Unethical Practice In The Pharmaceutical Sector Nursing Essay
Similar findings are reported in some studies which revealed that side-effects and contraindications were often neglected by medical representatives (Hemminki, 1977). Furthermore, a survey in France from 1991 to 2005 revealed that contraindications and side effects were less frequently mentioned by medical representatives (Othman et al., 2010).
Similar results were found in the study of Lagace et al. (1991) which supported that unethical practice in the pharmaceutical sector resulted from medical representatives over exaggerating drug capabilities. Cramton and Dees (1993) pointed out that success in negotiation is enhanced by the skillful use of deceptive tactics, such as exaggeration.
It should be noted that some authors had already identified this ethical issue in the negotiation context (Lewicki and Robinson, 1998; AL-khatib, 2008). Lewicki and Robinson (1998, p.667) define this issue as: "the introduction of erroneous, incorrect information as though it was true." In fact, according to Bellizzi and Hasty (2003), this behavior is considered as an unethical and inappropriate conduct. In the same line, Zeigler et al (1995) found that 11% of information provided by the medical representatives about drugs is inaccurate. Othman et al (2010, p.10) claimed that misleading information provided by medical representatives "is of concern and may lead to misrepresentation of the actual therapeutic value of the drugs."
Representatives do use illegal off-label promotion to promote their products without the Food and Drug Administration (FDA) approval (Gagnon and Lexchin, 2008).
In the previous studies, falsifying research data was considered as an ethical dilemma (Ferrell and Gresham, 1985; Gupta, 2006; Masood et al., 2009). In fact, according to Masood et al., (2006, p.1942), the research figures used by medical representatives are "manipulated to turn a two percent improvement into a fifty percent improvement. Graphs are doctored by altering the scales to show substantial improvements where none exist".
These incentives range from brand reminders to gifts of greater value (e.g., electronics, trips), according to our respondents. Funding participation to medical congress and events (stay, conference registration fees) is also another common incentive. Indeed, pharmaceutical firms may offer to physicians the conference fees and accommodation and also may pay the stay for their wives and children.
However, very few physicians recognized explicitly having accepted gifts. Those who did stated that accepting the gift would not influence their decision about which drug to prescribe. Ironically, almost all of them knew of another professional who had accepted gifts and believed that their prescribing had been influenced by this incentive. These results were found in Roy el al. (2007) and Masood et al., (2009). These authors claimed that the pharmaceutical sector is one of the most corrupt among the industries. In addition, previous studies confirmed that these incentives are "perceived as bribes or payments for favors received or expected" (Haines and Olver, 2008, p.264).
representatives were more willing to talk about the behavior of their competitors rather than their own.
Such a result offer support to the previous studies ones. As Cooper and Frank (1991) indicated, making disparaging remarks about competitors and their products is one of the six issues of concern identified in their study. In the same vein, Howe et al., (1994) and Cooper and Frank (2002) showed that misrepresenting a competitor's product to gain a competitive edge is one of the biggest problems of the insurance industry.
To the best of our knowledge, there are no empirical studies that deeply focused on stealing as an unethical behavior. In fact, Schwartz (2001) just mentioned that stealing among other practices is an example of misconduct.
To conclude, we identified a number of blatantly unethical and illegal practices -misleading and incomplete information; making disparaging remarks about competitors and their products; giving incentives; seducing physicians; making false calls and stealing samples. In fact, this raises the question of the effectiveness of the existing policies overseeing the relationship between medical representatives and physicians. But to which extent these unethical issues are considered appropriate or acceptable?
An individual's ethical judgment is the degree to which he or she considers a particular behavior morally acceptable (Gifford and Norris, 1987; Reidenbach and Robin, 1990; Bass et al., 1999). Many authors have employed ethical judgments regarding specific actions as an integral part of their research design (e.g. Akaah and Riordan, 1989; Mayo and marks, 1990). In our study, the content analysis revealed a large agreement among medical representatives about the inappropriateness of the identified questionable ethical issues by medical representatives. Physicians, have not a shared perception.
Very few medical representatives recognized to behave unethically. Ironically, those who did qualified these practices as inappropriate.
