Walt Kelly, the cartoonist who produced Pogo, created a poster for Earth Day in 1970. A year later, also on Earth Day, he did a two-panel comic in which Pogo is sitting in a trash-filled swamp and says, "Yep, son, we have met the enemy and he is us."1 Conflict of interest is about us as the potential enemy.The social contract that created professions mandates that all our actions, individually and collectively, are done with the interests of society and its members superseding our own interests. This is not easy because of the ubiquitous presence of conflicts of interest. However, one must keep in mind that conflicts of interests are not behaviors. Instead, they are conditions (sort of a state of being) and there is nothing inherently wrong with them as long as they are disclosed.2
There is a constant tug-of-war in daily practice between the competing interests of the patient and the doctor. Our professional biases can often make us believe that our decisions are always made in the patient's best interest, prevailing over our own. For example, let's consider the decision to take radiographs. We might believe that the decision to order radiographs is done for the patient's best interest and that we have no conflict. "To see is to know," right? The benefits to the patient of taking the radiographs may be large. But there are two ways the radiographs can produce gain for the doctor that may not benefit the patient. First, of course, is that if we own the radiographic equipment, we can make a profit by taking radiographs. Second, whether we own the equipment or not, the radiographs may be used to convince the patient that they need more treatment than they might have otherwise believed. The conflict is between the interests of the patient (the need for the diagnostic information) and the interests of the doctor (pecuniary).
In medicine, there is a lot of evidence that pharmaceutical companies' marketing practices have created conflicts of interest with doctors. The companies' educational junkets, free meals and various gifts (large and small) can subtly influence doctors to prescribe a drug that may not actually be the best one for the patient.
In my previous column, I noted that Levitt and Dubner say ethics is the study of what one ought to do and economics is the study of how financial incentives control our actual behavior.5 One can only fight the insidious effect of these financial incentives if one is cognizant of their impact on one's thinking. The consummate professional will subjugate their own biases, which are buoyed by financial incentives, and make recommendations based only on the patient's needs.
One often hears a critique of some study that notes who paid for it. For example, in a study about a drug, one might hear complaints that the outcome was influenced by the drug company that funded it. There is evidence that this is, in fact, the case.2,3 When it comes to conflicts of interest in research, the critical reader just adds that bit of information in with the most important information contained in the methods. If the methods are flawless, then the funding is not relevant. If the methods are biased in some way, then the funding might be the reason. However, the critique is still based upon the methods. Research has also shown that people's critiques are also biased by knowledge of conflicts of interest.3 Thus, bias rears its ugly head in more ways than one.
I am an associate editor of Chiropractic & Osteopathy. Our journal, as with most others today, asks authors to provide a declaration regarding competing interests. Our definition of competing interests is similar to other journals. We define these as follows:
In the past five years, have you received reimbursements, fees, funding or salary from an organization that may, in any way, gain or lose financially from the publication of this manuscript, either now or in the future? Is such an organization financing this manuscript? If so, please specify.
Do you hold any stocks or shares in an organization that may, in any way, gain or lose financially from the publication of this manuscript, either now or in the future? If so, please specify.
Do you hold, or are you currently applying for, any patents relating to the content of the manuscript? Have you received reimbursements, fees, funding or salary from an organization that holds, or has applied for, patents relating to the content of the manuscript? If so, please specify.
Do you have any other financial competing interests? If so, please specify.4
Yet in our journal, and others, I have seen various doctors declare no competing interests when it seems obvious to me that they have them. What competing interests have I seen that have not been disclosed? The doctor owns or works for a company that teaches some particular chiropractic technique or sells some device, and the article might influence readers to learn that method or purchase that device. The problem in recognizing that one actually has a conflict of interest is common to authors in all scientific journals, so chiropractic journals are not alone.2,3
I have also seen more than one organization in our profession in which individuals who teach some method or sell some product evaluate those methods or products, and even promulgate recommendations about their use. Research in the medical profession has shown that those with conflicts of interest appear to bias their opinions toward those methods or products in which they have financial interest.2,3 However, I do not know that this has been studied in our profession.
As I mentioned before, one cannot get rid of conflicts of interest. The issue is: Does one reveal these for all to see and make their own judgments? We may not be the enemy, but the only way to know is for everyone to have the information about what interests one has.
Competing Financial Interests
I teach various postgraduate programs, including ethics, for state chiropractic associations, New York Chiropractic College and Pinnacle Learning Center in Marlboro, N.Y. Those organizations that sponsor me do so without stipulations. Additionally, I am not on any of the boards, nor do I have any regulatory or financial interest in the operations or governance of these groups. These facts are merely to provide complete disclosure regarding the perception of conflict.
- Smith R. Beyond conflict of interest. Transparency is the key. BMJ, Aug. 1, 1998;317(7154):291-2.
- Smith R. Making progress with competing interests. BMJ, Dec. 14, 2002;325(7377):1375-6.
- Levitt SD, Dubner SJ. Freakonomics. New York: HarperCollins, 2006.
Click here for previous articles by Stephen M. Perle, DC, MS.