Why Are (Some) Conflicts of Interest in Medicine So Uniquely Vexing?

doi:10.1017/CBO9780511610332.012

11 - Why Are (Some) Conflicts of Interest in Medicine So Uniquely Vexing?

Published online by Cambridge University Press: 04 August 2010

Andrew Stark

Edited by

Don A. Moore ,

Daylian M. Cain ,

George Loewenstein and

Max H. Bazerman

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Andrew Stark: Affiliation:
University of Toronto
Don A. Moore: Affiliation:
Carnegie Mellon University, Pennsylvania
Daylian M. Cain: Affiliation:
Carnegie Mellon University, Pennsylvania
George Loewenstein: Affiliation:
Carnegie Mellon University, Pennsylvania
Max H. Bazerman: Affiliation:
Harvard University, Massachusetts

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Summary

Over the past decade, four kinds of biomedical conflict of interest – two besetting academic researchers, and the other two physicians – have proved unamenable to any substantial consensus as to their seriousness. For researchers, they are the conflicts inherent in (a) grants from pharmaceutical or biotech companies and (b) peer review. For doctors, they are the conflicts created by (a) gifts of professional travel or equipment from pharmaceutical or medical-device manufacturers and (b) self-referral.

Organizations and institutions have adopted a gamut of different policies on these conflicts. Each of the four continues to provoke “deep divisions” (Moore, 1996, p. 173) or “endless debate” (Grace, 1998, p. A12), with some commentators demanding that they be “proscribed” (Kassirer & Angell, 1993, p. 570) and others insisting that they pose “no problem” (McDowell, 1989, p. 75). In what follows, I step back from these debates and, aided by comparisons with other professions, ask why they are so contentious. As I shall argue, these four conflicts all share a characteristic not found in the same pronounced way in any other professional conflict of interest, whether in medicine or elsewhere. My goal here is not to take sides on the question of whether these conflicts are to be prohibited or permitted. It is to analyze the debates surrounding them and to explain, by examining underlying issues of comparative professional structure, why those debates seem so relatively polarized.

Type: Chapter
Information: Conflicts of Interest
Challenges and Solutions in Business, Law, Medicine, and Public Policy
, pp. 152 - 180

DOI: https://doi.org/10.1017/CBO9780511610332.012 [Opens in a new window]

Publisher: Cambridge University Press

Print publication year: 2005

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References

Ad Hoc Committee on Misconduct and Conflict of Interest in Research. (1990). Guidelines for dealing with faculty conflicts of commitment and conflicts of interest in research. Academic Medicine, 65, 488–496

Allman, R. L. (2003). The relationship between physicians and the pharmaceutical industry. HEC Forum, 15, 155–170CrossRef Google Scholar PubMed

Barrett, D. (2000). Lawyer busted in stocks bribe. New York Post. November 21

Bekelman, J. E., Li, Y., and Gross, C. P. (2003).Scope and impact of financial conflicts of interest in biomedical research. Journal of the American Medical Association, 289, 454–464CrossRef Google Scholar PubMed

Berger, J. T. (2003). Pharmaceutical industry influences on physician prescribing: Gifts, quasi-gifts, and patient-directed gifts. American Journal of Bioethics, 3, 56–57CrossRef Google Scholar PubMed

Bernat, J. L., Goldstein, M. L., and Ringel, S. P. (1998).Conflicts of interest in neurology. Neurology, 50, 327–331CrossRef Google Scholar PubMed

Bero, L. A. (1998). Disclosure policies for gifts from industry to academic faculty. Journal of the American Medical Association, 279, 1031–1032CrossRef Google Scholar PubMed

Berton, L. (1986). CPA self-regulation: A contradiction in terms? Wall Street Journal, August 19: 1

Blake, D. A. (1992). The opportunities and problems of commercial ventures: the university view. In R. J. Porter and T. E. Malone (Eds.), Biomedical Research: Collaboration and Conflict of Interest. Baltimore and London: Johns Hopkins

Blumenthal, D., Causino, N., Campbell, E., andLouis, K. S. (1996). Relationships between academic and industry in the life sciences – an industry survey. New England Journal of Medicine, 334, 368–373CrossRef Google Scholar PubMed

Boyd, E., Cho, M., andBero, L. (2003). Financial conflict-of-interest policies in clinical research: issues for clinical investigators. Academic Medicine, 78, 769–774CrossRef Google Scholar PubMed

Brett, A. S. (2003). Cheap trinkets, effective marketing: small gifts from drug companies to physicians. American Journal of Bioethics, 3, 52–53CrossRef Google Scholar

