By JEFFREY L. SEGLIN

or Dr. Rusty West, a physician at the Nocona Medical Clinic in Nocona, Tex., the free golf balls, dinners and sports tickets he had received over the years from drug companies were a "small price to pay" for access to him and the other doctors in his practice. But the trade group representing the pharmaceutical industry is now discouraging such gifts through a voluntary code of ethics that took effect in July.

Though many other doctors seem to feel the same way as Dr. West, such guidelines from the Pharmaceutical Research and Manufacturers of America should come as no surprise. Offering gifts unrelated to a physician's practice — a common way to gain access to a physician — was explicitly discouraged in 1991 by ethics guidelines of the American Medical Association, to which roughly 30 percent of physicians belong. The Texas Medical Association, to which Dr. West belongs, also denounces such gifts. (Dr. West says that he has not been offered any perks lately, but that he had no ethical qualms about accepting them before.)

"It's pretty hard to see how a round of golf entails a benefit to patients," said Dr. Alan R. Nelson, a former president of the A.M.A., who this year headed a group charged with educating its members about the ethics of accepting drug-company gifts.

The pharmaceutical group's code is viewed by some people in the industry as a leveler, helping to ensure that companies compete for a physician's attention based solely on the merits of their products. The guidelines, among other things, prohibit any gifts, even of modest value, that are not for the primary benefit of patients: anatomical models for examination rooms are O.K.; World Series tickets for a doctor's family are not.

Few pharmaceutical companies admit to engaging in the behavior that the guidelines reject.

"Quite frankly, complying with the PhRMA code is not going to require any changes on our part," said Bradley T. Sheares, president of the US Human Health division of Merck & Company.

But Scott Willoughby, assistant general counsel for the pharmaceutical group, said the industry was facing a growing perception problem. "Our C.E.O.'s kept getting beat up in the paper over our marketing practices and wanted us to find a way to put a code together to keep bad press from happening," he said. "If people thought we were doing a bad thing, we wanted to change that perception."

Perhaps not enough, however. It is up to each pharmaceutical company to establish mechanisms to punish representatives who break the rules.

Some consumer groups find the self-imposed call for better behavior disingenuous. "Here is an industry that has created, funded and built its livelihood around these conflicts," said Ronald F. Pollack, executive director of Families USA in Washington. "To expect effective policing of these practices when they're the creator of these problems is a stretch of credibility."

Some government officials feel that way, too. In June, Vermont became the first state in the country to enact a law requiring all pharmaceutical companies to report gifts for physicians if the gifts are worth more than $25.

"We think most physicians will not take anything over $25 if they know their names are going to be on the Web associated with these pharmaceutical companies," said Gov. Howard Dean of Vermont, who once was a practicing physician himself.

Doctors, meanwhile, seem to be wrestling with their own ethics code. Earlier this year, the Polyclinic, which runs three health care clinics in Seattle, started charging the pharmaceutical representatives $30 to drop off samples. Howard Springer, the practice's associate administrator, said that this did not violate the A.M.A.'s policy prohibiting physicians from accepting cash payments, because "we're not guaranteeing them access to the physicians."

But Dr. Leonard J. Morse, chairman of the A.M.A.'s Council on Ethical and Judicial Affairs, disagreed. "It's inappropriate to the A.M.A. code," he said. "Such payments should not be accepted." It's a moot point for now. Polyclinic, which once had 15 to 20 visits a day from pharmaceutical representatives, now has none after imposing the fee, Mr. Springer said.

For drug companies, the challenge goes beyond merely promulgating a new code of behavior. The public will be watching for attempts to skirt the spirit of the guidelines. Doctors should refresh their memories about their own code and refuse the gifts they should have been refusing all along.

If they fail to comply, state governments may have to step in. Laws like Vermont's will go a long way toward policing the ethical behavior of the companies and the physicians if they cannot police themselves. 
 

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