Debates about Conflict of Interest in Medicine: Deconstructing a Divided Discourse

Are Corporations Re-Defining Illness and Health? The Diabetes Epidemic, Goal Numbers, and Blockbuster Drugs

While pharmaceutical industry involvement in producing, interpreting, and regulating medical knowledge and practice is widely accepted and believed to promote medical innovation, industry-favouring biases may result in prioritizing corporate profit above public health. Using diabetes as our example, we review successive changes over forty years in screening, diagnosis, and treatment guidelines for type 2 diabetes and prediabetes, which have dramatically expanded the population prescribed diabetes drugs, generating a billion-dollar market. We argue that these guideline recommendations have emerged under pervasive industry influence and persisted, despite weak evidence for their health benefits and indications of serious adverse effects associated with many of the drugs they recommend. We consider pharmaceutical industry conflicts of interest in some of the research and publications supporting these revisions, and in related standard-setting committees and oversight panels. We raise concern over the long-term impact of these multifaceted involvements. Rather than accept industry conflicts of interest as normal, needing only to be monitored and managed, we suggest challenging that normalcy, and ask: what are the real costs of tolerating such industry participation? We urge the development of a broader focus to fully understand and curtail the systemic nature of industry's influence over medical knowledge and practice.

Discrepancies between author- and industry-reported disclosures of financial relationships at an annual gynecologic oncology research meeting

OBJECTIVE

Trillions of dollars pass to physicians from industry-related businesses annually, leading to many opportunities for financial conflicts of interest. The Open Payments Database (OPD) was created to ensure transparency. We describe the industry relationships as reported in the OPD for presenters at the 2019 Society of Gynecologic Oncology (SGO) Annual Meeting and evaluate concordance between author disclosures of their financial interests and information provided by the OPD.

METHODS

This is an observational, cross-sectional study. Disclosure data were collected from authors with oral and featured abstract presentations in the 2019 SGO annual conference. These disclosures were compared to data available for each author in the 2018 OPD, which included the amount and nature of industry payments.

RESULTS

We examined the disclosures of 301 authors who met inclusion criteria. Of 161 authors who had disclosure statements on their presentations,147 reported "no disclosures," and 14 disclosed industry relationships. The remaining 140 did not list any disclosure information. Sixty percent (184/301) of authors had industry relationships in the 2018 OPD, including 173 of 287 (60.3%) of authors who either reported no disclosures or did not have disclosure data available in their presentations. These transactions totaled over 43 million USD from 122 different companies, with most payments (46%) categorized as "Research or Associated Research." Accurate disclosure reporting was associated with receiving higher payments or research payments, and being a presenting author.

CONCLUSIONS

Most authors at the SGO annual conference did not correctly disclose their industry relationships when compared with their entries in the OPD.

After Conflicts of Interest: From Procedural Short-Cut to Ethico-Political Debate

This paper critically examines the proliferation of conflicts of interest (COI) discourse and how the most common conceptions of COI presuppose a hierarchy of primary and secondary interests. I show that a form of professional virtue or duty is commonly employed to give the primary interest normative force. However, I argue that in the context of increasingly commercialized healthcare neither virtue nor duty can do the normative work expected of them. Furthermore, I suggest that COI discourse is symptom of rather than solution to the problems of market forces in contemporary medicine. I contend that COI, as it is commonly conceived, is an inadequate concept through which to attend to these problems. It is used as a procedural short-cut to address ethico-political problems. That is, it is an economic and policy concept expected to do significant moral and political work. Like most short-cuts, this one also leads to entanglements and winding roads that fail to reach the destination. As such, I suggest that we need a different set of ethico-political tools to address normative fluidity of medical practice in the absence on a primary interest.

Mapping the characteristics of meta-analyses of pharmacy services: a systematic review

BACKGROUND

Suboptimal meta-analyses with misleading conclusions are frequently published in the health areas, and they can compromise decision making in clinical practice.

AIM OF THE REVIEW

This systematic review aimed to map the characteristics of published meta-analyses of pharmacy services and their association with the study conclusions.

METHOD

We searched electronic databases (PubMed, Scopus, and Web of Science) to identify published meta-analyses of pharmacy services up to January 2019. Components of meta-analyses were extracted (i.e. studies' metadata; methods used in the systematic review; description of the statistical model used for the meta-analysis; main results; conflict of interest and funding source). The methodological quality was evaluated using the R-AMSTAR tool.

RESULTS

A total of 85 meta-analyses were included, with 2016 as the median publication year. Overall, the methodological quality of meta-analyses of pharmacy services was considered suboptimal. Only one-third of authors registered a protocol; complete search strategy and raw data were provided by 55.3% and 9.4% of studies, respectively. Evidence strength (GRADE) was evaluated in only 19.2% of studies. PRISMA and Cochrane recommendations were stated to be followed in 60% and 27.4% of articles, respectively. Around half of studies performed sensitivity analysis, however, the prediction interval was presented by only one meta-analysis. Studies that favoured the pharmacists' interventions poorly discussed the methodological quality and heterogeneity of primary trials.

CONCLUSION

Poor conduction and reporting were observed in meta-analyses of pharmacy services, especially in those that favoured the pharmacist's interventions. Reproducibility and transparency should be rigorously ensured by journal editors and peer-reviewers.

