Conflicts of Interest: Is Disclosure Enough?


November 16, 2018

Hello and welcome. I'm Dr George Lundberg and this is At Large at Medscape.

There has been a lot of front-page news coverage and public discussion recently about overt conflicts of interest (COIs) in American medicine.

COIs exist when there is a power-imbalance relationship of some sort among involved parties that either does bias, or could be thought by a reasonable person to bias, a decision or a representation of a decision against the best interest of a second or third party or parties.

COIs are everywhere you look. In pure business capitalism, the buyer assumes that the seller will charge as much as the market will bear and may do everything possible to hide product defects in order to make the sale. Society deals with that by the traditional caveat emptor (let the buyer beware).

There is almost always a power imbalance when physicians, lawyers, and the clergy are given access to the innermost parts of a vulnerable person's body, mind, soul, and finances. That is why societies have, since antiquity, deemed that, in exchange for such access, the physician, the lawyer, and the clergy must efface their own self-interest in decision-making. This is the fundamental basis for their being called learned professions and professionals: public and individual trust.

Because the love of money and similar strong human drivers can even afflict the healing professions, medical journal editors determined that sunshine could be a deterrent to the temptation of malfeasance. Since 1986, the International Committee of Medical Journal Editors has published and updated COI disclosure rules for authors, peer reviewers, and editors of medical journals, which led the way for professional organizations to follow.

Recently, senior health journalist Charles Ornstein, of ProPublica, and reporter Katie Thomas, of the New York Times, blew the whistle on the failure of many in leadership positions at Memorial Sloan Kettering Cancer Center (MSKCC) to disclose rampant financial COIs in dozens of published articles.[1]

It was only the tip of the iceberg, though, because MSKCC is not an isolated case. As a physician, researcher, author, editor, employee of not-for-profits, and worker in the cancer field, I feel keen embarrassment because of the actions of many you-would-think esteemed MSKCC and other leaders, on behalf of all of those betrayed constituencies. Heads rolled, as they should, after public outrage over this multilayered violation of the public's trust.

On a lesser but still very troubling level for American patients with skin diseases—in other words, almost everybody—the highest levels of the American dermatology community have just been roiled by their own scandal of undisclosed, suspiciously unethical conduct and cross-organization incest, once again betraying the public's trust. Katie Hafner reported this story in the New York Times.[2]

I ask current leaders of the American medical profession: How much money is enough? Is there no limit to venality—personal and that of your allegedly not-for-profit institutions?

Is disclosure enough? No, it is the actual COI that is the problem. But disclosure is a good start. Let some sunshine in.

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

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