70

Eubios Journal of Asian and International Bioethics 27 (May 2017)

Attitudes of Future Doctors of
Bangladesh to Pharmaceutical
Incentives and Medical Ethics- Tonmoy Biswas, MBBS, MBGPH
Physician, Faridpur Medical College Hospital,
Bangladesh
Email: dr.tsb@yahoo.com-Darryl Macer, PhD, HonD
Director, Eubios Ethics Institute, Japan
Email: Darryl@eubios.info

Abstract
Introduction: Pharmaceutical companies offer
various gifts to physicians to encourage them toprescribe their products. This collaboration has
some negative and positive aspects. Different
countries have established guidelines to limit thecollaboration and reform such relationships. This
study aims to determine the attitude of Bangladeshi
medical students towards pharmaceutical gifts,
physician-pharmacist collaboration, and associatedfactors.
Methods:
An
onlinecross-sectionalandcorrelational study was conducted through email
and Google-Forms among Bangladeshi medical
students. A total of 435 students from different
medical colleges completed the questionnaires in
May and June, 2016.
Results: Monthly parental income was moderate
among the majority of medical students. Less than
16% had a physician or pharmacist parent. Most of
the students (89%) were taught about medical
ethics, but 73% were not taught about the ethics ofphysician-pharmacist collaboration. About 85% did
not have any experience of interaction withmarketing representatives. Drug samples and pennotepads
were
the
most
appreciatedpharmaceutical gifts. Jewelry and gifts costing morethan 100 thousand (Bangladeshi Taka) were said tobe the least appreciated pharmaceutical gifts.
Attitudes
towards
drug
companies
andrepresentatives were assessed by fifteenstatements. Medical students had a variety of
attitudes regarding its
ethical justification.
Attitudes were correlated with gender, parental
income, physician parents, academic years, andhaving been taught about pharmaceuticalcollaboration with physicians.
Conclusion and Recommendations: medical
students should elaborate on ethical reasoning
before accepting pharmaceutical gifts. Medicalcolleges and curriculums should teach them about
the interaction. A national guideline may be needed.

1. Introduction

1.1. Background
It is common practice that pharmaceuticalcompanies offer various gifts and incentives tophysicians to encourage them to prescribe theirdrugs. What are the advantages and risks of thiscollaboration? Are the doctors really influenced?
Does this influence affect prescribing proper drugs
for patients? Can this interaction lead to a biased
decision for therapy? Are these interactions ethicaland lawful? Is receiving incentives ethicallyjustified? When does it fall into the criteria of bribeor kickback? What are the doctors’ views regarding
this issue? Are they aware of the guidelines about
this concern? All these questions are knocking themind of scholars for many years. But the answers
change from time to time, person to person and,place to place as discussed in Biswas and Macer(2017).
There is a complex relation between physicians
and pharmaceutical companies. Pharmaceuticalcompanies offer various gifts, incentives, sponsor
CME (Continuing medical education), and provide
notepads, pens, and samples in many countries
worldwide. The approach somehow can influence
the decision of physicians in the treatment ofpatients which is based on trust driven byphysicians’ autonomy. Many countries like theUnited Sates have restrictions by law uponphysician-pharmaceutical interactions (Cicero etal., 2011, Conn and Vernaglia, 2011). American
Medical Associations’ (AMA) “Ethical Guidelines for
Gifts to Physicians from Industry” in 1998 is an
example of recommendations that is set to maintainthe interaction within ethical limits (Chimonas andRothman, 2005). However, the dilemma in thisfield has remained unsolved (Quan, 2007). The
guidelines are updated year by year to pace withchanging interaction-policies (Austad et al., 2013b).
Canada also set up an ethical guideline in 1991 todeal with this complex phenomenon and topreserve the morality of physicians (Woollard,1991). Japan, Korea, France, and Denmark also haveaddressed this issue with great concern (Rodwin,
2011; Harris, 2009; Kwon, 2003). Some foreign
researchers showed that physicians might have agreat role in drug industries directly (being apharmaceutical physician) and indirectly (Lopes etal., 1993; Hayward, 2011). Physician-pharmacist
collaboration is not an unethical matter always.
There are many positive outcomes if the incentives
are within ethical limits and prescriptions are notbiased. A Canadian study found that physicians andpharmacists both agreed in principle over thecollaboration, but differed in the areas ofcollaboration (Kelly et al., 2013).
Medical students are future doctors. A Saudi
study researched the attitudes of medical students

Eubios Journal of Asian and International Bioethics 27 (May 2017)
towards the incentives from drug companies andfound interesting results (Zaki, 2014). If theattitudes of medical students can be evaluated, we
can determine their level of ethical perception andinvestigate how these issues are being taught tothem. There was no previous study in Bangladesh
in this matter. Therefore, this study aims to answer
these questions from a Bangladeshi standpoint.
What do medical students think about the gifts andincentives? What are their views about theinteraction? Are there any demographic orcorrelated factors that influence the attitudes?
1.2. Rationale
Pharmaceutical representatives offer incentives
to physicians. These kinds of interactions may lead
physicians to irrational prescribing, selection biasof drugs, kickback issues, and other ethicaldilemmas. There is a greater chance that thedoctors may prescribe the drugs of that company
from where they have received some gifts, even if
the drugs are costly and less effective. Thus,
medicinal prices may increase and concerns overthe ethical call for beneficence to patients is mademore difficult. However, positively, representatives
help physicians to learn about new products andprovide needed financial assistance..
1.3. Objective
The general objective was to explore theattitude of future doctors regarding incentives
offered by pharmaceutical companies. Specificobjectives were:− To determine the demographic data, exposure,and experience about pharmaceuticals.
− To determine the attitude of medical students
towards pharmaceutical gifts and incentives.
− To evaluate the attitudes of medical students
towards drug companies and representatives.
− To find out the correlated and associated factorsof attitude by statistical analysis.
− To compare the results with other countries in
the literature.
1.4. Physician-Pharmaceutical Interactions
Physician and pharmaceutical interactions
influence physicians’ behavior and prescribing
patterns (Rubin, 1994). Drug representatives offer
gifts, drug details, and samples to physicians(Cicero et al., 2011; Jain, 2010). Especially financial
assistance and kickbacks raise ethical dilemmas(Rodwin, 2011; Quan, 2007). Some educational
programs, continuing medical education (CME),
and academic events are sponsored by drug
companies in medical schools (Johnson, 2001). In
developed countries, physicians often participate inclinical trials and lectures are facilitated bypharmaceutical companies (Ashar et al., 2004).

71

Meetings between different health professionals
take place there (Huang et al., 2005). Theinteraction is sometimes ethically acceptable andsometimes not (Quan, 2007). Many countries havelaws, legislations, and ethical guidelines regarding
this issue (Gorlach and Pham-Kanter, 2013; Connand Vernaglia, 2011; Harris, 2009). the UnitedStates and Korea have done pharmaceutical reform(Tobbell, 2008; Kwon, 2003). The attitude of
medical students and physicians to the interaction
is different country by country (Kelly et al., 2013;
Austad et al., 2013a). Public perception of thisinteraction varies and is not always positive(Arkinson et al., 2010).

2. Development and implementation of
the Survey
2.1. Ethical Implications
A questionnaire was developed and after pilot
testing it was used. This research was approved by
the American University of Sovereign Nations(AUSN) IRB. The survey was anonymous andconfidential, and gave enough autonomy to theparticipants.
2.2. Independent Demographic Variables
This is a cross-sectional and observational study.
Items include: Gender, current year of study, type of
medical college, parental income, doctor parents,
pharmacist
parents,
known
medicalrepresentatives, being taught about physicianpharmacist
collaboration,interaction
withpharmaceutical companies.
2.3. Dependent Variables
There are many types of gifts, including: Meals,
dry food and snacks, drug samples, pens andnotepads, textbooks, stethoscopes, penlight andmedical equipment, stationary, clothes, gifts(<10,000 BDT), gifts (10,000 to 50,000 BDT), gifts(50,001 to 1,00,000 BDT), gifts (>1,00,000 BDT),
hospital trips, personal or family trips, conference
registration fees, travel fees to any conference,cosmetics, jewelry, computer, and its accessories,
home electronics, home cooking accessories,
unique gadgets, home equipment, game equipment,
festival related gifts, and heard of any other.
2.4. Attitudes towards Pharmaceutical Companies
This was assessed by fifteen statements (A to O):A)theinformation
providedby
drug
representatives about their products can betrusted. B) The information from drug
representatives is important for the physicians. C)
It is ok for the physicians to accept gifts from drug
companies because the drug companies haveminimal influence on them. D) Most seminars

72

Eubios Journal of Asian and International Bioethics 27 (May 2017)

sponsored by drug companies are helpful andeducational. E) Drug representatives are a usefulway to learn about new drugs. F) Drug company
sponsored seminars are often biased in favor of
their products. G) Gifts from drug companies todoctors lead to increased prices of medicines. H)
Receiving gifts or incentives from pharmaceuticalrepresentatives increases the chance that I will
eventually
recommend/prescribethedrugcompany’s products. I) Drug companies act
unethically in promoting and advertising theirproducts. J) Students should not have any
interaction with drug companies in medical school.
K) Pharmacists should be accountable to thepatients for the drug they provide. L) If a drug
company agreed to pay for the printing costs of all
my class notes in the undergraduate medical
school, I would not mind the logo of that company
appearing in the bottom corner of the first slide ofclass lectures. M) It is acceptable for drug
companies to sponsor events/educational seminars
during medical school. N) Five drugs from fivedifferent companies are identical in terms of price,and therapeutic efficacy. I would preferentiallyprescribe a drug from one of the companies thatprovided me with gifts or incentives. O) There is aneed for guidance regarding the relationshipbetween the pharmaceuticals and the physicians in
the undergraduate medical curriculum.
Two scenario questions were also included.
Attitude towards gifts and incentives were assessedby three levels scale and attitudes towards
pharmaceutical companies were assessed by a fivelevel Likert scale. These variables have been
identified from previous studies by extensive
literature review and an online focus group
discussion. The distribution of the variables isclarified in the questionnaire (Attached inAppendices)
2.5. Study Population and SamplingThis study involved third, fourth, and fifth-year
medical students (as they have exposure in clinicalwards and hospitals) of different medical collegesin Bangladesh. Simple random sampling was done
among the medical students who were invited toparticipate in the study. Those who gave informed
consent were included. Incomplete questionnaires
were excluded. According to sampling statistics, aminimum sample size estimation is 384.16 ≈ 384(n= Z^2 pq/d^2, Z= 1.96, p = 0.5, q= 1-p= 0.5, d=
10% of p= 0.05, in 95% confidence interval). Total
sample size was targeted to be more than 400. At
last 435 clean responses were gathered from thesurvey.
2.6. Validity of Google Questionnaire and Focus
Group Discussion

