Conflicts of Interest: Concepts, Conundrums, and Course of Action

The Clinical Vignettes

Reasonable observers and medical ethicists are likely to reach various conclusions about the ethical issues raised in the 3 vignettes described at the beginning of this article. The following comments represent my own views as a psychiatrist, researcher, and bioethicist. I have also interpolated some additional remarks from my colleague, medical ethicist Cynthia M.A. Geppert, MD, PhD.

Dr. A and the slide set. Appelbaum and Gold^[10] state that continuing medical education (CME) is "heavily supported by industry funding and anecdotal accounts by physicians, including psychiatrists, who have been paid by industry to deliver promotional talks, indicate that they often face considerable pressure to shape their presentations to the companies' needs."

In my view, Dr. A is already dealing with a COI, merely by presenting a talk on antidepressants that is sponsored by a company that markets a particular antidepressant. (This would be a more obvious COI if Dr. A planned to discuss only or primarily the specific drug marketed by the company). There is nothing inherently unethical in Dr. A's actions, but the COI does require careful management. The level of the COI is raised by the large stipend Dr. A is receiving, which might predispose her to go easy on the company's antidepressant with respect to its risks during pregnancy.

As long as (1) the presentation's pharmaceutical sponsor is adequately disclosed to the audience and (2) Dr. A discloses that she is receiving a stipend from this company, this COI may be adequately addressed, without compromise of medical ethics on Dr. A's part or on the part of the institution hosting her talk.

However, accepting prepared slides from the sponsoring company would pose an undue biasing influence on Dr. A's presentation and should therefore be avoided. Even if the slides are entirely accurate and objective (by no means a sure bet), accepting them sets a bad didactic precedent, and at the very least creates the appearance of bias. This can detract from an otherwise useful presentation.

Finally, Dr. A should discuss several different antidepressants in her talk, pointing out the pros and cons of each agent.

Dr. B and the pharmacy committee. If Dr. B, who was receiving monthly stipends for participation in a pharmaceutical company's speakers bureau, did not inform his institution's Pharmacy Committee of this situation before accepting a position on the committee, he could be faulted for not disclosing a potential COI. (Whether this is a potential or an actual COI depends, in part, on whether the Columbia University definition or Thompson's definition of COI is used). The COI would exist, in my view, even if Dr. B did not know that drugs marketed by the company would be candidates for inclusion in the pharmacopeia.

In any case, having accepted a position on the pharmacy committee, Dr. B is obligated to disclose the potential (or actual) COI to the committee chairperson. That might result in Dr. B's being asked to leave the committee or, more likely, to recuse himself from any committee decisions about drugs produced by the company. Dr. Cynthia Geppert adds, "The highest standard now would require Dr. B to announce his COI at the beginning of every meeting, so [this would be] included in the minutes" (Personal communication; October 27, 2013).

Dr. C and the anxious, dependent patient. When assessing the ethical responsibilities of this physician, keep in mind the 4 cornerstone principles of medical ethics:

• Autonomy;

• Benevolence (or beneficence);

• Nonmalfeasance (or nonmaleficence); and

• Justice.^[11]

As Dr. Geppert observes, "The core of medical ethics is to place the interests of the patient above all others -- yet there are limits" (Personal communication; October 27, 2013).

There is a probable COI for Dr. C, whose primary interest is the emotional well-being of his patient -- but who also stands to lose a regular and substantial source of income (the "secondary interest," in Thompson's formulation of COI^[4]). It could be argued that continuing therapy after resolution of the presenting problem risks exacerbating Ms. Y's dependence traits. To that extent, continuing the sessions risks undermining Ms. Y's autonomy,even though she is perfectly happy to continue psychotherapy. Arguably, continuing treatment under these circumstances would also violate the principles of benevolence and nonmalfeasance.

This, of course, assumes that continuing treatment would worsen Ms. Y's dependence traits and perhaps contribute to interpersonal difficulties outside of the therapeutic relationship. This is the preeminent consideration in the case, and any financial repercussions associated with termination of therapy must be set aside.

One approach to this COI would simply be to terminate Ms. Y's treatment, but this might risk a reemergence of her generalized anxiety, and perhaps an unintended worsening of her symptoms. Another option would involve Dr. C discussing his concerns with Ms. Y, so that she is fully informed of the risks -- and also potential benefits -- of continuing treatment. For example, Dr. C might say:

You have made great progress over the past year, in terms of your anxiety. I understand your wish to continue seeing me, and I have some concerns about that. Because the problem you sought help for -- the anxiety -- has been resolved, I am concerned that continuing to see me might lead to you becoming overly dependent on psychotherapy. In the short run, this might seem fine, but it might undermine your ability to handle things on your own in the long run. On the other hand, there might be other issues for us to work on in treatment, such as how much you rely on others in your everyday life. What are your feelings about continuing to see me, given what I am saying?

One compromise might be to reduce the frequency of sessions to once per week over a period of a few months, with a plan to terminate treatment within a specified interval, assuming that Ms. Y remains stable. Dr. Geppert adds that "Some therapists also allow check-ins for a period of time [during] crises..." and that Dr. C might consider referring Ms. Y to a support group, either as a transitional step or as a new treatment modality (Personal communication; October 27, 2013). Some of the difficulties of terminating psychotherapy -- made famous in Freud's 1937 classic paper, "Analysis Terminable and Interminable" -- are discussed in a useful article by psychologist Dr. Ryan Howes.^[12]

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Cite this: Conflicts of Interest: Concepts, Conundrums, and Course of Action - Medscape - Nov 11, 2013.