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Analysing conflicts of interests

A Sydney doctor, who wishes to remain anonymous, has sent in the following piece examining the complexities of conflict of interest issues. It’s timely in view of the approaching NHMRC workshop on this issue, and recent debate surrounding Vioxx promotions, industry sponsored guidelines for DVT prevention, and the Baker/Sanofi deal, amongst other things.

The doctor writes:

It’s not about ‘goodies and baddies’
Some pharmaceutical companies operate for profit, including in some jurisdictions where company directors have a statutory responsibility and perhaps a fiduciary duty to shareholders to enhance the fortunes of the business by any legal means, including having their employees and contractors do whatever they can to sell drugs.

In the same environment those who care for patients have a professional duty to exercise their clinical judgement in the interests of their patients.  Not always will the interests of the company and of the patients be aligned; in those situations shouldn’t the health carers act with as little influence as possible from the competing interest of profit?

Conflict of interest, and influence by association
When guideline writers or prescribers are in particular relationships with profit seeking pharmaceutical companies conflicts of interest can arise, perhaps on both sides.  The resulting concern for those concerned about the public interest is that bias in doctors may compromise patient care.  Two issues seem relevant: competing interests are ubiquitous and can’t realistically be eliminated; and bias might result even without conflicts of interest.

Firstly, if I drive a bus but feel I am losing my concentration and putting pedestrians and passengers at risk, to keep driving is not in the public interest.  We can’t expect people not to have conflicts of interest, nor to themselves resolve these in the public interest always.

Secondly, ‘A conflict of interest occurs when a public official is in a position to be influenced, or appear to be influenced, by private interests when discharging their public sector duties and responsibilities.’ says ICAC.

Thus, someone who has a relationship described as travel funding (assume ‘no frills’ travel) may not have a conflict of interest.  But such a person may still have been influenced by the travel funding, by processes described by Robert Cialdini, and categorised by Libby Roughead with general practitioners.

These influences include:
1.    Friendship and liking: it’s harder to deny requests made by friends and those we like.
2.    Gifts and reciprocation: we learn early on that receiving a gift means we should reciprocate.

Perhaps these processes explain the relationship between the ‘closeness’ of doctors to drug companies, and those doctors’ usually poorer clinical competence with drug use. See Wazana.

Hence, disclosure
The shortcomings of disclosure of conflicts of interest, or of association, are that the ‘discloser’ may feel she has a moral licence to say anything biased she wishes because the audience has been warned to be wary; or she may feel she has to be so scrupulously cautious that her bias turns the other way, or the influence may not cause bias.

But the audience doesn’t know how much or which way, if at all, to adjust for her conflict of interest or association.

With those nine possible combinations, only one of which must be ‘neutral’, disclosure alone seems unsatisfactory.  A social science experiment has shown that disclosure detracts from the ‘audience’s’ ability to detect the ‘truth’.  Cain D, Loewenstein G, Moore DA. (The dirt on coming clean: perverse effects of disclosing conflicts of interest. J Legal Stud 2005;34:1–25).

The ‘regulator’ may feel satisfied the disclosure is made; the ‘discloser’ may feel she’s been open; and the audience may feel they’ve been respected.  But in the end the burden of the conflict of interest has been shifted to those least deserving of that burden – the audience, or worse still, their patients.  If we need to go further than disclosure, should those with avoidable conflicts be excluded from decision making roles?  See : Moore DA, Cain DM, Loewenstein G, Bazerman M, eds. Conflicts of Interest: Problems and Solutions from Law, Medicine and Organizational Settings. London: Cambridge University Press, 2005

Way forward?
In view of those considerations, the ball would seem to be in the court of the health care providers and regulators, not the pharmaceutical companies; and self-regulation by the pharmaceutical industry to not act contrary to the public interest would seem contradictory because of the competing interest of profit.

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