Guideline development group was not in the pocket of pharmaBMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e405 (Published 17 January 2012) Cite this as: BMJ 2012;344:e405
All rapid responses
Conflict of interest may not be the issue, but influence as a consequence of association may be.
Disclosure is a good first step when there are conflicts of interest, or associations that may influence guideline writers, but disclosure seems inadequate where conflicts or associations are found.
The shortcomings of disclosure alone are that the ‘discloser’ may feel he has a moral licence to say something biased because the audience has been warned to be wary; or he may feel he has to be so cautious in what he says that his bias turns the other way. And for the audience, the problem is they don’t know how much or even which way to adjust for his conflict or association, or whether to accept the disclosure as a sign of integrity, and put aside concerns of partiality. Put all those together, and in most of the nine possible combinations it is impossible for those aware of the disclosure to make best use of the discloser’s judgement (as guideline developer).
But a warm glow suffuses us: the disclosure makes the ‘regulator’ feel good; the discloser feels good; and some of the audience feel they’ve been respected. Unfortunately, the audience might actually be worse off with the disclosure, as some research has demonstrated. (Cain DM, Loewenstein G, Moore DA. The dirt on coming clean: perverse effects of disclosing conflicts of interest. J Legal Studies. 2005;34:1–25.) All up, disclosure alone simply shifts the burden of the conflict of interest to the end of the chain of those hearing it. How fair is that?
Disclosers will deny their competing interests or associations affect their judgment, as any decent person would; to do otherwise would be to insult those who solicit or use their guideline.
Bias is the concern with being associated with pharma, and bias is part of human nature. Stelfox (New England Journal of Medicine. 338(2):101-6, 1998 Jan 8.) demonstrated this with calcium channel blockers. Why wouldn’t we be concerned about it with VTE guidelines?
It’s not self-interest when pharma uses food, friendship and flattery (Ray Moynihan’s words) to garnish influence. Try ‘Influence – the psychology of persuasion’, Robert Cialdini.
Leaders in the field can be involved with pharma, but that could exclude them from writing the guidelines yet still allow for their anonymous input which would be judged on the merit of its argument. How do you ensure when you’re indebted to someone that you don’t feel indebted?
Competing interests: No competing interests