Argumentation (2008) 22:359–371 DOI 10.1007/s10503-008-9093-z
Strategic Maneuvering in Direct to Consumer Drug Advertising: A Study in Argumentation Theory and New Institutional Theory G. Thomas Goodnight
Published online: 15 April 2008 Springer Science+Business Media B.V. 2008
Abstract New Institutional Theory is used to explain the context for argumentation in modern practice. The illustration of Direct to Consumer Drug advertising is deployed to show how communicative argument between a doctor and patient is influenced by force exogenous to the practice of medicine. The essay shows how strategic maneuvering shifts the burden of proof within institutional relations. Keywords New Institutional Theory Legitimacy Practice DTC advertising Strategic maneuvering
1 Introduction In the latter half of the twentieth century, there are two paradigmatic moments within which argumentation as practical reasoning is imagined. In Perelman and Olbrechts-Tyteca’s (1969) vision, argumentation is embedded within a rhetorical model where a speaker addresses an audience with the idea of marshalling good reasons to influence opinion in a just way. In van Eemeren and Grootendorst’s (2004) pragma-dialectical understanding, interlocutors conduct conversation where ‘‘a procedure for resolving differences of opinion by testing standpoints’’ is enacted. In addition to the new rhetoric and pragma-dialectics, there are a host of theoretical and empirical schools of thought. However, in large part, argumentation has been dichotomized into rhetorical studies of influence or dialogical engagements of critical exchange. Recently, pragma-dialectics has been extended in two ways: first, ‘‘to give institutional considerations and requirements their due’’ by undertaking exploration of ‘‘the more or less conventionalized properties of argumentative discourse in a G. T. Goodnight (&) University of Southern California, Los Angeles, CA, USA e-mail:
[email protected]
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specific kind of institutionalized practice’’ such as the law (van Eemeren 2002, p. 9); second, to recognize that even within reasonable conversation ‘‘strategic maneuvering’’ is deployed. Thus, participants in an argument make an effort to prove and to question claims reasonably while seeking advantages in formulating the question and burden of proof. This paper studies strategic maneuvering in the context of institutions. Argument within and between advocates who take on an institutional role requires interlocutors to maintain the conventions of reasonability while struggling for influence. The essay will (1) provide a theoretical introduction to the limits and opportunities of argumentation grounded within the normative constraints of social institutions, (2) explain how institutional argumentation entwines provider and client in advocacy situations embedded in competing ‘‘institutional logics,’’ and (3) show how strategic maneuvering reshapes institutionally conventionalized presumptions and burdens of proof. The institution to be discussed is the medical field; and the maneuvering in question involves a debate between the United States pharmaceutical industry and consumer interest groups that contest the legitimacy of ‘‘direct to consumer drug advertising.’’ The end of the paper proposes a scholarly intervention into the controversy.
2 Social Institutions as Context for Argumentation ‘‘Social institutions are usually conceived of as the basic focuses of social organization, common to all societies and dealing with some of the basic universal problems of ordered social life.’’ (Samuel Eisenstadt observes 1968, p. 409) Institutions regulate behavior through providing norms that reward ‘‘acceptable’’ conduct, sanction the ‘‘inappropriate,’’ and order expectations of exchange. The family is the oldest institution for regulating procreative and biological behavior, with education and politics—extending notions of ‘‘reasonable’’ conduct grounded in norms of kinship-coming next. Modern institutions emerged with the creation of markets, the extension of professional training, the advance of technology to build and resource the metropolis, the coordination and growth of scientific research, and systems of information and communication exchange (Powell and DiMaggio 1991). While sociologists hold that human problems may be universal, they believe that that cooperative, human solutions vary endlessly, as well. In a modern world, cooperative exchange is identified at the micro level of human interaction, the meso level of firms or organizations, and the macro level of institutions (Haveman 2000, p. 478). Institutions are symbolic and material structures that offer codes of conduct, regulatory norms, standards of training and review for practices that cross individuals and organizations. Institutions develop over time. The shape and boundaries of institutions are influenced by the state and the market, but as each represents a field of practice no professional activity is reducible to either. Hence, institutions function as both (1) centers of authority where particular problems are identified and resolved according to state of the art standards and (2) contingent and fallible social constructions of a time and place that may err systematically, inviting
