Microsoft word - 6. building relationship with mediation.doc

American Communication Journal Vol. 11, No. 4, Winter 2009 Building a Relationship with a Medication: Are Public Relations 
Strategies Warranted in Advertising Medications? 

Keywords: Direct-to-consumer advertising, Dramatistic pentad, Identification, Imperceptible
persuasion, Health citizenship
Over the past several years, pharmaceutical companies have been increasingly pressured into
following restrictions, rules, regulations, and guidelines when advertising medications.
Consequently, medication ads have become much more informative and their persuasive appeal
restricted. Unsurprisingly, such developments have not been welcomed by advertisers. Some
have even openly complained that their hands are tied and that medication ads are no more than
simple and benevolent messages. Although this may be true in some cases, the age of aggressive
medication ads is not over. In this paper, an argument is made that some advertisers have
devised creative ways to sidestep rules and regulations governing medication ads by replacing
advertising and marketing strategies by approaches normally associated with public relations.
The imperceptible yet powerful persuasiveness of such strategies can exert a strong,
unnecessary, and potentially harmful influence on patients and prospective patients. In order to
draw attention to the latest persuasive strategies in advertising medications, the author draws on
Burke’s philosophy and, specifically, on his dramatistic pentad and his notion of identification in
analyzing an ad exemplifying the most recent developments. An understanding of
pharmaceutical companies’ new persuasive strategies can help broaden the patients’
circumference of action and contribute toward advancing the goal of responsible health
citizenship.

Slavica Kodish, Ph.D is an Assistant Professor of Communication for Eckerd College. Contact: [email protected]
American Communication Journal Vol. 11, No. 4, Winter 2009 Introduction
Direct-to-consumer advertising (DTCA)1 has stirred up significant controversy over the past decade. Its proponents hail the informative content of prescription medication ads and their role in helping patients advance their informative acumen. Kelly (2004), for example, states that DTCA empowers patients who can openly discuss their health concerns and treatment options with health care providers. The critics of advertising drugs to the general public, on the other hand, claim that DTCA encourages patients to request heavily advertised prescription drugs and thus influence the health providers’ decisions in prescribing medications and the patient-provider relationship in general (See, e.g., Kravitz, 2000; Mintzes et al, 2003). Over the past several years, DTCA has undergone a qualitative change. In the past, ads were exclusively centered on advertising a specific medication. Current medication ads typically go a step further and include information about side effects and a recommendation for the patients to consult their health care providers. Some recent ads feature a lengthy, albeit small-scripted, description of side effects, trial information, and various other pertinent pieces of information printed on the back page of the ad. Others feature real physicians who openly discuss side effects of the advertised medication. Accuracy of the ads has also been improved as a result of the involvement of the general public and the FDA. Concerted action on the part of the public, such as the petition of the Coalition for Healthcare Communication and the FDA, has placed an additional pressure on pharmaceutical companies to observe a clear set of rules when advertising medications (“Coalition for Healthcare,” 2005). Advertisers have not welcomed the changes. They are increasingly voicing their concerns that the pressures, rules, guidelines, restrictions, and regulations are making their advertising attempts seem like a mission impossible (“Drug Ads,” 2006). Judging from advertisers’ fretful comments, the era of persuasive medication ads has been replaced by an age of benevolent informative messages. This, unfortunately, does not reflect reality. Some advertising agencies and pharmaceutical companies that they represent are using an ingenious way to influence the decisions of customers by applying public relations rather than marketing strategies in positioning the drug on the market. The difference between the public relations and marketing approaches may not be easily discernible by a lay person. In the marketing approach, a specific product or service is being placed on the market by means of a sophisticated marketing strategy. At the heart of a public relations approach, on the other hand, is building relationships with the targeted market. There is no product or a service, but, rather, a multi-step process of initiating, building, and maintaining a relationship. The difference is seemingly subtle and by most part unnoticeable by an untrained eye, but its effects can be far-reaching and potentially harmful. When the public relations approach is used in placing a medication on the market, patients and prospective users of the medication are more apt to relax their prudent customer 1 The only countries in which prescription medications can be advertised directly to the public are the United States and New Zealand (Hoek & Gendall, 2002). In other countries, DTCA is not permitted. Canada, for example, allows advertising of over-the-counter (OTC) medications and generally prohibits DTCA of prescription medicines, although a 1978 exemption allows advertising of product name, price, and