Medical Ethics Update 2008

No, I’m not providing such … this was the conference I attended today. Needless to say, one full day wasn’t near enough, but when you don’t have industry sponsorship … The endowed lecture, this year entitled “How Financial Conflicts of Interest Endanger Our Profession”, was given by Jerome Kassirer, MD (Prof of Med, Tufts SOM; Visiting Prof, Stanford SOM; Editor-in-Chief Emeritus, NEJM). An equally fascinating keynote address was delivered by George Lowenstein, PhD (Herbert A. Simon Prof of Economics and Psychology, Dept of Social & Decision Sciences, Carnegie Mellon) on “A Psychological Perspective on Conflicts of Interest in Medicine.”

There was a consensus on the failure of disclosure as a means to remedy COI, despite its perception as the “great disinfectant.” Dr. Lowenstein presented a series of, yes, elegant studies demonstrating motivational information processing (brain processes information differently depending on whether processor wants to embrace or discard the information presented), that physicians are willingly misled even when they know the information being presented is biased, and that disclosure of a COI perversely corrupts the behavior, decisions, & actions of both the discloser and the disclosee. Dr. Kassirer added that disclosure alone requires an assessment of motives (difficult if not impossible) and gives the discloser license to proceed “unconflicted” in an “anything goes” mode.

Then there is the lack of disclosure due to the principals being so blinded to the potential for COI (or what a reasonable person might perceive as COI), as evidenced doubly at Cornell last week in terms of accepting (& hiding) tobacco industry funding for early CT screening for lung cancer (thank you NYT) and not disclosing multiple patent and licensing deals directly related to the screening technology (thank you Cancer Letter) … and then not even coming fully clean with JAMA (with regard to source of foundation funds). (I probably don’t need to remind you where I stand on University acceptance of tobacco industry largess.)

Speaking of Cornell, Dr. Kassirer presented data on just how small an incentive is necessary to influence behavior. In a study by the Cornell Hotel School (which he didn’t know existed), waitresses at an upscale Italian restaurant in NJ (which he really didn’t know existed) were randomly assigned to give no candy (simple piece of wrapped candy – nothing fancy), one piece with the check, two pieces with the check, or one piece during the meal and another piece with the check. Tips given in response to this most token of token incentives were 19.0% (none), 19.6% (1 piece), 21.6% (2 pieces), and 23.0% (1+1 pieces). He wondered how much greater the impact on behavior might be with a pizza lunch, lavish dinner, expense-paid trip, lab equipment, or $100K consulting retainer.

Aside from the issue of incentives (financial or otherwise), Dr. K discussed dozens of examples in which industry influences behavior (physicians & patients), policy (clinical guidelines, performance measures), and the research record (study design, publication bias, ghostwriting). He likewise was not happy to see Universities becoming mini-drug companies (such as at Duke), particularly if they next turn to marketing their developed products – at which point they should be taxed like the businesses with which they compete.

So, various interesting & challenging concepts, but nothing we haven’t heard before. Solutions? Again, nothing earthshaking. Eliminate COI as much as possible (food, gifts, travel, speakers bureaus, stocks & options, consultancies, equipment, personnel, etc. paid by industry); make all financial arrangements for industry-sponsored research & access to University expertise-facilities completely open and transparent (not just disclosed on pieces of paper that are locked away in filing cabinets); and clearly articulate every beneficiary & benefit from openly publicized agreements. Dr. K adds that society officers and journal editors should have no financial conflicts of any sort; that clinical guideline panel members have no or as few conflicts as possible (disclosure not enough to gain membership on the panel – COI must be investigated to assess potential impact); that professional decorum should be restored to scientific meetings by banning industry exhibitors/sponsors (those with marketing strings attached); and, as noted above, that financial support from industry should be minimized and completely & openly disclosed to society. Dr. Lowenstein concluded with this economic analysis: trust and respect are easier and less costly to maintain than to restore.

1 Comment »

  1. writedit said

    Just found the Prescription Project, which, with funding from the Pew Charitable Trusts, “seeks to eliminate conflicts of interest created by industry marketing by promoting policy change among academic medical centers, professional medical societies and public and private payers.”

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