medical ethics
Legal Bribery
how doctors may get paid (indirectly) for prescribing your meds
I recently visited my cardiologist and, as a result, learned something I didn’t want to know:
Doctors don’t always just prescribe the drugs you need the most. They at times may prescribe the ones they are paid to prescribe.
I’m not talking about shady deals in back alleys. I’m talking about perfectly legal ‘kickbacks’ they get (indirectly) for prescribing you certain medications.
People to whom I have told all this have urged me not to identify particular medicines or particular pharmaceutical companies. “You’ll get sued,” they warn me.
Let them sue me. Everything I’m going to say here is the truth, and openly acknowledged in certain circles. The drug companies freely admit what they’re doing. In fact, they are required by law to list all the activities they pursue in this regard. Nothing is secret. It’s all there for anybody to find out who wants to.
I didn’t particularly want to, but I found out anway.
I’m going to share here some personal history that is probably technically irrelevant to the discussion, but it will help clarify what I learned and how and why I learned it, as well as why I’m now sharing what I learned, so I think it’s something I really have to do.
Back in January of 2023, I had a minor stroke. Not the kind where a blood vessel bursts inside your brain [called a hemorrhagic stroke] and floods the neurons with blood and creates damage by creating pressure on the brain tissue. Nope. The other kind — where a small clot blocks the blood flow to some region inside your cranium, resulting in the brain substance there becoming starved for oxygen and simply dying if the situation isn’t dealt with within minutes. [This is ischemic stroke, which is much more common, amounting to more than 85% of all strokes.]
The first kind are very often fatal, especially if your blood is thin for some reason and refuses to clot properly.
The second kind can be fatal, but more usually results in loss of function in some part of your body. If this occurs when you are already in a hospital or doctor’s office for some other reason, you can be given an emergency blood thinner which may, if you’re lucky, dissolve the clot and restore the lost function.
In other words, the first kind is worse if your blood is too thin, and the second kind is worse if it isn’t thin enough. A dilemma of the worst sort.
But if you have the second kind, and you are home and it takes wenty minutes for the ambulance to get to you, and another twenty for them to get you to the Emergency Room? Well, it’s very simple. You can just say good-bye to that part of your brain. Permanently. Once a particular lobe is dead, there’s no bringing it back. Other parts of your brain may learn to perform the functions that the dead part used to do, and thereby lessen the impact, but as far as that piece of thinking tissue is concerned, it’s gone. Forever.
When I say I had a mild one, I mean that it was a very small clot and the region that was affected in my brain was only about the size of a walnut. It happened to be a region that helps you know how to speak, so ever since then I’ve had some difficulty in talking clearly. Which is one reason I joined Medium — so I could write what I wanted to say instead of having say it.
If it had been in a slightly different spot, it could have caused paralysis on one side of my body or the other. (It did make it so my mouth on the right side droops a bit in comparison to the left side, which is related to the speech difficulty.)
It happened while I was crossing the street, to go from a restaurant, where I had purchased a ‘to-go’ lunch, back to my place of work. By the time I got to my desk, I knew something was the matter. The right side of my face was slightly numb, and I had a bit of difficulty swallowing. I remember thinking, “I’ve had a stroke.” And then I remember deciding to ignore it. Feeling sure it would get better on its own. It was so mild, after all.
After finishing work that day, I drove the fourteen miles to my home, as I always did. And I ate a normal supper and went to bed.
When I woke up the next morning, I knew I had made a mistake. My mouth didn’t work right, and I couldn’t form words. And I could swallow, but with great difficulty.
Ambulances are slow. I drove myself to the ER and went in to be examined.
They asked me why I was there. “I think I had a stroke,” I said, and it was rather obvious from how the sounds came out that it was true. But they did all the usual tests and then told me that I was right. I had suffered an ischemic stroke. The local hospital where I had gone to the ER was not set up to handle stroke patients, so they called an ambulance, which took me to another more suitable hospital 70 miles away. I then sat in that hospital’s waiting room for three hours, waiting to be admitted.
While my car sat in the first hospital’s parking lot.
The clot was so small they never did find it. But it did the damage all the same. As one doctor put it, “We can see where it must be, but we can’t see it.”