The Google Questionnaire was created byconsidering the questions used in manyquestionnaires and results of previous studies(Siddiqui et al., 2014) (Sergeant et al., 1996;
McCormick et al., 2001; Gibbons et al., 1998; Yeh etal., 2014). The questionnaire was reviewed byestablished validation criteria and measurement
scales (Van Winkle et al., 2011). Some previous
studies used Google questionnaires on the same
topic had been validated and indexed in PubMed(Zaki, 2014). A Focus Group Discussion (FGD) was
carried out in the social media where a question
was asked to the members of a medical group, both
physicians and students. To include gift-types asmuch as possible, everyone was asked to share
their experience about gifts and incentives from thepharmaceuticals. About two hundred medical
students and physicians answered in the discussion
forum and twenty six types of gifts were finallyadded in the questionnaire for the Likert scale ofappropriateness.
2.7. Procedures and Methods of Data Collection
Respondents were contacted through social
media or personal contacts. The study had taken
double informed consent from the participants. At
first, verbal informed consent was taken before
sending the online link to the consent form. In thelink there was a detailed consent form (available
upon request). The survey needed only 10 to 15
minutes. Once the questionnaire was filled,
respondents were asked to submit. Data obtained
from this survey were totally anonymous. No name
was taken in the questionnaire. After submission,
the responses were unlinked from the respondents
and could never be identified. As this was an online
survey, retrieved responses were archived
automatically in a Google spreadsheet and thenfurther downloaded and saved as Microsoft Excel
file.
2.8. Data Analysis
From Excel, data were converted into SPSS
software for analysis. After interpretation, thepotential correlations among different variables
were analyzed using SPSS software version 21.0.
Pearson Chi-square test was used to find significant
correlations. Two-sided P value less than 0.05 wasconsidered significant in 95% confidence interval.
Statistical Significance is indicated by S=
Significant; NS= Non-Significant. Cross tabulation
was done keeping independent variables in a row(considering 100% in a row) and dependent
variables in a column. Bivariate analysis was doneto assess the relation of attitude with any othervariables.

Eubios Journal of Asian and International Bioethics 27 (May 2017)
3. Results

3.1. Demographics and Experience
There were more female respondents (53%)
than male. Most of the students (59%) werestudying in the fifth year (final year) of MBBS, with
23% in the fourth year and 18% in the third year.
Among the respondents, 45% were from Private
or non-government institutions or medical colleges,
and the rest of them (55%) were from Public orgovernment institutions. Most of the students had
parental income between 20,000 BDT to 50,000
BDT ((80 Bangladeshi Taka = 1 USD).
Only 12% of the respondents had physician
parents and the rest (88%) of them did not haveany parent working as a physician. Similarly, mostof the respondents (96%) did not have any
pharmacist parent while only 4% of them had. 67%of the respondents did not know any medical
representative of any company. But 33% of themknew at least one pharmaceutical representative.
Most of the respondents (89%) claimed thatthey were taught about medical ethics in their
medical college. But most of the students (73%)
said that they were not taught about guidelines ofphysician-pharmacist interaction or collaboration.
While asking ‘where and when were they taught
about physician-pharmacist interaction’, 67
respondents gave specific answers.
Most of the respondents (85%) said that they
did not have any experience of interaction with apharmaceutical company. 57 respondents detailed
about the place and time of the interaction.
3.2. Attitudes towards Gifts and Incentives
The most positively valued gift was drug
samples, where 89% of the respondents agreed(Figure 1). The least valued (only 13%) was Gifts
costing 50 thousand to 100 thousand BDT (80Bangladeshi Taka = 1 USD), because it was notconsideredappropriate.
Specifically”inappropriateness” was perceived most for gifts
costing more than 100 thousand BDT where 75% of
the respondents said so. Only 4% respondents
thought of a pen and notepad as inappropriate gifts.
Attitudes and opinion about different gifts andincentives offered by pharmaceuticals aredescribed in Figure 1 and 2
Respondents were asked whether they heard of
any more types of gifts and incentives or not. A few
respondents reported hearing of Car, Television,
Automobiles, Mobile, Commissions, Flats orApartment, and other Vehicles as gifts bypharmaceutical companies.
3.3. Attitudes towards Drug Company andrepresentatives

73

Attitudes towards drug companies andrepresentatives were determined by 15 statements
and levels of agreement are presented in Table 1.

Opinion on appropriateness of
Gifts-Incentives- Set A
14.5
10.8

Gifts_more than 100K
BDT
Gifts_50K to100K BDT

12.9
17.7

Gifts_10K to 50K BDT

19.1
19.3

69.4

61.6
34.7
18.6
46.7
18.9
20.5
60.7
52.2
23.2
24.6

Gifts_<10K BDT
Clothes
Stationery
MedicalEquipment

15.2
7.1

Stethoscpoe

15.6
10.8

Text Book

14.7
8.3

Pen_Notepad

10.8
3.7

Drug Samples

6.9
4.1

Dry Food_Snacks
Meals
0

Appropriate

74.7

20

Neutral

77.7

73.6
77
85.5
89

46.7
26.7
26.7
38.6
29
32.4
40

60

80

100

Inappropriate

Figure 1: Opinions on Appropriateness ofDifferent Gifts and Incentives (set-A)
Horizontal axis presents percentages of respondents
opinion on gifts and incentives. Abbreviation: K=thousand, BDT= Bangladeshi Taka (80 Bangladeshi
Taka = 1 USD).

4. Two More Attitude Questions andSelf-judged Biasness

A scenario was given to assess the attitude of
future doctors. The scenario was the following: A
drug company wants to increase its visibility to the
medical profession and has recently approached the
medical school. They would like to provide a one-day
seminar regarding their product at the end of thesecond year. In return, they are willing to pay for afraction of the second year tuition for each student
who attends their seminar. As a medical student
faced with increasing tuition costs, I think that it
would be fair if the pharmaceutical company pays
this percentage of my second-year medical school
tuition.

Table 1: Attitudes towards Drug Companies and Representatives (%)
Statements:
Strongly Disagree
disagreeA. The information provided by drug representatives
11.0
28.7
about their products can be trusted
B. The information from drug representatives is
8.5
10.8
important for the physicians
C. It is ok for physicians to accept gifts from drug
21.6
32.2
companies because drug companies have minimal
influence on themD. Most seminars sponsored by drug companies are
6.9
6.0
helpful and educational
E. Drug representatives are a useful way to learn about
8.7
20.7
new drugs
F. Drug company sponsored seminars are often biased
7.9
6.0
in favor of their products
G. Gifts from drug companies to doctors lead to
10.6
18.6
increased prices of medicines
H. Receiving gifts or incentives from pharmaceutical
12.2
22.8
representatives increase the chance that I will
eventually recommend/prescribe the drug
company’s products
I. Drug companies act unethically in promoting and
7.6
12.0
advertising their products
J. Students should not have any interaction with drug
12.6
13.3
companies in medical school
K. Pharmacists should be accountable to the patients
9.4
6.7
for the drug they provide
L. If a drug company agreed to pay for the printing
28.5
15.4
cost of all my class notes in the undergraduate
medical school, I would not mind the logo of thatcompany appearing in the bottom corner of the firstslide of the lecture.
M. It is acceptable for drug companies sponsor
11.0
7.8
events/educational seminars during medical school.
N. Five drugs from five different companies are
33.3
26.2
identical in terms of price, and therapeutic efficacy. I
would preferentially prescribe a drug from one of
the companies that provided me with gifts or
incentives.
O. There is a need for guidance regarding relationship
10.1
5.7
between the pharmaceuticals and the physicians in
the undergraduate medical curriculum
Based on the above scenario, medical students
gave their opinions. Half (54%) declined to accept
any percentage of tuition fees. But 7.4% of themwanted 1 to 10% fees support, 9.9% wanted 10 to
20% fees support, 9% wanted 20 to 30% fees
support, and 19.6% wanted more than 30%
payment of tuition fees by pharmaceuticalcompany.
Another statement examined the attitude of
medical students towards profit and interest of
drug companies. More (62%) of respondents
agreed to a statement that said: “They are primarily
interested in profit: however, they still try to work inthe best interest of doctors and patients”. But 21%
respondents agreed with the statement, “They are

Neutral

Agree

34.3

25.1

Strongly
agree
9

18.6

52.0

10.1

22.5

22.1

1.6

20.2

55.6

11.3

12.9

46.7

11.0

14.5

53.3

19.9

23.2

37.0

10.6

15.2

37.7

12.2

23.7

42.8

14.0

16.3

40.0

17.7

19.8

42.1

22.1

16.8

32.0

7.4

17.0

50.8

13.3

16.8

18.2

5.5

14.9

40.7

28.5

fundamentally interested in profit and never on theside of either doctors or patients”. 17% agreed with,“They are fundamentally on the same side as doctors
and patients and should be regarded as an importantpart of the health care system”.
Respondents were asked whether any previous
experience or interaction biased their responses ornot. Only a few respondents admitted thepossibility of biased responses.

