One flew over the conflict of interest nest

Giovanni Fava has given us an excellent analysis of the development of crisis about commercial conflicts of interest in psychiatry. But there are some grounds to think the entire subject is something of a red herring, or that Fava's position is itself industry-friendly.

If we view the issues from the frame of the past 400 years, and consider where science has come from, then it is clear that a key triumph of the new branch of knowledge lay not just in any of the so often celebrated breakthroughs in physics, chemistry or biology, but rather in the fact that society had found a means to move knowledge forward that overcame the issue of conflicting interests. If they adhered to the scientific method, then the fact that scientists might be Catholic, Protestant, Hindu, Muslim, Jew or atheist was irrelevant.

Aside from these powerful social prejudices, several studies of the scientific process suggest that individual scientists are all but insane. Many of our most famous scientists can be seen to have pursued their goals obsessively and with a conviction that must have appeared to many contemporaries as close to delusional.

But the scientific method, which involved a new emphasis on observable and replicable data, has provided us with a way to overcome both social prejudice and individual idiosyncrasy (1). The success of science lies in the fact of its being a communal and empirical process rather than a process whose success depends on the motives of individual practitioners. It is against this background that Nature and other journals cited by Giovanni Fava have been slow to respond to the new proposals for statements of conflicts of interest. Why would scientists in general expect relatively small amounts of money given to a few individuals to undo a system that has tamed far more powerful inner demons than this?

Reframed in this way, the fact that there is an undoubted crisis at present suggests that focussing on conflicting interests as the origin of this crisis may be mistaken. Another option is that the apparent studies and related reviews that are at the centre of this crisis are in fact not scientific - they are a cuckoo's egg in the nest of science. And indeed a key feature of the clinical trial reports and review articles that Fava makes reference to is that they do not conform to the central tenet of science which is to engage with issues that are replicable and/or to make the data publicly available.

The current problem for any aspect of medical science involving therapeutics with agents that are on patent is that a significant proportion of trials now remain unpublished and those that are published are often ghostwritten and bear an ambiguous relationship with the underlying data (2). Company postings of trials on the internet do little to mitigate this problem. The difficulties are best symbolised by the case of the pediatric trials of selective serotonin reuptake inhibitors, where we have the greatest known divide in medicine between the raw data on an issue on the one side and the published accounts purporting to represent those data on the other. The data can now be seen to indicate that the drugs do not convincingly work and are hazardous, but prior to the release of the data the scientific literature universally portrayed these agents as safe and effective (3). This divide, it is important to note, only came to light as a result of the efforts of journalists and lawyers. It came to light not because they chased the question of conflicting interests but because it seemed obvious to lay people that the data did not add up. To our shame, no clinician or scientist had a hand in questioning the validity of the "science". What lessons can be drawn from this situation?

If companies want to market their product under the banner of science, they can be required to conform to the norms of science. This will require journal editors and academic meeting organizers to refuse publication to articles or presentations on data not freely accessible. Taking a stand like this will challenge the conflicts of journal editors and meeting organizers, but this rather than conflict of interest declarations from individual academic authors or speakers is much more likely to have teeth.

Ghost writers are in fact much more likely to insert conflict of interest declarations into articles or lecture slides in a manner that conforms to journal or meeting protocols than are academics. If I were employed in a company marketing department I would much prefer to have the field think that all that is wrong is that a few corrupt academics fail to declare competing interests than to have the field think that company practices that restrict access to data while still claiming the moral high ground of science are the real source of the problem.

Disclosure

The author has been a consultant, principal investigator, clinical trialist, chairman or speaker at international symposia for, or received support to attend meetings from: AstraZeneca, Boots/Knoll Pharmaceuticals, Eli Lilly, Janssen-Cilag, Lorex-Synthelabo, Lundbeck, Organon, Pharmacia & Upjohn, Pierre-Fabre, Pfizer, Rhone- Poulenc, Roche, Sanofi, GlaxoSmith- Kline, and Solvay. He has been an expert witness for the plaintiff in 15 legal actions involving SSRIs and has been consulted on a number of attempted suicide, suicide and suicidehomicide cases following antidepressant medication, in most of which he has offered the view that the treatment was not involved. He has also been an expert witness in a number of patent cases.