade.[11]

Christian doctors should know best

General Medical Council guidance advises doctors that they 'must act in [their] patients' best interests… [They] must not ask for or accept any inducement, gift or hospitality which may affect or be seen to affect [their] judgment.'[12] As Christians, our calling is higher still: we are exhorted to 'rid [our]selves of all…deceit' and 'make every effort to be found spotless, blameless and at peace' with the Lord.[13] It is a challenge for us to nurture this integrity in all aspects of our lives, including our professional one. A doctor who accepts gifts despite evidence that he is being influenced in favour of the drug company (rather than the patient) may rightly be accused of wrongdoing.

A decision not to accept pharmaceutical gifts or hospitality must depend on whether or not the gift is a bribe. Perhaps the most important question, however, is not who paid for my sandwiches but whether I am using my voice to speak up for the neglected. We have to decide whether the issue is a clear-cut matter where the same choice is either right or wrong for everyone, and therefore where all Christians should agree, or whether it is a matter of conscience: but as Paul said, 'Each one should be fully convinced in his own mind.'[14] Think about that the next time you pick up a pen from those smiling drug reps.