An honest appraisal of conflict of interest, and a suggestion for one thing that might mitigate it.

First point: Conflict of interest is virtually unavoidable, for social and psychological reasons. The author recalls his dealings, as a young researcher, with a medical device manufacturer.

As we developed content, I soon found myself advocating the use of studies that featured the manufacturer’s product as the best illustrations. My experiences at the pleasant luncheon and in the scientific discussions made me feel as if the other consultants and I had a kind of social duty to reciprocate both the kindness and the investment made by the sponsor in the slide set. Accordingly, I spoke out about the importance of using some of the sponsor’s studies as examples.

At the time, I failed to recognize that this sense of duty might be in conflict with an intention to create an unbiased presentation about the risks and benefits of [their product]. It turns out that I am not alone. In a study of medical residents, 61% were confident that drug company promotions did not influence their practice, but only 16% were equally confident that their colleagues were not influenced by those same drug company promotions.

How is this possible? Self-interest simply distorts the way we render judgments about ourselves. As Katz and colleagues describe the problem, “When a gift or gesture of any size is bestowed, it imposes on the recipient a sense of indebtedness. The obligation to directly reciprocate, whether or not the recipient is directly conscious of it, tends to influence behavior. . . . Feelings of obligation are not related to the size of the gift.” Precisely my experience.

Other interesting social science insights have emerged from the field of behavioral economics. For instance, Ariely conducted a series of experiments in which study participants were rewarded financially for the number of correct answers on tests. The experiments were designed so that cheating was possible. On the basis of the results of these experiments, Ariely concluded that many individuals cheat when they have a chance, but only by a small amount; they know that they are overclaiming the number of correct answers; but this low-level cheating does not cause them to view themselves as dishonest. When I recently used a university envelope to mail a letter to my daughter, I too did not view myself as dishonest, perhaps because I used my own postage stamp.

Two: However small, gifts influence behavior.

These minor dilemmas fail to cross key moral boundaries with the result that they are not experienced as a conscious and deliberate choice between the size of the reward and the potential cost to credibility or reputation. The frequently expressed view that industry gifts or consulting fees are too small to influence behavior simply misses the point that, regardless of their size, they influence behavior, and a self-serving bias distorts the way that individuals perceive themselves. As a result, industry gifts, fees, or funding have become culturally acceptable even though service in a profession does not itself provide immunity from potential conflicts of interest or from the appearance of conflicts of interest.

Point Three: We ought to be ashamed.

Recent high-profile failures to disclose financial relationships with industry have been major embarrassments to the profession. Several professors who promoted the use of atypical antipsychotics for bipolar illness in children had received hundreds of thousands of dollars that went unreported to their institutions. The new guidelines from the
Association of American Medical Colleges on the efforts to manage the relationships between academic scientists and industry sponsors emphasize transparency. Senators Chuck Grassley (R, Iowa) and Herb Kohl (D, Wisconsin) have introduced the Sunshine Act, which would require the public posting of information about all industry payments or transfers of value worth $100 or more. This act, if passed, will help ensure the transparency that the profession on its own has not yet been able muster.

The author concludes:

The bias of conflict of interest is a behavioral phenomenon. Under the assumption of an accurate report, the design of the trial, the conduct of the study, and the interpretation of the results are perhaps the best measures that clinicians, researchers, and other readers have to assess the possibility of such a bias among their scientific colleagues and themselves.

It’s a fine irony that the worst conflict of interest offenders come from the psychiatrists who are supposed to be experts in these sorts of human motivations.

The article is from JAMA. You need to subscribe or pay $15 to read it in full.

UD thanks Bill.