As Dr. Ross notes, companies do, of course, have a fiduciary obligation to their stockholders, but my editorial was intended to appeal to forces in corporate life other than purely fiscal ones. In fact, many pharmaceutical companies, as well as those in other sectors of the economy, take seriously their nonfinancial obligations, including those to their customers and other parts of the community, not just because it's the "right thing" to do but because it makes good, hard business sense. A well-known example is Johnson & Johnson's credo, which begins: "We believe our first responsibility is to the doctors, nurses and patients, to mothers and fathers and all others who use our products and services" (1). This policy is widely credited with helping the company make good business decisions during the so-called Tylenol crisis (2), which suggests that it is more than just window dressing.

The number of prescriptions written is, to be sure, driven primarily by doctors' willingness to write them. But lower drug prices could very well encourage doctors to write prescriptions, to their patients' benefit, in just those discretionary situations where they now hold back because they know patients would have trouble paying for them. Moreover, because of high costs, patients frequently fail to fill, or refill, prescriptions that could do them good. On this account as well, lower prices would almost certainly increase the actual volume of drug sales.

I agree totally with Dr. Ross about the need for universal health care, as I've stated previously (3). The College is also on record as supporting universal access.

Dr. Lisker provides a number of important insights on drug sales and promotion, including the role of the FDA. The cost of FDA approval clearly influences drug prices, but the degree to which it does so is a complex subject. It does seem, however, that the current system, in which manufacturers' fees help pay for drug approval, muddies the regulatory waters, since it potentially provides industry with a kind of leverage that may not always be in the public's best interest.