"I Didn't Make That Call" — How Externalized Responsibility Keeps Misconduct Invisible

"That wasn't my characterization — Professor X said it." "My manager was sitting right there, so I assumed it was fine." "The physician asked me a question, so I answered it." These three sentence patterns share one structure: the sense that I did not make the decision. By attributing the origin of an act to someone else, the speaker releases responsibility for the deviation. Reading seven years of records from Japan's promotional activity monitoring program, this transfer of accountability appears not as an unconscious slip but as a refined, repeating mechanism.

So What / So Why — The Core Argument

Externalizing responsibility is the psychological process of attributing the origin of your own action to another person. "The KOL said so," "my manager stayed silent," "the field asked for it" — each sounds like a factual description. In behavioral economics, however, this is called delegated moral disengagement: the agent transfers the decision while keeping the act. The representative selected the information, arranged the meeting, and delivered the slide. That fact does not disappear because the attributed origin changes.

Why is this fatal? The Guidelines on Promotional Activities for Prescription Drugs (MHLW, September 25, 2019, Yakushokanma-hatsu 0925 No. 1) explicitly state that the responsible party for promotional activity is the marketing authorization holder. If a KOL says something out of scope during a sponsored lecture, the company that planned the event, prepared the slides, and assembled the audience remains responsible. "The speaker said it" is not a defense. A manager's silence is passive acceptance, not an instruction — yet to the MR it functions as an organizational green light. If the conversation was engineered to elicit a physician's question and the representative then says "I was only responding," the sequence reveals inducement, not information provision.

When this psychology spreads through an organization, no one becomes the decision-maker. The KOL says "I spoke as the company requested." The MR says "the professor said so." The manager says "the MR on the ground made the call." Marketing says "we supplied data the physician requested." Everyone narrates themselves as a bystander; no one appears to be the origin. Patient risk accumulates at the end of that chain.

The Structure of Pressure — Who, Which Deadline, What Number

The pressure of maintaining KOL relationships. Professors at major hospitals and prominent specialists (Key Opinion Leaders, KOLs) influence prescribing across their referral networks. When such a professor states at a sponsored symposium that "this product is effective," that statement becomes quotable in sales calls. To keep the relationship intact, companies offer lecture opportunities, pay speaker fees, and hold back "revision suggestions" on slides. Fear of fracturing the relationship relaxes pre-meeting slide review and suppresses objections to borderline content. When a supplemental indication is under regulatory review — or when a post-launch quarter target coincides with that timeline — this pressure to defer intensifies.

How a manager's presence creates silent approval. A manager accompanying an MR on a call signals to the physician that the account matters. For the MR, however, the manager's presence can also become a safety net: "if anything is off, my manager will step in." That dependency reduces the MR's own incentive to verify accuracy. If the manager says nothing, the MR reads it as clearance. If there is a problem, some share of responsibility has already shifted upward. The manager's inaction thus sustains the MR's deviation — a structural outcome, not an individual failure.

The commercial habit of citing "what the physician said." "Another institution uses it this way, according to their physicians." "A doctor told me this." These formulations present themselves as third-party observations rather than personal recommendations. Yet when specific dosing practices, off-label uses, or diagnostic approaches travel in the form of "a physician said," the origin of the suggestion already lies with the representative. During periods when quarterly targets and indication timelines converge, or when a competitor gains share, these citation forms intensify in use.

Reconstructing the Interior — Belief, Feeling, Deeper Psychology

Belief: "I am simply delivering evidence the physician needs. The physician decides."

This belief sounds legitimate on its face — it appears to respect the physician's autonomous judgment. The question is who determines what the physician "needs." If the representative has already decided what information this physician should want, designed a conversation to surface that want, and selected slides using a KOL's remarks as scaffolding, the representative is an inducer, not an information provider. The belief's apparent legitimacy masks the fact that the representative is actually the origin of the information flow.

Feeling: relief and dependence cross each other in the manager's gaze. With a manager present, the representative feels two things simultaneously: tension — "I need to get this right because my manager is watching" — and dependency — "if something is wrong, my manager will stop it." When the second wins, the representative stops self-checking accuracy and instead watches the manager's face for signs of trouble. Silence becomes the signal for "OK." This perception has no logical basis yet feels completely real. As Stanley Milgram demonstrated in his obedience experiments, the presence of an authority figure contracts an individual's sense of moral responsibility — an effect that does not stop at the laboratory door.

