Letters

Conflict of interest: Sometimes consultancies cannot be disclosed

J Garrow

1. Smith R. Conflict of interest and the BMJ. BMJ 1994;308:4-5. (1 January.) [Free Full Text]

Speakers should declare financial support

EDITOR, - With regard to avoiding potential conflicts of interest,¹ I was impressed recently by a procedure used at a satellite meeting of the American Heart Association. The meeting was recognised for the continuing education that American doctors are required to undertake for reaccreditation. At the start of the meeting every participant was given a sheet of paper listing the speakers and any financial support they received that might lead to a conflict of interest. For example, it was possible to tell which speakers were receiving financial support directly or indirectly from particular pharmaceutical companies. Clearly, for meeting on contentious issues concerning prescribing it would be helpful to the audience to have such information and to be able to judge, for example, the balance of speakers chosen to talk on the topic. Surely such a procedure should be incorporated into the requirements for accreditation of postgraduate educational courses in Britain.

G Watt

1. Smith R. Conflict of interest and the BMJ. BMJ 1994;308:4-5. (1 January.)

Public funding should also be declared

EDITOR, - Though I understand the principle behind identifying the interests of the authors of published articles and that pharmaceutical and industrial interests are being distinguished, there are other factors.¹ The influence of governments must not be forgotten, one particular example of this being the current controversy regarding the use of the more expensive antidepressants rather than the older, cheaper tricyclic agents. Song et al did not make clear that their research had been funded by the Department of Health.² Though it is usually obvious when a pharmaceutical company is involved in a study, the involvement of some government funded bodies is much more difficult to ascertain.

It would also have been helpful on that occasion to have allowed counterarguments to be made to help prescribers make up their minds. Just because an agency is not sponsored by a pharmaceutical company does not mean that the concerns that Richard Smith has highlighted¹ cannot arise. May readers assume that when the BMJ identifies sources of funding in the future it will identify not only private but also public funding?

D P Doogan

1. Smith R. Conflict of interest and the BMJ. BMJ 1994;308:4-5. (1 January.)
2. Song F, Freemantle N, Sheldon TA, House A, Watson P, Long A, et al. Selective serotonin reuptake inhibitors: meta-analysis of efficacy and acceptability. BMJ 1993;306:683-7.

Authors of letters should also disclose interests

EDITOR, - We were disappointed that Richard Smith's editorial on conflict of interest and the BMJ made only passing reference to the problem of undisclosed conflict of interest in the correspondence pages of medical journals.¹ The pharmaceutical industry watches medical journals carefully, and letters in reply to potentially influential articles are often written by people who reveal links with the industry. For example, we recently published a meta-analysis in the BMJ comparing the efficacy and tolerability of antidepressants; of the eight letters published in response,² two were from people who had financial links with the pharmaceutical industry (those from R A Foulds and Joanna Nakielny).

While such correspondence may be legitimate, it sometimes seems like campaigning. After a recent article on changes in bronchial epithelium in smokers the Journal of the American Medical Association received four critical letters, all from authors with links with the tobacco industry.³ Two of the correspondents had had at least 20 letters on the topic published.

The Journal of the American Medical Association is not alone in making editorial comment. A recent letter in the New England Journal of Medicine on lipid lowering diets was followed by a note by the editor on the links between one of the authors and a commercial company.⁴

In an effort to curtail manipulation of the medical literature the net should not be cast too wide. There may well be non-financial sources of conflict - personal, political, religious, academic, and so on - but they are harder to define reliably. There is a danger of encouraging personalisation of the debate about contentious issues if every utterance has to be accompanied by a defence of personal integrity as well as careful intellectual argument. A reasonable start would be to place journals' correspondents under the same obligation as authors of peer reviewed papers.

A House, N Freemantle

1. Smith R. Conflict of interest and the BMJ. BMJ 1994;308:4-5. (1 January.)
2. Effective and acceptable treatment for depression. BMJ 1993;306:1124-6.
3. Rennie D. Smoke and letters. JAMA 1993;270:1742-3. [Medline]
4. Ornish D, Brown SE. Treatment of and screening for hyperlipidemia. N Engl J Med 1993;329:1124-5. [Free Full Text]

Openness is not the only answer

EDITOR, - Richard Smith's editorial on conflicts of interest in publication is important.¹ My experience of establishing a software company while working as a professor of geriatric medicine highlights the problem. A colleague and I had developed a new method of measuring bed use,² but companies we approached showed little interest. Accordingly, with the permission of the medical school, my son established an independent company, Millard Associates (UK), to develop and market the software. Openness is necessary but is not the sole answer. Though the company's name was chosen to ensure openness, colleagues thought that I was trying to make a profit from them; potential collaborators in research balked at the idea of paying; and organisations that award grants asked for advice on contracting, copyright, and patents.

If new products are to be brought to the market someone has to risk losing money. Whether the loss is personal or not is irrelevant. Markets work on the principle that a product brings benefit to the user. If the product is not beneficial there is no market, so it is not in the interest of a company to publish false facts. Thus academic departments tread a fine line when they market products that they believe to be beneficial to those who will buy them. To varying degrees our papers, seminars, teaching days, workshops, conferences, and research groups are all involved with the product. In the long term a company may bring profit, yet we must believe in its benefits for if we did not we would not risk our money and the job of those we employ.

P H Millard 

1. Smith R. Conflict of interest and the BMJ. BMJ 1994;308:4-5. (1 January.)
2. Harrison GW, Millard PH. Balancing acute and long-term care: the mathematics of throughput in departments of geriatric medicine. Methods Inf Med 1991;30:221-8. [Medline]

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