When professional societies contribute to the public
debate on health care issues, they also face important conflicts of interest with respect to their receipt of advertising
dollars. On one hand, the societies have a duty to advocate
on behalf of patient welfare. On the other hand, certain
policy positions may affect the societies' revenues from
health care companies. If a particular position would be
good for patients but bad for pharmaceutical companies,
device companies, or other health care businesses, a professional society would help patients at the risk ofhurting its
own financial well-being. Members of the affected industry
could limit their advertising expenditures either to retaliate
against the society or because the change in public policy
led to a decline in the companies' profits and therefore their
advertising budgets.
This conflict is especially serious because professional
societies play a critical role in the shaping of health care
policy in the United States. When the President, Congress,
state legislatures, or courts decide matters of health care
regulation or law, they rely substantially on the perspectives ofthe medical profession as represented by their professional organizations. 3 2This is so not only because physicians can explain how a change in policy or law will affect
the health care system, but also because lawmakers lack the
medical expertise that would make them confident about
their own perspectives.
As with the conflicts faced by journal editors, appearances ofimpropriety are also important here. Even ifa professional society's positions are not in fact influenced by
their receipt of advertising revenues, people will wonder
whether the professional society was so influenced. If the
AMA opposes price controls on prescription drugs, for example, the public will be unsure whether the opposition is
truly rooted in legitimate concerns, like the potentially harmful effects on research spending by industry, or whether the
opposition reflects the AMAs defense of its own pecuniary
interests. Similarly, ifother readers ofboth the AM.s Drug
Evaluationsand the independent Medical Letter found, as
one of us did, that the authors of The MedicalLetter gave
more definitive prescribing recommendations and were
more likely to conclude that there was nothing to be gained
by prescribing some drugs instead of their alternatives, a
the readers might have wondered whether the AMA.s analyses were subconsciously affected by the Association's interest in maintaining good relations with all ofthe companies
in the pharmaceutical industry.
Countervailing benefits ofhealth industry
advertising
Given the potential harms from health care advertising in
medical journals, the editors should refuse health care advertisements unless there are countervailing benefits that
outweigh the risks. We will now discuss the benefits and
consider whether they are sufficient to justify health care
advertising in medical journals. In doing so, it is useful to
consider whether journals should be able to rely only on
the health care industry for their advertising or whether
journals should be able to rely on the health care industry
together with other industries for advertising.
Exclusive relianceon health care advertising
As mentioned, it is common for medical journals to accept
advertisements only when they feature a health-related product or service.34 We find it hard to see how this policy can
be justified. Ifadvertisements are accepted from airlines (for
example, Delta), credit card companies (for example, American Express), golf equipment suppliers (for example, Callaway), jewelers (for example, Tiffany's), or automobile manufacturers (for example, Cadillac), journals would have a
larger pool of companies to which they could sell advertising space, and they would reduce the conflict of interest
that arises from the practice of only accepting health care
advertisements. This suggests that health care companies
are not the first place medical journals should look for advertising. Rather, they are the last place medical journals
should look.
To be sure, medical journals and their parent professional societies would owe the same sense ofgratitude to
these other companies, but it is hard to see how their relationships with the companies Would come into conflict with
their duties to scientific integrity and patient welfare. IfJAMA
accepted advertisements from the Callaway Golf Company
for its Big Bertha golf driver, JAMA editors might add the
club to their golf bags, and the AMA might oppose efforts
by the Professional Golfers' Association to regulate golfclub
size;"5 but these activities would not affect the quality of
JAMA or ofhealth care delivery in this country. Similarly, if
theAnnals ofInternalMedicine ran advertisements for Delta
and USAirways, the editors at Annalsmight start flying those
airlines more often, and the ACP might oppose government regulations that would help start-up airlines, but these
activities also would not compromise journal quality or
health care delivery.
Some journal editors explain a policy of accepting only
health-related advertising as a way to foster the mission of
their journals. In this view, health-related advertisements
are included because they have educational value that augments the information provided by the journal's articles.
Nonhealth-related advertisements, on the other hand, would
not contribute to the journal's educational mission. 6 This
argument is not persuasive. The mission of medical journals is to provide the most reliable educational information
available. However, as discussed above, advertisements compromise the educational value of medical journals. Advertisers see education as one oftheir goals, but it is secondary
to the primary aim of using advertisements to increase sales.
TheJournalofLaw, Medicine & Ethics
Typically, a company can maximize its profits by providing
imperfect rather than perfect information to potential consumers. To put it another way, medical schools would not
give classroom time to pharmaceutical company sales representatives as a way to enhance their educational mission.
The U.S. Supreme Court also has rejected the argument that health-related advertising fosters the educational
mission of medical journals.3 7 The issue has come up because advertising revenues would constitute tax-exempt
income if the advertising "contributes importantly" to the
educational purposes ofa journal's tax-exempt, parent professional society. When the ACP asked for a refund of taxes
paid on advertising revenues from the Annals ofInternal
Medicine, the Supreme Court concluded that, although
advertising might in theory contribute importantly to a
journal's educational mission, it did not in fact do so in the
case ofAnnals. The Court observed that the journal's advertising decisions turned on whether companies were willing to pay for the space (rather than on the goal ofproviding a systematic presentation of the goods or services being
advertised) and that the repeated advertising of established
drugs undermined the claim that the advertisements were
principally designed to alert readers to new developments. 3
Another possible justification for the exclusion ofnonhealth advertising lies in aesthetic considerations. It may
seem in poor taste to run advertisements for cars, credit
cards, or jewelry in a professional journal. However, aesthetic tastes are not a sufficient reason to embrace a significant conflict ofinterest. Tackiness is a small price to pay for
greater scientific integrity and higher quality health care.
Of course, when advertising goes beyond tackiness to include
deception or fraud or otherwise to promote unethical practices, the advertising should be rejected. But mere bad taste
is less troubling than a financial conflict of interest.
It seems fairly clear, then, that medical journals should
eliminate their requirement that advertisements come only
from companies with a health-related product or service.
The harder question is whether journals should sell some
of their advertisement space for health-related products or
services. 39
Reliance on both health-relatedandother kinds of
advertisements
We could conclude that medical journals should sell advertising space only to nonhealth-related companies. Such a
practice would avoid the conflicts ofinterest from healthrelated advertising. Moreover, many consumer-oriented
companies, especially sellers of luxury items, ought to be
interested in advertising to a readership with the average
household income of physicians.
However, it may be the case that excluding health-related advertisements would have negative consequences for
medical research and education. Journals could see a decrease in their advertising revenues if they excluded healthrelated advertising. Any advertiser can reach physicians
when they advertise to the public at large through magazines like Business Week or Time, but health-related companies probably have a stronger interest than nonhealth
care companies in targeting physicians specifically with their
advertisements. 40 Indeed, an almost exclusive reliance on
pharmaceutical advertisements exists even with Diversions,
a magazine for physicians with articles about leisure activities and therefore a seemingly natural place for airlines,
hotels, and speedboat manufacturers to advertise. Journals
that have tried to interest nonhealth care companies in advertising have apparently found it difficult to do so. Moreover, health-related companies may especially perceive an
advantage in having their advertisements appear in leading
medical journals. Association with the journals may result
in some of the journals' prestige rubbing offon the companies. Given the benefits of advertising in medical journals,
health-related companies are probably willing to pay higher
rates than are other kinds ofcompanies for medical journal
advertising. If excluding health-related advertisements reduces the revenue