Conflicts of interest

The World Health Assembly Resolution 49.15 of May 25, 1996 urges member states "to ensure that the financial support for professionals working in infant and young child health does not create conflicts of interest". But what is a conflict of interest? This is one of the accepted definitions: "A set of conditions in which professional judgment concerning a primary interest tends to be unduly influenced by a secondary interest" (ref. 1). There is no doubt about the primary interest of a health professional: to act for the maximum benefit and do the minimum harm to the individual and the community he or she serves. But what is a secondary interest and where does it come from?

A health professional can have a political, academic, religious or personal conflict of interest, but very often the nature of a secondary interest is financial. Sixteen different forms of financial entanglement between health professionals and companies have been described: acceptance of direct and indirect gifts to attendance at sponsored dinners and social or recreational events, ownership of stock or equity holdings to conducting sponsored research, funding of academic chairs or medical associations to paid consultancies and ghost-writing of "scientific" articles... (ref. 2) From this short list it is clear that a financial conflict of interest can be individual and/or collective; i.e. a health professional may have no individual entanglement with a company, but may belong to an association or attend an event that does.
Collective conflicts of interest may involve huge amounts of money. In 2001-03, for example, the American Academy of Pediatrics (AAP) sold a total of 600,000 copies of "The New Mother’s Guide to Breastfeeding" to Abbott Ross, for an undisclosed amount of money. Abbott Ross distributed the book to mothers of newborn infants, with its name and logo, through doctors and nurses. More recently, Nestlé paid for each AAP member (more than 60,000 in total) to receive a copy of the "Pediatric Nutrition Handbook". Both instances are good examples of "image transfer", a strategy to enhance image by association with respected professional bodies. Similar links between health professionals and their associations, and industry, are common. The magnitude of financial conflicts of interest is even larger when drug companies are involved. A recent analysis of 37 biomedical research articles from major medical journals found that a third of the lead authors had financial conflicts of interest: for example, patents, shares, or remuneration for being on advisory boards (ref. 3). Infant food and drug companies do not reveal the amount of money they spend on health professionals, individually or collectively, but they spend 10-15% of their budget on marketing, and a large proportion of this could be used for such funding.

It is often said that conflict of interest is a "condition", not a "behaviour". As a consequence, the suggested solution is transparency: health professionals and their associations should disclose and declare competing financial interests. Unfortunately this does not happen. Most health professionals do not declare their conflict of interest because they think they are honest and unbiased (ref. 3). It is probably true that most health professionals are honest but at the same time, they are very likely to be biased, i.e. unconsciously influenced by their funders. Both social science and medical research show this. For example, when the results of studies sponsored by industry were compared with those of non-sponsored studies, results more favourable to industry were almost four times more likely to be found in sponsored studies than in non-sponsored ones (ref. 4). The reason is that "even when individuals try to be objective, their judgments are subject to an unconscious and unintentional self-serving bias" (ref. 5). Disclosing one’s financial attachments is not only difficult to enforce, but more seriously, it does not eliminate the influence of industry funding on research or doctors’ behaviour. Putting limits to the amount of funds given to individuals or associations, as recently done by the American Medical Association, does not solve the problem: even small gifts feed an unconscious and unintentional self-serving bias. More radical proposals, such as recommending that health professionals should receive no payment of any kind from industry, are unlikely to be accepted: most medical conferences would be cancelled!

There is no simple solution. The first thing to do is to recognise that the problem exists, that it is huge, and that it is complex. All health professionals should then ask themselves the following questions: what would our patients, the people we are serving, think if they were aware that part of our income comes from the manufacturers of the products we prescribe, and that the cost is retrieved in the price of these same products? What would they think if they knew that our advice is not based on independent judgment, but that indeed it is biased? Failure to give an adequate individual and collective response to these questions will progressively undermine the image of health providers and the confidence of users.

As pointed out by law professor Mark A. Rodwin, disclosing financial links is only a first step: "Disclosure can help address conflicts of interest, but only if it is a part or a coordinated policy that sets high standards of conduct, clearly delineates the permissible from the unacceptable, develops institutions to monitor behaviour and imposes meaningful sanctions to ensure compliance." (ref. 6). And as noted by Dana and Lowenstein, "Because bias induced by monetary interests is unconscious and unintentional, there is little hope of controlling it when monettary interests exist. The implication for industry gifts is straightforward: they should be prohibited." (ref. 7)

References

1. Thompson DF. Understanding financial conflicts of interest. N Engl J Med 1993;329:573-6
2. Moynihan R. Who pays for the pizza? Redefining the relationships between doctors and drug companies. BMJ 2003;326:1189-96
3. Hussain A, Smith R. Declaring financial competing interests: survey of five general medical journals. BMJ 2001;323:263-4
4. Bekelman JE, Li Y, Gross CP. Scope and impact of financial conflicts of interest in biomedical research. A systematic review. JAMA 2003;289:454-65
5. Dana J, Lowenstein G. A social science perspective on gifts to physicians from industry. JAMA 2003;290:252-5
6. Rodwin MA. Medicine, money and morals: physicians' conflicts of interest. New York and Oxford, Oxford University Press, 1993
7. Dana J, Lowenstein G. op. cit.