Editorials

Revisiting the commercial-academic interface in medical journals

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h2957 (Published 02 June 2015) Cite this as: BMJ 2015;350:h2957
  1. Elizabeth Loder, acting head of research,
  2. Catherine Brizzell, head of education,
  3. Fiona Godlee, editor in chief
  1. 1The BMJ, London, UK
  1. Correspondence to: E Loder eloder{at}bmj.com

The New England Journal of Medicine goes on an ill advised journey

Public trust in the pharmaceutical and biotechnology industry is low.1 Many practising physicians share that mistrust and are inclined to discount the results of otherwise sound studies that are industry funded.2 3 There are good historical reasons to be sceptical. But has suspicion degenerated, as some have charged, into “mindless demonisation?”4 The New England Journal of Medicine (NEJM) seems to think so. It has published a series of commentaries and an editorial suggesting there have been serious negative consequences of strict, “oversimplified” conflict of interest and disclosure policies, including the development of a “hostile climate” and “loss of trust.”5 6 7 8 Editor in chief, Jeffrey Drazen, says the “divide” between academic researchers and industry is not in the best interests of the public because “true improvement can come only through collaboration.”

A close reading of Drazen’s editorial suggests he is having second thoughts about policies put in place by many journals—including The BMJ—that make it “harder and harder for people who have received industry payments or items of financial value to write editorials or review articles . . . Having received industry money, the argument goes, even an acknowledged world expert can no longer provide untainted advice.”9 These policies, he says, came about “largely because of a few widely publicized episodes of unacceptable behavior.” He urges revisiting of the reasons that “medical journal editors remain concerned about authors with pharma and biotech associations.”

We are deeply troubled by a possible retreat from policies that prevent experts with relevant commercial ties from authoring commentary or review articles. The pharmaceutical and biotechnology industries may well be our medical saviours, but that is not a good reason to return to past practices. Such policies were not motivated solely by a few events, as Drazen asserts, but by recognition of extensive, systemic problems. These problems are far from solved, including internationally, as shown by recent events in India and China.10 11

Checks and balances remain important

We agree that people with industry affiliations may be capable of expressing impartial views about matters affecting the commercial interests with which they are associated. Journal readers and editors, however, have no reliable way of identifying which industry affiliated views are disinterested and which are inappropriately influenced by commercial considerations, particularly in subtle ways. Bias is not always overt or easily detected. Authors with industry ties may be likely to approach a topic from a perspective shaped by their associations, so that their views will reflect industry assumptions, priorities, and preferences. The existence of academic and non-financial conflicts of interest does not reduce the need to be wary about conflicts that arise out of the powerful economic incentives associated with industry connections.

In our view, no one has such superior knowledge that he or she is the only one qualified to write an article on a subject. Checks and balances are important in any system. In the case of medical evidence, they should be based on the assumption that it is a mistake to combine evidence production and appraisal functions in a single person or group. Some academics must work closely with industry to develop and commercialise new medical treatments, but they should not also author editorials, reviews, or guidelines that appraise them. These are different professional responsibilities, and they clash.

The stakes are high. Editorials, reviews, and guidelines legitimise medical knowledge and shape clinical practice. Society needs a group of people who can evaluate medical evidence completely free of the appearance of commercial taint. One goal of The BMJ’s zero tolerance policy on education pieces by authors with industry ties was to offer unconflicted authors “prominence and visibility.” The success or failure of this policy can be evaluated only after the distinction between these different responsibilities—developing treatments or evaluating their place in practice—has been established long enough to influence the career choices of young doctors.

Disclosure does not solve the problem of bias and might make it worse. Advisers who disclose conflicts may subsequently feel more comfortable giving biased advice, a phenomenon called moral licence. Those who receive advice from a biased adviser often do not discount it sufficiently.12 Finally, “requiring disclosure is much easier than changing the status quo . . . I’d rather tell you I’m on the gravy train than get off it.”13

We don’t find much to agree with in NEJM’s anecdotal analysis, but we do agree that criticism of the pharmaceutical and biotechnology industry is often reflexive and unfair. In fact, industry leads academia in complying with trial registration and reporting requirements.14 Many companies have embraced the open data movement.15 These are good things, but improvements in obvious problems should not be a pretext for regressive change. Instead, we should encourage all medical journals to separate the functions of evidence generation from those of appraisal. Policies that prevent experts with commercial ties from participating in evidence evaluation institutionalise this protection instead of making it optional. They are an important safeguard against bias and a defence against the perception of a “trial-journal pipeline” in which “companies treat trials and journals as marketing vehicles.”16 We agree with Steinbrook and colleagues that journal editors have a responsibility to lead on this issue and that “financial conflicts of interest in medicine are not beneficial.”17 It is a mistake by NEJM to suggest that rigorous standards should be revisited. To do so would undermine the trustworthiness of medical journals and be a disservice to clinical practice and patient safety.

Notes

Cite this as: BMJ 2015;350:h2957

Footnotes

  • Feature, doi:10.1136/bmj.h2942
  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare FG has been a long standing advocate of transparency around conflicts of interest and instigated The BMJ’s current policy of zero tolerance for relevant financial conflicts of interest in education articles.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References

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