Conflicting interests and doing right

Although Giovanni Fava's title is "Financial conflicts of interest in psychiatry", the definition he gives is a more general one, which I like: "conflicts of interest... are characterized by individual occupying dual roles which should not be performed simultaneously". And he asks which roles these are. In answer, he focuses exclusively upon all those that academics may play for pharmaceutical companies. He could have added roles with a voluntary organization, a charity, a law firm, a department of government, an investment company or any other formally constituted body with interests in the field of psychiatry. But it is part of the current Zeitgeist that pharmaceutical companies are particularly demonized (1).

Is there a current problem? Unfortunately, I must accept that there is. Do some individuals in academia abuse their position in exchange for fees from companies, for example, by putting their names on articles they have scarcely read, let alone written? I am sure some do and it is wrong. Is the influence of industry on medical prescribing excessive? Yes. At present we have far more spent on continuing medical education by companies than by anyone else. But that also represents a failure of healthcare systems funded by governments. Are some roles incompatible one with another? Obviously so: one cannot personally buy and sell shares in a specific company and claim not to have an interest in its success; advising regulatory bodies is an activity that largely precludes working with industry. But the majority of research academics do not, or certainly need not occupy roles that are incompatible with involvement with industry, and many that are most critical of such contact may have problems of an analogous kind, that they do not have to declare.

To understand why I say this, let us explore a more general definition of conflict of interest - in other words the positions, allegiances or interests that shape the people we are and the decisions that we reach. Some of the most compromising allegiances may be less quantifiable than the fees received from a pharmaceutical company.

Such issues provide part of the reason this debate seems to have become so vitriolic in psychiatry. I believe it taps into a more profound disagreement about the status of drug treatment per se, for what we still call in English "mental disorder". I do not know Giovanni Fava personally, but, from reading his published papers, I would not be surprised if he believes, as I know many social psychiatrists do, that drugs ultimately do not work, or anyway do not work very well, and that psychotherapy or social interventions are superior, or anyway preferable. This is often associated in my experience with a high-minded view that social factors cause or exacerbate mental illness and that ultimate solutions lie in a better society, rather than better medicines. My own position is more or less the opposite of this: I see medicines as holding a primary role for significantly improving the chances that an individual patient may recover from severe psychiatric disorder. I accept the value of pragmatic psychotherapies, but, while drug-placebo differences seem to be magnified by illness severity, psychotherapies tend to look less effective as illness severity increases. Finally, I am pessimistic about social solutions to personal problems. If I have asthma, I want an inhaler: I can complain about the air quality later.

There is a more explicitly political argument, which is also close to the surface in the current controversy. Is the making of money on the back of drug development and sales somehow immoral? It is part of a more general political critique of capitalism, whereof Winston Churchill once remarked: "The inherent vice of capitalism is the unequal sharing of blessings; the inherent virtue of socialism is the equal sharing of miseries". Those of us who want to see an improvement in the efficacy, tolerability and use of medicines are bound to accept the capitalism of pharmaceutical companies. Innovation may start in academia, but it can only be delivered by companies. Along with that come marketing, consultancy, and hype, and the countervailing forces of government regulation, attention seeking whistle blowers, newspaper-puffed scandals, etc. It is untidy, but it is how a free society works. In my opinion, my patients have benefited directly and significantly from the new medicines licensed in the last 20 years. And there is no doubt, either, that the first generation drugs were a major breakthrough at the beginning of the psychopharmacological era. They were also no doubt a major source of profit to the companies that made them. However, drug companies are for the most part public companies. In other words, we may all benefit through the employment they create, the taxes they pay and the pension funds that invest in them. Further, they spend much more on medical research than any other sector of the economy.

Can we improve the current state of affairs? I agree with Giovanni Fava that the USA is ahead of Europe in relation to policies of disclosure, and that transparency is a minimum essential safeguard. Journal editors need to be vigilant, and learned societies need to decide what the ethos of their meetings is to be and get the balance right: the atmosphere in some is embarrassingly commercial. But to seek to sterilize academic activity from the pharmaceutical industry is to deny a key link between academic innovation and actual delivery of a product to the consumer. There has to be a relationship if we want any more new compounds. And it is a real further concern that, if we protest too much, psychiatry may come to seem not worth the bother.

Finally, while I applaud Giovanni Fava's focus on individual responsibility, I am not convinced that a narrow obsession with what he refers to as un- necessary risks offers clinical research any kind of intellectual freedom at all. Intellectual freedom comes from a training that instils independence of mind, a sceptical approach to evidence and a taste for the truth. These are classical virtues. I see nothing that should prevent their display in one's relationship with pharmaceutical companies.

Disclosure

The author currently holds grants from P1Vital, Sanofi-Aventis, Servier, Baily Thomas Charitable Fund, Economic and Social Research Council and Medical Research Council, and in the last year has acted as advisor to Bristol-Myers Squibb, P1Vital, Roche, Sanofi-Aventis, Servier and Wyeth, and accepted honoraria for chairing or speaking from AstraZeneca, Bristol-Myers Squibb, Lilly, Eisai, Lundbeck, Sanofi-Aventis and Servier.