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Conflict of interest — who benefits?

The elusive method of how to determine the appropriate manner and proper degree to which organizations should reasonably define and communicate potential conflicts of interest (pCOI) has both ethical and legal implications. The solution also requires a more pragmatic and equitable approach. However, the standards for determining the degree of transparency of financial disclosures are at question, and the results of that increased disclosure on improving the accuracy or bias of scientific information requires increased clarity. As members of any professional society it is incumbent upon us to consider both the issues and the consequences. Of note, the issue is identifying a potential conflict of interest. Unfortunately, to require more intensive voluntary reporting of interactions or by limiting those interactions may or not be the solution. In addition, financial transparency does not ameliorate the issues with non-financial benefit and other potential conflicts that may compromise scientific truth. In truth, the act of disclosure and the determination of what must be disclosed, certainly cannot guarantee personal integrity. When we hear or read the list of potential conflicts, we are still left to judge whether the declarations are made as a compromise to the imposed requirements or are substantial enough to compromise the truth. We are also left to wonder about the declarations that are not made. Should we also consider the motivation to scrutinize, legislate, and judge based on a perception of another individual’s intentions? Do we need to understand what we have the need and right to know before we decide what others need to reveal? Why would individuals alter protocols, data, observations, conclusions or general perceptions of their work, or work they have chosen to represent? We all acknowledge and condemn the egregious behavior of those who have abused the privilege of reporting information to their peers, but doubt that any form of voluntary disclosure of financial information or personal agenda would have prevented their behavior. What should be the consequence of such behavior at the medical society level and who should decide? Dr. Brubaker and Dr. Abrams have presented excellent summaries of conflict-reporting issues and mechanisms, and have suggested some barriers and solutions to successful reporting. Dr. Brubaker insightfully highlighted terminology and process. Dr. Abrams illuminated the issue of indirect financial gain. How does one define and consequently judge with accuracy the influence of a competing interest on an individual? Does the declaration imply that the interest is potentially or actually competing and conflicting with the ability of the individual to tell the truth? The precise documentation of monetary compensation from industry has received almost if not all of the focus, probably because it is perceived by some as the ‘‘conflicter’’ and is conveniently the easiest to identify, catalog, and scrutinize. This approach may seem pragmatic but it may not address conflicts within disclosure itself. How should we define pCOI? If I may quote, ‘‘I shall not today attempt further to define . . . that shorthand description, and perhaps I could never succeed in intelligibly doing so. But I know it when I see it,’’ said Potter Stewart, United States Supreme Court Justice in 1964. Potter was attempting to describe hard core pornography [http://www.firstamendmentcenter.org/remembering-justice-potter-stewart]. Do you agree with Justice Potter intellectually and viscerally about your ability to perceive the indefinable? Although in a different venue, do you believe that although you cannot define it, you can recognize a potential or real conflict of interest when you see or hear one? We have all listened to thousands of presentations and have read innumerable medical publications submitted by peers who may be perceived to have additional, alternative, competing, and/or potential conflicting interests. Among those individuals were lecturers or authors who had received compensation as inventors, consultants, or promotional speakers. Before we eliminate expertise based on guilt by association, we should acknowledge that insightful observations have been gained from the inventors of products, original interpretations of data have been evoked from consultants who have dedicated hours to attending advisory boards or analyzing clinical data, and useful information has been gleaned from compensated on-label promotional presentations about the approved data of a new product. Pursuant to the integrity of the speaker, we have found that all of the prior interactions can generally be appropriately vetted and valued without the benefit of a polygraph or a tax return. Of note, a medical license in the Commonwealth of Massachusetts prohibits physicians from accepting any meal at the aforementioned promotional presentation; because the state government legislated that such gift (the meal) may compromise the physician’s judgment and result in the prescribing of a more expensive product.