COHEN: The civil liability system in this country has assumed, for as long as I can remember, that the drug company's responsibility is to warn prescribing doctors of benefits and risks. And ultimately the decision about whether to script that drug rests with the prescribing doctor. Even though there have been assaults made on that doctrine by some lawyers because of direct-to-consumer advertising, so far the courts have rejected it, saying the responsibility to make that decision and to warn the patient falls squarely on the prescribing doctor. My question is what can be done to make sure that prescribing doctors are as knowledgeable as they can be, within the confines of the ethical decisions we're talking about.

PEREA-HENZE: Our premise is that there's not a drug that is 100 percent safe. So you try to educate physicians as much as possible. It is part of our responsibility. Well, if you want to call it marketing, so be it. But the reality is that there's a huge educational component that we're losing because physicians have less and less time.

You also cannot assume that all consumers have the same level of education or understanding. And there we get into the issue of health literacy. You can put all the information in the ads, but if patients cannot read above the sixth-grade level, you're missing the boat. Ethically, is that one of our responsibilities in the pharmaceutical industry? Most people will say yes.

COHEN: What do you think should be the standard for what's ethical and what's not in dealing with these third-party payers?

LOUIS: I'd say try to keep the focus on clinical concerns and away from the economics, if possible. And muster the support of the physicians and the patients, who believe they know what the right thing is from a clinical perspective. It's a tough question.

CAPALDI: You might want to look at some long-term strategies, such as including this in the high school curriculum. If we spend as much time on pharmaceuticals as we do on saving the ecosystem, and if we required students to take economics, I think this might make a difference. If you want to get the public to understand the complexities of issues, you may have to change the educational system.

There's an irony here. If we keep fit and take care of ourselves, we live longer, which means that we're probably going to cost the system a lot more money. By the time we die, it will be of some exotic disease, and the amount of care that can be given to prolong your life at the end will be even greater.

But somehow the message has to be put across that this is a problem that's been created because we're doing good things for you. If you were born in the 1920s or 1930s, you probably never thought there would be all these medical advances, so you would not have thought about putting aside money to take care of medical expenses when you got older. But surely everybody should understand that now.

PEREA-HENZE: There is a very striking example around HIV and AIDS. When the drug programs were first set up for taking care of people with HIV in this country, they were for people who were dying. Right now they're bursting at the seams, because people are living longer. But if you talk to anybody with HIV, that person will say, "You know, one more day is good enough for me, because there may be something else coming along." Where do you stop?