Throughout history, physicians have treated patients for conditions that generations of their professional successors later deemed figments of their (the physicians’) imaginations. The list is long, but in just the last 100 years, it has included such disorders as female hysteria, homosexuality, moral insanity, neurasthenia, and vapors, among many others. The consequences of such diagnoses were not trivial, and in some cases, patients were stigmatized, ostracized, subjected involuntarily to a variety of noxious treatments, and even incarcerated because of them. Yet we now believe that each of these conditions was a fiction, and they are absent from today’s textbooks.
Something similar may be afoot in the profession of medicine today. The affliction is known as conflict of interest, and medicine is thought to be suffering a pandemic of it. In fact, its proponents argue that no physician is safe. Its symptoms among researchers are a tendency to conduct investigations and publish results that are biased, and among clinicians, to prescribe tests and therapies that their patients do not really need. The underlying cause of the condition is thought to be financial inducements from industry, which lead these gullible physicians and scientists to betray their personal and professional integrity without even knowing it.
For example, industry funding of research might lead physician-scientists to bias their results in ways that line the pockets of pharmaceutical companies and medical device manufacturers. Likewise, the presence of industry representatives in offices and hospitals might lead physicians to write inappropriate prescriptions for industry-promoted drugs. If physicians are presented with a gift such as a pen, a notepad, a book, or a free meal from an industry representative, they might be more inclined to use that company’s products in their practice. The implication? Physicians are insufficiently self-aware and trustworthy to put patients’ interests above their own.
These putative dangers have attracted the attention of a number of organizations that have taken it upon themselves to protect patients and the public. For example, consider this piece of advice from the Accreditation Council for Continuing Medical Education, which oversees the content of education programs for practicing physicians. An online questioner asked whether it would be permissible for an educator to request suggestions on topics or speakers from an industry representative. The ACCME not only responded in the negative, but also said that such requests are essentially nonsensical, since it would be impermissible to act on any response.
CME providers cannot receive guidance, either nuanced or direct, on the content of the educational activity or who should deliver that content. If the provider implements the suggestions of a commercial interest, then this undermines the independence of the educational activity from the commercial interest.
However, the organization makes clear, this does not prevent the educator from accepting money from industry. It is permissible to take money, but not advice.
There are numerous problems with this line of reasoning. First, why would industry, which is an important funder of continuing medical education, continue to incur such expenses if they do not offer any hope of financial return? Second, why would anyone suppose that scientists and physicians, who are among the most trusted and respected professionals in our society, cannot distinguish between education and advertising, or resist the latter’s undue influence on their decision making? Third, how strong is the evidence that industry educational initiatives have undermined the quality of scientific research or led physicians to betray their patients’ trust?
Let’s focus on this third question. In the June issue of International Journal of Clinical Practice, investigators at Boston’s Brigham and Women’s Hospital, Harvard Medical School, and the Carolinas Medical Center state in unequivocal terms that there is “no solid evidence of harm” concerning financial conflicts of interest. In fact, they say that even proponents of tighter controls on conflicts of interest “admit that no data are currently available to ascertain the truth or falsehood of the statement [that] physicians make prescribing decisions that conflict with the best interests of their patients.” They go on to argue that such restrictions probably produce more net harm than good for patients.
How could such restrictions harm patients? First and foremost, they threaten to impede the exchange of new information between biomedical professionals and industry. Beneficial new tests, drugs, and procedures often take longer to reach patients if industry is not engaged in helping to promote them. Likewise, physicians’ efforts to innovate are impeded when they cannot interact meaningfully with the firms that develop, market, and distribute products commercially. Most of the important innovations in medicine in the past 100 years – insulin for diabetes, angioplasty for opening up blocked blood vessels, and CT scanners for diagnosis of disease – were the product of such collaborations.
The authors of the Clinical Practice article go on to argue that stringent conflict of interest policies have also diverted resources away from research, clinical care, and medical education and toward offices and organizations that develop and enforce such policies. There are direct effects in terms of diverted personnel, time, and money, but there are also indirect effects, such as the development of a culture in which potential collaborators interact much less frequently, know one another less well, and increasingly regard one another with an attitude of suspicion. It is difficult to form a productive working relationship with someone whose very presence is prohibited.
The authors also argue that the proponents of stringent conflict of interest policies are undermining the intellectual integrity of the same professions they are policing. Because there is no solid evidence that patients have been harmed by such conflicts, policy makers must resort to arguments that cannot withstand close intellectual and scientific scrutiny. Some critics of such policies have even accused proponents of engaging in a new form of McCarthyism, creating a presumption of guilt based strictly on association. “If you are caught talking with the wrong person or engaging in the wrong kind of discussion,” they seem to say, “we will punish you, whether we can prove that any harm has resulted or not.”
If such conflict of interest policies are so seriously at odds with the facts, how did matters progress to this point? The answer, the authors suggest, is what behavioral economist and Nobel Laureate Daniel Kahneman has labelled an “availability cascade.” So many people have given speeches and published articles decrying the dangers of conflicts of interest that the majority of professionals have simply assumed that there could be no basis for doubting their dangers. As a result, interactions between biomedical professionals and industry have become some of the most strictly regulated forms of speech and association in our society.
This cultural transformation has broader implications that extend far beyond the boundaries of biomedical science, clinical medicine, and the pharmaceutical and medical device manufacturing sectors of our economy. It threatens both public esteem and the professional self-regard of researchers and clinicians, by calling into question their judgment and ethics. Without doubt, money can corrupt, and there are egregious cases of physicians who have been corrupted by money, but it is a mistake to subject every physician to stifling policies and regulations in response to the abuses of a few outliers. And we should not overlook the fact that such policies represent a rather strident assault on civil liberties.
In short, there is good reason to raise three questions about the putative pandemic of conflict of interest afflicting contemporary biomedical science and medicine: Is it as widely prevalent as commonly supposed, are its consequences really so severe as its proponents have argued, and most significantly, does it in fact exist, at least in the sense that patients and physicians are being harmed? Strange as it seems, it is quite possible that this scourge of biomedicine is more bogeyman than real threat. As a result, many of the preventative and therapeutic responses being mounted against it, like the bloodletting of days of yore, are likely doing more harm than good to the very people they aim to protect.