Deeper psychology: responsibility externalization (④) operates at full force. When citing a KOL's remarks, the representative consciously chooses the frame "I conveyed what the professor said." This is not accurate transmission of information; it is displacement of origin. Responsibility externalization provides an internal narrative that justifies the displacement: "I simply relayed a specialist's view" — a narrative that removes the need to own one's own judgment.

Layered on top is the sin of omission (③). In the scene where the manager sat silently, the representative never asked: "Was this explanation acceptable?" Asking would have handed the manager the obligation to correct. Not asking left everything in an ambiguous pass-through state. A history of never being held accountable for what was left unsaid makes the next silence easier to accept.

Local rationalization (②) adds another layer. Cutting the scene to "the physician asked, so I answered" erases the surrounding context — the guiding conversation that preceded the question, the appointment that created the setting, the slides that were chosen. Isolate a single exchange and it looks like compliance with a request. This cut is not unconscious; it is chosen because it makes the representative's situation easier to hold.

Grounding Incidents

Incident 1: "Professor X said efficacy is fully expected, so there is no problem" — Deflection Through Authority Citation

Channel / Product area: Prescription drug / verbal (individual meeting). Recorded in the FY2025 Report of the Promotional Activity Survey Program (MHLW commissioned project).

What happened: A representative presented Japanese-population subgroup analysis data and explained that "a clear difference is also seen in Japanese patients." When the healthcare professional pointed out that the difference was not statistically significant, the representative replied: "Professor X has said that sufficient efficacy can be expected, so there is no problem."

Where responsibility was externalized: The moment a flaw in the representative's own statistical interpretation was identified, the response was to retreat behind a named authority's statement. The representative substituted a professor's remark for the evidentiary basis of the explanation — transferring responsibility for the error. Even if the professor did make that statement, using it as an immunity claim within a promotional context is not what the guidelines contemplate. Overwriting data that showed no significant difference with "the professor's words" is a compound of motivated reasoning and responsibility externalization.

Regulatory basis for deviation: Guidelines Section 3-2(3)-i (prohibition on presenting inappropriate comparative data); Standards for Appropriate Pharmaceutical Advertising (restrictions on superiority claims).

Incident 2: "Before approval, the manufacturer can't bring it up" — Actively Staging the Appearance of Being Asked

Channel / Product area: Dementia drug (pending approval) / verbal (individual visit). Recorded in the FY2020 Report of the Promotional Activity Monitoring Program. See also Analysis vol.04 "Presenting Unapproved Indications and Dosing".

What happened: An MR opened a conversation with a pharmacist by mentioning an upcoming generic entry. When the pharmacist responded vaguely, the MR continued anyway. The moment the pharmacist mentioned the product's name, the MR said "before approval, the manufacturer can't bring it up" — and then promoted the pre-approval product. The reporting pharmacist stated: "I did not intend to make an inquiry; I was led there by the manufacturer's side and it became a conversation about this product." The monitoring program's evaluation concluded that the representative had "made it appear as though the healthcare professional had requested the information."

Where responsibility was externalized: The statement "before approval, the manufacturer can't bring it up" is itself a declaration of transfer — "this did not start with me." But the appointment that enabled the conversation, the timing of the topic shift, and the design of the exchange that led the pharmacist to say the product's name first were all the representative's doing. Formally, the pharmacist named the product first. In practice, the representative engineered that moment. Actively constructing the appearance of being asked, then invoking that appearance to claim compliance, falls squarely under what the guidelines explicitly prohibit (Section 3-2(1)-i).

Incident 3: "The MR's manager was also present and said nothing" — The Atmosphere of Tacit Approval Created by a Manager's Silence

Channel / Product area: Central nervous system drug / in-person (hospital product presentation). Recorded in the FY2025 Report of the Promotional Activity Survey Program.

What happened: An MR and manager visited a hospital and delivered a product presentation. The MR showed a plasma concentration-time curve and explained that "this product has a gradual peak, making adverse reactions less likely." When the healthcare professional asked for supporting evidence, the answer was "there isn't any." A subsequent inquiry to the company's drug information center confirmed that the regulatory review report showed slightly more adverse reactions with tablets than with the comparator, and that the company did not promote "fewer adverse reactions" as a message. The manager, present throughout, did not correct the MR during the explanation.

Where responsibility was externalized: For the MR, the manager's silent presence almost certainly functioned as a signal that the explanation was acceptable. The manager may later say "I didn't say anything" — but that not-saying closed off the opportunity to stop the deviation. From the MR's vantage point, the manager's silence was read as approval. This asymmetric recognition of responsibility is how misconduct passes through organizations. A product claim the company did not sanction continued because a manager's inaction let it through — a compound of the sin of omission (③) and responsibility externalization (④).