Brett, A. S., Burr, W., and Moloo, J. (2003). Are gifts from pharmaceutical companies ethically problematic?Archives of Internal Medicine, 163, 2213–2218CrossRef Google Scholar PubMed

Brody, B. A. (1996). Conflicts of interest and the validity of clinical trials. In R. G. Spece, D. S. Shimm, and A. E. Buchanan (Eds.), Conflicts of interest in clinical research and practice. New York: Oxford University Press

Business Editors. (2002). Technical findings for water program reaffirmed. Business Wire, March 2: 1

Cantekin, E., and McGuire, T. W. (1989). Biomedical information, peer reviews, and conflict of interest as they influence public health (abstract). In Guarding the guardians: Research on peer review. The First International Congress on Peer Review in Biomedical Publication, May 10–12: 19–20

Cho, M. K., and Billings, P. (1997). Conflict of interest and institutional review boards. Journal of Investigative Medicine, 45, 154–159Google Scholar PubMed

Cho, M. K., Ryo, S., Schissel, A., and Rennie, D. (2000). Policies on faculty conflicts of interest at US universities. Journal of the American Medical Association, 284, 2203–2208CrossRef Google Scholar PubMed

Chren, M. M., and Landefeld, C. S. (1994).Physicians' behavior and their interactions with drug companies. Journal of the American Medical Association, 271, 684–689CrossRef Google Scholar PubMed

Council of Ethical and Judicial Affairs of the American Medical Association. (1991). Gifts to physicians from industry. Journal of the American Medical Association, 256, 501

Dana, J., and Loewenstein, G. (2003). A social science perspective on gifts to physicians from industry. Journal of the American Medical Association, 290, 252–256CrossRef Google Scholar PubMed

Davidoff, F. (1997). Where's the bias?Annals of Internal Medicine, 126, 986–988CrossRef Google Scholar PubMed

DeAngelis, C. D. (2000). Conflict of interest and public trust. Journal of the American Medical Association, 284, 2237–2238CrossRef Google Scholar PubMed

Donaldson M. S., and Capron, A. M. (1991). Patient outcomes research teams: Managing conflict of interest. Washington, D.C.: National Academy Press

Editors. (1991). Whistle blows at BCCI: Sounds of silence. Bank Systems and Technology, 28,30–32

Editors. (2003). Editorial procedures reviewed. Nature Cell Biology,5, 583–584

Emanuel, E. J., and Steiner, D. (1995).Institutional conflict of interest. New England Journal of Medicine, 322, 262–268CrossRef Google Scholar

Fogarty, T., and Ravenscroct, S. (1999). Making accounting knowledge: Peering at power. Panopticon, California State University at Stanislaus, 1–18

Foster, R. S. (2003). Conflicts of interest: Recognition, disclosure and management. Journal of the American College of Surgeons, 196, 505–517CrossRef Google Scholar PubMed

Frankel, M. S. (1996). Perception, reality and the political context of conflict of interest in university-industry relationships. Academic Medicine, 71, 1297–1304CrossRef Google Scholar PubMed

Friedberg, M.Saffran, B., Sinson, T. J., Nelson, W., andBennett, C. L. (1999). Evaluation of conflict of interest in economic analyses of new drugs used in oncology. Journal of the American Medical Association, 282, 1453–1457CrossRef Google Scholar

Friedman, P. J. (1990). We need to find new ways to help scientists avoid ethical problems without overly limiting research. Chronicle of Higher Education, October 31: A48

Gatehouse, J. (2001). Journals push back at drug giants. National Post, August 13: A1

Gibbons, R. V. et al. (1998).A comparison of physicians' and patients' attitudes toward pharmaceutical industry gifts. Journal of General Internal Medicine, 13, 151–154CrossRef Google Scholar PubMed

Goldrick, B. A., Larson, E., and Lyons, D. (1995). Conflict of interest in academia. Image the Journal of Nursing Scholarship, 27, 65–69CrossRef Google Scholar PubMed

Goodman, B. (2003). All rationalizations large and small. American Journal of Bioethics, 3, 57–58CrossRef Google Scholar PubMed

Grace, S. (1998). Physicians disagree on the ethics of self-referral. Times-Picayune, May 10: A12

Gray, B. H. (1991). The profit motive and patient care: The changing accountability of doctors and hospitals. Cambridge, MA: Harvard University Press

