Health Organization’s Conflicts of Interest Bring Up Ethical Issues

In this must-read reflection piece from the Annals of Family Medicine titled “Professional Medical Organizations and Commercial Conflicts of Interest: Ethical Issues,” Howard Brody, MD, PhD of the Institute for the Medical Humanities and Department of Family Medicine, University of Texas Medical Branch, in Galveston, Texas spectacularly explains the issue of conflicts of interest between health organizations and the food and beverage industry’s most notorious companies.

This article was written in 2010, after the American Academy of Family Physicians (AAFP) was severely criticized for accepting funds from Coca-Cola to help fund patient education on obesity prevention.

Dr. Brody starts off by articulately stating that:

“Accepting funds from commercial sources that seek to influence physician organizational behavior in a direction that could run counter to the public health represents one of those circumstances and so constitutes a conflict of interest. Most of the defenses offered by AAFP are rationalizations rather than ethical counterarguments. Medical organizations, as the public face of medicine and as formulator of codes of ethics for their physician members, have special obligations to adhere to high ethical standards.”

The entire piece does a spectacular job of laying out the many problems with these sorts of partnerships.

Highlights:

• “A conflict of interest arises when individuals or organizations enter into a set of arrangements which under usual circumstances would lead to the reasonable presumption that they will be tempted to put aside their primary interests (such as advocacy for the patient and the public health) in favor of a secondary set of interests (the financial well-being of some commercial entity, or their own financial profit).”

• “It is true that where a conflict of interest exists, no actual unethical behavior has necessarily arisen. There may be a strong temptation to serve a competing interest instead of doing one’s duty, and yet one may have successfully withstood the temptation. To many critics of the concept of confl ict of interest, it seems arbitrary to assume the worst and to attach blame without proof of wrongdoing. These critics, however, neglect the significance of the basic concept—trust in a social role.”

• “A common defense is to argue that conflict of interest is actually ubiquitous in medicine, and it is therefore arbitrary and foolish to single out one particular form (pharmaceutical financial ties) for special condemnation. In my view, the ubiquity argument serves as a smoke screen that confuses a narrow concept, conflict of interest, with the much wider concept, investigator bias. The empirical record suggests that these two concepts are vastly different in terms of their impact on the outcomes.

• “The leading argument offered by AAFP appears to be that any accusation of conflict of interest is premature until critics have seen the content of the patient educational materials actually produced as a result of the Coca-Cola funding. The suggestion is that the AAFP may well issue serious recommendations against the consumption of sugar-containing soft drinks, in which case it will have been proved that no conflict of interest existed. The definition of conflicts of interest given above demonstrates that a conflict occurs when one enters into certain social arrangements with other parties—not when the final behavioral outcomes become known.”

• “To offer a crude analogy, imagine that a judge who is sitting on a case involving a contract dispute between two companies is discovered to own $100,000 worth of stock in one of the companies. The judge cannot divert criticism of this conflict of interest by saying, “But you haven’t waited until I delivered my verdict—how do you know that I won’t rule against the company in which I own stock?” In the AAFP case, if the final educational material includes a strong statement against sugary soft drinks, we will never know whether, absent the Coca-Cola funding, the statement would have been even stronger. That such questions will inevitably be raised shows the conflict of interest is both present and serious, quite apart from the eventual contents of the educational materials.”

• “The argument against AAFP’s accepting funding from Coca-Cola does not hinge in any way upon an assertion that the company is evil. Similarly, to say that a physician and a drug company have a conflict of interest if the former accepts free dinners from the latter is not to say that the drug company is evil. We live in a capitalist society, and it is both legal and ethical for companies to market their wares. The problem is not good vs evil but differing interests (or duties).”

• “We ought to be concerned about the development of a corporate culture within a medical professional society. Over time, its leaders come to decide that a certain revenue stream is “necessary” for the organization to function, and then notes that it is unable to maintain that amount of revenue without generous funding from commercial sources.”

Mic drop.