quantity. American Communication Journal Vol. 11, No. 4, Winter 2009 guard because they are not being sold anything, but, instead, offered a beneficial relationship. Such a relationship is appealing; so is the underlying message of support and caring. Patients and prospective users can be imperceptibly drawn into a world that is filled with ease and safety. They may also find that they can be happy by effortlessly ingesting an alluringly colored pill, without taking into consideration the side effects and without considering other, more effortful and healthier options that may be available. The public relations approach in positioning medications on the market should not be taken lightly. By imbuing the predominantly impersonal world of marketing2 with the interpersonal component of public relations, some pharmaceutical companies are blurring the distinction between a product and a relationship. From a theoretical perspective, their approach is intriguing. From an ethical perspective, their approach is potentially harmful. Pharmaceutical companies utilizing such an approach may be building a life-long dependence on medications which are intended to be used over a limited number of weeks or months. At a time when extensive research, multi-million dollar campaigns, and efforts to raise the levels of health citizenship are being made, and when overuse of certain medications is beginning to cause a variety of problems (See, e.g., Albrich et al., 2004; Cohen, 1992; Harbarth & Samore, 2005; Reger, Wootan, & Butterfield, 1999; Vanden Eng et al., 2003), understanding strategies that do not support such efforts becomes highly salient. The purpose of this essay is twofold: to shed light on ethically questionable strategies utilized by some advertisers and pharmaceutical companies, and also to raise awareness of the new advertising approach in order to help the general public in making informed decisions. In order to provide a foundation for subsequent analysis, this essay begins by a description of an ad that reflects the public relations approach in advertising medications. The section that follows includes an explanation of Burke’s dramatistic pentad and his concept of identification. The third section contains a Burkean analysis of the ad. In the final section, implications of the imperceptible communication strategies applied in the ad are addressed. Description of the Nexium Ad Introduction Nexium is a medication used for treating a variety of problems associated with increased acid production in the stomach. One such problem is a condition popularly known as acid reflux or, officially, gastroesophagal reflux disease (GERD), a condition that when untreated can lead to an erosion of the esophagus and in some cases to more serious complications such as esophagal cancer. By reducing the acid producing proton pumps in the lining of the stomach, Nexium allows for the esophagus to heal. It also helps restore the lining of the stomach in the cases of ulcerative changes and problems induced by gastritis. Since the reasons for increased acid-related problems are many, including those directly linked with dietary habits or bacterial infections, a large number of people are potential Nexium users. The Nexium ad 2 Over the past decade, the field of marketing has adopted a relational approach (see, e.g., Duncan, 1998; Shultz, Tannenbaum & Lauterborn, 1993; Shimp, 1997). Still, the difference between marketing and public relations remains. In marketing, there is a specific product or a service that is being offered to the public, whereas in public relations the thrust of the effort is on building and maintaining a relationship. American Communication Journal Vol. 11, No. 4, Winter 2009 The Nexium ad depicts a typical entrance to a suburban home: a path leading to the front door, a door and the front of a house, a couple of bushes, simple landscaping, and a mailbox. The ad would be rather inconspicuous if it were not for a tinge or two of purple strewn over the page and skillfully combined with patches of a shade of blue that make the purple stand out. The center stage belongs to the mailbox. The white supporting post looks sturdy, new, and very clean, as if freshly painted. The box itself is purple with three golden lines painted across, in a symbolic representation of the purple-colored Nexium tablet. The colors of the mailbox represent the actual pill, and its shape somewhat resembles the elongated tablet. The red flag on the side of the mailbox is raised, perfectly straight, as if to suggest what the reader of the ad needs to do – mail the attached slip to the address provided. The text of the ad is of special significance for the purpose of this essay. The first thing that strikes the reader is that the ad does not sell anything. Furthermore, the ad does not provide any information about Nexium. The text of the ad is divided into three sections strategically placed on the door of the house, underneath the picture of the house, and on the attached card. The message on the door reads: “If you take NEXIUM, free support can show up in some free places.” Underneath the picture, we can read the following: “Be a part of a free program designed for NEXIUM users. Valuable savings, delicious recipes, advice from experts, helpful lifestyle tips, refill reminders – we’ll deliver all this and more right to your door when you sign up for our free program. You see, we understand that you may want information about how to manage your condition wisely, and we want you to have it. So sign up today and get the help and support you deserve” (Nexium ad). The text on the no-postage-necessary card for those who prefer to join by mailing the card rather than by logging on the website, reads: “Just one easy step, and you’ll get: In addition to the picture of the front door and the mailbox, the bottom of the page contains a series of small-scale photos of people who look active and happy, and pictures of two $30 coupons. The overall message of the ad is enticing. By joining the free program, the individual will be able to obtain helpful information about his or her health problem and recipes for tasty dishes. There is, however, a deeper significance of the ad than the description provided in the paragraphs above reveals. Critical methodology that served as a foundation for providing a deeper analysis was Burke’s pentad and his concept of identification. American Communication Journal Vol. 11, No. 4, Winter 2009
