Marc Rodwin is the author of Medicine, Money and Morals: Physicians’ Conflicts of Interest, first published in 1993. At the time, conflict of interest was not the buzzword it has since become in debates about medical ethics, publication ethics, and health policy. His earlier book set a high standard for the discussion of the role of commercial pressures, ties, incentives and influences in shaping doctors’ conduct towards their patients. It was deservedly widely noticed at the time, with considerable praise from influential voices in the medical community. The arrival of his new book, some eighteen years later, is a useful occasion for reflecting on what progress, if any, has been made in tackling the problem of conflict of interest.
As the subtitle indicates, this is a comparative study. Rodwin examines the different ways in which medical care is organised institutionally in three very different health systems in the developed world. He describes carefully the attempts made in each country since the nineteenth century to identify the nature of medical conflicts of interest, and to control such conflicts as they arise in each context. He shows in detail the interactions between the structural organisation of the profession, the policy of the regulatory and professional bodies, the economic organisation of health services, and business practices of professionals, commercial providers of goods and services instrumental to healthcare, and the ways in which conflicts are conceived, arise, and are managed.
I found the book a wearying read. This is not because the author has a difficult prose style – he writes lucidly and for a general readership. The accumulation of detail and the winding path through each country’s difficulties is impressive. But it is a profoundly pessimistic book. At each turn, a measure to contain or control conflicts is introduced; it fails; the very mechanism introduced itself becomes a vehicle for conflicts in a fresh form. There is neither a ‘land of lost content’ to frame the story’s beginning, nor much prospect of a ‘reformed medicine’ at the end, nor indeed any putative location of which we might say ‘they do it better elsewhere’. There is just difference.
From a historical point of view, and from a historiographical point of view, this is unsurprising, perhaps. However, from a normative or practical policy-making point of view, it would be useful to know what our expectations of doctors, and healthcare systems, should be, and how they could better be enforced. The concluding pages of the book do offer some proposals, but they involve better ethics statements, more continuing professional development, a tougher debate within the profession about conflicts. As the history of conflict of interest sketched in his book shows in detail, the ways in which professional ethics and the professional and regulatory bodies more or less thoroughly mystify the operations of conflict of interest by portraying them as legitimate business practice, necessities of good professionalism, and even, on occasion, union rights, this set of proposals does not inspire hope or confidence. Similarly, Rodwin’s practical proposals for institutional and structural reform depend on introducing a greater regulatory role for the state, a more thoroughgoing transition of medical care into the public sector, and more scrutiny and oversight by public officials and the courts. Again, his own historical narrative, and the general lessons of the history and economics of regulation, suggest that regulatory capture is just as serious a risk here as in previous generations and under previous forms of healthcare governance.
All of this gloomy reflection noted, Rodwin does us an important service in bringing these issues into clear sight. Too often medical ethics, health policy and indeed history of medicine focuses on the social, normative, and technological side of medical change. The economic and business side is every bit as important and influential. And while we might despair of ways to improve the practice of medicine in the face of conflicts of interest, he does show us how it could get worse without continuous public and professional efforts to resist the steady pressure of conflicts of interest on good, patient-centred medical practice.