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change and improvement. Consequently, all institutional activities are potential centers for consensus and dissent. The study of institutions begins in the sociological inquiries of Max Weber, Emile Durkheim, and Thorstein Veblen. The overlay between social theory, institutions and argumentation is a project of substantial scope. Perhaps, the best place to begin is in the concepts of an interdisciplinary discussion among sociologists, economists, psychologists, and other researchers: New Institutional Theory. New Institutional Theory was developed as a counter to rationalist, positivists who in the 1950s held sway in economics by predicating all human decisions on maximizing utility calculations. Humans do not perfectly reason to self interest; rather, limits of knowledge, time and trust necessary involve all actors in fallible thinking within a domain of ‘‘bounded rationality’’ (Fligstein 1991). From a rationalist, utilitarian orientation, human activities were to be understood as the products of thinking machines who assess situations, calculate costs and benefits, and then form contracts that optimize self-interest. The strong form of economic theory held that market is the example par excellence; but in the end all reasoned human behavior is held to be reducible to pragmatic assessments of utility. New Institutional Theorists countered this premise with the counter-assumption that while humans did indeed calculate utility, this calculation was bounded by a preference for stable, predictable and ordered relationships that could provide an embedded context within which reasonable decisions could be reasoned through (Friedland and Alford 1991; Meyer and Rowan 1991). In this view, social actors can reach reasonable decisions and reach agreement because their training, identity, and allegiance within a field creates a partnership that transcends particular utility calculations and contractual arrangements. While it may be rational to maximize self-interest moment by moment, over time it is more trustworthy to engage with partners who subscribe to common standards of reasonable conduct. Thus, firms that conduct similar business, with similar resources, processes and knowledge needs imitate and come to resemble one another. Institutional logics are the rules that are consensually held by those who are members of a profession. Professionals learn behavior and speak a language that addresses peers and publics in powerful ways. Communicative argumentation—within institutional boundaries—is reducible neither to interactions which are regulated by conversational norms nor to the obligations of achieving effects on opinion through persuasive exchange. Rather, what counts as reasonable thinking and valid judgment is grounded in the logic of the institution. Simon (1986) calls this condition ‘bounded rationality’ where due to limits of time and information humans make judgments from a set of givens. The judgment that certain behavior is ‘rational’ or ‘reasonable’ can be reached only by viewing the behavior in the context of a set of premises or ‘givens.’ These givens include the situation in which the behavior takes place, the goals it is aimed at realizing, and the computational means available for determining how the goals can be attained. (p. 210) Thus, institutional logics are ‘‘both material and symbolic—they provide the formal and informal rules of action, interaction, and interpretation that guide and constrain decision makers in accomplishing the organization’s tasks and in
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obtaining social status, credits, penalties, and rewards in the process’’ (Thorton and Ocasio 1999, p. 804). The institutional logics of any given field are typically a mixed-bag of ‘‘givens.’’ As North (1991) observes, institutions ‘‘consist of both informal constraints (sanctions, taboos, customs, traditions, and codes of conduct), and formal rules (constitutions, laws, property rights)’’ that develop over time (p. 97). Actors within firms or organizations that subscribe to an institutional field, such as a group of clinicians who are part of the field of medicine, learn to follow valid procedures and what counts as valid evidence, inference and judgment within the institution. Institutional actors are trained in state of the art practices by reading cases, studying theory, mastering techniques, and observing the trial and errors, the performances, of fellows. According to Suddaby and Greenwood (2005) institutional ‘‘logics enable actors to make sense of their ambiguous world by prescribing and proscribing actions. Action re-enacts the institutional logic, making them durable’’ (p. 5). Thus, institutional logics provide the grounds to decide, justify, and offer persuasive reasons for decisions within a particular case and for adopting a general policy regarding practice. The regulatory power of an institutional logic is structured into the legitimacy of organizational practices. Schuman (1995) explains: Legitimacy leads to persistence because audiences are most likely to supply resources to organizations that appear desirable, proper, or appropriate (in reference to Parsons 1960). Indeed, to the extent that legitimacy reflects embeddedness in a system of institutionalized beliefs and action scripts… legitimate organizations become almost self-replicating, requiring little ongoing investment in collective mobilization. (p. 574) Thus, to argue as a doctor, educator, engineer, attorney, musician, penologist, or accountant is to subscribe to a logic embedded in state of the art standards that have evolved over time. Institutional norms shape relationships among symbolic terms, reasoning structures, and the material steps of coming to an agreement among practitioners and between practitioners and clients. Institutional logics are historical and evolve over time. As a body, institutionally bounded practices of communicative reasoning are not coherent entities with a set of deductively ordered, self-evident rules. As environments are altered, institutions adapt practices to accommodate (1) advances in technologies, (2) changes in social needs, (3) the availability of talent, (4) the rise of competing institutions, or (5) political intervention by the state. Institutional change may lag behind alterations in opportunities or constraints. Not all progress is forward looking. The history of an institution may offer resources for recovery and replacement of current norms with older goals that went out of fashion. At a macro level, institutions sometimes offer support to each other in common cause. Sometimes advocates compete to increase or decrease the power of institutions and redefine purpose by advocating for new duties or the recovery of older purposes. Thus, institutional logics change over time, rise and fall for purposes of internal validity and external pressure, and render state of the art practice sometimes unstable.