Human Motives and Actions
Kenneth Burke’s study of language as a symbolic, grammatical, and rhetorical construction provides insights into human motives and behaviors. He was aware that a complete understanding of the communicative act and related motives and behaviors occurs only when the communicative act is “analyzed and understood in the light of its total context” (Holland, 1960, p. 180). Convergence of a communicative act within its context and human motives and behaviors is reflected in Burke’s concept of dramatism. According to Burke, dramatism is the study of human relations and motives by means of “a methodological inquiry into cycles or clusters of terms and their functions” (Burke, 1968, p. 445). At the core of dramatism are five key terms: scene, act, agent, agency, and purpose. For Burke, the central term is act from which the other four elements of the pentad radiate (Golden, Berquist, & Coleman, 1989, p. 333). Burke writes: “for there to be an act, there must be an agent. Similarly, there must be a scene in which the agent acts. To act in a scene, the agent must employ some means, or agency. And it can be called an act in the full sense of the term only if it involves a purpose” (Burke, 1989, p. 341). The five terms, scene, act, agent, agency, and purpose, are capable of forming “ratios” or relationships. In this way the concept of a particular term can be widened or narrowed, that is, conceived of in terms of varying scope of circumference (Burke, 1987). The pentad allows for ten ratios or distinctive vocabularies of motives: scene-act, scene-agent, scene-agency, scene-purpose, act-purpose, act-agency, act-agent, agent-purpose, agent-agency, and agency-purpose (Burke, 1969a). The reverse is also possible (Anderson & Prelli, 2001). Ratios are useful in explaining acts in that they provide an additional layer of meaning. For example, a purpose-agency ratio indicates a focus on the means, or adapting the means to accomplish an end. It is also an indicator of inherent instrumentalism and of a diminished role of the agent. Anderson and Prelli (2001) note: “The central motivation locked within technological discourse is agency-purpose; its strict instrumentalism not only transforms acts, agents, and scenes into terms of agency, but even purposes themselves become meaningful only when nearly synonymous with agency” (p. 80). From Burke’s perspective, in an open universe of discourse no single term dominates other terms. In a closed universe of discourse, however, a particular term dominates other terms and constrains them by its circumference of motives. In the case of scientific and technological rationality, it is the terminologies of agency or of scene that become dominant (Burke, 1969a). In this way, the narrow circumference of motives becomes associated with motion rather than with action. The distinction between motion and action was an overriding concern of Burke’s (Golden et al., 1989). The distinction is important because it has an implication on widening or narrowing of circumference of motives (Burke, 1989). According to Burke, action is symbolic and requires deliberation or an active participation of the agent. Motion, on the other hand, refers to extrasymbolic or nonsymbolic operations of nature, or an instinct-based, mechanical, passive response similar to the simplistic stimulus-response principle that undergirds behaviorism. The distinction between action and motion and the resulting consequences become American Communication Journal Vol. 11, No. 4, Winter 2009 more perceptible when we compare Burke’s concepts of action and motion with similar concepts from Arendt’s Human Condition and Aristotle’s Nicomachean Ethics, respectively. Arendt (1958) writes that the fall from action into making, or a substitution of a thoughtful, meaningful, and teleological action for a mechanical skill or technique that is an end in itself is the source of social malaise. Both Burke and Arendt reflect Aristotle’s distinction between praxis or doing, that is, taking action, on one hand, and poiesis, or making, that is, using a skill, on the other. Doing means acting upon one's prudent decisions and, in a more general sense, taking an active role in the world one belongs to for the sake of improving it. It may be understood to include what Weaver (1948) referred to as “zest for labor,” or what Polanyi (1958) termed “passionate commitment.” Making, on the other hand, is a skill and technique oriented view, unable to provide a basis for action and meaningful change, and is similar to what Stewart & Zediker (2000) refer to as instrumental action. Burke’s pentad can be used as a device for understanding the universe of discourse and for the consequent analysis of discursive and other behaviors and various relationships.