Eubios Journal of Asian and International Bioethics 27 (May 2017)
5. Association and Correlation among
Variables
5.1. Gender and Experience about Pharmaceuticals
Gender had a strong correlation (P value= 0.000,
chi-square) with personally knowing any medical
representative. Only 22% of female respondents
knew any medical representative, compared to
46% of male respondents who knew at least one
medical representative.
Moreover, ‘Gender’ and ‘Experience ofinteraction with pharmaceutical representative’
had also a strong correlation (P value= 0.015, chisquare). Only 10% of female respondents had
experience of interaction with representatives, but
19% of male respondents had experience of thatinteraction.

Game Equipment
Home Equipment
Unique Gadgets
Cooking accessories
Home Electronics
Computer Accessories
Jewelry
Cosmetics
Conference travel fees
Conference registration
Personal/Family_Trip
Hospital Trip0

Appropriate

Neutral

20

40

60

Table 2: Items of Significant Correlation
between Gender (Independent Variable) andOpinion on Gifts and Incentives [Dependent variable
Opinion about Gifts
Meals
Text Books
Stationery options
Clothes
Gifts less than 10,000 BDT
Gifts 50,001 to 100,000 BDT
Gifts more than 100000 BDT
Personal or Family Trip
Computer Accessories
Game Equipment
Festival Gifts

45.7
22.3
32
19.1
21.8
59.1
23.2
20.2
56.6
32.4
24.8
42.8
19.1
17.7
63.2
22.3
18.2
59.5
31.5
19.5
49
14
12.2
73.8
19.3
16.6
64.1
57.2
23.2
19.5
56.3
23.7
20
28
19.8
52.2
60.5
23.2
16.3

Festival Gifts

gender of the respondents as detailed with Pearson
chi-square 2-sided P values in Table 3.

Conference Travel Fees

Opinion on appropriateness of
Gifts-Incentives- Set B

80

Inappropriate

Figure 2: Opinions on Appropriateness ofDifferent Gifts and Incentives (set-B)
Horizontal axis presents percentages of respondents
opinion on gifts and incentives. Abbreviation: K=thousand, BDT= Bangladeshi Taka (80 Bangladeshi
Taka = 1 USD).

5.2. Effect of Gender
Gender was strongly associated with opinions on
12 items (dependent variables) shown as “S” in
Table 2. Thirteen out of fifteen statements ofattitude were associated significantly with the

75

Pearson Chisquare Test: P
value (2-sided)

Statistical
Significan
ce

0.007
0.025
0.016
0.000
0.000
0.019
0.011
0.003
0.023
0.000
0.025
0.000

S
S
S
S
S
S
S
S
S
S
S
S

5.3. Effect of Academic YearA correlation test was run between academic
year and personally knowing any medical
representative. Data showed percentages ofknowing
representatives
increasedwithadvancement of academic year, but there was no
statistically significant correlation (2-sided P value
0.150 in Pearson chi-square test) between those
two variables.
Current academic year of study had a significant
effect on opinion about different gifts andincentives. Academic year was strongly associatedwith opinions on meals, text books, stethoscope,stationary items, clothes, gifts less than 10
thousands, personal or family trip, conference
registration fees, conference travel fees, computer
accessories, unique gadgets, game equipment, andfestival gifts. A significant correlation was foundbetween academic year and 13 dependent variablesof opinions on gifts and incentives (Table 4).
Seven out of fifteen statements of attitude
were associated significantly with academic year of
respondents (Table 5).
5.4. Effects of Parental income
Parental income was strongly associated with
opinions on drug samples, clothes, gifts less than 10
thousand BDT, personal or family trip, computer
accessories, home electronics, cooking accessories,
unique gadgets, and home equipment as describedin Table 6.
Five out of fifteen statements of attitude wereassociated significantly with parental income of
respondents (Table 7).

Eubios Journal of Asian and International Bioethics 27 (May 2017)76

Table 3: Attitudes of Significant Correlation
between Gender (Independent Variable) and
Attitudes toward Drug Companies andRepresentatives
Dependent variable
Attitude towards drug
companiesA.

The information provided bydrug representatives about theirproducts can be trusted
B. The information from drug
representatives is important forthe physicians
C. It is ok for physicians to accept
gifts from drug companies
because drug companies haveminimal influence on them
D. Drug representatives are auseful way to learn about new
drugs
E. Gifts from drug companies todoctors lead to increased prices
of medicines
F. Receiving gifts or incentives
from pharmaceuticalrepresentatives increase thechance that I will eventually
recommend/prescribe the drug
company’s products
G. Drug companies act unethicallyin promoting and advertising
their products
H. Students should not have any
interaction with drug companies
in medical school
I. Pharmacists should be
accountable to the patients forthe drug they provideJ.
If a drug company agreed to pay
for the printing cost of all myclass notes in the undergraduate
medical school, I would notmind the logo of that company
appearing in the bottom cornerof the first slide of the lecture.
K. It is acceptable for drug
companies sponsor
events/educational seminars
during medical school.
L. Five drugs from five different
companies are identical in terms
of price, and therapeutic
efficacy. I would preferentiallyprescribe a drug from one of thecompanies that provided mewith gifts or incentives.
M. There is a need for guidance
regarding relationship between
the pharmaceuticals and thephysicians in the undergraduate
medical curriculum

Pearson Chisquare Test: P
value (2sided)

Statistical
Significan
ce

0.000

S

Table 4: Significant Items of Correlation
between Academic Year (Independent Variable)
and Opinion on Gifts and Incentives.
Dependent variable
Opinion about Gifts
Meals
Text Books
Stethoscope

0.012

S

0.017

S

Stationery options
Clothes
Gifts less than 10,000 BDT
Personal or Family Trip
Conference Registration Fees

0.000

Conference Travel Fees
Computer Accessories

S

Unique Gadgets

0.000

S

0.000

S

0.044

S

0.002

S

0.014

S

0.019

S

Game Equipment
Festival Gifts

Dependent variable

A.
B.
C.

S

S
F.

0.014

0.001
0.016
0.002
0.010
0.030
0.006
0.028
0.002
0.017
0.001
0.012
0.004
0.003

S
S
S
S
S
S
S
S
S
S
S
S
S

Pearson Chisquare Test: P
value (2sided)

Statistical
Signific
ance

Most seminars sponsored bydrug companies are helpful andeducational
Drug representatives are a usefulway to learn about new drugs

0.048

S

0.041

S

Gifts from drug companies todoctors lead to increased prices
of medicines
Receiving gifts or incentives frompharmaceutical representatives
increases the chance that I will
eventually recommend/prescribe
the drug company’s products

0.008

S

0.014

S

Students should not have any
interaction with drug companies
in medical school
Five drugs from five different
companies are identical in terms
of price, and therapeutic efficacy.
I would preferentially prescribe adrug from one of the companies
that provided me with gifts or
incentives.
There is a need for guidance
regarding relationship between
the pharmaceuticals and thephysicians in the undergraduate
medical curriculum

0.015

S

0.016

S

0.004

S

Attitude towards drug companies

E.

0.014

Statistical
Significance

Table 5: Attitudes of Significant Correlation
between Academic Year (Independent Variable)
and Attitude toward Drug Companies andRepresentatives

D.

0.005

Pearson Chisquare Test: P
value (2sided)S
G.

Eubios Journal of Asian and International Bioethics 27 (May 2017)
Table 6: Correlation between Parental Income(Independent Variable) and Opinion on Gifts
and Incentives.
Dependent variable
Opinion about Gifts
Meals
Dry Foods and Snacks
Drug Samples
Pen and Notepad
Text Books
Stethoscope
Medical Equipment
Stationery options
Clothes
Gifts less than 10,000
BDT
Gifts 10001 to 50,000
BDT
Gifts 50,001 to 100,000
BDT
Gifts more than 100000
BDT
Hospital Trip
Personal or Family Trip
Conference Registration
Fees
Conference Travel Fees
Cosmetics
Jewelry
Computer Accessories
Home Electronics
Cooking Accessories
Unique Gadgets
Home Equipment
Game Equipment
Festival Gifts

77

group agreed with appropriateness while 40% of
PP group agreed.
Appropriateness of cosmetics was agreed by
19% of NPP group and 23% of PP group. It wasconsidered inappropriate in the sense of 67% of
NPP group and 46% of PP group. The strongest
correlation was found for the opinion about
computer accessories. Only 11% of PP group found
it appropriate where 34% of NPP group thought so.
Having physician parents and experience about
the pharmaceutical issue were not found to haveany strong correlation (2 sided P value 0.069).

Pearson Chisquare Test: P
value (2-sided)

Statistical
Significanc
e

0.309
0.308
0.028
0.397
0.255
0.430
0.050
0.050
0.021
0.037

NS
NS
S
NS
NS
NS
NS
NS
S
S

0.178

NS

Dependent variable

0.158

NS

Attitude towards drug
companies

0.341

NS

0.081
0.019
0.393

NS
S
NS

0.062
0.052
0.122
0.004
0.043
0.000
0.011
0.001
0.358
0.211

NS
NS
NS
S
S
S
S
S
NS
NS

5.5. Effects of Physician or pharmacist parents
The variable ‘Physician Parents’ is strongly
correlated with the opinions about five gifts thatare meals, hospital trip, conference registration,
cosmetics, and computer accessories (Table 8). As
only 16 respondents had pharmacist parents (only3.7% of total), no correlation statistics was done forthe variable ‘pharmacist parents’. Respondents
having physician parents are named as ‘PP Group’and others having no physician parents are namedas ‘NPP Group’.
Only 25% of PP Group said meals wereappropriate gifts while 31% said they were
inappropriate and 44% were neutral. Comparing tothat, 41% of the NPP Group said a meal was an
appropriate gift, while 33% said it was
inappropriate and 27% were neutral. 44% of PPGroup accepted a hospital trip as appropriate while
63% of NPP group said it was appropriate. In thecase of conference registration fees, 59% of NPPTable 7: Significant Correlations between
Parental Income (Independent Variable) and
Attitude toward Drug Companies andRepresentatives
PearsonChi-square
Test: Pvalue (2sided)

Statistical
SignificanceA.

The information provided bydrug representatives about theirproducts can be trusted

0.017

S

B.