However, it should be noted that very few physicians admitted to accept gifts and those who did stated that accepting gifts is not an unethical practice. In fact, 6 of the interviewed physicians explain that this is how things are done around here. As a matter of fact, they considered that these practices are morally acceptable. These findings offer support to the prior studies especially Bansal and Das (2005) and Roy et al., (2007, p.59) ones who argue that physicians "felt that some gifts were expensive enough to serve as inducements". Indeed, they found that physicians and medical representatives perceive that accepting gifts is morally inacceptable.
The results of the content analysis are consistent with some studies findings which showed that the corporate culture is a major influential determinant of ethical medical representatives' behavior (Schwepker et al., 1997; Schwepker and Hartline 2005, Ferrell et al., 2007). In fact, the organizational culture was defined by Maignan and Ferrell (2004, p.) as the "set of values, norms, and artifacts shared by members that result in behavior to resolve problems and decisions". The organization culture affects tremendously medical representatives' ethical behavior. According to our respondents, it is different whether the pharmaceutical firm is national/international or genereic/princeps.
As matter of fact, past research findings have been somehow controversial. Indeed, while some studies have reported that in large companies, there are less questionable ethical practices, because larger firms have more established and formally defined ethics and business compliance programs (Chavez et al., 2001; Roy et al., 2007), others have found a negative relationship between size and ethical behavior (Weber, 1990; Chonko and Hunt, 1985) because the larger the firm, the more complex the operations.
This result is consistent with previous research findings. Indeed, Delaney and Sockell (1992) showed that the existence of an ethics program is positively related to the refusal by the sales representatives to behave unethically. In this regard, Thompson (1990) reported that studies of ethics training have tended to focus on the nature of ethics programs instead of the effectiveness of that training. However, the informants' responses confirmed an astounding result which suggests that the quality and the effectiveness of corporate ethics training is very important. And the medical representatives will be less likely to behave unethically.
In this regard, we noticed that the non-compliance of codes of ethics by medical representatives operating in local firms can explain the previous results which show these medical representatives behave less ethically than the others operating in international firms.
In this regard, literature review related to sales representatives ethical issues stress the need to develop codes of ethics in order to resolve ethical dilemmas (e.g., Rudelius and Bucholz 1979; Dubinsky et al., 1980; Dubinsky 1985). In fact, previous studies have already showed that code of ethics is positively related to ethical behavior (Newstorm and Ruch, 1975; Hegarty and Sims, 1979; McCabe et al., 1996; Peterson, 2002).
Previous researches have also showed that control system is a noticeable determinant of a salesperson's ethical behavior (Roman and Munuera, 2005). In fact, our results give support to Verbeke et al. (1996) conclusions that control systems influence positively ethical decision making because of their effect on the climate. These findings had already been substantiated by Robertson and Anderson (1989).
In this section, we identified the main organization related factors. Generally, organizational factor appears to be a prominent organizational factor behind the ethical behavior of medical representatives. What are then the individual determinants that influence their ethical behavior?
Salespeople's job tenure can be "either total sales experience or length in their present position" (Dubinsky and Ingram, 1984). According to three of the interviewed medical representatives, the more experience salespeople have in their jobs, the more they are ethical. In other words, senior medical representatives can recognize that certain questionable business practices are inacceptable.
To conclude, the recurrence of job tenure in the respondents' speech illustrates the importance they give to the influence of medical representatives' experience on their ethical behavior. Shapeero et al. (2003) had already argued that senior sales representatives are less likely to engage in unethical behavior. In fact, these authors showed that there may be a maturation process where, as employees gain experience, they become more confident in their abilities and feel less pressure to engage in unethical activities. Furthermore, there may be an investment aspect where as individuals build their careers they are less willing to place their investment in danger by engaging in unethical activities.