Anderson & Prelli (2001) refer to the Burkean critic as a pentadic cartographer “ who charts the
symbolic terrain of linguistic structures using the pentad as the “critical projection device”
(Anderson & Prelli, 2001, p. 83). He or she tracks the dominant vocabulary of motives within a
variety of linguistic structures. Just as empirical maps make it possible to track spatial
relationships among the features, pentadic maps “symbolize linguistic structures with the
pentad’s vocabulary and reveal pivotal relationships among them as dramatistic ratios”
(Anderson & Prelli, 2001, p. 83). In addition to Burke’s pentad, another concept from his
philosophy that can help us further understand the implications of building relationships with
customers is that of identification.
The Subtlety and Magic of Identification
Burke developed his theory of identification for the purpose of understanding human behavior. Interwoven with his notion of symbolic action, identification probes into numerous facets of human life and human interaction. According to Burke, identification as a rhetorical strategy can be interpreted in three ways. First, it is a way in which the rhetor explicitly identifies himself or herself with the audience. The message in this case would be of the type, I am like you. “You persuade a man only insofar as you can talk his language by speech, gesture, tonality, order, image, attitude, idea, identifying your ways with his.”(Burke, 1969b, p. 55). The second type of identification is based on aligning oneself with another party against a third party perceived to be the enemy. The third type of identification is the one that goes unnoticed. Burke purports that the major power of identification derives from situations in which identification arises as a cooperative response of a “we” (Burke, 1972, p. 28). The unconscious plays a very important role in this type of identification. “For there is a wide range of ways the rhetorical motive, through resources of identification, can operate without conscious direction by any particular agent (Burke, 1969b, p. 35). Another important facet is that identification possesses a special allure or “magic”: “The use of symbols, by one symbol-using entity to induce action in another (persuasion properly addressed) is in essence not magical but realistic. However, the resources of identification whereby a sense of American Communication Journal Vol. 11, No. 4, Winter 2009 consubstantiality is symbolically established between beings of unequal status may extend far into the realm of the idealistic. And as we shall see later, when on the subject of order, out of this idealistic element there may arise a kind of magic or mystery that sets its mark upon all human relations” (Burke, 1969b, p. 46). For thousands of years, skillful individuals have been applying some form of identification when attempting to impact others. In the modern age, advertising and marketing companies have been using identification extensively when advertising and marketing goods and services. An example of a marketing effort based on identification will serve an illustrator purpose. Back in 1989, the food and tobacco giant, Phillip Morris, decided to participate in the bicentennial celebration of the Bill of Rights by offering to send a free copy of the document to
anyone who requested it. This seemingly generous offer was based on pragmatic motives – the
company attempted to identify its image with the Bill of Rights and thus create a more favorable
notion in the minds of the consumers. Cheney and McMillan (1990) note how in this instance,
Phillip Morris, by acting as a “corporate rhetor” enhanced the persuasiveness of its message. It
has also drawn the attention of the Congress, which discussed the company’s flagrant use of
identification. In most cases, however, the use of identification is more subtle, but not
necessarily less effective. The magic and the mystery that inhere in identification, as Burke
noted (1969b), can exert a powerful influence on people’s attitudes and behaviors. In the section
that follows, we will take a look at the imperceptible influence of identification in the Nexium ad.