The information from drug
representatives is important forthe physiciansDrug representatives are auseful way to learn about new
drugs
Pharmacists should be
accountable to the patients forthe drug they provide
Five drugs from five different
companies are identical in terms
of price, and therapeutic efficacy.
I would preferentially prescribe
a drug from one of thecompanies that provided mewith gifts or incentives.

0.000

S

0.030

S

0.033

S

0.009

S

C.
D.
E.

Table 8: Items of Significant Correlation
between Physician Parents (Independent
Variable) and Opinion on Different Gifts andIncentives
Dependent
variable
Opinion about
Gifts
Meals
Hospital Trip
Conference
Registration Fees
Cosmetics
ComputerAccessories

Pearson Chi-square
Test: P value (2sided)

Statistical
Significance

0.020
0.034
0.017

S
S
S

0.005
0.000

S
S

Four out of fifteen statements of attitude wereassociated significantly with physician parents of
respondents (Table 9).

Eubios Journal of Asian and International Bioethics 27 (May 2017)78

Table 9: Significant Correlations between
Physician Parents (Independent Variable) and
Attitudes toward Drug Companies andRepresentatives
Dependent variable
Attitude towards drug
companies
A.
B.
C.
D.

Drug representatives are auseful way to learn about new
drugs
Drug company sponsoredseminars are often biased infavor of their products
Gifts from drug companies todoctors lead to increased
prices of medicines
Five drugs from five different
companies are identical interms of price, and therapeutic
efficacy. I would preferentiallyprescribe a drug from one of
the companies that provided
me with gifts or incentives.

Table 10: Correlation between Personally
Knowing a Medical Representative(Independent Variable) and Opinion on Gifts
and Incentives

PearsonChi-square
Test: Pvalue (2sided)

Statistical
Significance

0.011

S

Dry Foods and Snacks
Drug Samples

0.045

S

Pen and Notepad

0.015

S

0.028

Dependent variable
Opinion about Gifts
Meals

S

5.6. Effects of Experience about Pharmaceutical
Companies and Representatives
Correlation between personally knowing a
medical representative were strongly correlatedwith the opinion about seven gifts - text books,
medical equipment, Gifts of 50 thousand to 100
thousand BDT, hospital trip, computer accessories,
cooking accessories, and festival gifts (Table 10).
Respondents who personally know medical
representatives are named as ‘E Group’ and others
who do not know any representative are named as
NE group where E stands for Experience.
About 84% of E group accepted a textbook as
gifts whereas 74% of the NE groups accept that.
And only 5% of E group said it inappropriate
whereas 10% of NE group said so. Acceptance of
medical equipment as gifts was also strongly
correlated with knowing any representatives. With
more respondents of E group (85%) agreeing toaccept it while 74% of NE group said so. The
inappropriateness of medical equipment as gifts
was less in E group (2.8% vs 9.3%).
17% of E group found gifts of 50 thousand BDT
to 100 thousand BDT (80 BDT= 1USD) as
appropriate but only 11% of NE group thought so.
The study found that 67% of E group accepted
appropriateness of hospital trip, but only 57% of
NE group accepted that. Neutrality in case of
hospital trip was less in E group (15% vs 28%)
Computer accessories were appreciated as gifts
by 36% persons of E group, but only 29% of NE
group. More respondents of E group (26%) than NE
group (16%) thought cooking accessories wereappropriate. Festival gifts are more appreciated by
E group than NE (53% vs 42%).

Text Books
Stethoscope
Medical Equipment
Stationery options
Clothes
Gifts less than 10,000
BDT
Gifts 10001 to 50,000
BDT
Gifts 50,001 to 100,000
BDT
Gifts more than 100000
BDT
Hospital Trip
Personal or Family Trip
Conference Registration
Fees
Conference Travel Fees
Cosmetics
Jewelry
Computer Accessories
Home Electronics
Cooking Accessories
Unique Gadgets
Home Equipment
Game Equipment
Festival Gifts

Pearson Chisquare Test:
P value (2sided)

Statistical
Significance

0.989
0.170
0.780
0.166
0.043
0.254
0.018
0.900
0.312
0.096

NS
NS
NS
NS
S
NS
S
NS
NS
NS

0.078

NS

0.004

S

0.394

NS

0.011
0.514
0.691

S
NS
NS

0.513
0.093
0.476
0.010
0.128
0.015
0.574
0.186
0.165
0.028

NS
NS
NS
S
NS
S
NS
NS
NS
S

None of fifteen statements of attitude wereassociated significantly with personally knowing
any representative with Pearson chi-square 2-sided
test.
5.7. Effect of Being Taught about Physicianpharmacist Collaboration
The variable ‘Taught about PhysicianPharmacist Collaboration’ is strongly correlatedwith opinion about computer accessories only.
About 40% of respondents who said that they had
been taught about it said it inappropriate while
52% of other respondents said so. Among the
respondents who was not taught about it, only 27%
accepted it as appropriate, but 41% of the
respondents who had been taught said it was.
Five out of fifteen statements of attitude wereassociated significantly with ‘Taught about
Physician-Pharmacist Collaboration’ (Table 11).

Eubios Journal of Asian and International Bioethics 27 (May 2017)
Table 11: Significant Correlation between Being
Taught about Physician-Pharmacist
Collaboration (Independent Variable) and
Attitudes toward Drug Companies andRepresentatives
Dependent variable
Attitude towards drug
companies
A.
B.

C.
D.
E.

The information from drug
representatives is important
for the physicians
It is ok for physicians to accept
gifts from drug companies
because drug companies haveminimal influence on them
Drug representatives are auseful way to learn about new
drugs
Drug company sponsoredseminars are often biased infavor of their products
Five drugs from five different
companies are identical interms of price, and therapeutic
efficacy. I would preferentiallyprescribe a drug from one of
the companies that provided
me with gifts or incentives.

6. Discussion

PearsonChi-square
Test: Pvalue (2sided)

Statistical
Significance

0.029

S

0.033

S

0.000

S

0.036

S

0.001

S

6.1. Summary of Results
The most common monthly parental income was
between 20,000 to 50,000 BDT for medical
students. Less than 16% medical students had aphysician or pharmacist parent. More than half of
medical students did not know any pharmaceuticalrepresentative personally. Almost all the students(89%) said that they were taught about medical
ethics in medical colleges. But three quarters (73%)
said that they were not taught about ethics ofphysician-pharmacist collaboration.
Most of the medical students (85%) did not haveany experience of interaction with pharmaceuticalcompany representatives though they were inclinical phases of their education (3rd, 4th, and 5thyear). Drug samples and pen-notepads were themost appreciated pharmaceutical gifts, whereas
jewelry and gifts costing more than 100 thousand
BDT (1200 USD) were the least appreciatedpharmaceutical gifts.
Attitude towards drug companies andrepresentatives were explored and the majority ofstudents felt that:• Information provided by drug companies are notalways authentic. But the information isimportant for physicians.
• It is inappropriate to receive pharmaceutical
gifts in spite of the minimal influence ofpharmaceuticals on physicians.

79• Receiving gifts from pharmaceuticals will
eventually affect my prescribing behavior infavor of them.
• Most drug company sponsored seminars are
educational. Although the programs are biased
in favor of company products.
• Drug companies are an important way oflearning new drugs.
• Receiving gifts by physician cause increase of
drug prices.
• Drug companies act unethically in promoting
their products.
• Companies should be accountable to patients forthe drugs provided by them.
• Students should not have any interaction withdrug companies in medical school. But drug
companies
cansponsorseminars
andeducational programs in medical schools.
• If a drug company agrees to pay for the printing
cost of all class notes in the undergraduate
medical school, the logo of that company
appearing in the bottom corner of the first slideof the lecture is acceptable.
• Drug companies should not assist students’
tuition fees.
• They will not choose a drug based on given
incentives or gifts from a bunch of drugs of same
therapeutic efficacy.
• There is a need of guidance about therelationship of pharmaceuticals and physiciansin the undergraduate medical curriculum.
• Pharmaceuticals are primarily interested in
profit. However, they still try to work in the bestinterest of doctors and patients.
The above statements were found to be true basedon attitudes of medical students of Bangladesh.
6.2. Identified Correlations
The sample was enough to represent the
population according to the single proportion
formula of sample size calculation. Based on
statistical significance, distribution of variables, chisquare test, and P values, the following correlations
are proposed in Bangladesh:
Gender of the medical student is associated withexperience about pharmaceutical reps. More male
medical students know medical representative sand have had interactions than female students.
I.
More female students think clothes, gifts
costing more than 50 thousand BDT, gameequipment, and personal and family trip are
inappropriate gifts than do male students. The
study found that the majority of male students
think it appropriate to receive gifts less than 10
thousand BDT, festival gifts, and computer
accessories: whereas the majority of female
students think it inappropriate. More male students