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The penology field, for instance, is well-known to be constructed of at least four institutional logics that have evolved over time: punishment for evil where crime is regarded as a sin; retribution where compensation is owed for an injury done to a victim; rehabilitation where the incarcerated are trained with the utilitarian goal of making useful citizens; and deterrence that raises the probability of capture and punishment. Penology draws its logics from larger societal categories of moral, ethical, pragmatic, and economic discursive logics—but in ways peculiar to its own historically evolving material conditions and politics of mission. Rehabilitation was popular as guiding institution logic in the 1960s with its hopes for social reform; as crime increased, older views of incarceration came to dominate. Latent conflicts within institutional logics need not lead to controversy and change, however. The functions of an institution may at times be fortified by overlapping and reinforcing justifications of action drawn from distinct logics governing the dispatch of particular cases (Both retribution and incarceration get felons off the street, for instance, even if for different reasons.). However, when goals are brought into conflict, controversy gives rise to a legitimation struggle. Within the institution or the public at large, advocates champion alternative practices. The state may intervene to regulate practice (Retribution is sometimes at odds with rehabilitation, and so the state builds more prisons and ends job-training programs). Sociologists admit: ‘‘We know little, however, about the means by which shifts in logics occur. More specifically, we lack accounts of the process by which the cultural assumptions that define institutional logics are contested and changed’’ (Suddaby and Greenwood 2005, p. 2). It can be concluded, however, that: ‘‘The major institutions of society—the market, the state, the corporation, the professions, religion, and the family—provide a distinct set of often contradictory logics and form the bases of political conflicts’’ (Thornton and Ocasio 1999, p. 805). In cases of conflict, institutional advocates draw upon higher order principles of argument to criticize the norms of reasoning in organizations. As a result, an argumentation paradigm needs to be developed to understand how the ‘givens’ of the everyday world of modern communication generate enlightened thinking and grounded practice on the one hand and political controversy struggles for legitimation on the other. Such inquiry begins with examining how discussants are situated typically within a context of institutional advocacy.