Pentadic Analysis of the Nexium Ad
According to Burke, in an open universe of discourse, all five components of the pentad are represented in a balanced manner. Within the context of health discourse, a balanced arrangement of the five pentadic components would likely take the following form: The patient and the doctor are co-agents because an active participation of both the health care provider and the patient can ensure desired results. The patient is in need of a medication, that is, he or she is in need of a means or an agency to accomplish the purpose of getting well. What will help the patient get well is the act of taking the prescribed medication within a certain environment or scene, whether a health facility or some other location such as the patient’s home. In a closed universe of discourse, the relationship among the pentadic terms takes on a different form. When the universe of discourse is closed, there is a disbalance rather than a balance among the pentadic terms. A closed universe of discourse favors the scene or agency (See Anderson & Prelli, 2001) and is dominated by the agency-purpose ratio. When we apply Burke’s pentad to the Nexium ad, we can see that the desirable balance among the terms is absent and that the pentadic terms are arranged in a peculiar manner. The scene – the walkway and the entrance to the house – is dominant in the Nexium ad. The agency, symbolically presented by the purple mailbox with three straddling golden lines is another pentadic term that dominates the ad. The remaining terms also depart from the balance that characterizes the open universe of discourse in the health care elated context. The act has been altered dramatically: rather than taking the medication, the act has become relationship American Communication Journal Vol. 11, No. 4, Winter 2009 building. The agent’s role is that of a respondent rather than an active participant in the treatment process. The purpose has also been altered: rather than alleviating the symptoms or getting healed, the purpose is to establish a friendly relationship. In addition to the disbalance among the five pentadic terms, another characteristic of a closed universe of discourse, the purpose-agency ratio, is evident in the ad. According to Burke, the presence of the purpose-agency ratio indicates a focus on the means, or adapting the means to accomplish an end. It is also an indicator of inherent instrumentalism and of the diminished role of the agent whose circumference of action becomes limited and relegated to a more passive position. The purpose-agency ratio in the Nexium ad is expressed in the centrality of the two components – purpose and agency. The underlying purpose of the ad is to establish a friendly relationship with patients and prospective patients. Furthermore, the agency, symbolically represented by the purple and gold mailbox, visually dominates the ad. The disbalance among the pentadic terms and the presence of the purpose-agency ratio indicates a closed universe a discourse – one that limits human deliberation and action. A closed universe of discourse is typical of our age characterized, in Burke’s terms, by technological rationalization and scientism at the expense of the humanistic and the poetic. In the light of Burke’s philosophy, a closed universe of discourse necessitates a corrective rationalization or a counterstatement that will expand both the circumference of motives and the circumference of behaviors. Corrective Rationalization Burke recommends a “corrective rationalization” or a counterstatement rather than a passive acceptance of scientism of our time. In Burke’s words, “the corrective of the scientific rationalization would seem necessarily to be a rationale of art – not however, a performer’s art, not a specialist’s art for some to produce and many to observe, but an art in its widest aspects, an art of living” (1965, p. 66). It is the art of living, or a fulfilled, happy, productive, and meaningful human life that I have as a goal when proposing a corrective rationalization. I begin the corrective rationalization by comparing marketing strategies with public relations principles. I proceed by providing information about Nexium that suggests that the public relations approach utilized in placing medications on the market is ethically troublesome and potentially harmful for patients and future patients. The ingenuity of marketing companies in placing products is well known. For example, one of the most recent developments is the blending of entertainment and advertising or advertainment (see, e.g., Deery, 2004). Advertainment involves the dissemination of a vivid and interesting message to a targeted audience that at the same time entertains the public and markets a specific product. Persuasion in the advertainment approach is less perceptible than in a traditional ad, but is nevertheless present. However, despite their imperceptible persuasiveness, advertainment strategies maintain their marketing character. There is a service or a product that is being promoted, which means that at least some viewers, or, perhaps, many, will be able to understand that they are being targeted as potential customers, and, consequently, will be able to make a relatively informed choice. In other words, as long as the persuasive message is built around a tangible product or a service, there is a possibility of acting upon the American Communication Journal Vol. 11, No. 4, Winter 2009 message as an agent with a more or less defined sense of agency. The agency, however, becomes diminished when public relations strategies are used in lieu of marketing strategies. The core of both the theory and practice of public relations is the notion of relationship. Public relations is about establishing and maintaining “mutually beneficial relationships between an organization and the publics” (Cutlip, Center, & Broom, p. 