Green, R. M. (1990). Physicians, entrepreneurism and the problem of conflict of interest. Theoretical Medicine, 11, 287–300CrossRef Google Scholar PubMed

Gunderson, M. (1997). Eliminating conflicts of interest in managed care organizations through disclosure and consent. Journal of Law, Medicine and Ethics, 25, 5–15CrossRef Google Scholar PubMed

Hensley, S. (2002). Drug group sets guidelines to curb hard-sell tactics. Wall Street Journal, April 19: A2

Hilts, P. J. (2000).Medical-research official cites ethics woes. New York Times. August 17: A20

Hodges, B. (1995). Interactions with the pharmaceutical industry: experiences and attitudes of psychiatry residents, interns and clerks. Canadian Medical Association Journal, 153, 553–559Google Scholar PubMed

Horrobin, D. (1989). The philosophical basis of peer review (abstract). In guarding the guardians: Research on peer review. The First International Congress on Peer Review in Biomedical Publication. May 10–12: 24

Horton, R. (1997). Conflicts of interest in clinical research: opprobrium or obsession. Lancet, 349, 1112–1113CrossRef Google Scholar PubMed

James, A., and Horton, R. (2003). The Lancet's policy on conflicts of interest. Lancet, 361, 8–9CrossRef Google Scholar

Johns, M. M. E., Barnes, M., and Florencio, P. S. (2003).Restoring balance to industry-academic relationships in an era of institutional financial conflicts of interest. Journal of the American Medical Association, 289, 741–746CrossRef Google Scholar

Kassirer, J. P. (2000). Financial indigestion. Journal of the American Medical Association, 284, 2156–2157Google Scholar PubMed

Kassirer, J. P., and Angell, M. (1993). Financial conflicts of interest in biomedical research. New England Journal of Medicine, 329, 570–571CrossRef Google Scholar PubMed

Katz, D., Caplan, A. L., and Merz, J. F. (2003).All gifts large and small. American Journal of Bioethics, 3, 39–46CrossRef Google Scholar PubMed

King, C. R., McGuire, D. B., Longman, A. J., and Carroll-Johnson, R. M. (1997).Peer review, authorship, ethics and conflict of interest. Image, 29, 163–167Google Scholar PubMed

Korenman, S. G. (1993). Conflicts of interest and commercialization of research. Academic Medicine, 9: S18–S22CrossRef Google Scholar

Korn, D. (2000). Conflicts of interest in biomedical research. Journal of the American Medical Association, 284, 2234–2237CrossRef Google Scholar PubMed

Kraus, W. (1999). Certification – improvement thanks to peer review. Cost Engineering, 41, 22–24Google Scholar

Kravetz, A. (2000). Judge to rule on bribery charge in Mitsubishi case. Peoria Star Journal. January 21

Krimsky, S., and Rothenberg, L. S. (1998).Financial interest and its disclosure in scientific publications. Journal of the American Medical Association, 280, 225–226CrossRef Google Scholar PubMed

Krimsky, S. (1999). Conflict of interest and cost-effectiveness analysis. Journal of the American Medical Association, 282, 1474–1475CrossRef Google Scholar PubMed

Latham, S. (2001). Conflict of interest in medical practice. In M. Davis and A. Stark (Eds.), Conflict of interest and the professions. New York: Oxford University Press

Lemmens, T. L., and Singer, P. A. (1998).Bioethics for clinicians: Conflict of interest in research, education and patient care. Canadian Medical Association Journal, 159, 960–965Google Scholar PubMed

Levinsky, N. G. (2002). Nonfinancial Conflicts of Interest in Research. New England Journal of Medicine, 247, 759–761CrossRef Google Scholar

Lewis, R. (2002). Rules stall quick hire of Boston Highway megaproject reviewer. Knight Ridder Tribune Business News, February 26: 1

Lexchin, J. (1993). Interactions between physicians and the pharmaceutical industry: What does the literature say?Canadian Medical Association Journal, 149, 1401–1407Google Scholar PubMed

Lock, S. (1994). Does editorial peer review work?Annals of Internal Medicine, 121, 60–61CrossRef Google Scholar PubMed

McDowell, T. N. (1989). Physician self referral arrangements: Legitimate business or unethical “entrepreneurialism.”American Journal of Law and Medicine, 15, 61–109Google Scholar PubMed

McKinney, W. P. et al. (1990).Attitudes of internal medicine faculty toward professional interaction with pharmaceutical sales representatives. Journal of the American Medical Association, 264, 1693–1697CrossRef Google Scholar PubMed

