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Conflict of Interest

Conflict of interest within the medical context occurs when a doctor’s ability to act in the best interest of the patient is influenced by an outside relationship Relationship A connection, association, or involvement between 2 or more parties. Clinician–Patient Relationship with a person, group, or business. The conflict may be expressed at the individual or institutional level. The most common conflicts of interest Conflicts of interest A situation in which an individual might benefit personally from official or professional actions. It includes a conflict between a person's private interests and official responsibilities in a position of trust. The term is not restricted to government officials. The concept refers both to actual conflict of interest and the appearance or perception of conflict. Medical Ethics: Basic Principles arise when the potential for financial gain exists for the physician, which is often due to relationships with industry sponsors, or with personal ownership of testing facilities. The conflict may ultimately compromise the patient's standard of care Standard of care The minimum acceptable patient care, based on statutes, court decisions, policies, or professional guidelines. Malpractice or bias Bias Epidemiological studies are designed to evaluate a hypothesized relationship between an exposure and an outcome; however, the existence and/or magnitude of these relationships may be erroneously affected by the design and execution of the study itself or by conscious or unconscious errors perpetrated by the investigators or the subjects. These systematic errors are called biases. Types of Biases research studies. Conflicts of interest Conflicts of interest A situation in which an individual might benefit personally from official or professional actions. It includes a conflict between a person's private interests and official responsibilities in a position of trust. The term is not restricted to government officials. The concept refers both to actual conflict of interest and the appearance or perception of conflict. Medical Ethics: Basic Principles should always be disclosed and attempts made to minimize bias Bias Epidemiological studies are designed to evaluate a hypothesized relationship between an exposure and an outcome; however, the existence and/or magnitude of these relationships may be erroneously affected by the design and execution of the study itself or by conscious or unconscious errors perpetrated by the investigators or the subjects. These systematic errors are called biases. Types of Biases.

Last updated: 15 Jun, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Definition

Conflict of interest within the medical context describes situations in which a doctor’s ability to act in the best interest of the patient is influenced by an outside relationship Relationship A connection, association, or involvement between 2 or more parties. Clinician–Patient Relationship with a person, group, or business.

Underlying ethical principles

  • Trust: The physician, investigator, and/or institution is entrusted with a patient’s well-being; a conflict of interest violates trust by placing another party’s interests above the patient’s interests. 
  • Fidelity to the patient: the faithfulness of 1 person to another

How conflicts of interest Conflicts of interest A situation in which an individual might benefit personally from official or professional actions. It includes a conflict between a person’s private interests and official responsibilities in a position of trust. The term is not restricted to government officials. The concept refers both to actual conflict of interest and the appearance or perception of conflict. Medical Ethics: Basic Principles arise

A conflict of interest most commonly arises in medicine when a physician has the potential for financial gain. The conflict can happen when the physician:

  • Has a relationship Relationship A connection, association, or involvement between 2 or more parties. Clinician–Patient Relationship (either personally or professionally) with drug or medical-device companies:
  • Owns the testing or treatment facility
  • Is involved in industry-sponsored research:
    • Research requires funding: The funding source can lead to bias Bias Epidemiological studies are designed to evaluate a hypothesized relationship between an exposure and an outcome; however, the existence and/or magnitude of these relationships may be erroneously affected by the design and execution of the study itself or by conscious or unconscious errors perpetrated by the investigators or the subjects. These systematic errors are called biases. Types of Biases within the study.
    • Research activities may impact a physician’s compensation Compensation Respiratory Acidosis either from their employer or from the industry sponsor.
    • Physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship may be compensated for enrolling patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship into clinical trials, which may impact a patient’s willingness to enroll.

