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The hidden costs of the financial conflict of interest in medicine

In a paper published in the current issue of Psychotherapy and Psychosomatics, Giovanni A. Fava, MD, provides an analysis of some subtle and yet important consequences of financial conflicts of interest in medicine. He also strongly criticizes the recent positions expressed by the New England Journal of Medicine which called for a reexamination of the views and regulations of financial conflicts of interest in medicine. Dr. Rosenbaum’s editorial in the NEJM suggested that current restrictive rules may ‘undermine potentially productive research collaborations, dissemination of expertise, and public trust’. She acknowledged that studies by pharmaceutical companies are more likely to have outcomes favorable to the sponsor and that physicians who attend events funded by pharmaceutical companies tend to prescribe the featured drugs. However, she claimed that these interactions might actually be beneficial to the patient and that much of the harm was ‘invented’. A recent viewpoint published in the JAMA moves toward this direction. Also, these authors complain of the policies on conflicts of interest that were developed in reaction to a limited number of investigators but, once introduced, applied to all. They suggested substituting the pejorative term of ‘conflict of interest’ with ‘confluence of interest’. A name change can be important in labeling a phenomenon as harmless.

According to Dr. Fava, books such as Jerome P. Kassirer’s “On the Take” and John Abramson’s “Overdosed America” illustrated how corporate interest manipulated science, misled doctors and threatened the health of the community, and how medical journals and medical societies had a role in this. These and many other subsequent publications, such as Whitaker and Cosgrove’s “Psychiatry under the Influence”, documented a systematic, even though not universal, phenomenon in clinical medicine. Members of special interest groups, by virtue of their financial power and close ties with other members of the group, have the task of systematically preventing the dissemination of data which may be in conflict with their interests. It is certainly not because of a few bad apples or the behavior of journalists that the medical field is being discredited in the general public.

In addition, the growth of evidence-based medicine (EBM) provided an ideal ground for multiplying the effects of financial conflicts of interest in medicine. Indeed, it is not simply that trials sponsored by drug firms are more likely to report positive outcomes. Selective publication, overstatements of benefits and minimization of risk appear to characterize clinical trial reporting funded by the industry, whether of drugs or medical devices. Fava thus suggests various level to unveil the conflict of interest in medicine. First, he introduces specific criteria to evaluate the presence of substantial COI, including for a research being an employer, consultant or board director of a firm as well as being stockholder or owing a patent related to the published work.

He then suggests alternative modalities of Academia-Industry collaboration. For instance, the industry may interact with academic investigators through consulting agreements that benefit the university but not the investigator, eliminating any source of direct financial benefit for the individual from the company. In addition, he calls for the financial support of researchers without substantial conflicts of interest. The risk is that otherwise the scientific community could soon drain itself of a reservoir of truly independent experts who can be called upon to advise policy makers on the safety and efficacy of treatments, the hazards of chemicals and the safety of technology.

Dr. Fava concludes stressing that these concerted actions may not only address many of the problems entailed by the presence of researchers with conflicts of interest in medicine; they may also foster an intellectual renewal of medical research and thinking.