Andrew Burd on conflict of interest

Andrew BurdFollowing on from my blog on professionalism, I want to discuss conflict of interest. The term has been appearing more and more in the world of medicine.  A 2009 study reported in the New England Journal of Medicine found that orthopaedic surgeons at a large annual meeting were somewhat reluctant to share details of their financial support from industry.

In the same year the medical world was rather shocked by the editor in chief of the Journal of the American Medical Association being embroiled in a tale of threat, accusation, and counter accusation which all revolved around the failure of the publication of a conflict of interest declaration by the author of a paper reporting the use of the antidepressant Lexapro in stroke victims. An interesting post appeared in the Wall Street Journal and also a commentary in the journal Society (2009;46:472-476).  Jonathan Leo, the “nobody” who authored this commentary details a novel conflict of interest declaration at the end of his article. I am quoting this at some length as it brings a very interesting perspective into the discussion about what constitutes a conflict of interest “conflict of interest declaration: Since conflicts of interest are the catalyst behind this firestorm, it is only appropriate for me to be forthcoming.  While I do not have a financial conflict of interest, my ideological conflict is that I believe that the relationship between academic medicine and the pharmaceutical industry is not healthy and the clinical trial process has become tainted by marketing pressures. I also believe that, unfortunately, medical journals shoulder part of the blame for this situation. This state of events has resulted in patients being given only a partial presentation of the science behind many of the medications they take. While I look at all of these problems as ideas worthy of debate, some see this viewpoint as a declarable conflict of interest.” 

There are other areas of conflict of interest that can be of importance to medical professionals that do not relate directly to medical practice, or academia. These concern the more publically accountable aspects of the professional life and come under the term corporate governance.

The key elements of good corporate governance include honesty, trust and integrity, transparency and accountability, mutual respect, and a commitment to the organisation. In particular medical professionals who might be part of the management team in a hospital or officers of a professional association should conduct themselves honestly and ethically, especially concerning actual or possible conflicts of interest.  It is generally recognised that reliance on the integrity and ethics of individuals is bound to eventual failure.  Because of this, many organisations establish complicance and ethics programs to minimise the risk of acting outside ethical and legal boundaries. In particular it is necessary to promulgate unequivocal policy and guidelines for the avoidance and declaration of actual and possible conflict of interest.

In this context a conflict of interest is a situation in which the best interests of an organisation competes or is in conflict with the financial or personal interests of one of the officers or trustees or those of their relatives and close personal friends. The area of contracts and tenders has the greatest scope for abuse and corruption and to minimise risk it is essential that robust procedures and guidelines are in place. These will include procedures such as drawing up rules on conflict of interest to be re-circulated at annual intervals; ensuring that declarations of conflict of interest should be made in writing, preferably on a standard proforma and ensuring that any member of the management board who has declared a conflict of interest or has a possible conflict of interest should refrain from being involved in the matter in question.

The key element as to whether a declared or possible conflict of interest is sufficient to mandate withdrawal from a committee responsible for a decision making process is whether an independent, fair-minded, and properly informed observer would conclude that there was a real possibility of bias in the contribution of the individual concerned to the discussion and process of making the decision.  It must be emphasised that this real possibility must be distinguished from a mere suspicious or fanciful speculation.

Clinical governance and corporate goverance go hand in hand in medical professionalism and let no one pursuade you otherwise.

Andrew Burd is professor of plastic, reconstructive and aesthetic surgery at the Chinese University of Hong Kong. His major clinical interests involve paediatric burns care and the role of plastic surgery in the palliation of advanced malignancy. Academic interests include pragmatic ethics related to the practice of medicine including research and publication.