3 The Practices of Modern Advocacy In modern institutional settings, conversational argument is couched paradigmatically in advocacy exchange between a provider and client. These cooperative arguments constitute the routine and diverse interactions of doing business within modern institutions around the globe. We engage in cooperative reasoning with doctors, lawyers, accountants—all representatives of institutions—who hear our complaint, question the case, give advice, and execute interventions to bring about state of the art solutions or mitigations of problems. Reciprocally, we engage in our own professional roles to give advice, and intervene in the world on behalf of our own clients. Modern arguers communicate as teacher and student, doctor and
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patient, lawyer and client, architect and builder, tax-expert and payer, therapist and counseled, librarian and patron, mechanic and car owner. The requests, advice, discussions, and outcomes are as varied as the versions of modern institutions around the globe permit; however, the reasoning engaged has highly contextualized and relatively stable positions for presumption and burden of proof. Any specialist is trained to think within the models of discovery that translate a client’s description of problems into a problem-solution format. The specialist is part of a practice with field-grounded knowledge certified by studies that specify causes and weight alternatives in line with state of the art practice particular to a profession. The specialist translates the everyday-language of the client into a more precise, ordered, testable language of the institution; the specialist has access to technologies of proof that are assembled to probe the case, gather further evidence, and situate a choice. Even should a client acquire rudimentary competence of the field, the provider is licensed and embedded in a network where she is authorized to make restricted resources available—if convinced that access is warranted in the specific case. Further, the specialist has schedule time available, a network of contacts, and (most crucially) a detached interest that renders her duty-bound to advise and judge with a comparatively dispassionate and objective stance. The enthusiasms that drive the expert’s argument, properly constructed, are those found in the satisfactions associated with proper dispatch of a case in question. The client is in the obverse situation. Typically, the power to pose critical questions in technical terms is not a natural strength. The client may have observed a set of disturbances in his everyday world, but he may not know whether the differences in routines are passing or severe; or whether, if severe, remediable or irreparable. The client may have access to informal advice through anecdotes from friends, family, the press, or mass-advertising; but, these stories typically follow the agendas of the tellers, not the logic of the issue, and remain, in any case, not authoritative. Typically, the technologies of a special field and the risks associated with intervention—even if known in terms of general effects—are not within the scope of experience of the individual; nor, can expert solutions be accessed by a client’s own judgment alone, particularly when state authorities regulate personal decisions, and the costs associated are pooled by insurance protocols or state access procedures. The language within which elements of a condition or change in condition is articulated are general terms, pointing toward symptoms, things of notice; perhaps an intuitive judgment of the situation informed by social knowledge can be rendered by a client, but it is up to the expert to break down special intuitions and general social knowledge into field of related specific elements. Most importantly, the client cannot come to the discussion with the same self-detached pose as the provider; the client is engaged, in need, and is expending resources to address what for him is a compelling situation. Of course, the provider utilizes resources in the exchange too, her time and energy, in the hope of gaining benefit of more resources—either personal in terms of reward for an intervention or professional in terms of standing, reputation, or competent practice. Participants in arguments bare different risks. Errors affect interlocutors differently. For instance, while the provider may lose reputation; the client loses out in a successful or efficient resolution of the problem.
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In all client–provider conversations, reasons are exchanged. Given the asymmetries of power, sophistication, knowledge, and risk, however, it cannot be assumed that the ability to pose objections is equal to the task of testing a decision to a satisfactory conclusion. Put differently, the threshold for critical testing may be lower for the provider who has seen situations like this before; it may be higher for the client whose resources are limited and risks high, but who does not have the time, knowledge, or standing to put expert advice to the test. Moreover, objections may be translated as expressions of reluctance to responsible, rational decision making—which may remove the decision-making power of the objector. In some cases, the state intervenes for a client who is incapacitated, a spouse for a spouse, a parent for a child in dire cases of emergency. If social theory is correct, asymmetries of power are breeding grounds for abuse (Habermas 1983). The provider exploits the patient by appearing to make decisions on grounds apt to the case, while keeping in the background constraints that render the judgment based on reasons other than those which are directly provided to the dependent interlocutor. Crassly put, a procedure is recommended, not because it is necessary, effective or needed, but because the provider finds it convenient, easy, and profitable—and she judges that the client does not have the resources to question the decision. Even if not motivated by an opportunity to benefit from making a false claim, a provider may yield to insufficient deliberation of routine arguments due to the costs of time and resources in gathering further information. A single course of action is offered to the client without presentation of alternatives. Convenience may trump argument when a provider judges that the client is not sophisticated enough to imagine, research, and request discussion. Even if a provider is not exploitative and willing to do more testing and assessment of alternatives with the client, organizationally structured constraints may provide insufficient discussion time by demanding routines that do not calibrate the serious, complicated, and difficult nature of conversationally reasoned choice with the time available for discussion. Institutions offset asymmetries of power in order to assure a stable, trusting client base across organizations. Institutions transcend particular individuals or firms by providing a space where the practices of an industry can be studied, reviewed, and publicized. A professional code of practice, for instance, establishes a burden of proof in reaching an informed judgment. Additionally, the state may also regulate decisions by intervening to set standards, punish exploitation, and create legal partnerships by authorizing and licensing serious practice. Conversely, an institutional code may reinforce the power of the provider; and, a state may intervene to enhance the interests of an industry. Individuals may withdraw support from institutions; public polls may reflect skepticism or a decline in confidence in practice, thereby provoking a legitimation crisis and renewed efforts to establish trust. Controversies—engulfing institutions such as education, the law, the press, or religion—invite students of argument to investigate how burdens of proof are set, how old burdens are being redrawn and new ones added, and how burdens are justified by reference to favored institutional logics. What strategic resources are available to providers and clients who are working to reach a common judgment on
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a proposition of practice? Do proposed changes in access to information or other resources help or hinder a reasonable outcome? I now turn to the issue of direct to consumer drug advertising to explore these questions.