McNutt, K. (1999). Conflict of interest (nutrition research). Journal of the American Diet Association, 99, 1–4CrossRef Google Scholar

Mancuso, A. J. (1991). The road to quality. CPA Journal, 61, 94Google Scholar

Mansfield, P. R. (2003). Bribes for doctors: A gift for bioethicists?American Journal of Bioethics, 3, 47–48CrossRef Google Scholar PubMed

Marshall, E. (1992). When does intellectual passion become conflict of interest?Science, 257, 621CrossRef Google Scholar PubMed

Miller, T. E., and Sage, W. M. (1999).Disclosing physician financial incentives. Journal of the American Medical Association, 281, 1424–1430CrossRef Google Scholar PubMed

Moore, N. J. (1996). Entrepreneurial doctors and lawyers: Regulating business activities in the medical and legal professions. In R. G. Spece, D. S. Shimm, and A. E. Buchanan (Eds.), Conflicts of interest in clinical research and practice. New York: Oxford University Press

Morin, K., and Morse, L. J. (2003).The ethics of pharmaceutical gift-giving: The role of a professional association. American Journal of Bioethics, 3, 54–55CrossRef Google Scholar PubMed

Morreim, E. H. (1996). Conflict of interest for physician entrepreneurs. In R. G. Spece, D. S. Shimm, and A. E. Buchanan (Eds.), Conflicts of interest in clinical research and practice. New York: Oxford University Press

Murray, D. (2002). Gifts: What's all the fuss about? Medical Economics, October 11

Omenn, G. S. (1983). University-corporate relations in science and technology. In Partners in the research enterprise: A national conference on university-corporate relations in science and technology. University of Pennsylvania, Dec. 14–16, 1982; Philadelphia: University of Pennsylvania Press

Parmley, W. W. (1992). Conflict of interest: An issue for authors and reviewers. Journal of the American College of Cardiology, 20, 1017CrossRef Google Scholar PubMed

Parmley, W. W. (2000). Full disclosure: The antidote to conflict of interest. Journal of the American College of Cardiology, 25, 1693CrossRef Google Scholar

Patterson, K. (2002). What doctors don't know (almost everything). New York Times Magazine, May 5

Pisetsky, D. S., Hunder, G. G., and Gravallese, E. (2003). New policy on disclosure of interest for American College of Rheumatology journals. Arthritis and Rheumatism, 48, 863–875CrossRef Google Scholar PubMed

Porter, R. J. (1992). Conflict of interest in research: Personal gain – the seeds of conflict. In R. J. Porter and T. E. Malone (Eds.), Biomedical research: Collaboration and conflict of interest. Baltimore and London: Johns Hopkins University Press

Relman, A. S. (1985). Dealing with conflicts of interest. New England Journal of Medicine, 313, 749–751CrossRef Google Scholar PubMed

Relman, A. S. (1989). Economic incentives in clinical investigation. (1989). New England Journal of Medicine, 320, 933–934CrossRef Google Scholar

Rennie, D., Flanagin, A., and Glass, R. M. (1991). Conflicts of interest in the publication of science. Journal of the American Medical Association, 266, 266–267CrossRef Google Scholar

Rennie, D. (1993). More peering into editorial peer review. Journal of the American Medical Association, 270, 2856–2858CrossRef Google Scholar PubMed

Rhodes, R., and Capozzi, J. D. (2003).The invisible influence of industry inducements. American Journal of Bioethics, 3, 65–67CrossRef Google Scholar PubMed

Rodwin, M. (1993). Medicine, money, and morals. New York: Oxford University Press

Rodwin, M., and Okamoto, A. (2000).Physicians' conflict of interest in Japan and the United States: Lessons for the United States. Journal of Health Politics, Policy and Law, 25, 343–375CrossRef Google Scholar PubMed

Rothman, K. J. (1993). Conflict of interest: The new McCarthyism in science. Journal of the American Medical Association, 269, 2782–2784CrossRef Google Scholar

Rumsey, T. S. (1999). One editor's views on conflict of interest. Journal of Animal Science, 77, 2379–2383CrossRef Google Scholar PubMed

Sadovi, C. (2002). Lawyer accused of seeking bribe. Chicago Sun-Times, April 4

Sage, W. M. (1999). Regulating through information: Disclosure laws and American health care. Columbia Law Review, 99, 1701–1829CrossRef Google Scholar PubMed

Scanlon, B. (2003). Safety versus secrecy; Physician peer reviews conflict with patients' right to know, critics say. Rocky Mountain News, Dec. 6: 25A