To conclude, medical representatives who have a favorable attitude toward their jobs are probably less likely to turn over and more likely to engage in positive behaviors. As found in Eagly and Chaikhen (1993, p.12) studies, "people who evaluate an attitude object favorably tend to engage in behaviors that foster or support it, and people who evaluate an attitude object unfavorably tend to engage in behaviors that hinder or oppose it"
In fact, after the revolution, we witness the rise of Islamist governments that encourage religiosity. A growing conservative mind-set is spreading across the country and the more frequent appearance of women wearing headscarves (Tchaicha and Arfaoui, 2012) explains somehow the importance of this factor. The results of the content analysis are in line with previous study findings. According to Stead et al., (1990), religious backgrounds have an impact on ethical attitudes of individuals. Individuals with higher level of religiosity will be probably more ethical. Kennedy & Lawton (1998) claim as well a negative relationship between religiosity and the disposition to do unethical practices.
Unlike previous results suggesting that females are more ethical than male (Nguyenet al., 2008), our study suggests an opposite result. It is worth noting that in previous research, a major interest had been devoted to the influence of gender on the ethical behavior (Sidani et al., 2008). In fact, according to Sidani et al., (2008), the Arabic females are expected to behave more according to ethical considerations and to adhere to strict social and moral guidelines, as understood by the society. In the same line, Al-Ghazali (1990) showed that a "female's sin" is never forgiven and in many cases she pays dearly for the same actions that a male would unapologetically do.
However, unlike previous findings, our study suggests that age negatively affects medical representatives' ethical behavior. In fact, almost all the studies have indicated an increase in ethicality with age (Sidani et al., 2008). For instance, Barnett and Karson (1989) claim that younger persons acted less ethically compared to older ones. Furthermore, Peterson et al. (2001) found that younger participants had lower ethical standards. However, in the Arab countries research addressing the link between age and ethics is virtually non-existent (Sidani et al., 2008).
This factor appears to be one of the most important determinants of medical representatives' ethical behavior. A medical representative's stakeholders are the persons with whom he interacts. Some authors classified this factor as an organizational factor (Schoderbek and Deshpande, 1996); others considered it as an individual determinant of sales representatives' ethical behavior (Jones and Kavanagh, 1996; Andersson and Bateman, 1997; Beams et al., 2003).
Results of the content analysis suggest that potential of prescription can be a factor to behave unethically. In fact, the six interviewed medical representatives claimed that the more the potential of prescription is high, the more medical representatives do questionable practices. These results give support to Roy et al., (2007) conclusions that pharmaceutical firms offered "gifts" only to physicians who were considered "good" prescribers, because they were more likely to get returns of their investments in such physicians.
Our results are consistent with some previous studies findings. According to Roy et al., (2007), general practitioners don't receive the expensive gifts received by the specialists because they are not profitable.
Results of the content analysis suggest that a medical representative's peers have been found to influence unethical behavior. In this study, these referent peers are medical representatives who are employed by their pharmaceutical firms or by competitors.
The results of the content analysis are consistent with these previous study findings. In fact, authors have already found that peers influence positively the unethical behavior of sales representatives (Jones and Kavanagh, 1996; Beamset al., 2003; Deshpande et al., 2006). Altheide et al., (1978) asserted also that peers set the standards for which types of unethical practices are acceptable. Furthermore, according to Schein (1984), peers provide the guides to behave ethically or unethically.
According to the content analysis, medical representatives (f=10) as well as physicians (f=5) mentioned that pressures from superiors within an organization seem to exert a major impact on unethical behavior.
It should be noted that according to the analysis results, we noticed that hierarchical superiors (15 out of 40) have a greater influence on the medical representative than his peers (7 out of 40). These results offer support to Ferrell and Gresham's (1985) findings suggesting that superiors might influence the ethical behavior because of their power and authority. In fact, according to Brenner and Molander (1977), the main cause of unethical conduct is pressure imposed by superiors.
Results of the content analysis suggest that pharmacists can influence negatively the ethical behavior of medical representatives. In fact, according to one of the interviewed physicians,
The results of the content analysis are in line with previous study findings. As a matter of fact, some authors argue that the commission-based compensation encourages salespersons to do unethical behaviors (Bellizi and Hite, 1989, Hechinger, 2003; Mantel, 2005). According to Honeycutt, commission-based compensation methods might motivate automobile salespeople to act in a manner that will result in maximum sales.
Data analysis revealed that when business competitiveness is extreme, medical representatives may find that unethical practices questionable are a normal way of doing their job. Our results show that both medical representatives (f=11) and physicians (f=8) think that business competitiveness influence negatively the ethical behavior of salespersons.