4 Strategic Maneuvering and Institutional Controversy A shift to institutional contexts for argumentation enables us to examine critically key controversies where institutional logics are brought into competition. Controversy results when the legitimate and settled relationships among providers and clients become the subject of public debate. The case in question concerns direct to consumer (DTC) pharmaceutical advertising. In the United States, the relationship between a doctor and a patient is private, exclusive, and may be taken as a paradigm of high modern practice. The institution of medicine standardizes procedure and practice by training and certification, provides access to restricted and potentially dangerous materials for patients through licensing doctors and other providers, and establishes relationship to access through prioritization of cases. Medical treatment depends upon a complicated combination of market forces, insurance pools, and government regulations. Indeed, the old fashioned ideal of the neighborly family doctor has been replaced by the advance of medicine, specialization, and technologies. Across urban areas, one’s own doctor acts as a docent or guide into the complicated networks of testing, treatments and specialization that render efficient and reliable medical care. The trust of a patient in a doctor is the contact point where the institution meets its public—even in spite of the complicating concerns of insurance payments and government regulation of access. Within institutional boundaries, a doctor-patient exchange is private, nonjudgmental, and constructive—or at least bounded by the constraint of doing no harm. Normatively, a patient engages in exposition, the doctor questions and translates the discussion into field-grounded terms; the doctor recasts reasons into terms available to patient understanding and choice; discussion ensues and cooperative choices to act or defer, to proscribe treatment or withhold options are enacted. There are two additional connections that bear on the exchange: the doctor’s connection to her institution provides knowledge, review, standards, and information that constitute state-of-the-art practice. A patient’s access to family, friends, and publications augments his ability to ask questions, pose alternatives, and question justifications. From a social standpoint, the basic pattern of conversational exchange is only apparently a form of dialogue because the overall field of exchange shapes the information and expectations constituting any particular exchange between a client and a provider. One factor that is changing the context of doctor-patient interaction substantially in the United States is pharmaceutical advertising. Pharmaceutical companies have long advertised their products. Research is expensive. The power of drugs progress to effect new cures or mitigate chronic problems is progressive. While the ‘‘snakeoil salesman’’ preyed upon human vulnerabilities and hopes, the federal Food and Drug Administration has regulated the ballyhoo for new miracle cures. For most of the twentieth century, drug company representatives could only hawk their product
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to doctors. Only these experts were judged to hold the technical capability to evaluate the product and to make informed judgments of what could be medicines prescribed in a patient’s interest. ‘‘In 1985, the FDA lifted its moratorium but emphasized that DTC advertisements must meet the same standards as those aimed at professionals’’ (Calfee 2002, p. 174). Advertising could not meet this standard. So, drug advertising was limited to pushing a company’s overall reputation and reminding publics that help was available generally for given maladies. In 1997, the FDA took off this restriction. While ads must report in a fair and balanced way about the risks and benefits of a product, the industry was told that it could ‘‘communicate all information relevant to the product’s indication (including limitations to use) in consumer-friendly language’’ (p. 174). Shortly after this ruling, advertising exploded from $340 million in 1995 to $2.7 billion in 2001. Publication in newspapers, journals, magazines, television and the Internet has been continuing upward ever since. The American consumer is showered with drug advertisements promising all kinds of relief, augmentation and other pleasantries. Most advertisements are directed at symptom relief such as alleviating problems associated with allergies, menopause, hair loss, Alzheimer’s-related memory loss, erectile dysfunction, and wrinkles. The second largest category is associated with medications used to treat diseases such as diabetes, depression, and hypertension. Finally, preventative drug advertisements appeared for problems such as osteoporosis, smoking, breast cancer or hypercholesterolemia. A study published in The Lancet by Woloshin et al. (2001) found that 87% of advertisements ‘‘described the benefit of a medication in vague, qualitative terms. For example, ‘Help your child out of the jungle of allergies,’ ‘Naturally, the response has been positive,’ and ‘If your diabetes is uncontrolled...Glucophage can help’’’ (p. 1144). Additionally, the researchers observed personal testimonials and band wagon techniques associating drug popularity with medical desirability. There are differences between drug advertising and selling hot dogs, however. With all the positive news, the FDA requirement is honored, and each ad