2). The underlying rationale is that the relationship frame will be beneficial for the organization and for the publics that the organization serves, and also for the broader community. A rather important aspect of relationship building in public relations is the quality of the relationship. Broom et al. (2001) and Thomlison (2001) write that in developing the relationship approach, the field of public relations has borrowed heavily from the field of communication and, specifically, from interpersonal communication. The aim of the public relations approach, therefore, is not to build a business relationship or an impersonal relationship with the public, but rather an interpersonal relationship – a cordial and friendly relationship, similar to the relationship that develops in friendships or close personal relationships. As stated earlier in the essay, when a public relations approach is applied to placing a medication on the market, there is no product or service that is being advertised. As a result, an ad based on such principles is much less likely to be recognized as an ad. This means that the likelihood of accepting the offer to develop a relationship is higher because there is no product or service that is being sold, and, therefore, nothing to be wary or guarded about. What this means in the case of Nexium is that we can turn to our virtual friend for information and advice on a variety of topics, as provided on the manufacturer’s website. And as over time the manufacturer’s website and the symbolically portrayed Nexium become our trusted friends, if we get heartburn or experience symptoms that Nexium can relieve, there is a likelihood that we will ask the doctor for a prescription for Nexium. The problem with the strategy based on relationship building is its ethical paucity. The relationship approach to marketing medications would not be able to pass the test of ethical sales strategies, especially since Nexium is a medication that is not intended for long-term
use. According to the manufacturer of Nexium, there are no [emphasis mine] clinical studies
testing the effectiveness and side effects of Nexium usage that exceed 6 months. Also, according
to the manufacturer, Nexium heals ”in just 4 to 8 weeks.” Granted, Nexium treatment can be
repeated, but what is clear from the information provided by the manufacturer, Nexium is not to
be taken for a prolonged amount of time. The side effects of Nexium are not to be disregarded,
either. Nexium can cause headache, diarrhea, and abdominal pain. Additionally, there is a
possibility of Nexium relieving symptoms that are linked with a much more serious condition
such as stomach cancer by masking the symptoms and making it more difficult for physicians to
detect cancerous changes. Some research even suggests that the inhibition of acid production –
the effect of taking Nexium – may be linked with reduced ability of the body to fend off bacterial
infections.
The use of Nexium requires prudent decision making both on the part of the patient and the health care provider. Rather than being drawn into a relationship that could cloud their reasoning, patients and prospective users need to be able to make fully informed decisions when American Communication Journal Vol. 11, No. 4, Winter 2009 it comes to using a potent medication such as Nexium. They also need to be able to evaluate their lifestyles and to change them if necessary. If the heartburn they are experiencing is a result of their diets or bad eating habits, they need to be able to realize the importance of switching to healthier behaviors. If the heartburn is a symptom of a more serious condition, which needs to be treated more aggressively, they need to be able to seek help. Relationships are based on trust, mutuality, liking, and sharing rather than on logic. Building a relationship with a medication can hamper the ability to think rationally and can pose
a barrier to becoming a full-fledged health citizen. And, lest we forget, true relationships possess
a special magic and mystery, but not of the kind which we can find in a deliberate, purposeful,
and tactical use of identification. In Burke’s spirit, a relationship should be an art based on the
principles of action rather than relegated to a skill and the principle of motion.

Conclusion
In this essay, I applied Burke’s dramatistic pentad and his concept of identification to reveal the imperceptible, yet potentially powerful persuasive technique utilized by some pharmaceutical companies. Instead of taking advantage of sophisticated marketing and advertising strategies, which is the normal practice, some pharmaceutical companies utilize public relations strategies. Theoretically, this can be viewed as an intriguing development. In reality, however, and especially having in mind that the products positioned on the market are medications with possible side effects, this strategy can have serious ramifications. Unlike marketing strategies, which can be recognized as such, and therefore, can be potentially resisted by a number of users, or whose message can be lost in the cacophony of competing ads, messages based on the public relations approach are much less likely to be recognized as sales ads because they do not sell, but rather invite and lure unsuspecting readers into a relationship. Additionally, since the approach is relatively new, these ads stand out from the majority of ads that follow the marketing approach and, as a result, may have a higher persuasive potential. This essay was written with the purpose of shedding light on ethically questionable persuasive strategies and the principles on which they are based. Understanding such strategies can help us depart from the role of passive consumers of medications and become a society of responsible and well-informed health citizens.
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