These results are in line with previous study findings on ethical behavior of salespeople (Dubinsky and Ingram, 1984). Business competitiveness can have an obvious impact on ethical behavior of medical representatives. In fact, Baumhart (1986) conclude that as the intensity of the market's competition rises, so do unethical practices.
In fact, such results give support to the negative relationship found later between method of compensation and medical representatives' unethical behavior. Similar results are found in Molander (1987), Posner and Schmidt (1984), Robertson and Rymon (2001), and Weaver et al. (1999) studies. Cohen (1993) offers a possible explanation to this relationship. It seems that organizations emphasis on the goals they wish their sales representatives to attain. Employees are then forced to use means that may be unethical.
Previous studies indicate that situation related factors play an important role in determining ethical behavior (Cadogan et al. 2009; Barnett and Valentine, 2004).
Similar findings are reported in Ferrell and Weaver (1978) study suggesting that questionable ethical practices become acceptable because of the absence of sanctions. Furthermore, Barnett and Valentine (2004) concluded that when a specific unethical action has more serious or harmful consequences, salespeople are less likely to undertake the unethical action.
These findings are in line with the results of our content analysis. Ford and Richardson (1994) point out that organizational reward have a negative effect on sales representatives' ethical behavior. Idris et al., (2011, p.824) showed that "any tendency towards deceit may be attributed to the greed for sales which grants incentives and possible better job promotion and status".
Barrels (1967) was one of the first authors to emphasize the importance of cultural factors (e.g. values and customs, religion, law, respect for individuality, national identity and loyalty (or patriotism) and rights of property) in ethics decision-making. According to Hunt and Vitell theory of ethics (1986), cultural environment is one of the constructs that affect individual's perceptions in ethical decision, which includes: legal system, religion and political system.
Westing (1967) claims that law is a key factor of ethical behavior. In fact, individuals believe that they are ethical if they respect the law. Thus, as found in Bommer et al., (1980), legal environment legislation has a significant influence on the ethical decision making of sales representatives. Furthermore, according to Honeycutt et al., (2001), it appears that illegal practices discourage sales representatives to behave unethically because they fear their negative consequences.
It appears that Tunisia has been doing not well in terms of corruptions indicators which explain the results found in our study. In fact, according to the 2011 Annual Corruption Report issued by Transparency International, Tunisia scored 3.8 on a ten point scale, where ten represents no corruption. Tunisia ranked 73 dropping 14 positions compared to 2010 (Transparency International, 2011). Furthermore, in 2011 one of the USA government cables released by Wikileaks exposed a high level corruption in Tunisia  .
As a matter of fact, some authors showed that cultural values are at the heart of individual's personality and cognitive personality (Parsons and Shils, 1951; Rokeach, 1973). According to Ouannes (2010), it seems that the Tunisian society can be characterized as an opportunist society where Tunisians are making the best of circumstances even against their moral principles. However, to the best of our knowledge, there are no empirical studies that investigate the influence of culture on the ethical decision making (Vitell et al., 1993).
We believe our study has made a number of contributions to the existing body of research regarding ethical behavior of medical representatives. Results of the content analysis provided answers to our central question and to the study objectives concerning ethical issues in the pharmaceutical industry and determinants of medical representatives' ethical behavior.
To the best of our knowledge, previous studies aimed attention at only sales representatives' perception when investigating about the questionable ethical issues and the determinants that are behind these practices (Al-Khatib et al, 2002). Thus, this research fills this gap and provides the perception of Tunisian medical representatives as well physicians in the Tunisian pharmaceutical sector.
Unethical behaviors are a double-edged sword. In fact, they could be interesting for medical representative because they raise sales quotas (Bellizzi and Hasty, 2003). However, these questionable ethical practices may cause bad public image of the firm, poor reputation, customer complaints (Paine, 1994; Chonko et al., 2002; Bellizzi and Hasty, 2003). Thus, the investigation of determinants that encourage such practices is extremely serious.
