Conflicts of Interest in Medical Ethics
Diamond, Eugene F., Ethics & Medicine
Medicine is a learned profession that has its own intrinsic ethic. Under this intrinsic ethic, the end of medicine is ordered to a good that is health. Technique and conduct are not value-neutral but rather are ordered to this overarching good, the nature-given end of health. Medicine is a profession precisely because it professes such a goal. Being a professional is more than being a technician. The public profession of medicine as a way of life is an affirmation of the moral nature of our activity. Medicine as a profession is a public declaration of a willingness to devote oneself to others and to serve a higher good. The physician is a moral being who professes and affirms the moral nature of his activity.
We have in recent years seen an attempt to convert our profession to a killing activity. Doctors as abortionists kill unborn children; doctors accept the responsibility to kill patients with or without their consent as in Holland or to engage in the subterfuge of physician-assisted suicide as in the state of Oregon in America. The doctor true to his calling will not violate the taboo against killing. He will not do it for love and he will not do it for money.
This is why medicine must be a profession and not merely a business. A physician guided primarily by the profit motive will have conceded the best interests of his patient in the patient's pursuit of health.
Recently there has been an erosion of some of the safeguards that have accrued to the protection of the patient and the society.
Let us start with information published in medical journals. This information helps shape diagnostic and therapeutic decisions. For a medical journal to be of value, it must publish authoritative, up-to-date information that is free of commercial influence. This requires that the financial associations of authors are disclosed and that these associations do not influence published articles. This is the only way to avoid bias or the appearance of bias based on a conflict of interest. Beyond the authors themselves, this freedom from conflict of interest must extend into the process of peer review. If those who are assisting the editor in selecting articles suitable for publication are not also free from similar financial associations, the possibility of bias is reinforced.1 Relationships between biomédical companies and research are growing rapidly. Beyond the direct support of research or therapeutic trials, authors may receive consulting fees, serve on advisory boards, own equity, receive patient royalties or receive honoraria for lectures or expert testimony.
Recently the New England Journal of Medicine2 and by inference,3 the Journal of the American Medical Association have altered their policies so that authors of original articles as well as review articles and editorials will not have any "significant" financial interest in a company (or its competitors) that makes a product discussed in an article. The National Institutes of Health4 and the Association of American Medical Colleges5 have likewise relaxed their requirements regarding financial association and resultant possible bias. The key provision is to set an upper limit on the annual sum received by an author in order to have a relationship considered "significant." Currently $10,000 is the de minimus level. Beyond this any holding in which the potential for profit is not limited (such as stock, stock options, or patent holdings) would probably be disqualifying.
The justification for these changes in policy is said to be an inability to impanel an adequate number of authors and/or reviewers to carry out the functions of the journal because so many academicians and clinicians are involved in intertangling financial relationships with pharmaceutical companies.6
Inevitably the outcome of the policy will be an enhanced opportunity for the introduction of conflict of interest and a reduced confidence in the reliability of published data. …