Wednesday, May 24, 2017

Viewpoint article in JAMA issue devoted to conflicts of interest

The article is available here as free full text. Here are a few points of interest.

Early on in the piece the author, Harvey V. Fineberg, MD, PhD, says:

An individual’s conflict of interest is not tantamount to saying her or his judgment is affected, nor does it constitute an accusation of bias or prejudgment. The presence of a conflict of interest is no judgment about the appropriateness or value of the relationship that engenders the conflict in a particular situation.

Why then should we be worried about COI at all? The answer comes in the next paragraph (emphasis mine):

Some erroneously take a financial interest that qualifies as a conflict of interest to be an allegation that their thinking is tainted. They seek to defend their scientific integrity and adherence to evidence, and aver that the monetary payment they received or financial interest they hold could not possibly influence their scientific or clinical judgment. They may be right, and they miss the point. If a reasonable person would perceive that the financial circumstances could potentially influence their judgment, a failure to acknowledge and respond to the conflict of interest threatens to erode the trust that undergirds the value of professional judgment and expertise.

In short, it’s about the possibility that perceptions would be tainted. I’m looking for substance here and it’s a bit of a stretch. If the argument has any substance it is weakened by the postmodern view expressed a few paragraphs down:

If the presence of a conflict of interest is ultimately subjective—based on the judgment of a reasonable person—it is also situational, that is, dependent on the specific financial circumstances and relationship to the specific role of the person involved. The standards for adjudging a conflict of interest may also be bound by time and place, having different meaning in different cultures and at different moments in history.

The author addresses some of the many questions that arise in the management of COI. There appear to be no definitive answers:

What relationship to a payer and financial level triggers disclosure, discussion, and possible remedy? If not contemporaneous, for how long in the past is a financial relationship deemed relevant? Should the financial interests of a spouse, a parent, a minor child, and a sibling be considered as pertinent as those of the individual involved? In general, the answers to these questions should be guided by the reasonable person standard. To preserve public trust, it is better to lean toward more disclosure rather than less, while also protecting individual privacy and avoiding tangential matters. For example, the financial interests of a cousin or a niece are of less interest than those of a spouse or sibling.

On a refreshing note he takes an appropriately broad view of COI by not singling out industry, acknowledging many other types of financial conflicts as well as non financial conflicts.

The concluding paragraph says we need “disinterested expertise” (is there such a thing?) and reminds us once again that it’s mainly about perception:

Adherence to carefully considered, transparent, and evenhanded policies on conflict of interest can help physicians earn and maintain their trusted place in the minds of the public and policy makers.

What is conspicuously absent from the entire piece is a strong declarative statement that COI really does impair physician judgment let alone harm patients.

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