Managing Conflict of Interest: sense and sensibility

Mistrust of individuals and institutions is endemic in modern society. Indeed “‘Loss of trust’ has become a cliche of our times”¹ as the media and public call almost daily upon politicians, professionals and pastors to be more accountable and for processes to be more open and transparent.

This general “loss of trust” has also caught the research community in its wake and promoted the concept of conflict of interest (or competing interest).

The Oxford Concise Dictionary defines conflict as “clash, be incompatible” and interest as “the self pursuit of one’s own welfare, self interest”. Not withstanding these simple meanings, there are currently many definitions of conflict of interest. These range from “a set of conditions in which professional judgment concerning a primary interest (such as patients’ welfare or the validity of research) tends to be unduly influenced by a secondary interest (such as financial gain)”² and, we would add, personal prestige or commercial advantage. More pragmatically, conflict of interest might be described as anything personal, commercial, political, academic or financial, “which when revealed later, would make a reasonable [onlooker] feel misled or deceived.”³

But ultimately these declarations have one aim - to minimise deception and bias. The codifying of conflict of interest has been driven by irrefutable evidence of the erosion of scientific integrity with increasing involvement of commercial interests in research and academia - a partnership actively promoted by governments in order to reap the economic benefits of research findings transferred into commercial products.⁴

Whether one is concerned appears currently to depend on individual and institutional philosophies. The policies governing conflict of interest at universities and research institutions may vary widely.⁵ Meanwhile, the mounting evidence for the blurring of research integrity is considerable:

• Up to one third of authors, who recently published in major medical journals, had financial interest in their research through: patents, shares, or payments for related advisory or consultancy work.⁶

• However, authors often decide not to declare conflicts of interest. In a survey of five leading medical journals (Annals of Internal Medicine, BMJ, Lancet, JAMA, and New England Journal of Medicine) in 2001, less than 2% declared potential conflicts of interest.⁷

• The outcomes of research by investigators with financial interest in, or research support from industry sponsors of products related to the research, are likely to be of inferior quality⁸ or to favour the sponsor’s product,^9,10 and less likely to be published or have delays in publication.^11,12

• Commercial organizations that have engaged in industry-related research are less likely to adhere to the International Committee of Medical Journal Editors’ (ICMJE) Guidelines¹³ for authors to participate in study design, and to have access to all trial data and control over publication.¹⁴

• Attending industry-sponsored presentations or continuing medical education events and accepting funding from the industry for travel or lodging for educational symposia has been associated with non-rational prescribing and with increased prescribing of the sponsor's medication.¹⁵ Yet the attitudes of individuals and professional bodies to industry gifts and sponsorship of local and national meetings, including continuous medical education, are ambivalent.¹⁶

With overwhelming evidence such as this, it would seem apt that the management and policing of conflict of interest would be a top priority in the governance of universities, and research and healthcare institutions. Sadly, this is not the case, as evidenced by the recent fracas at the US National Institutes of Health, rocked by accounts of undisclosed financial arrangements between some employees and industry.¹⁷ In the field of publishing, its management is usually left to individuals with the least resources to uncover the truth - journal editors!

A more recent development is partnerships between hospitals and giant corporations such as that between New York-Presbyterian Hospital and General Electric (GE) Medical Systems, in which the hospital will spend a reported US$500 million over 10 years on GE products and services such as imaging equipment and change management and quality improvement programs.¹⁸ While there are clear benefits of such an arrangement (e.g. the potential standardisation and simplification of tasks), the concerns include whether GE Medical can give the hospital disinterested advice on the purchase of new equipment or services.

What Can be Done to Safeguard Public Trust?

Readers of this journal will have different professional relationships that may be affected by competing interests. These include:

• research investigators, with a duty of care toward research participants and future beneficiaries of their findings

• laboratory purchasers of services and equipment, working with clinicians who use their services

• authors, reviewers, and editors of publications, with a responsibility to readers

• speakers and organisers of professional meetings, with a responsibility to meeting participants

Each has an ultimate impact on public health and trust. However, having a conflict of interest is not wrong in itself. In fact, it may sometimes be unavoidable. The key to safeguarding the public interest lies not in prohibiting competing interests (which would be nearly impossible), but in disclosure. In biomedical publishing, the requirements of the ICMJE are for disclosure of competing interests from authors, reviewers and editors.¹³ Authors are also asked to describe the role of any study sponsors in the study, and in the writing and publication of the report. Editors may choose not to consider an article if the conflict of interest is considered too strong or if a sponsor has asserted control over the data or the authors’ right to publish.

In the area of laboratory practice, the guidelines are less clear. The Royal College of Pathologists of Australasia advises generally against entering into contracts that may diminish patient autonomy, the College Fellow’s own autonomy, or a colleague’s professional integrity.¹⁹ We would further propose that, where exclusive arrangements such as those between New York-Presbyterian Hospital and GE exist, the process of acquisition should be clearly defined, with those involved in the decision-making process declaring their conflicts of interest, including any quid pro quo.

Similarly, the issue of conflicting interests in professional meetings may lie not in complete prohibition of commercial sponsorship but in disclosure of conflicting interests on the part of speakers and organisers. The degree of commercial support could also be limited,¹⁶ with speakers and professional associations retaining complete professional independence. Another means of achieving this is to involve independent organising bodies, with some of the costs borne by industry sponsors (without influencing the content of meetings).

The situations in which conflicts of interest arise are myriad. We need to recognize that having competing interests is not the main problem - we all have them in one form or another. To eliminate them may simply provoke deception, and, in the case of commercial conflicts of interest, deny the possible benefits of partnerships with industry. However, the solution for healthcare, research, and professional organisations alike, as well as individual professionals and biomedical journals, is to promote the disclosure of potential competing interests. Perhaps the question to ask is, “Could I sleep at night if I didn’t disclose?” Anything other than such transparency promotes public perception of duplicity and undermines trust.

“If in doubt, disclose.”³

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