Shimm, D. S., and Spece, R. G. (1991).Industry reimbursement for entering patients into clinical trials: Legal and ethical issues. Annals of Internal Medicine, 115, 148–151CrossRef Google Scholar PubMed

Shimm, D. S., Spece, R. G., and DiGregorio, M. B. (1996). Conflicts of interests in relationships between physicians and the pharmaceutical industry. In R. G. Spece, D. S. Shimm, and A. E. Buchanan (Eds.), Conflicts of interest in clinical research and practice. New York: Oxford University Press

Shipp, A. C. (1992). How to control conflict of interest. In R. J. Porter and T. E. Malone (Eds.), Biomedical research: Collaboration and conflict of interest. Baltimore and London: Johns Hopkins University Press

Smith, R. (1994). Conflict of interest and the BMJ. British Medical Journal, 308, 4–5CrossRef Google Scholar PubMed

Smith ⅴ. U.S. 1962. 305 F. 2d 197 (9th Circuit)

Sollitto, S. et al. (2003).Intrinsic conflicts of interest in clinical research: A need for disclosure. Kennedy Institute of Ethics Journal, 13, 83–91CrossRef Google Scholar

Southgate, M. (1987). Conflict of interest and the peer review process. Journal of the American Medical Association, 258, 1375CrossRef Google Scholar PubMed

Steinman, M. A. (2000). Gifts to physicians in the consumer marketing era. Journal of the American Medical Association, 284, 2243CrossRef Google Scholar PubMed

Stelfox, H. T., Chua, G., O'Rourke, K., and Dresky, A. S. (1998).Conflict of interest in the debate over calcium-channel antagonists. New England Journal of Medicine, 338, 101–106CrossRef Google Scholar PubMed

Taylor, M. (1999). Healthcare struggles with Stark reality. Modern Healthcare, July 5: 30–31

Thompson, D. F. (1993). Understanding financial conflicts of interest. New England Journal of Medicine, 329, 573–576CrossRef Google Scholar PubMed

U.S. House of Representatives. (1989). Committee on Government Operations, Subcommittee on Human Resources and Intergovernmental Relations. Hearings: Is science for sale? Conflicts of interest vs. the public interest. 101st Congress, 1st Session, June 13

U.S. House of Representatives. (1988). Committee on the Judiciary. Subcommittee on Administrative Law and Governmental Relations. Post-employment restrictions for federal officers and employees. 100th Congress, 2nd Session, May 4

U.S. House of Representatives. (1986). Committee on Science and Technology, Task Force on Science Policy. Hearings. 99th Session, 2nd Congress. April 8–10

U.S. House of Representatives. (1985). Committee on Science and Technology, Task Force on Science Policy. Hearings: Science in the political process. 99th Congress, 1st Session, June 25, 26

U.S. Office of Government Ethics. (1986). Letter to an employee (86 × 10), August 8

Wazana, A. (2000). Physicians and the pharmaceutical industry: Is a gift ever just a gift?Journal of the American Medical Association, 19, 373–380CrossRef Google Scholar

Welch, S. J. (1997). Conflict of interest and financial disclosure. Chest, 112, 865–867CrossRef Google Scholar PubMed

West Bank Bureau. (2001). Engineer receives fine, 3 years probation. New Orleans Times Picayune, July 21: BW1

Wilkinson, P. (1993). “Self-referral”: A potential conflict of interest. British Medical Journal, 306, 1083–1084CrossRef Google Scholar PubMed

Wilson, C. (2002). Contractor to pay back $145,000; Woman sentenced in bribery case. South Florida Sun-Sentinel, March 10: 5B

Witt, M., and Gostin, L. (1994). Conflict of interest dilemmas in biomedical research. Journal of the American Medical Association, 271, 547–551CrossRef Google Scholar PubMed

Wyden, R. (1987). When doctors sell drugs: A conflict of interest. Washington Post, April 28: Z6

Wyngaarden, J. (1983). Government, industry and academia: A Bermuda triangle in partners in the research enterprise: A National Conference on University-Corporate Relations in Science and Technology, University of Pennsylvania, December 14–16, 1982. Philadelphia: University of Pennsylvania Press

Zientek, D. M. (2003). Physician entrepreneurs, self-referral and conflicts of interest: an overview. HEC Forum, 15, 111–133CrossRef Google Scholar PubMed

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11 - Why Are (Some) Conflicts of Interest in Medicine So Uniquely Vexing?

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