80

Eubios Journal of Asian and International Bioethics 27 (May 2017)

accept meals, textbooks, and conference travel fees
appropriate than female students. Only stationery
items are accepted by more female students thanmale students.
Change in gender also changes the attitude
towards drug companies and representatives asshown in Table 3. Generally male students weremore supportive of the interactions still the
majority of female students than that of malestudents support the following statements: Drugrepresentatives are a useful way to learn new
drugs; Receiving gifts or incentives frompharmaceuticals increases the chance eventuallyfor me to prescribe that product. The majority ofmales agree but majority of female disagree withthe following statement: “If a drug company agreed
to pay for the printing cost of all my class notes in theundergraduate medical school, I would not mind thelogo of that company appearing in the bottom cornerof the first slide of the lecture”
The academic year of study has no association
with the experience about pharmaceuticals, but has
a strong association with opinions on some specificgifts and incentives. The percentage of students
agreeing to the appropriateness of textbooks,
stethoscope,stationery
items,
conference
registration fees, and conference travel fees isinversely proportional to the academic year. The
more academic year advances, the more thepercentage falls. The proportion of medical
students perceiving inappropriateness of clothes,
meals, personal or family trip, game equipment,
unique gadgets, and computer accessories as gifts is
proportional to the academic year. The moreacademic year advance, the more the proportion
rises.
Third year students could be a better target for
drug companies than later years, but this study did
not explore whether that would have a lasting
influence on attitudes. Festival gifts are accepted tomore third year students than the fourth and fifth
year. Current academic year affects the attitude of
medical students significantly. More third-year
students than other years support the following
statements:
Drugcompanies’
sponsored
educational seminars are helpful; Receiving
pharmaceutical gifts by physicians increase drug
costs; Students should not have interaction withpharmacists in medical schools; I will not choose adrug from a bunch of drugs of same therapeutic
efficacy based on given incentives or gifts.
Morefourth-year students than other years appreciate
drug companies as a useful way to learn about new
drugs.
Parental income has a strong association withthe opinion of medical students on some gifts andincentives, and has a strong correlation with somestatements of attitudes. Comparing to any othergroups, a majority of students having parental
income more than 150 thousand BDT consider thatthe information provided by drug companies areuseful for physicians. More students having
parental income 100 to 150 thousand BDT agree tothe following statements than any other parentalincome groups: Drug representatives are a usefulway to learn about new drugs; Pharmacists shouldbe accountable to the patients for the drug they
provide. The majority of medical students having
monthly-parental-income less than 20 thousand
BDT disagree to choose a drug based on given
incentives or gifts from a bunch of drugs of same
therapeutic efficacy.
Having physician parents has a strong
association with the opinion on some gifts andincentives. Meals, hospital trips, conference
registration fees, and computer accessories areappropriate to more students of non-physician
parents than students of physician parents. It
seems like the students with physician parents
were more sensitive to the influence ofpharmaceutical companies, and that education athome may have been a positive influence on theirethics.
More students who know any medical
representative personally accepts textbooks,
hospital trip, gifts costing 50 to 100 thousand BDT,
computer accessories, cooking accessories, festival
gifts, and medical equipment as appropriate gifts
more than that of those who do not know.
Teaching on physician-pharmacist interaction
does not affect opinion on gifts and incentives
except for computer accessories. Teaching on
physician-pharmacist interaction has an effect on
the attitude of medical students towards drug
companies and representatives. Support for thefollowing statements increases after teaching:
Information of drug companies as important forphysicians; physicians should not accept gifts frompharmaceuticals in spite of minimal influence onthem; I will not choose a drug from a bunch ofdrugs of same therapeutic efficacy based on given
incentives or gifts. Drug companies are accepted asa useful way to learn new drugs to more students
who had not been taught compared to thosestudents who said they had been taught.
6.3. Limitations of the Study
The study findings should be viewed in the
background of certain methodological limitations.
The data collection took place via Google forms
online, so the students who did not have access tothe internet could not participate. Since data werecollected on self-administered questionnaires, we
could not rule out information bias. There is also
some non-response bias. Anonymity andconfidentiality of the respondents were ensured inEubios Journal of Asian and International Bioethics 27 (May 2017)
the study. Hence we did not have the opportunity toidentify and re-invite the non-responders on a
separate occasion. The statements were insufficient
to measure every aspect of attitudes. A longitudinalor cohort study could provide more data.

7. International Comparisons7.1. Comparisons to the United States
Medical students of the United States have moreexperience of interactions with pharmaceuticalindustry than Bangladeshi medical students of this81

study. But less American medical students thanBangladeshi students do not agree that receiving
gifts will affect their prescribing behavior (Austad
et al., 2013b, Sierles et al., 2005). Austad et al.
reported attitude of first and final year students,
Sierles et el. Reported third-year students, and Kim
et al. reported preclinical students (Sierles et al.,2005, Austad et al., 2013b, Kim et al., 2012). Detailsof comparison are presented in Table 12.

Table 12: Comparison of the attitudes of medical students towards pharmaceutical industry in
Bangladesh and the United States (% agreeing to the statement)
Bangladesh (thisstudy)- Final year
students

The United States(Austad et al.)- final
year students (Austad
et al., 2013b)

The United States(Sierles et al.)- Thirdyear students (Sierles
et al., 2005)

The United States (Kimet al.)- Preclinicalstudents (Kim et al.,2012)

Physician Parents
12.8
Personally known
36.6
pharmacists
Experience of interaction with
18.7
pharmaceuticalrepresentatives
Agreement to the following statements:
It is acceptable for physicians to
23.7

24.8
6.7

-

-

44.4

93.2

-

-

-

41.1

52.2

36.3

31.2

-

68.1

36.6

89

-

64.1

-

-

61.5

71.6

76.9

67.4

-

56

30.1

71.3

71

60

69.8

17.3

56.5

33.5

69.1

-

-

accept gifts from pharmaceuticals
Receiving gifts from representatives
increases the
chance that I will eventuallyprescribe the drug company’s
products
Educational programs or rounds bydrug companies are educational andhelpfulDrug companies should sponsor
programs in medical school
Drug company sponsored programs
are often biased in favor of theirproduct
Representative of drug companies
and their materials are useful way tolearn new drugs
Medical students should not haveinteraction with pharmaceuticalrepresentative in medical schools
I was educated about physicianpharmacist interaction

7.2. Comparison to Canada
No Canadian research on medical students
regarding this theme is available. But Sergeant et al.
studied the attitude of the Canadian family
medicine residents towards pharmaceuticalindustry (Sergeant et al., 1996). Details ofcomparison are presented in Table 13.
7.3. Comparison to Germany:
German medical students have moreexperience of interaction with pharmaceuticalindustry than Bangladeshi medical students. But
less German students than Bangladeshi students

agree that receiving gifts will change theirprescribing behavior. And less German students
than Bangladeshi students deny that students
should not have interaction with pharmaceuticals
in medical school (Lieb and Koch, 2013). Details ofcomparison are presented in Table 14.
7.4. Comparison to Pakistan
Siddiqui et al (2014) conducted a similar
study in Pakistani medical students. In
demographics Siddiqui et al. has 31.2%, 44.3%,
24.5% medical students of the third, fourth, andfifth year respectively. But we have 17.9%, 23%,

Eubios Journal of Asian and International Bioethics 27 (May 2017)82

and 59.1% respectively. More Pakistani students
than Bangladeshi students accept drugs companies
to sponsor educational events in medical schools.
But More Bangladeshi students than Pakistani
students consider meals, textbook, pen, stethoscope
as appropriate gifts. Other attitudes sound pretty
similar (Siddiqui et al., 2014). Details of comparison
in presented in Table 15.
Table 13: Comparison of attitudes towards
pharmaceutical industry between medical
students of Bangladesh and Residents ofCanada.
Bangladeshi
Canadian
Agreement to theMedicalFamilyfollowing statements:

The information from drug
representatives is important
for the physicians
Receiving gifts or incentives
from pharmaceuticalrepresentatives increases the
chance that I will eventually
recommend/prescribe thedrug company’s products
There is a need for guidance
regarding relationshipbetween the pharmaceuticals
and the physicians in theundergraduate medical
curriculum
Gifts from drug companies todoctors lead to increased
prices of medicines

Students (thisstudy)

Medicine
Residents(Sergeant etal., 1996)

62.1

58.5

49.9

69.2

47.6

43.4

Experience of pharmaceutical
14.7
interaction
Agreement to the following statements:
Most seminars sponsored by
56.9
drug companies are helpful
and educational
Drug company sponsored
73.2
seminars are often biased infavor of their products
Drug representatives are a
57.7
useful way to learn about new
drugs
Receiving gifts or incentives
49.9
from pharmaceuticalrepresentatives increases the
chance that I will eventually
recommend/prescribe thedrug company’s products
Students should not have any
57.7
interaction with drug
companies in medical school

Physician parents

Bangladeshi
MedicalStudents(this study)

Pakistani
MedicalStudents(Siddiqui etal., 2014)

12

27.1
3

Pharmacist parents
3.7
Agreement to the following statements:
Medical students should not
57.7
have interaction withpharmaceutical representativein medical schools
Physicians should not receive
43.8
gifts in any form
Acceptable gifts: meals, pen,stethoscope, textbook
I will not choose a drug from abunch of drugs of same
therapeutic efficacy based on
given incentives or gifts.
The information provided bydrug representatives about
their products can be trusted

38.6 to
85.5
59.5

35.9

GermanMedicalStudents(Lieb and
Koch,
2013)

87.9
48
89
61
25

22

It is acceptable for drug
companies sponsor
events/educational seminars
during medical school.
If a drug company agreed to
pay for the printing cost of all
my class notes in theundergraduate medical
school, I would not mind thelogo of that company
appearing in the bottom
corner of the first slide of thelecture.
There is a need for guidance
regarding relationshipbetween the pharmaceuticals
and the physicians in theundergraduate medical
curriculum

41.3 to 46

25.4 to29.1
36.3 to40.4
56.1 to56.5

34.1

15.8 to 41.8
(significant
variation
among medicalcolleges)

64.1

79.8 to83.2

39.4

39.1 to49.1

69.2

54.9 to84.2(significant
variation
among
medicalcolleges)

45.6

Table 14: Comparison of the attitude towards
pharmaceutical industry between medical
students of Bangladesh and Germany.
Bangladeshi
MedicalStudents (thisstudy)

Table 15: Comparison of attitudes towards
pharmaceutical industry between medical
students of Bangladesh and Pakistan

7.5. Comparison to Saudi Arabia
No Saudi study on medical students
regarding this theme is available. But the attitude ofSaudi physicians has been studied (Zaki, 2014).
More Saudi physicians than Bangladeshi medical
students find information of drug companies asimportant. But less of them accept that drug
companies are unethically promoting their drugs.
More Saudi physicians than Bangladeshi medical
students disagree that pharmaceutical incentive tophysicians increases drug cost. However, less Saudi
physicians than Bangladeshi medical students
admitted being affected in prescribing behavior byreceiving gifts. Other attitudes are more or less

Eubios Journal of Asian and International Bioethics 27 (May 2017)
similar (Zaki, 2014). Details of comparison inpresented in Table 16.
Table 16: Comparison of attitudes towards
pharmaceutical industry between medical
students of Bangladesh and Physicians of Saudi
Arabia.
Agreement to the following
statements:

Bangladeshi
MedicalStudents (thisstudy)