I was in that hospital for four days, and at discharge was told that I shouldn’t expect miracles, but that I would slowly regain some of my speech capabilities and that the numbness on the right side of my face might go away or at least lessen, and, in the long run, those predictions largely came true. I was also put on a blood thinner called Eliquis, to help prevent a recurrence of the problem.
End of story. Right?
Wrong!
Not quite a year later, I came out of a grocery store to go to my car to drive home from shopping. And I couldn’t get my breath. It was at though I was at the top of some 8,000 meter mountain like Mount Everest with no oxygen pack to breathe from. This time, having learned my lesson last time, I did immediately call an ambulance, which took me to the local ER again, which once again transferred me to a different hospital, a little farther away than the one last time. I’m told that I was diagnosed immediately: congestive heart failure, but nobody bothered to tell me. It was almost a week before I found out what the problem was. And they seemed surprised I hadn’t figured it out on my own.
The cardiologist on call came to see me. He told me what the problem was. Then he delivered the really bad news. I would have to undergo two operations, to save my life. The first one was to put a stent in one of the external blood vessels on the outside of my heart. (They ended up having to put two of them.) The second operation was even more important: my aortic valve, the one that controls the flow of blood from the heart into the body, was severely damaged. It was allowing only a 15% flow rate, where anything less than 50% is considered unsafe. The valve would have to be replaced, either with an artificial one, or one from an animal such as a pig or sheep. (It turned out to be from a calf.)
They couldn’t do both procedures at once, so I would have to have two operations.
I had them, lived through them, and am in much better shape than I was.
But here’s where the Eliquis comes back.
When you get a new aortic valve, the blood tends to stick to it, because it’s a ‘foreign substance.’ If blood sticks to it, a clot can form and go into your brain.
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Hello, another stroke.
They had to take me off the Eliquis to do the two operations, as my blood would be so thin I could easily bleed to death while being operated on. But once the operations were finished, I would have to go back on the medication, at a vastly increased dose, to prevent the kinds of issues that would be presented by the new, ‘foreign’ valve.
Sigh. I was already bruising terribly from the medication, which was insanely expensive in spite of my insurance. And it would be increased?
Yep. To prevent new strokes.
I was on the new, higher dose of medicine for a year. My left hand became so bruised that it was solid purple half the time.
So I took myself off of Eliquis. Didn’t tell the cardiologist (yet). Just did it. I did tell my regular ‘family’ doctor, and he put me on another medicine that would also thin my blood (though less effectively) but contribute less to bruising.
OK, all was well. Six months ago, I went to see my cardiologist. He was a bit startled to learn what I had done, but reluctantly approved it.
Then this week, I went to see him again. He insisted that I go back on Eliquis again, in spite of the bruising. I felt that he was a little more insistent than he needed to be. Which got me to thinking in a paranoid sort of way. Which led to my discovery of legal bribery.
Eliquis has an interesting history. It was not ‘discovered,’ like most drugs. It was invented. A team of scientists at Bristol-Myers Squibb decided that a new blood thinner was needed. This was around the year 2000. The most often prescribed blood thinner at that time was Warfarin, which had indeed been discovered, not invented. (It was closely related to a livestock poison!) Warfarin was effective, but it had a lot of problems, not the least of which being that it was difficult to control the effective dosage, and some people were dying by bleeding to death from it. So this team at BMS decided to invent a better one. And they succeeded.
But it took a long time and the process was extremely expensive. So much so, that when it was time to do the human testing to make sure it was safe, BMS formed a partnership with another pharmaceutical company named Pfizer to help them conduct the tests. The drug was patented in 2007, but didn’t make it to market till 2012. The success rate was astronomical, and in short order it had replaced Warfarin as the number one blood thinner.
But drug companies don’t do these sorts of things merely out of the kindness of their hearts. They have investors, and the investors expect to share in the profit from the invention. But in order for there to be a profit for those investors to share, two things have to happen. One, the price of the drug has to be set high enough so that after all the insurance discounts and pharmacy discounts and other exceptions to the list price are accounted for, there’s still enough profit left to share.
The other thing that has to happen is — there has to be a lot of promotion, to make sure doctors are prescribing it often enough to make sure the profits come in.
So — this is where the legal bribery arrives.