Conflicts of interest in medicine: a never-ending story

Individuals may have conflicts of interest (CoI) when they choose between the duties of their jobs and their own private interests. In medicine, CoI are potentially ubiquitous and their disclosure has now become the most frequent strategy to address them in professional lives. In the medical literature, CoI are classified into two different types-financial and non-financial. Financial CoI are easy to identify and can bias any kind of results in research; so, their disclosure is very important. The unsolvable dilemma is where to set the lowest limit for sums received from industry. Non-financial CoI are a very large category intrinsically related to the individuals concerned, ranging from family relationships to religious beliefs, and the mere disclosure of many of them can raise privacy and ethical issues. Two opposite narratives characterize the debate on financial CoI caused by pharmaceutical industry. The critical side argues that, because the primary goal of pharmaceutical industry is inevitably to promote its products, the best strategy is to stay away from financial CoI. On the other hand, the defensive side claims that financial CoI are boosted by ideology but meaningless in real practice, since any kind of interest can raise a potential conflict. A missing point in the debate on financial CoI is that health care is a classical example of 'market failure' in the economic theory. Since health cannot be considered a 'consumer good', the economic paradigm of 'free market' does not fit for healthcare products. To conclude, even though transparency on financial CoI cannot itself deter the risk of bias, rejecting it would be an even bigger mistake. At variance, mandatory disclosure of non-financial CoI risks to be confusing and questionable in many cases, paradoxically distracting attention from the potential bias created by financial CoI.

Two's company, is three a crowd? Ethical cognition in decision making and the role of industry third parties in pediatric diabetes care

Families of children with diabetes increasingly obtain health information from a variety of sources. Doctor-patient relationships have accordingly become more fluid and dynamic with input from other parties. These outside parties include representatives from the diabetes health care industry-industry third parties (ITPs). This review is an exploration of the ethical principles and cognitive processes involved when doctors and patients negotiate around health care practices and the role of ITPs in that dialogue. Ethical principles of conflicts of interest, beneficence (act in the best interests of the patient), non-maleficence (act so as to do no harm) and justice (act so as to allocate resources fairly or justly) are relevant considerations. Reflexive and analytic thinking and various cognitive biases also play a significant part in clinical decision making. A complex case example is analyzed to highlight a process of ethical cognition in decision making to ensure high-value care and optimal patient outcomes.

Scientism, conflicts of interest, and the marginalization of ethics in medical education

AIM

This paper reports on the findings from 6 focus groups conducted with Australian medical students. The focus groups sought students' perspectives on how the influence of commercial interests on medical practice and education could be managed.

METHOD

We conducted 6 focus groups with medical students in New South Wales, Australia. Participants were recruited via student-run medical society and faculty e-mail lists. Forty-nine students from 6 medical schools in New South Wales participated. The research team reflected on the extent to which students uncritically appealed to science in the abstract as a management solution for conflicts of interest. Data analysis was largely inductive, looking for uses of scientific terminology, EBM, and appeals to "science" in the management of COI and applied theoretical analyses of scientism.

RESULTS

The students in our study suggested that science and evidence-based medicine, rather than ethics or professionalism, were the best tools to deal with undue influence and bias. This paper uses philosophy of science literature to critically examine these scientistic appeals to science and EBM as a means of managing the influence of pharmaceutical reps and commercial interests. We argue that a scientistic style of reasoning is reinforced through medical curricula and that students need to be made aware of the epistemological assumptions that underpin science, medicine, and EBM to address the ethical challenges associated with commercialised health care.

CONCLUSION

More work is needed to structure medical curricula to reflect the complexities of practice and realities of science. However, curricula change alone will not sufficiently address issues associated with commercial interests in medicine. For real change to occur, there needs to be a broader social and professional debate about the ways in which medicine and industry interact, and structural changes that restrict or mitigate commercial influences in educational, research, and policy settings.

Should disclosure of conflicts of interest in medicine be made public? Medical students' views

CONTEXT

Conflicts of interest (CoIs) are considered to be ubiquitous in health care and biomedicine. The disclosure of relevant interests is a first step in managing conflicts, although its usefulness is contested. Although several countries have mandated the public disclosure of doctors' financial relationships with the pharmaceutical industry, little is known about medical students' understanding of mandatory public disclosure.

METHODS

Six 90-minute focus groups were conducted with medical students in New South Wales, Australia. Participants ranged from first- to final-year students. Students were asked about their understanding and experiences of CoIs and, more specifically, for their views on and experiences of disclosure in medical education, mandatory disclosure and public registers. Qualitative data analysis was based on a framework approach.

RESULTS

Participants were generally not supportive of mandatory public disclosure of financial relationships with industry, principally because of concerns about privacy, control over disclosure, and others' (mis)interpretations of disclosures. Further, they did not know how to assess the disclosures presented to them as part of their medical education and described a wide range of reactions to disclosed information.

CONCLUSIONS

This study suggests that students are currently not well prepared for mandatory public disclosure of CoIs. The subsequent discussion draws on Bourdieu's doxa to highlight assumptions of altruism in medicine, assumptions that are potentially in tension with recent events that have exposed doctors to moral scrutiny by the public. Medical students could be better prepared for future obligations by encouraging disclosures, and contextualising and helping students to interpret them. Disclosure as a box-ticking exercise is unlikely to achieve goals implied by transparency, but a more reflective approach may assist both scrutinisers and the scrutinised.