Saudi
Physicians(Zaki,
2014)

Educated about physicianpharmacist interaction
Personally knowing a drug
representative

27.4

22.8

33.1

28

62.1

80

57.7

65

56.9

45

23.7

20

34.1

42

56.8

31

49.9

34

47.6

27

73.2

63

Agreement to thefollowing statements:
The information from drug
representatives is important
for the physiciansDrug representatives are auseful way to learn about new
drugs
Most seminars sponsored bydrug companies are helpful
and educational
It is ok for physicians to
accept gifts from drug
companies because drug
companies have minimal
influence on them
The information provided bydrug representatives about
their products can be trusted
Drug companies act
unethically in promoting andadvertising their productsReceiving gifts or incentives
from pharmaceuticalrepresentatives increases the
chance that I will eventually
recommend/prescribe thedrug company’s products
Gifts from drug companies todoctors lead to increased
prices of medicines
Drug company sponsoredseminars are often biased infavor of their products

7.6. Further International Comparisons of
Attitudes towards Gifts
Various countries reported attitude of medical
students and physicians towards pharmaceutical
gifts. Some comparisons are presented in Table 17.
7.7. Attitudes towards Pharmaceutical Gifts andAssociated Factors
Among Bangladeshi medical students in thisstudy, drug samples were found to be a more
acceptable gift than other examples. It might be dueto the educational purpose. Drug samples help tolearn about new drugs and formulary. Drugsamples are also appreciated by most students of
Saudi Arabia (Zaki, 2014). But it is not that83

acceptable to German and American medical
students (Lieb and Koch, 2013, Sierles et al., 2005).
Pen and notepads are also highly appreciated by
medical students in this study. Probably it helps
them in academic purpose a lot. About half of Saudi
Arabian physicians support it, though not thatmuch as Bangladeshi students (Zaki, 2014). Jewelry
was most depreciated among the participants inthis study, perhaps because it is a luxury productunrelated to medicine or education.
More than one-third of students in this study
supported meals as gifts. This proportion is lessthan Saudi Arabian physicians and German medical
students (Zaki, 2014, Lieb and Koch, 2013). On theother hand, a very high acceptance of meals as gifts(more than 70%) is seen among the medical
students in Norway and the United States (Lea etal., 2010, Sierles et al., 2005). The probable reason
may be the difference in economic condition andsocial culture.
Among the academic gifts, textbook andstethoscope
werehighlyappreciatedbyBangladeshi medical students in this study. It iseven higher than Saudi physicians, medical
students of Germany, Norway, and the UnitedStates (Zaki, 2014). More than half of this study
participants accepted conference travel fees asappropriate. The ratio is pretty similar to Germany
and Norway (Lieb and Koch, 2013, Lea et al., 2010).
Even more than half of Saudi physicians accept it
too (Zaki, 2014). But less percentage of the U.S.
medical students accept conference travelassistance as appropriate (Sierles et al., 2005).
More than half of Bangladeshi medical students
in this study considered stationary items as
appropriate gifts. But only 36% Saudi physicians
support that (Zaki, 2014). The acceptance rate ofpersonal or family trips as appropriate gifts is 20 to
30% in this study, in Saudi physicians, and the U.S.
medical students. But it is only 11.7% among
German medical students (Zaki, 2014, Sierles et al.,2005, Lieb and Koch, 2013).
We also investigated attitude towards somemore gifts such as dry food, medical equipment,
clothes, gifts in the different amount, hospital trip,
and cosmetics etc. But no significant data isavailable in the literature about them. However,this results also showed a significant correlation
between opinion on some gifts and students’
academic year. This correlation is supported bysome studies of the United States too (Bellin et al.,2004, Fitz et al., 2007). This may be due to thechange in experience and exposure topharmaceutical interaction in different years(Bellin et al., 2004).
This results showed that the more the cost ofgifts increased, the more inappropriate it became to
medical students. Thus, medical students mightTable 17: International Comparison of Attitude of Medical Students and Physicians towards
pharmaceutical gifts (% in Agreement)
Agreement to
Bangladeshi
Saudi
GermanNorwegian
The United
appropriateness of theMedicalPhysicians
Medical
MedicalStates Medical
following gifts:
Students (this(Zaki,
Students
Students (Leastudents
study)
2014)(Lieb andet al., 2010)(Sierles et al.,Koch, 2013)
2005)
Stationery
52.2
36
Textbook
77
55
64.2
69.1 to 84.4
71.1
Stethoscope
73.6
39
56.5
Conference Travel Fees
57.2
63
52.2
47.7 to 82.2
35.4
Conference Registration
56.3
67
Fees
Pen-Notepad
85.5
50
Personal or Family trip
28
26
11.7
30.2
Drug samples
89
66
33.4
21.4
Meals
38.6
28
46.4
75.5 to 90.5
77.4
problem in accepting gifts (Brett et al., 2003,
emphasize on ethical behavior more than selfKorenstein et al., 2010). Even medical students also
beneficence. Female students felt more neutral orappreciate getting gifts or financial support frominappropriate about most of the gifts than male.
pharmaceuticals if they have a financial problem
Probably they were more concern about ethics or it(Grande et al., 2009). And when pharmaceutical
was a part of the female behavioral difference.
companies approach students, their main intention
However, this issue should be investigated further.
is to introduce them repeatedly about the name of
We found that textbook, stethoscope, anddrugs and company. In that way, most of theconference fees were more popular among thetargeted students easily memorize brand names,
junior students than the seniors. It might be due topromotional products, book titles, and company
a fact that juniors were less exposed to those. The
name (Sandberg et al., 1997).
more students expose to them or use them
Although most seminars sponsored by drug
personally, the more acceptability of gifts declines
companies are biased in favor of their products,(Bellin et al., 2004). Clothes, gaming and computer
they are helpful and educational, according to thisequipment and trips are more acceptable to senior
study participants. The academic year of students
students. But the reason behind it is unknown,
affected that attitude of them. Similarly, U.S. study
should be studied.
shows that more than half of the U.S. medical
students believe those programs as educational.
7.8. Attitudes towards Drug Companies and
The attitude of students varies from school to
Associated Factors
school, region to region, and year to year. Variation
The reliability of the information provided byof opinion is also seen between exposed anddrug companies was questioned by almost all
unexposed to pharmaceutical interaction (Grande
students in this study. They might think thatet al., 2009). A systemic review shows that more
information as fabricated for better promotion byclinical students than preclinical students support
drug companies. But despite unreliability, they
those programs as educational (Austad et al., 2011).
thought the information as important of physicians.
About 80% of the U.S. physicians also find theChange in gender and parental income affected
programs helpful (Korenstein et al., 2010). A study
their opinion. Literature also suggests thatamong medical students shows that more than twoinformation provided by them have some potential
third of them agree with the biasness of thebias (Kalb, 2004). Most Canadian residents andprograms (Grande et al., 2009). About two-third ofphysician trainees consider the information as
the U.S. physicians think alike (Korenstein et al.,untrustworthy. Most of them also want to ban this2010). Even nearly half of pharmacy students also
type of pharmaceutical promotion (Hodges, 1995).
think so (Ashker and Burkiewics, 2007). But
Bangladeshi medical students declined thepharmacy students are found to be more taught
appropriateness of accepting pharmaceutical gifts
about drug marketing and professional ethics thanwhether they have minimal influence or not,medical students. They are generally moreaccording to this study. Female gender and formallysupportive to pharmaceutical gifts and sponsoredlearned students about the interaction depreciatedseminars (Monaghan et al., 2003).
the gifts most. In contrast, a systemic review shows
Future doctors of Bangladesh in this study
that more clinical students than preclinical students
considered drug representatives as a useful way tosupport to accept gifts (Austad et al., 2011). And
learn new drugs. Gender, academic year, parental
most physicians do not perceive any ethicalincome, physician parents, and formal education onEubios Journal of Asian and International Bioethics 27 (May 2017)
physician-pharmacist interaction affected theirconsideration. Variation of the agreement was
found in different years. Similarly, a systemic
review shows that more clinical students thanpreclinical students agree to the efficacy ofrepresentatives about educating on new drugs(Austad et al., 2011). About 65% U.S. physiciansalso think this as a way to learn new drugs(Korenstein et al., 2010).
Pharmaceutical gifts to doctors increase
medicinal prices, this students thought so. Gender,
academic year, and physician parents affected thisattitude. However, Bangladesh has no such data ofawareness of physicians about patients’ out-ofpocket expenses. In the United States (U.S.),
physicians are often unconcerned about thatmatter. A study shows that 88% of the U.S.
physicians agree that patients’ drug costs should bewithin their financial ability. But only 59% prefers
less costly drugs to prescribe. While searching forreasons, only 25% of them believe that it is a
responsibility of physicians. And 69% of thembelieve that it is a responsibility of pharmacists(Shrank et al., 2005).
Most of this students agreed that receiving
pharmaceutical
gifts
would
changetheirprescribing behavior in favor of that company. Less
females agreed to that act than males. Academic
year also affected that opinion. Similarly, a systemic
review also supports the variation in different
academic years. It shows that more clinicalstudents than preclinical students are afraid ofbiasness of their future prescribing after receiving
gifts (Austad et al., 2011). A study among the U.S.
medical students shows that from 29.4% to 63.3%
students agree to the influence on prescribing
which may vary from school to school, and year toyear (Grande et al., 2009). Many faculties of medical
schools of the Unite States think that personal
relationship affects prescribing more than receiving
gifts. They ask for more restrictive regulations on it(Banks 3rd and Mainous 3rd, 1992). Most Canadianresidents and interns disagree to have an influenceof gifts on their prescribing behavior. And they
admit having the same behavior and prescription
without any gifts and incentives (Hodges, 1995).
Many physicians of Iraq prefer low-cost gifts thanhigh costs. They also switch to generic prescribing
occasionally (Mikhael and Alhilali, 2014). But
pharmaceutical representatives usually have an
impact on the prescribing behavior of physicians,
claimed by many studies (Cleary, 1992, Korenstein
et al., 2010). Educational assistance, selling andpromoting strategies of pharmaceuticals have asignificant effect on physicians’ prescription(Andaleeb and Tallman, 1995). In the United States,
gifts or quasi-gifts by representatives influence theprescribing pattern of physicians (Berger, 2003).