The drug industry as a whole is spending several billion dollars a year to promote (and protect) their products. Billions, not millions. Pharmaceutical representatives spend a lot of money on doctors. They take them out to eat and provide free meals. They arrange for speaking engagements at universities and hospitals, where the doctor will be paid to lecture on the benefits of the drug. The universities and hospitals do the paying, but they are reimbursed by the drug company. So the money that ends up in the doctor’s pocket in essence eventually comes from the drug company, even though a direct payment would be illegal. And they are paid to do ‘research studies’ on the drug itself. Not by prescribing it, but just by ‘studying’ it. Whatever that means.
And while the doctors themselves can’t be paid to advertise the drug, the clinic where the doctor works can. When you sit in the waiting room (usually for an hour or so) waiting for your name to be called, the silent TV set in every corner — with subtitles, since you can’t hear the voices — is showing ad after ad after ad for various medications, along with exhortations and instruction about your condition. And guess what those ads are for. Yep. They’re for the medicine your doctor is prescribing for you to take. Just in case he or she forgets to prescribe it, you’re being conditioned to ask for it, just as a reminder.
Guess who is paying the clinic to show those ads on their waiting room TV? On this last visit to cardiology, I was in the waiting room for 55 minutes. I sat through the ad for Eliquis at least seven times. The ads didn’t mention that BMS and Pfizer were paying the clinic to show them. But they were.
Now am I saying that your doctor is likely to prescibe something he’s being paid to promote in place of something less expensive, and less highly promoted, that does a better job managing your symptoms? No, I am not saying that. That would be unethical. And doctors, if they are anything, are scrupulously ethical.
But what if there are two drugs that are equally effective, and one of them is taking your doctor to dinner and the other one isn’t. What then?
Right. That’s what I’m saying.
And the doctor, if he or she is even aware that the costs to the patient are vastly different, can’t afford to care. The money that is paid to the drug companies by the pharmacy where your prescription is filled isn’t coming out of his pocket. It’s coming out of yours. And somebody has to pay for all that promotion.
Guess who?
Now, as it turns out, my paranoia was misplaced. I’ve done my research: Eliquis really is the only drug that safely manages my situation (so far). So I’m going to be taking it for a while, in spite of the cost and the questionable morals. (And the bruising.)
‘What about generic?’ you say.
Yes, generic drugs are a lot cheaper, because the formulas are purchased (or, occasionally, stolen) from the original developer, without the need for any expensive development and testing work. And the standard patent on a new drug is supposed to expire 20 years after the drug was first patented. So that the generic companies can compete. That’s the theory.
Eliquis was patented in 2007. The patent should expire next year. Manufacturers of generic equivalents to it should be champing at the bit already, ready to get their greedy hands on some of that money. And they are. There is already one new company making the ‘generic’ drug.
But they can’t sell it in the USA, and they won’t be able to in 2027 either. Bristol-Myers Squibb, in partnership with Pfizer, has filed for an extension to the patent. They have appealed to the courts to postpone the expiration till 2032, twenty years after the drug went to market, rather than twenty years after the patent was issued. So far, they have been granted an extension only of a single year. The patent is now scheduled to expire in 2028. But meanwhile, huge teams of lawyers are preparing arguments to extend it even further, and the expectation within the industry is that they will win. (It’s worth noting that the court decision awarding them the one-year extension was unanimous.)
If they do win, the patent will expire in 2032, and then, and only then, will it be legal to buy the generic variety of Eliquis in the USA. Meanwhile, the cost will remain sky high, and the patient will pay (indirectly) for legal bribery to his doctor to prescribe the drug that costs so much. Charming.
If I knew how to do it legally, I could get the drug in Canada for $35 a month. In the USA it costs more than $300 per month. Yes, my insurance ‘covers’ it. After I’ve met my yearly deductible, which takes three months at full price, I get it for ‘only’ $47 a whack. Cheaper than flying to Canada.
“But,” the apologists say, “there has to be a profit or nobody would bother to develop the new drugs in the first place.” I think this is true. I also thinks it’s rather sad. The practice of medicine when first invented was to help people. I don’t think that’s really what it’s about any more. Medicine is now mostly about money. It’s all plainly there in the public record. Lists of where the money comes from and where it goes. All totally legal.
Any human help involved is merely one of the side effects.
I had no idea what was going on behind the scenes with the pharmaceutical industry.
Now I know.
Now you know, too. Do you wish you didn’t? Welcome to the club.
Note — this article was entirely human-written. No aspect of AI involved.
Copyright ©2026 by Warlen C. Bassham. All rights reserved.