must warn consumers of side-effects. Typically, the advertisement creates a bi-furcated rationale. Benefits are shown through telling a story, where images are shown of suffers. Typically, the victim’s face transforms, from dark to bright, through the act of taking a pill. In video advertisement, music accompanies the transition as well. Simultaneously with these emotional arguments, however, is a second part of the argument. On video, a discursive, abstract reading of side-effects is rushed through in hushed breath subtext. In magazine ads, warnings are put at the bottom of the page in a box to warn of problems associated with the drug. It appears that the structure of drug advertisements leave potential consumers with incomplete information and incoherent justifications. The general effects of the advertisements have been studied. The results are mixed (Harker and Harker 2007). According to the FDA, ‘‘72% of physicians agreed that DTC advertising increases awareness of possible treatments, and 44% believed that it facilitates earlier awareness of health conditions’’ (Aikin et al. 2004, p. 8). On the negative side, nearly half the doctors reported ‘‘pressure to prescribe’’ and both patients and doctors find that advertisements ‘‘overstate drug efficacy and
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do not present a fair balance of benefit and risk information’’ (pp. 8–9). For good or ill, the arguments made by drug advertisements have come to play a role in the dialogues between doctors and patients. In sum, physicians are divided as to the effects of advertising: ‘‘40% of physicians believe that it has had a positive effect on their patients and practice, 30% say it has had a negative effect, and 30% see no effect at all’’ (Berndt 2005, p. 325). When there is a substantial impact on institutional practice and disagreement whether changes in policy regulating communication bode well or ill, the result is a legitimation controversy: what is right to do? Those that defend drug advertising follow the institutional logic of health campaigns. Drug advertising follows a traditional logic of medical practice, the dissemination of information for improving public health. Thus, consumers who are happy with the advertisements emphasize how the messages stimulate seeking new information and empower discussions with doctors (Williams and Hensel 1995; Perri and Dickson 1987). Particularly, for DTC drug advertising champions, advertisements provide information about disease and drugs, symptoms and cures. They give the patient new resources to create a standpoint, make claims, and challenge a doctor to either act or explain alternatives. From the strategic maneuvering perspective, advertising augments the power of the patient at the expense of the doctor to the extent information enables him or her to strengthen ‘‘their position as much as possible in all stages of the resolution process’’ (van Eemeren and Houtlosser 2002, p. 21). Drug advertising shifts the burden of proof and the burden of rebuttal among partners. The patient may become convinced that he has a disease and that he has found alleviation through following the instructions of the advertisement; the doctor is put in a position whether either she can agree or prove that either the disease is imagined or the cure is inappropriate. Those championing drug advertising claim that ‘‘information’’ puts more decision-making power in the hands of the patient. Wyke (2004) notes, however, that whatever power advertisements have given to consumer it has been even better for promotion. ‘‘From the pharmaceutical industry’s perspective, DTCA has been a superbly successful tool for boosting sales’’ (p. 310). The complaints against advertising are many. The Women and Health Protection group of Canada ‘‘insist that pharma advertising...focuses on promoting new, rather than the best, medicines’’ (Wyke 2004, p. 311). New medicines have an unproven track with large populations. The Center for Medical Consumers (2007) reports: Ads are designed to sell a product, not to provide balanced information. That’s why you see so many ads devoted to new, i.e., expensive, ‘‘me-too’’ drugs (think: Celebrex and Vioxx, Prilosec and Nexium, Lipitor and Zocor). That’s why you see little in the way of education— just a few promising words in the headlines like power and strength. (Para. 5) Further, advertising emphasizes purchasing a drug for relief rather than inviting cost-free habits of prevention. The result is that consumers march into a doctor’s office, armed with inaccurate information, to ask for a product; if turned down, there is evidence that some may doctor-shop until they find a physician who will prescribe
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(Cohen 1990). It seems that motivation rather than information characterizes most advertising. As Villanueva and Librero (2003) explain of medical journals when contrasting slogans in the advertising to the effects stipulated in their clinical trials, ‘‘the promotional statement was not supported by the reference, most frequently because the slogan recommended the drug in a patient group other than that assessed in the study’’ (p. 27). Imagine the departure in publicity directed to the mass audience. Given the complex context of human understanding and risk taking, the institutional logic of medicine—do no harm—appears at odds with the mass of advertising prompts that are motivating consumers. Patient advocates thus call for restoring regulation.
