A Battle for Medicine's Soul Over Conflict of Interest

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Conflict Over Conflict of Interest

Hello. I am Dr George Lundberg, and this is At Large at Medscape.

Bias and conflict of interest are closely related. Altruism and venality are two opposite but powerful human motivators.

The current editor-in-chief and a national correspondent of the New England Journal of Medicine (NEJM) are in a most unusual public fight with two former NEJM editors-in-chief and a former national correspondent. Their dispute is centered on conflict-of-interest issues related to authors, peer reviewers, editors, and publishers.

On the pages of both the NEJM and the BMJ, there are numerous related spin-off discussions in countless letters, columns, newsletters, blogs, and the like. Raw nerves have been struck.

For a physician new to medicine and not very familiar with the rules of medical journals, this dispute looks like a fraternity food fight. For experienced medical editors, learned academics, and leaders of the ethics community, it is seen as a battle for the very soul of medicine, science, publishing, truth, and trust.

Many see this set of four publications over 3 weeks in the NEJM[1,2,3,4] as a prelude to an impending change to an established editorial policy that is intended to prevent authors with known conflicts of interest from writing editorials, commentaries, and review articles on those topics.

Others see a much broader assault on the entire disclosure policy of many medical journals, pioneered by NEJM in 1984 and incorporated into the policies of leading journals worldwide since 1986 through the International Committee of Medical Journal Editors (ICMJE).

Is This Just About the Money?

Still others see this discourse through the prism of modern American money-driven medicine. These days, American doctors, the patients they treat, and all the competing big-money interests are chasing small clinical effects for big bucks. The money part is huge. The NEJM purists—both the horrified former editors and vast numbers of trusting readers—are right. Journals should beard that roaring money-lion into its den as much as they can.

I have previously discussed this topic on Medscape. The relationship need not be all bad. The newest entry into this discussion is Thomas P. Stossel's book titled Pharmaphobia: How the Conflict of Interest Myth Undermines American Medical Innovation,[5] with more than 300 (sometimes tedious) pages.

But all of this brouhaha about money ignores the real elephants in the room. Conflict of interest and the biases they represent are not myths; the NEJM and ICMJE policies did not solve these problems, nor will any new journal or medical institution policy changes have any serious impact.

This is why:

When we implemented the ICMJE policy on financial disclosure in the 10 journals of the American Medical Association nearly 30 years ago, one editor-in-chief delayed for years. The late Daniel Xander Freedman, a great psychiatrist, refused. He believed, fundamentally, that conflicts of interest were so deep, varied, and omnipresent that making rules based on the money aspect was naive and disingenuous.

Daniel X Freedman was right, although I did eventually overrule him and implemented the ICMJE policy for his journal, the Archives of General Psychiatry. Later, we learned that psychiatry may have needed the financial disclosure policy more than any other medical field.

Undisclosable Disclosures

Think about yourself; I do. I'm Swedish. I can't trust anything out of Norway. The examples are numerous: I'm from Alabama. Trust Auburn research? You've got to be kidding. I was a Harvard faculty member for 15 years, so I can't trust Yale. I am on the Stanford faculty. What's Berkeley? I am a white male; do I trust women authors? I was in the Army for 11 years; what's the Navy? I am a pathologist; do I care about the opinions of surgeons? I am a journalist. I can't trust anything unless it is intensively researched. Mary was your secret girlfriend, and now there is a research paper written by Mary to consider. John was your son's friend; he has a new research idea and is looking for a grant, and you are the National Institutes of Health (NIH) person who decides.

And the beat goes on, and the beat goes on.

I have a few more disclosures. I am either a long-time personal friend, colleague, student, or mentor of most of the key players participating in this drama. I have to worry about those relationships as I endeavor to shine a bit more light on this evolving conundrum.

Disclosure in medicine is a good thing and should be done. If I am a cardiologist, I make my money by putting stents into you, whether or not you need them. Or, if I am a geriatrician, I make my money by scheduling more frequent visits to monitor your condition. 

But disclosure is not enough. Conflict of interest itself is the problem. And unbalanced power relationships overpower disclosures. Every day, we all look for an advantage.

One cannot but be impressed by Jonas Salk, who gave the Salk vaccine to the world's people, without a patent. On behalf of my children, grandchildren, and great-grandchildren who will not be paralyzed by polio, thank you, Saint Jonas.

But let us not forget the scourge of hepatitis C—uncontrollable until American capitalism's for-profit, publicly traded company Gilead solved the problem. Gilead is not a saint, but Sovaldi® [sofosbuvir] is one hell of a good drug. Thank you, Gilead.

So, let all of the various motivators do their thing. You can't stop them. As a human, I believe that the total human condition is the final arbiter. One does the best one can with honesty and then sits back and watches what happens.

I recommend that you doubt most of what you read or hear or are told on paper, the radio, television, online, or in person. Truth often remains illusory.

That's my opinion. I'm Dr George Lundberg, at large at Medscape.


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