Conflicts of Interest in Health Care
A conflict of interest in health care exists when a health care professional “with responsibility to others is influenced, consciously or unconsciously, by financial, personal, or other factors which involve self interest.” In a profit-driven capitalistic system the typical motive for the existence of a conflict of interest is usually related to financial considerations. The Editor’s experience in medicine has been that decision making not infrequently does not take into consideration the best interests of the patient as opposed to the best interest of the doctor, the hospital, the third party payor, or the government.
Our society uses “experts” in many different capacities ranging from governmental advisors and consultants to “expert witnesses” in the courtroom or legislature, “expert” independent medical examiners, and “expert” specialists. It has been a healthy departure from “business as usual” to find that, more and more, an “experts'” credentials are being taken into consideration as well as any potential conflict of interest.
Advisors to Governmental or Institutional Organizations
It is a factual observation that those who are truly “expert consultants” (possessing the greatest knowledge and understanding regarding a specific subject) typically do have a bias or potential conflict of interest. Their “expertise” regarding a particular subject has usually resulted from their past activities related to incentivization involving personal gain. For example: knowledgeable experts who were members of United States Food and Drug Administration advisory panels in the past have been dismissed because they had potential conflicts of interest. They were replaced by others not having such conflicts but who were, unfortunately, selected only because they were representative of “politically correct” groups having little or no expertise in the issues under consideration. The intelligent utilization of expertise for the benefit of society requires more than political correctness. It involves using the expertise but also limiting the effect of bias. This can be effectively accomplished by the application of the “Sunshine Principal.” This involves prior public disclosure of any and all potential biases or conflicts of interest.
The Expert Medical Specialist
When a patient turns to a specialist for advice and/or treatment it is fair to assume that the recommendations for treatment will reflect the patient’s best interests and that the individual being consulted is qualified to give an expert opinion. Unfortunately this is not always the case and it behooves the patient to be aware of potential risks in this regard. In surgical specialties it is not uncommon for surgeons to have developed treatments or medical devices or to have been involved in industry-academia connections for which a financial conflict-of-interest may exist. Minimally invasive heart surgery is considered very promising in medicine. A recent marketing blitz by a start-up company and its surgeon stockholders suggested that their enthusiasm for the procedure was premature and was apparently only a reflection of a significant conflict of interest on their parts and not on demonstrated efficacy of the procedure itself.
Another area of concern has to do with paying physicians to enlist patients to participate in drug company sponsored clinical trials without the patient’s being informed of the conflict of interest. There may be undisclosed financial benefits is to the physician based on the number of patients enrolled. Clinical drug development studies which used to be staid academic enterprises in the past in which researchers were motivated by desires for knowledge, fame or career advancement. In today’s world drug and device development have become multi-billion dollar industries with hundreds of testing and drug companies working with thousands of specialists (Research for Hire, N.Y. Times, May 16, 1999). In lieu of medical institutions requiring “Sunshine” disclosures it becomes prudent for patients to inquire if potential bias exists prior to their giving permission for treatment.
Professional experts represent an important asset to the welfare of society. The best manner of using this expertise for the benefit of all is to limit the effect of bias in qualified experts as much as possible by the public identification of potential (or real) conflicts of interest. By the consistent utilization of “Sunshine” rules and requirements the liability of bias can be greatly reduced. The “Sunshine” approach represents an important means of avoiding one of the great pitfalls of the free enterprise system while also maintaining competition as means of improving service to patients. Routine disclosure of potential conflict of interest should be a basic inherent ethical responsibility of each and every professional care giver in our health care system.