5 Critical Intervention and Institutional Controversy Institutions are sites where norms of reasoning and practice are developed. Institutions order expectations, regulate exchange, and retard free experimentation. Institutions can be changed, however, for good or ill. The United States and New Zealand are the only developed nations that permit DTC advertising of prescription drugs (Mintzes et al. 2002, p. 278). ‘‘Canada and the European Union (EU) nations have continually debated whether to follow the United States’ example’’ (Calfee 2002, p. 176). Debate on the issue may be mute in the case of Canada since many of the advertisements cross borders; and as the Internet becomes a circulation network for advertising, drug advertising may reach a global market, even without specific national or regional approvals. Before Europe goes to DTC drug advertising or rejects it, the subject should be given careful assessment. The United States authorized DTC without undertaking research into whether such advertising would have a positive or negative impact and set standards for advertisements without pretesting the effects of each add on doctor-patient relationships (Roth 1996, p. 63). Imagine a set of studies that would assess the quality of a potential drug advertising campaign by its effects on strategic maneuvering and the burden of proof in a doctor–patient exchange. Recall, that in deciding to advertise a drug, there are competing institutional logics. The public health presumption rests always in favor of dissemination because information is seen to further patient competence and choice. The health care presumption rests with the injunction of the institution for its practitioners to ‘‘do no harm.’’ This puts presumption against advertising because ads target inexpert audiences. Thus, analysis of this institutional controversy leads to the key question: How can the benefits of dissemination and the safety of competent, dispassionate advice be reconciled? In proposing a solution, let us borrow from a recently developed institutional logic: environmental safety. In the United States, a chemical is released into the environment if there are no proven harms. In Europe, environmentalism follows the precautionary principle. The proponent must prove that there is no harm to the proposed chemical (Harremoes et al. 2002). Note this shifts the burden of proof to industry that will reap the profit from its new products. Similarly, for the drug industry, the benefits of information dissemination may be achieved for pharmaceutical industries in Europe if advertising is legalized. However, to avoid the
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problems experienced in the United States, the burden of proof needs to be situated carefully. Advertisers should follow the precautionary principle. Before a drug can be advertised, proponents must do studies that demonstrate that in a proposed commercial sales campaign (1) a reasonable case has been made, (2) that the balance of risks and benefits can be understood by the public, (3) that discussions between doctor and patient in the area of medical practice would be helped, rather than adversely effected, by the proposed texts and video products. Letting the drug industry police its own advertising should not be expected to be effective, of course. Rather, scholars need to be consulted and evolve reasonable standards for what constitutes sound institutional principles for the profession of health care in dissemination of information as it adapts to revolutions in medical practice through connecting information about new products to its populations of clients. The study of argument practice involves context that are internal to institutions. In the case analyzed, the relation between a doctor and patient involves ritual patterns of trust, obligation, information exchange and choice involving serious matters of illness and well-being, life and death. However important institutionally grounded interaction may be, relationships may be changed by exogenous factors such as publicity. Since organizations follow a variety of institutional logics, changes outside the institution can stress the patterns of everyday reason that constitute legitimate practice. This paper has engaged the study of drug advertising to illustrate this point. In the study of strategic maneuvering, the critic of argument may become an advocate to reset the balance to a more reasonable course. Thus, argumentation theory describes, engages, and strives to reshape the grounds of practice.
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