Regarding the determinants of medical representatives' ethical behavior, most of the previous studies focused on organizational and individual factors as the main factors of ethical behavior. Our study revealed that other factors are important too. In this regard, 6 main categories of factors had been identified.
First, when we consider the organizational factors, it seems that Tunisian medical representatives are mainly influenced by organizational culture. These findings corroborate previous studies findings about the significance of corporate culture as a critical determinant of medical representatives' ethical behavior (Schwepker et al., 1997; Schwepker and Hartline 2005, Ferrell et al., 2007). Our study identified two facets of this factor: national versus international companies and genereic versus princeps firms.
Besides, our study revealed that training, control system, organization size and code of ethics are also organizational factors of the ethical behavior. In fact, the medical representatives of large pharmaceutical firms adopting codes of ethics seem to behave ethically when they are controlled by their management. Analysis also revealed that the unethical behavior of medical representatives is influenced positively by their attitude toward the selling job.
Second, concerning the individual determinants, it appears that personality traits are the main factor that influences the ethical behavior of medical representatives. However, there is unanimity about the influence of this factor (such as Machiavellianism and cognitive moral development) on the ethical/unethical behavior of sales representatives (Singhapakdi and Vitell, 1991; Verbeke et al., 1996). Our study also indicates that job tenure appeared to be quite important in influencing the ethical behavior of medical representatives. The results of our study are somehow controversial. The interviewed medical representatives reported that job tenure influences positively the ethical behavior of medical representatives. These findings are supported in Shapeero et al.'s (2003) and Dubinsky and Ingram (1984) studies. In fact, these authors had already argued that job tenure influences positively the ethical behavior of medical representatives. However, the physicians say the opposite. Our results showed that as medical representatives gain experience, they become more unethically. Another factor that influences positively the ethical behavior is education level. In fact, the less educated the medical representative is, the less ethical will be. These results are supported by Giacalone et al. (1988) and Kraft & Singhapakdi (1991). Both researchers claim that sales representatives with higher level of education are more ethical because they can judge if this behavior is ethical or not. Last, gender, age and religiosity also appeared to be a determinant of medical representatives' ethical behavior.
One other major finding of this study is the critical role of stakeholders which appear to be one of the most important determinants of medical representatives' ethical behavior. In this context, our study indicates that medical representatives can be under the influence of stakeholders with whom they interact. Thus, as Ferrell and Gresham (1985) contended: "the more frequent the contact with the significant other, the more likely the employee will adopt similar un/ethical beliefs". This factor is expressed through the physicians, peers, hierarchical superiors and pharmacists. Indeed, respondents noticed that physicians influence positively the medical representatives to behave unethically. Moreover, pressures from hierarchical superiors seem to exert a greater impact on unethical behavior than his peers. In addition, pharmacists influential represent a factor that drives medical representatives to behave unethically.
As to job characteristics, the method of compensation significantly influences ethical behaviors. Some authors have already found a positive relation between commission-based compensation and unethical behaviors (Mantel, 2005; Hechinger, 2003). Furthermore, the interviews suggest that business competitiveness is a prominent factor that influences ethical behavior of medical representatives. These findings offer support the prior studies especially Schwepker (1999) who emphasized the negative influence of business competitiveness on ethical behavior. Another job characteristics related determinant is performance pressure. In fact, medical representatives seem to behave unethically in order to attain the goals fixed by their management. This result supports Molander (1987), Posner and Schmidt (1984), Robertson and Rymon (2001), and Weaver et al. (1999) findings that performance pressure force sales representatives to use unethical means.
With regard to the situation related factors, an important factor emerges among interviewees is the magnitude of consequences. Previous studies indicated that has a major impact on the ethical behavior of medical representatives (Barnett and Valentine, 2004). In fact, our study identified two aspects of this factor: the threat of being fired and rewards and promotion opportunities.
Results of our study as to cultural factors reveal two main determinants: 1-legislation and 2-cultural values. First, legislation appears to be the main important cultural factor that influences the ethical behavior of medical representatives. This finding joins Honeycutt et al., (2001) who argues that legislation discourage medical representatives to behave unethically because they fear their negative consequences. Not surprisingly, the Tunisian medical representative appears to be affected by the cultural values of his society.
A summary of the main findings is
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