Should we try to manage non-financial interests?
BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k1240 (Published 12 April 2018) Cite this as: BMJ 2018;361:k1240
- Miriam Wiersma, master of philosophy candidate1,
- Ian Kerridge, professor of bioethics and medicine1 2,
- Wendy Lipworth, associate professor1,
- Marc Rodwin, professor of health law34
- 1Sydney Health Ethics, University of Sydney, Sydney, NSW 2006, Australia
- 2Royal North Shore Hospital, St Leonards, NSW, Australia
- 3Suffolk University Law School, Boston, MA, USA
- 4Fondation IMéRA, Aix Marseille Université, Marseille, France
- Correspondence to: M Wiersma miriam.wiersma{at}sydney.edu.au, M Rodwin mrodwin{at}suffolk.edu
Yes—Miriam Wiersma, Ian Kerridge, Wendy Lipworth
Non-financial conflicts of interest in medical research and practice, which include those of a political, ideological, individual, or religious nature,12 are often overlooked, denied, and even defined out of existence.34 The focus is directed instead towards financial interests, such as those stemming from drug industry sponsorship of research, or payments to doctors.
But dismissing non-financial conflicts of interest is naive, empirically unfounded, and dangerous. It is also unnecessary because non-financial conflicts can be managed with nuance and sensitivity.
Strong drivers
Research shows, and common sense dictates, that people are driven at least as much by non-financial motives as they are by financial gain. These motives, which include the desire to protect ourselves or our family from harm, to reinforce our deeply held beliefs and values, to reciprocate gifts or favours, to attain status, and to avoid social disapproval, unquestionably exert a powerful influence on human behaviour.56 As argued by Cappola and Fitzgerald in relation to academia, “the prospect of fame may be even more seductive than fortune.”7
For example, the decisions of well remunerated doctors to participate in drug industry advisory boards or accept the role of “key opinion leader” are far more likely to be driven by other motives than by financial gain.8 Indeed, the financial incentives associated with advisory board membership—for example, $1000 (£700; €800) or a free flight—seem to pale in comparison with the social and psychological importance of being invited to contribute to clinically relevant research, “improve” patient care, and gain status and respect in the medical community.89
Effects on policy and practice
Although non-financial conflicts have been much less studied than financial interests, emerging evidence indicates that they can affect biomedical research and policy. For example, evidence shows that non-financial interests may “call into question the impartiality of [systematic] reviews”10 and negatively affect the equitable allocation of health resources in grant funding procedures.11
Even without formal research, it is not difficult to find examples of the far reaching effect of non-financial interests. Take, for example, the influence that Christian beliefs regarding the moral status of the embryo have had on stem cell research, particularly in the United States, through prohibiting the public funding of embryonic stem cell research and human somatic cell nuclear transfer.12
Identify, assess, manage
The dismissal of non-financial conflicts of interest often stems from the notion that they are too complex and ubiquitous to be effectively managed.9 However, non-financial conflicts can be identified, assessed, and managed using similar strategies to those for financial interests—including, for example, disclosure and recusal. For instance, it is reasonable to expect a member of a committee deciding whether to approve the subsidisation of a new drug to declare if he or she or a relative has a medical condition that may benefit from the drug being considered.
Clearly, the disclosure of non-financial interests, some of which may be highly personal, must be handled with discretion to avoid needlessly intruding into people’s privacy or placing them at risk of discrimination. However, mechanisms are often put in place to balance the tension between disclosure and privacy, such as controls over documentation and public access to declarations of certain conflicts, and these could be applied more broadly.
It is equally important that people with non-financial conflicts of interest are not automatically excluded from key roles such as participation in advisory committees. For example, it is concerning that FDA regulation of “intellectual interests” may allow those with important financial conflicts of interest to participate while excluding those who may have safety concerns.13
In medicine, as in life more generally, money is not the only determinant of behaviour. Values, beliefs, and social relationships matter just as much, and we cannot afford to deny the effect of these forces on decision making and health policy.
No—Marc Rodwin
Some doctors and academics argue that intellectual interests and points of view are conflicts of interest because they can bias medical researchers or practitioners. Some propose trying to regulate the intellectual conflicts,9 while the solution for others would be to reduce or cease oversight of financial conflicts.14 However, consider that the law—which is where the notion of conflicts of interests first emerged—does not define conflicts of interest simply as anything that creates bias, nor does it regulate non-financial biases as conflicts of interest.15
And for good reason. Treating intellectual conflicts as conflicts of interest would unmoor the concept from its original meaning, making it merely another phrase for bias. Although intellectual interests can cause bias, this does not mean that they constitute conflicts of interest and can be regulated as such.16
Legal construct
The concept of conflicts of interest originates in the law used to regulate fiduciaries—individuals entrusted to serve the interest of another party or to perform a designated mission—who are held to the highest standards of conduct.17 The law does not permit fiduciaries to promote their own financial interests or those of third parties. It requires fiduciaries to be loyal to the party they serve, to act prudently, and to account for their conduct.
Legally, there are two broad types of conflicts of interest: conflicts between an individual’s obligations and financial interests and conflicts resulting from an individual’s conflicting duties, roles, or divided loyalties—sometimes referred to as conflicts of commitments. For example, a physician might treat patients and conduct clinical trials. However, having your patient participate in your research creates conflict of interest because the goals of research are different from those of caring for patients.18
Consider the typology of interests in box 1.
Typology of interests
1.Intellectual commitments (eg, working within a theoretical framework, school of thought, or having proposed a hypothesis)
Interest in a positive outcome to a study that will support your previous findings
Interest in maintaining professional reputation
Interest in career advancement
Interest in finding potential practical applications of research
Interest in maintaining good relations with entities that can provide future research funding
Legal conflicts of interest
Income or gifts from a commercial interest that will profit if you make professional decisions that favour their interests
Income from consulting related to your research
Intellectual property in fruits of research
Financial interest in a firm sponsoring your research
Equity interest in firms that commercialises your research
These interests are quite different, and not all them are conflicts of interest.192021 The law defines only the last five interests as potential sources of conflict. Redefining “conflicts of interest” to include any potential intellectual interests that conflict would make the concept a less practical tool.16 There is no effective way to eliminate most intellectual conflicts, which are widespread and an inherent part of life. Regulating these potential sources of bias using a conflict of interest framework would burden professionals and institutions for little benefit. On the other hand, financial conflicts of interest generally can be avoided or eliminated.
Routine scientific debate
Certainly, a predilection for a hypothesis and intellectual commitments can influence a person’s work and interpretations. Yet these tendencies are revealed in people’s publications, and routine scientific debate effectively counters intellectual bias.1319 In contrast, a researcher’s financial interests are often unknown. And studies show that financial conflicts influence results, especially industry supported studies that evaluate the industry’s products. Furthermore, having researchers with diverse intellectual perspectives enriches scientific inquiry.
Although desire for recognition can affect a researcher’s conduct in undesirable ways, these interests cannot be eliminated. In contrast, financial conflicts are an unnecessary source of bias22 and eliminating them protects the integrity of research.
Society has long regulated the financial conflicts of interest for public servants, judges, lawyers, and financial professionals, but it has not regulated their intellectual conflicts, for good reasons. The fact that other activities can compromise medical research and practice does not mean that we should cease to regulate financial conflicts of interest.23 There may be reasons to address these other sources of bias, but we should not do so using a conflict of interest framework.
Footnotes
Competing interests: All authors have read and understood BMJ policy on declaration of interests and declare the following: MW, IK, and WL received funding from the National Health and Medical Research Council for research related to the topic.
Provenance and peer review: Not commissioned; not externally peer reviewed.