Conflict, what conflict?

When trust goes, so does the healing power of physicians.

There is almost nothing more important in the doctor-patient relationship than trust. By trust we mean the knowledge, on the part of patients, that whatever is discussed, whatever information is shared, and whatever advice is offered by the physician, is done so in his or her best interest. Trust in the “fiduciary” behavior of the physician—who will put his or her interest secondary to that of the patient—is one of the basic tenets of professionalism. A profession has unique, defining characteristics, including a group membership to which entry is limited, a special area of knowledge, a position of authority (because of that special knowledge), self-regulation and community sanction, formal and binding codes of ethics, and a distinctive culture defined by values, norms, and symbols. Along with the status that society grants our (medical) profession, the handsome economic rewards, and patients upon whom we can learn and practice our art, society also bestows on us the autonomy to control and govern ourselves. All this is given in the expectation that we will deserve society's trust, by functioning in the interest of our patients. If we allow self-interest to trump our fiduciary relationship to patients and the community, society has the power to change the rules and take away the enormous privileges it has previously granted.

Such a process is evident regarding the medical profession in the United States today, where the intrusion of economic demands by practice organizations and non-medical administrators, regulation by non-physicians, threats from the ever-present plaintiff's bar, and even intrusion by legislators into the practice of medicine, threaten to further erode our relationship with patients, but are first and foremost a reflection of an already changing attitude of society towards physicians. Rather than blame others, however, we must look at our own behavior and its impact on this fragile relationship.

Rarely a day goes by without our newspapers reporting on breaches of trust by physicians. The details in each case differ, but they share the same dynamic: a trusted doctor (Dr Koop), healthcare organization (the American Medical Association, or the New England Journal of Medicine) or company (Pfizer) is shown to be behaving in a way that is clearly more self-interested than trustworthy. Physicians take “gifts” from drug companies and then spend patients' money to help make the same pharmaceutical industry the most profitable in the world. They recruit “research” subjects without advising them of the personal financial gain that accrues to them. They order more tests when this stands to earn them more money and fewer tests when that does. They take payments for journal “articles” written by ghost/writers paid by proprietary companies, and the commentaries and editorials they themselves write are greatly influenced by their personal and financial relationships to such companies. All these behaviors are directly opposed to what patients and society expect from us in return for the privileges they have bestowed.

Journals need to develop cogent and coherent policies regarding conflicts of interest: in writers, editorialists, reviewers, and editors. The WJM would define conflicts of interests as a set of conditions in which professional judgment about one area may be influenced by clear-cut competing interests, such as personal financial gain. We have no doubt that a conflict of interest exists when the New England Journal of Medicine publishes drug reviews written by authors who are, or have recently been, in the pay of the pharmaceutical industry.¹ Similarly, it is a conflict of interest when the former surgeon general—a man who has been held out as a beacon of righteousness and probity—runs a for-profit web page that offers advice through messages that are actually paid advertisements, without acknowledging this fact to consumers. Similarly, when the same man criticizes the findings of an expert public body without acknowledging that he is being paid by the industry (latex glove manufacturers)² that stands to lose because of the report in question, conflict of interest is clear, and societal trust is threatened.

Does any of this really matter? Isn't it just the American way? And isn't science pure, with its methods transparent, such that motives really don't make a difference to outcomes? So what if scientists receive grant support from a drug company—that won't influence what they write or think. So what if doctors receive boondoggles and cash from drug companies? That won't influence their prescribing practices. What of medical schools that sell their departments or hospitals for a few million in exchange for hanging a company's name over the front door—does that really impact the teaching and patient-care missions? And what of medical journals that are full of drug advertising—this in no way suggests that they will select research papers in such a way as not to offend the hand that feeds them—right? Perhaps the alarms and warnings are just being raised by a bunch of do-gooders who are ranting and raving about morals and righteousness without any evidence of harmful impact.

In fact many of these areas have been carefully studied, with the constant finding that conflicts of interest do make a difference. As pointed out recently in the BMJ,³ the potential for financial gain will lead doctors to refer more patients for tests, operations, research studies, and hospital admissions and it will lead physicians to ask that drugs be placed on a hospital formulary.^{4, 5, 6} Papers published in sponsored journal “supplements” are inferior in quality to those published in the mother journal.⁷ Reviews and commentaries in which the author has a link to a company with a vested interest are more likely to be positive in their conclusions than are those with no such link.^{8, 9, 10} Authors and researchers feel obligated to sponsoring companies and are concerned about what will happen if their findings are not those desired by the sponsor.^10,11

Of course conflicts of interest need not be solely financial; they can be political, academic, religious or self-aggrandizing (related to prestige). And conflicts are not the sole domain of authors. Peer reviewers, government officials, and even journal editors can have conflicts of interest. It is impossible to avoid them entirely or to estimate in every case the presence or degree of conflict. Nevertheless we strive to limit clear-cut conflicts of interest wherever possible and to assure transparency, so that readers can evaluate for themselves the possibility of biased results, analysis, or recommendations. To this end, we have chosen to adopt many of the “conflict of interest” guidelines used by the BMJ (see http://www.ewjm.com), and have added some of our own.

• We will not publish papers, articles, or commentaries that are not directly and personally written by the “author” (we will not accept prose that is penned by a company or public relations agency or prose for which the author has been paid by a party with a vested interest).

• We will try not to solicit commentaries from anyone who has what we believe is a clear-cut conflict of interest. In a case for which we suspend this rule, in order to include the thoughts of someone who is clearly a leader in the area of interest, we will let you, the reader, know of the perceived conflict on the first page of text, so you can estimate for yourself its importance.

• Given the hard financial reality of journal publishing we may need to accept advertising. We will however try to focus on advertisers who are selling products to our readers themselves (vacations, books, cars, sports equipment, etc), rather than those marketing products for physicians to use on patients.

• We will ask all authors, including those who send letters to the editor, to sign our conflict of interest statement (see Guidelines for Authors) and divulge any potential conflicts.

• We will be honest with ourselves in acknowledging that conflicts are everywhere—even at a high quality journal such as the WJM.

We invite you, our readers, to inform us if there are biases or conflicts that we don't recognize. And we will do our best to listen to you and always strive to do better.