{'fraction_non_alphanumeric': 0.016205266711681297, 'fraction_numerical': 0.0009002925950934053, 'mean_word_length': 5.121212121212121, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Conflict of interest: No such thing as a free lunch

We use the term ‘conflict of interest’ frequently, but a potential conflict of interest is not always easy to define, and the appropriate response to a conflict of interest is not always straightforward. The most common conflicts of interest are pecuniary and involve the conflicted person receiving some sort of financial benefit that conflicts with the doctor’s professional commitment to the good of the patient. That seems easy. Although the significance of the size of the benefit is often debated, it seems clear that any gift or payment puts an obligation on the recipient that often outweighs the size of the gift. Non-pecuniary conflicts also need to be considered. If you are asked to review a grant application or manuscript written by your most hated bitter rival, you are conflicted, just as much as if it were written by a dear friend or relative. In their April 2009 report on conflicts of interest, the US Institute of Medicine defines a conflict of interest as ‘a set of circumstances that creates a risk that professional judgement or actions regarding a primary interest will be unduly influenced by a secondary interest.’ If defining conflict of interest is difficult, deciding what to do about conflicts of interest is even more fraught. All conflicts and potential conflicts of interest should be declared, we all agree, to avoid even the perception that your decision has been unduly influenced. There seems to be a common belief, however, that mere disclosure of conflicts of interest is sufficient to solve the problem. I believe that a speaker or writer who declares a long list of consultancies, research and travel funding is still conflicted when he/she gives his/her talk or writes his/her paper. Disclosure does not expunge or exonerate bias. Meeting organisers and journal editors often act as if disclosure in and of itself is sufficient and that it is then the responsibility of the listeners or readers to judge the reliability of the information. The Institute of Medicine report recommended limiting the participation of individuals with conflicts of interest on committees writing clinical practice guidelines, a recommendation that is long overdue. Persons with significant conflicts of interest cannot expect to be making recommendations that require a dispassionate analysis of the scientific evidence. Most of us think conflicts of interest are important, but those pharmaceutical industry inducements affect other people, not us. We are unbelievably naive. A review of the literature on the safety of calcium channel antagonists found a strong association between authors’ published positions arguing for safety and their openly declared financial relationships with pharmaceutical manufacturers. Physicians who attended a pharmaceutical company-sponsored symposium all said that their prescribing patterns would not be affected but, after the meeting, prescribed significantly more of the company’s drug than beforehand and significantly more than other physicians in the country. Is this just education, as the company would argue, or effective advertising? Companies have a right and indeed a commercial duty to their shareholders to advertise, but physicians need to realise that advertising works and affects us all. What should doctors’ response be to promotional activities by pharmaceutical companies and other commercial groups such as medical defence organisations? One responsibility is to be aware of, and to contribute to updating, guidelines on the interaction between physicians and industry, such as those of the RACP. While not binding, these can at least be used to point out to the organisers of meetings, including the annual RACP meeting, that they have transgressed the guidelines and allowed industry what many would consider too much influence. In this issue, Ian Kerridge discusses the merits of industry sponsorship of medical education. Whether we do or do not believe in halting or limiting interactions with industry, we should all be aware that the pharmaceutical industry is not in the game for philanthropic reasons. Their advertisements and their involvement with education are designed to sell their products and increase their profits. If we want to help our patients best, we need to be less naive about the pharmaceutical industry, and we need to realise the degree to which our decisions are being influenced.