The free mouse pads and pens that popped up every time a baby formula salesman visited Indiana University Hospital annoyed Marsha Glass, a former lactation consultant there.
However, the cases of baby formula-left not for newborn mothers but for nurses on her floor who had babies at home-prompted her to take action. Giving formula to nurses, she said, went way beyond the $75 limit set for such gifts by Clarian Health Partners, the hospital network that includes IU.
Glass complained to her supervisor and confronted the formula rep the next time he visited. She believes pricey gifts are all too common and all too improper in health care these days.
"That's a huge issue," she said. "It really needs to be a national issue because it's unethical."
Gift and sample giving is a national issue and has been for a long time, according to experts in medical ethics.
Glass' case spotlights a longstanding quandary for medical professionals. The same free drug samples that help patients can also influence the prescribing habits of their doctors.
Many hospitals have tightened the reins on gift acceptance, and some providers have even launched a Web site protest of the practice.
Gifts from industry representa- tives come in many forms. The list of possibilities includes cruises sponsored by drug companies, a more common tactic 10 or 15 years ago, according to Ray Moseley, a professor of bioethics, law and medical professionalism at the University of Florida.
It also includes textbook purchases for medical students or sponsoring a campus speaker, according to Joy Skeel, a medical ethics professor at The Medical University of Ohio in Toledo.
Drug samples, pens and notepads sit on the lower end of the scale. Glass also saw formula representatives drop off doughnuts, bagels and candy for the nursing staff on her floor.
"They'll do as much as they can get away with," said Glass, who believes her protests eventually cost her her job.
She filed a gender discrimination lawsuit earlier this year against Clarian over her situation. Her complaint alleges that some Clarian doctors limited her ability to help new mothers breastfeed after she complained about the formula. The case, which was filed in U.S. District Court, Southern District of Indiana, is pending.
Clarian spokesman Jon Mills declined to comment on the legal matter or Glass' employment at IU.
To one extent or another, freebies are widespread in health care, according to Patrick G. Derr, a health care ethics expert and professor at Clark University in Massachusetts.
"Just check out the pens in people's pockets," he said. "They've all got a company name on them, and they're not cheap pens."
Sales representatives pass stuff out for a simple reason: They see results.
Many studies have shown that gifts and samples from pharmaceutical representatives influence prescription patterns, Skeel said. They also build brand loyalty for a product and help pharmaceutical companies track the popularity of certain drugs.
"It's kind of scary to know it's the big brother looking over your shoulder," she said.
But the benefits aren't limited to sales reps. Drug samples give patients a chance to try a medication before committing to a prescription, noted Dr. Priscilla Ray, chairwoman for the American Medical Association's Council on Ethical and Judicial Affairs.
"Some of my patients would have trouble affording their medications if I couldn't provide them with samples," said the Texas-based psychiatrist.
In the same light, free textbooks help medical residents who might not have the money to buy them, Skeel noted.
A vendor-sponsored fancy dinner that includes a speaker or entertainment might seem excessive. But doctors will say it provides a chance to talk to their colleagues and learn about new medicines, Skeel said.
All this gift giving does not go unchecked. Several years ago, the AMA introduced recommendations for doctors to follow.
They state, among other things, that gifts should primarily benefit patients and "should not be of substantial value," a term with no set definition, according to Ray.
"Physicians have to be mindful that we have to put our patients first," she said. "That's our job; that's why the guidelines exist."
Gift giving and sample taking have been around for years. Ray remembers receiving a textbook and a black bag with her name embossed in gold when she graduated from medical school in 1974.
But the practice is changing. Skeel said some Ohio hospitals started limiting samples in recent weeks because their leaders felt staff were taking them for personal use.
A New York City doctor has launched a Web site-www.nofreelunch.org-devoted to protesting the practice. The site offers a "pen amnesty program" that asks doctors to give up their drug company pens in exchange for one from No Free Lunch. Those drug company pens will wind up at "a worthwhile charity," the Web site states.
Doctors have become more aware of the possible conflicts and influences that come with accepting gifts and samples, Moseley said, adding that medical schools are teaching students more about the issue.
Industry reps, in turn, have discovered the joys of direct marketing. They've found better results by focusing their marketing energies on patients and not the doctors.
Even so, samples and pens and free lunches are here to stay, according to Moseley. Freebies still market a product by putting its name out there.
Nothing short of a complete overhaul of the health care system will change that.
"As long as we have a system that treats providing medicine as a business where you have products and consumers, marketing is going to occur," he said.