Examples of external influence

Many outside influences may constitute a conflict of interest, including the potential for:

  • Financial gain (most prevalent):
    • 43% of researchers have received gifts, discretionary funding, and/or consulting fees.
    • Almost 33% of researchers have personal financial ties with industry sponsors.
  • Professional recognition and promotion
  • Successful acquisition of research funding: 23%–28% of academic investigators have received funding from the industry.
  • Quest for knowledge (may occur at the expense of the patient)
  • Political implications (e.g., personal values, affiliation, political agenda)

Positions at risk of developing conflicts of interest Conflicts of interest A situation in which an individual might benefit personally from official or professional actions. It includes a conflict between a person’s private interests and official responsibilities in a position of trust. The term is not restricted to government officials. The concept refers both to actual conflict of interest and the appearance or perception of conflict. Medical Ethics: Basic Principles

  • Physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship/individual researchers, especially with:
    • Long-standing relationships with pharmaceutical companies
    • Significant financial relationships with involved parties
  • People involved in clinical research
  • Journal editors and reviewers
  • University faculty members, trustees, and department chairs

Consequences of Conflicts of Interest

The consequences of conflicts of interest Conflicts of interest A situation in which an individual might benefit personally from official or professional actions. It includes a conflict between a person’s private interests and official responsibilities in a position of trust. The term is not restricted to government officials. The concept refers both to actual conflict of interest and the appearance or perception of conflict. Medical Ethics: Basic Principles can have a significant impact on both patient care and research outcomes.

Medical care and medical education

  • Prescription of newer and/or more expensive drugs, equipment, or procedures with no clear advantage when compared to older/generic alternatives:
    • May be unintentional on the part of the physician and the result of a highly effective marketing/influencing activity on a subconscious level
  • Referral to specific testing or treatment centers owned by the physician (may not be the best option for the patient):
    • Studies show more tests are ordered when the physician or practice owns the lab or imaging equipment.
  • Biased training of medical students and residents

Research

Conflicts of interest Conflicts of interest A situation in which an individual might benefit personally from official or professional actions. It includes a conflict between a person’s private interests and official responsibilities in a position of trust. The term is not restricted to government officials. The concept refers both to actual conflict of interest and the appearance or perception of conflict. Medical Ethics: Basic Principles may result in:

  • Biased study results in favor of the sponsor’s product Product A molecule created by the enzymatic reaction. Basics of Enzymes
  • Study designs favoring positive conclusions
  • Publication delays
  • Raw-data and interpretation manipulation:

Solutions, Disclosures, Limitations, and Funding

  • Limitations: The physician/investigator should limit Limit A value (e.g., pressure or time) that should not be exceeded and which is specified by the operator to protect the lung Invasive Mechanical Ventilation ties to industry as much as possible:
    • Limits subconscious bias Bias Epidemiological studies are designed to evaluate a hypothesized relationship between an exposure and an outcome; however, the existence and/or magnitude of these relationships may be erroneously affected by the design and execution of the study itself or by conscious or unconscious errors perpetrated by the investigators or the subjects. These systematic errors are called biases. Types of Biases in prescribing/referring patterns
    • Researchers may associate with impartial institutions (e.g., universities or governmental agencies).
    • Preference can be given to funding from university or government grants over unrestricted industry donations.
  • Disclosures: The physician/investigator is obligated to report sponsors and/or financial ties:
    • Includes any presentations, courses, and/or manuscripts submitted for publication
    • Different journals have distinct policies regarding external ties (some reject work by authors with potentially conflicting interests).
    • Sources of funding must be disclosed prior to publication.
  • Importance: 
    • Gives readers/learners a lens Lens A transparent, biconvex structure of the eye, enclosed in a capsule and situated behind the iris and in front of the vitreous humor (vitreous body). It is slightly overlapped at its margin by the ciliary processes. Adaptation by the ciliary body is crucial for ocular accommodation. Eye: Anatomy to view the information and assess potential biases
    • All potential biases should be adequately addressed
    • All readers should ask if the information is presented by a paid spokesperson (more like an advertisement)

References

  1. Muth, C.C. (2017). Conflict of interest in medicine. JAMA. 2017;317(17):1812. Retrieved June 10, 2021, from https://jamanetwork.com/journals/jama/fullarticle/2623608
  2. Shmerling, R.H. (2018). Conflict of interest in medicine. Harvard Health Publishing. Retrieved June 10, 2021, from https://www.health.harvard.edu/blog/conflict-of-interest-in-medicine-2018100114940 
  3. MacKenzie, C. R., & Cronstein, B. N. (2006). Conflict of interest. HSS journal: the musculoskeletal journal of Hospital for Special Surgery, 2(2), 198–201. https://doi.org/10.1007/s11420-006-9016-1
  4. Celentano, D., Szklo, M. & Gordis, L. (2019). Gordis epidemiology. Philadelphia, PA: Elsevier.

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