Should we try to manage non-financial interests?BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k1240 (Published 12 April 2018) Cite this as: BMJ 2018;361:k1240
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Whether or not to regulate conflict-of-interest (COI) of any type, financial or non-financial, is only part of the debate on this subject 1. Another concern is bringing COI to public attention so that its effects on outcomes can be constructively debated. We recently encountered this problem in an attempt to raise the issue of financial COI amongst a guideline development group (GDG).
In its March 19, 2018 issue the Medical Journal of Australia (MJA) published guidelines from the Royal Australian and New Zealand College of Psychiatrists for the long-term management of bipolar disorder 2. We were concerned that the composition of the GDG appeared to violate four of the recommendations from the Institute of Medicine in its 2011 report on the creation of guidelines 3. Specifically, the IOM recommended that members with conflicts of interest (COI) should not be a majority of the guideline development group (GDG), but seven out of the thirteen committee members declared financial links with pharmaceutical companies or other commercial interests. The IOM recommended that the chair not have COI. The first author, and presumably the committee chair, reported COI with nine pharmaceutical companies. The IOM recommended that the GDG should include a current or former patient, and a patient advocate or patient/consumer group representative, but none of the thirteen committee members fulfilled this criterion. Finally, the IOM recommended that the GDG should have methodological experts as members, but all of the committee members appear to have clinical rather than methodological expertise.
We sent a letter to the MJA outlining the points above. The response was that the journal was not the appropriate venue to present our criticisms of the composition of the GDG. When medical journals decline to allow a discussion of COI then regulating them is made that much more difficult.
1. Wiersma M, Kerridge I, Lipworth W, et al. Should we try to manage non-financial interests? BMJ 2018;361:k1240.
2. Malhi G, Outhred T, Morris G, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders: bipolar disorder summary. MJA 2018;208:219-25.
3. Institute of Medicine. Clinical practice guidelines we can trust. Washington, DC, 2011.
Competing interests: In 2015-2017 Joel Lexchin received payment from two non-profit organizations for being a consultant on a project looking at indication based prescribing and a second looking at which drugs should be distributed free of charge by general practitioners. In 2015 he received payment from a for-profit organization for being on a panel that discussed expanding drug insurance in Canada. He is on the Foundation Board of Health Action International. Barbara Mintzes was an expert witness on behalf of plaintiffs in a Canadian class action suit on cardiovascular risks of a testosterone gel.
Wiersma and colleagues argue convincingly that non-financial interests in medicine can and should be managed. Unfortunately, Rodwin’s intended contrary argument gets diverted by a useful but not wholly relevant legalistic description of interests (mainly pecuniary) that can properly constitute “conflicts of interest” (1).
The emphasis on financial conflicts in biomedical journals has important unintended consequences, including the fact that authors now increasingly describe their relationships with industry with euphemisms such as “unpaid consultant” or “non-financial support”. These often amount to faux disclosures, which are fundamentally misleading as they often signal, but do not explain, a variety of benefits derived from industry involvement (2).
So what disclosures should journals require from authors? I suggest the following hierarchy of reportable conflicts: 1) direct financial payments or interests, 2) indirect benefits with obvious financial value, such as meals, accommodation, travel, conference expenses, research funding, and 3) unpaid but financially relevant involvement, such as serving on a for-profit company’s advisory board.
Expanding the range and required detail of disclosures is hardly likely to solve the problem completely (3), but would provide readers with the means to fairly appraise potential sources of bias that might not be evident from an author’s discipline or previous publications. For some purposes, such as treatment guideline preparation, it may be necessary to eliminate rather than manage such conflicts (4).
1. Wiersma M, Kerridge I, Lipworth W, Rodwin M. Should we try to manage non-financial interests? BMJ 2018;361:k1240.
2. Menkes DB, Masters JD, Broring A, Blum A. What Does 'Unpaid Consultant' Signify? A Survey of Euphemistic Language in Conflict of Interest Declarations. J Gen Intern Med 2018;33:139-41.
3. Loewenstein G, Sah S, Cain DM. The unintended consequences of conflict of interest disclosure. JAMA 2012;307:669-70.
4. Menkes DB, Bijl D. Credibility and trust are required to judge the benefits and harms of medicines. BMJ 2017;358:j4204.
Competing interests: No competing interests