85

Only detailing by a drug representative can cause
selection bias by a physician (Datta and Dave,2016). So, incentives may easily alter a physician’s
choice of drugs. And if that happens, it will goagainst physicians’ autonomy (Kalb, 2004).
Drug companies act unethically in promoting
and advertising their products, that is what most of
the Bangladeshi medical students thought. Moremale students thought it than female students did.
However, it can be true. Even sometimes
representatives also may feel ethical dilemmas inmarketing products. Especially when they describe
the benefits of their products and offer incentives,
they may sense ethical dilemma but do not express
it (Tengilimoglu et al., 2004). Moreover, it ispossible to change form and content of a drug after
proving its scientific credibility. Sometimes
marketing and promotional strategy become
different in different time and circumstances (vander Hoogte and Pieters, 2010, Bergman et al.,2016).
Students should not have any interaction withdrug companies in medical school, according to theopinions of this study participants. Gender andacademic year affected that attitude. Similarly,
about 33% of the U.S. physicians also suggest thatprohibiting policy (Korenstein et al., 2010). But
some students may desire for this interaction which
varies in different academic years. A systemic
review suggests that preclinical students thanclinical students like to have more interaction withcompanies (Austad et al., 2011).
Most Bangladeshi future doctors think thatpharmacists should be accountable to the patientsfor the drug they provide. Gender and parental
income were associated factor of that opinion. Moremale than female agreed of pharmaceuticalaccountability to patients. However, it is true that if
any drug provided by pharmacists does any harm
to patients, physicians and patients can take lawful
action against that company (Cacciatore, 1997).
Most participants agreed to have the logo of adrug company on the first lecture slide if thecompany agrees to pay for the printing cost of allclass notes in the medical school. Gender affectedthat agreement greatly. More female disagreed but
more male agreed. This study also found that mostmedical students accept drug companies to sponsor
educational events in medical schools. More malethan female significantly supported that matter.
Similarly, a systemic review shows that moreclinical students than preclinical prefer educationalseminars in their medical school (Austad et al.,2011). Moreover, 70% of U.S. physicians also
support that matter (Korenstein et al., 2010). Even
pharmacy students also support those educational
events. A study shows that most of them think the

86

Eubios Journal of Asian and International Bioethics 27 (May 2017)

events helpful to acquire more knowledge (Ashker
and Burkiewics, 2007).
Future doctors of Bangladesh in this study would
not like to choose a drug from a bunch of drugs ofsame therapeutic efficacy based on given incentives
or gifts. Gender, academic year, parental income,
physician parents, and formal education about theinteraction affected that attitude significantly inthis study. Similarly, a review suggests that morethan half of medical students think that gifts will
not influence their future prescribing behavior. And
more than one-third think that interaction withpharmaceutical will not affect their prescribing
pattern (Carmody and Mansfield, 2010).
There is a need for guidance regarding
physician-pharmaceutical interaction in theundergraduate medical curriculum of Bangladesh,according to the most opinions in this study. As
only a few medical students got a formal education
about it. The scenario of other countries also
supports the fact. A systemic review shows thatmostly less than of half medical students learn
about the ethical interaction in their medical school(Austad et al., 2011). Even in the developed
countries, the knowledge of faculties or resident
doctors about drug marketing, drug cost,
pharmacist collaboration can be limited (Watkins
and Kimberly, 2004). A study shows that only 40%of the physicians of Washington DC agree to have astructured curriculum. More of those curriculums
support the interaction. But most of them want theinteraction to be with institutional affiliation. The
source of drug information and ethics of physicianpharmacist interaction are the most common
subjects among the curriculums (Evans et al.,2016). Education does influence the attitude of
medical students and physicians. So, it is highly
demanded. There will be a positive change inbehavior after learning pros and cons of physicianpharmacist interactions (Vinson et al., 1993)(Hopper et al., 1997).

8. Conclusions and Recommendations

8.1. Conclusions
The interactions between physicians andpharmaceutical producers has continued for
centuries. But sometimes, questions of ethics andconflicts of interests create debates. Pharmaceuticalcompanies offer various gifts to physicians thatvary to be low or high cost, rational or irrational,
and ethical or unethical. Gifts, on one side, help
people to remember the names of new products
and companies. On another side, it may cause
selection bias in physicians’ prescriptions. In
Bangladesh, drug samples, textbooks, stethoscope,pen-notepad, hospital trip, and conference travelregistration fees are highly appreciated among
medical students. The choices are different in somecountries. Meals and festival gifts become moreinappropriate as the academic year advances, may
be due to an increasing professionalism. Parental
income greatly affects the attitudes towards gifts.
Students with low parental income appreciatecomputer accessories and low-cost gifts. The
choices can have a link to their financial problem.
Because, the more parental income grows, the moreinappropriateness of low-cost gifts increases.
Having physician parents also affects the attitude
towards gifts considerably, making them moreneutral. Moreover, personally knowing a
representative affects the choice of gifts too. And it
is surprising that teaching on pharmaceuticals does
not have any association with gift choices. The
reasons should be thoroughly investigated.
The
information
providedby
drug
representatives is not always fully accurate.
Potential biases for drug marketing can be seen
there, Bangladeshi students also do support that.
There is an ethical question in drug marketing
perceivedby
many
medicalstudents,
representatives, and pharmacists. Medical students
consider pharmaceuticals as a way of learning new
drugs. No ethical problem is revealed in learning
new drug names. Accepting gifts are depreciated by
the most Bangladeshi medical students, because of
their ethical concern. They are aware thatpharmaceutical gifts may bias their prescription in
the future. Most of the medical students do notagree to choose a drug from a group of drugs withsame therapeutic efficacy based on company
incentives. And it is an obvious unethical matterthat many physicians in the world write biased
prescriptions in favor of companies who give gifts.
The duty of physicians is to recommend the mostappropriate drug with high efficacy rate at theirknowledge.
Pharmaceuticalincentives
mayincrease the cost of drugs, many medical students
and physicians know that. But they might notconsider it during prescribing. Both pharmacists
and physicians should be concerned about
medicinal prices for greater benefits of patients.
Even pharmacists should be accountable to patientsfor the drugs they provide.
However, pharmaceutical companies often
sponsor educational events in medical schools.
Most of the students and physicians know those arebiased to their products. But they still support theevents considering the educational value andfinancial needs, the support varies among academic
years. Many students also have interaction withpharmaceuticals
inmedicalschools.
The
phenomena are more common in developed
countries than in Bangladesh. But, many students
and physicians of the world want to prohibit thepharmaceutical interaction in medical schools.
However, the attitude of medical students is

Eubios Journal of Asian and International Bioethics 27 (May 2017)
affected by gender, academic year, parental income,
physician parents, and formal education on
pharmaceutical interaction. The attitude may also
vary in different settings, medical schools, andcountries. But it is really astonishing that
personally knowing representatives does not affectthe attitude.
Medical schools do not provide enough teachingon pharmaceutical interaction. Formal education on
medical ethics and ethics of physician-pharmacist
interaction can promote more promising behavior
and ethical medical practice. Formal education also
may help students to set a better attitude.
Collaboration between physicians and pharmacists
is definitely necessary for better health care. But it
is better if the collaboration occurs in a more
ethical way.
8.2 Recommendations
The following recommendations are suggested
according to this study findings:
A. Recommendation for Medical Students:
1. Medical students should learn themselves
about ethical aspects of pharmaceutical gifts.
2. The financial problem should be balanced withthe acceptance of pharmaceutical gifts.
3. Drug
samples,
pen-notepad,
textbook,stethoscope, and other educational equipment canbe acceptable to certain limits. Medical schools candetermine the limits.
4. Students can accept hospital trips, conference
registration-travel fees, and financial assistancefrom pharmaceuticals within a certain limit only
they are in financial crisis and if they disagree towrite biased prescriptions in the future.
5. Medical schools should form guidelines on
pharmaceutical gifts for students with pros andcons listed.
6. They should be introduced by medical schools
to sources of drug information other thanrepresentatives.
7. Students should evaluate the possible positive
and negative aspects of the information provided
by pharmaceuticals.
8. Medical schools should train students on how
can they avoid the influence of pharmaceuticals in
the future practical life.
9. Students should take only the educational partwhen they attend any seminar or event sponsoredby drug companies.
10. Students should interact with more patients inthe clinical wards and know more about theirfinancial problems to buy drugs.
11. Students should evaluate themselves about
positive-negative and ethical-unethical aspects ofthe marketing strategy of drug companies.

87

12. Students should have less interaction withpharmaceuticals in medical schools, they should
not interact before learning ethics.
13. Students should avoid financial assistancefrom drug companies unless they are in extreme
financial crisis. Medical schools can increasefinancial aids to students.
14. Students should learn appropriate prescribingof drugs from a group of drugs of same therapeutic
indication and efficacy.
B. An inclusion of ethics of physicianpharmaceutical interaction should be includedin the undergraduate curriculum. The following
topics should at least be taught:
1. Ethics of physician-pharmaceutical interaction,national and international guidelines
2. Ethics of drug prescribing
3. Physician-patient and pharmacist-patient
relationship
4. Limits and effects of receiving pharmaceuticalgifts
5. History of pharmaceutical reform in different
countries
6. Current policies and scenario in different
countries
7. Marketing strategy of pharmaceuticals
8. Ethics for pharmacists
9. Difference in ethics for medical students andphysicians
10. Effect of prescribing on medicinal prices
C. Recommendation for physicians:
1. Physicians should try to minimize the effect ofdrug representatives while prescribing rationally.
2. Physicians should consider drug prices while
prescribing for poor patients.
3. Physicians should rationally evaluate theinformation provided by drug companies.
4. Physicians ought to be concerned about ethicalmeasures of pharmaceutical marketing.
5. Physicians can move to generic prescribing if
they feel ethical dilemma during practice.
6. If some drugs have same therapeutic efficacy
and equally indicated for a patient, a physician
should choose the cheaper one, not the promoted
one by pharmacists.
7. Physicians should decrease their dependence
on drug industries
8. Physicians should adhere to all statements ofmedical ethics and ethics of pharmaceuticalpractice by all means
D. Recommendationsforpharmaceuticalcompanies:
1. Pharmaceutical companies should promote
their products within the ethical limit.

88

Eubios Journal of Asian and International Bioethics 27 (May 2017)

2. New drugs with same therapeutic efficacy
should not be marketed for better business.
3. Pharmaceutical companies should makethemselves concerned about medicinal price andpatients’ affordability.
4. Helping people should be prioritized thangaining profits.
5. Pharmaceutical companies should also receive
the idea of ‘do no harm’ for patients.
6. The companies should be accountable topatients for the drugs they supplied
7. Drug companies should have an ethical board
regulating
ethicalmattersofpromotion.
Representatives should report their activities tothat committee
8. Pharmaceuticals should report national ethicalcouncil about their annual marketing and businessfor ethical clearance.
Recommendations for the Government:
The government should establish an ethicalbody to maintain ethics in the health system. The
ethical body can maintain all issues in nationally
includingphysician-pharmacist
collaboration.
Pharmaceuticals should report their annual
activities to that ethical board. A national guidelinein this issue is needed to be structured soon.
Guidelines on ethics of receiving pharmaceutical
gifts and interaction should be more clarified. The
government can train teachers and faculties of
medical schools in this issue so that they can pass it
on to medical students. The national ethical bodycan establish ethical monitoring boards in different
hospitals to maintain different aspects of medical
ethics.

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LURK, J. T., DEJONG, D. J., WOODS, T. M., KNELL, M. E. &CARROLL, C. A. 2004. Effects of changes in patient cost sharing
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The Scottish Government (2015) Should the use of wild
animals in travelling circuses be banned in Scotland?
Consultation
Analysis,
availableat
http://www.gov.scot/Resource/0048/00480385.pdf;
Veterinary Ireland, Veterinary Organisation’s Opinion on
the Needs of Wild Animals in Travelling Circuses, July
29,
2016,
availableat
http://www.veterinaryireland.ie/images/Veterinary_I
reland_Press_Release_on_Wild_Animals_in_Travelling_
Circuses_29th_July_2016.pdf
Wells D. L., Hepper P. G. (1997) Pet Ownership andAdults' Views on the Use of Animals, Society andAnimals, Vol. 5, No. 1, pp. 45-63;
Zanola R. (2007) Major influences on circus attendance,
Department of Public Policy and Public Choice – POLIS,
Working paper n. 99, October 2007, in "POLIS Working
Papers", Universita’ del Piemonte Orientale “Amedeo
Avogadro” Alessandria, Italy;
Zoocheck (eds.) (2016) Take action for elephants. A
resource guide, Zoocheck, Toronto, Canada;*** (2012) The Circus - A Nightmare For Animals,
Humane Review, Spring/Summer 2012.

For forthcoming conferences see:www.eubios.info or www.ausn.info
Email for information: darryl@eubios.info
Bioethics, Law, and Society: Joint AUSN,
Center for Ethics of Science andTechnology, and Eubios Ethics InstituteConference 24-26 June 2017 at theInternational Peace Park@kaeng Krachan,and Chulalongkorn University, Bangkok,
Thailand. Organizers: Center for Ethics of Scienceand Technology, Chulalongkorn University, Thailand,
American University of Sovereign Nations (AUSN),
USA, the International Peace and Development Ethics
Centre, and Eubios Ethics Institute.

Social Work, Human Security, Ethics andHuman Ability, 1 July 2017, UKM, Kuala
Lumpur, Malaysia. Organizers: UKM; American
University of Sovereign Nations (AUSN), USA, AsiaPacific Forum on Ethics.

Intensive courses on research ethics andbioethics in the Philippines:
Catanduanes State University, Virac, 6July 2017
Bicol University, Legapzi, 7-8 July 2017
University of San Jose-Recoletos, Cebu,
10-12 July
Visions of Social and Ethical Change in
ASEAN, and Beyond, 17 July 2017 (9:0017:00)
Chulalongkorn
University,

Bangkok, Thailand. Organizers: Center for Ethics
of Science and Technology, Chulalongkorn University,
Thailand, American University of Sovereign Nations(AUSN), USA, Youth's UNESCO Club, and Eubios
Ethics Institute.

Joint
AUSN-Bangladesh
SocietyofBioethics Intensive Bioethics Training
Course, 15-16 July 2017 in Dhaka,Bangladesh.
International
Bioethics
Roundtable:
Bioethics Across and Between Continents
and Peoples for the Betterment of All
AUSN, Arizona, USA, 2-5 September 2017
Eighteenth Asian Bioethics Conference:
The Future of Bioethics and Healthcare(ABC18), 25-28
October2017
inSeoul, Republic of Korea, followed by a Joint
AUSN-Gangneung-Wonju
National
University
Intensive
Bioethics
Workshop(ABA Satellite meeting) 29-30
October 2017 in Gangneung, Korea.
The Eleventh Kumamoto University
International
Bioethics
Roundtable: Philosophy and practice of
bioethics across and between cultures,
18-19
November
2017,
University, Japan.
Contact: Kimiko Tashima,ktashima@kumamoto-u.ac.jp

Kumamoto

EJAIB Editor: Darryl Macer
Associate Editor: Nader Ghotbi (Ritsumeikan Asia
Pacific University (APU), Japan)
Editorial Board: Akira Akabayashi (Japan), Sahin Aksoy(Turkey), Martha Marcela Rodriguez-Alanis (Mexico),Angeles Tan Alora (Philippines), Atsushi Asai (Japan),
Alireza Bagheri (Iran), Gerhold Becker (Germany),
Rhyddhi Chakraborty (India/UK), Shamima Lasker(Bangladesh), Minakshi Bhardwaj (UK), Christian Byk(IALES; France), Ken Daniels (New Zealand), Ole Doering(Germany), Amarbayasgalan Dorjderem (Mongolia),
Hasan Erbay (Turkey), Soraj Hongladarom (Thailand),Dena Hsin (Taiwan), Rihito Kimura (Japan), Abby
Lippman (Canada), Umar Jenie (Indonesia), Nobuko
Yasuhara Macer (Japan), Masahiro Morioka (Japan),Anwar Nasim (Pakistan), Jing-Bao Nie (China, New
Zealand), Pinit Ratanakul (Thailand), Qiu Ren Zong
(China), Hyakudai Sakamoto (Japan), Sang-yong Song
(Republic of Korea), Takao Takahashi (Japan), Noritoshi
Tanida (Japan), Ananya Tritipthumrongchok (Thailand),Yanguang Wang (China), Daniel Wikler (USA), Jeong Ro
Yoon (Republic of Korea).

Eubios Journal of Asian and International Bioethics 27 (May 2017)103

Eubios Ethics Institute Publications(Books sent by SAL post, Journal by Airmail - Price included)
Eubios Journal of Asian and International Bioethics (Annual subscription)
Shaping Genes: Ethics, Law and Science of Using Genetic Technology in Medicine and Agriculture
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Equitable Patent Protection in the Developing World
by William Lesser, May 1991, 150pp.
Attitudes to Genetic Engineering: Japanese and International Comparisons (Bilingual)by Darryl Macer, May 1992 330pp.
Human Genome Research & Society
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ISBN 0-908897-03-0 (English), 230pp. ISBN 0-908897-04-9 (Japanese), 240pp.
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Feb. 1994 ISBN 0-908897-06-5 (English), 320pp. ISBN 0-908897-07-3 (Japanese), 340pp.
Bioethics for the People by the People by Darryl Macer, ... May 1994 ISBN 0-908897-05-7, 460pp.
Bioethics in High Schools in Australia, Japan and New Zealand, by D. Macer, Y. Asada,
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Bioethics in India Eds: Jayapaul Azariah, Hilda Azariah & Darryl R.J. Macer
June 1998 ISBN 0-908897-10-3, (includes 115 papers) 403 pp. (Printed in India)
Bioethics is Love of Life: An alternative textbook by Darryl Macer, July 1998 ISBN 0-908897-13-8,
152pp. (Note 2nd edition published on iTunes Store as an iBook in 2015)
Bioethics in Asia Eds: Norio Fujiki & Darryl R.J. Macer, (includes 118 papers from Nov.1997
conferences, ABC’97 Kobe and Fukui Satellite) June 1998 ISBN 0-908897-12-X, 478 pp.
October 1999 ISBN 0-908897-14-6 (Japanese), 320pp.
Ethical Challenges as we approach the end of the Human Genome Project
Editor: Darryl Macer, April 2000 ISBN 0-908897-15-4, 124pp.
Bioethics Education in Japanese High Schools (in Japanese only)
Editor: Darryl MacerApril 2000 ISBN 0-908897-16-2, 112pp.
Bioethics and the Impact of Human Genome Research in the 21st Century
Eds: Norio Fujiki, Masakatsu Sudo, & D.R.J. Macer March 2001 (English and Japanese bilingual, 350pp).
Bioethics in Asia in the 21st Century
Eds: Song Sang-yong, Koo Young-Mo & Darryl R.J. Macer
August 2003 ISBN 0-908897-19-7, 450pp.
Challenges for Bioethics from Asia Ed: Darryl R.J. Macer
November 2004 ISBN 0-908897-22-7 656 pp.
A Cross Cultural Introduction to Bioethics, Editor: Darryl Macer 2006, 300pp. (A4)
(Note 2nd edition published on iTunes Store as an iBook in 2015)
Bioethics in Iran, Editor: Alireza Bagheri, 2014. ISBN 978-0-908897-25-4 262 pp.
Bioscience Ethics Education Curriculum for Pre-Schoolers to Elementary Age Children,
Irina Pollard and Amara Zintgraff,. 2017 ISBN 978-0-908897-28-5, 60pp. (A4)
Getting Along: The Wild, Wacky World of Human Relationship, Laura R. Ramnarace 2017
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