Intended for healthcare professionals


Managing conflicts of interest in healthcare: the new frontier

BMJ 2021; 375 doi: (Published 11 November 2021) Cite this as: BMJ 2021;375:n2772

Linked Research

Mapping conflict of interests: scoping review

  1. Susan Chimonas, qualitative research consultant12,
  2. Deborah Korenstein, chief attending23
  1. 1Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
  2. 2Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, New York, NY 10017, USA
  3. 3Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA

Our research team spent countless hours examining over 500 original research reports to identify, characterise, and map all documented ties between the medical products industry and the individuals, institutions, and activities in the healthcare ecosystem.1 Our goal was to move beyond discrete ties to understand the full network of relationships through which industry can influence care delivery. We were struck by the incredible breadth and variety of industry targets and strategies. Beyond these superficial findings, however, our map exposes the deeper structure that underlies these potential conflicts of interest—the stable, patterned system of direct industry ties and indirect, “downstream” interrelationships that consistently incentivise some choices and opportunities while discouraging or curbing others. The result: seemingly unlimited possibilities for commercial bias, once introduced, to circulate, like an infinite loop, through the system and magnify in potency as it reaches patients. The variety on the surface is therefore deceiving—lying beneath are persistent, repeating arrangements that continually prioritise, refresh, and advance industry interests.

Current efforts to oversee and manage conflicts of interest do not take a structural approach to industry ties. Rather, they examine a single individual’s or institution’s industry ties in isolation, dissociating them from the larger structure of which they are a part. This strategy consequently fails to reveal, account for, or “manage” how specific ties may interact with others to perpetuate influence and accumulate impact as they percolate through the system. The opioid epidemic provides a stark example, with manufacturers leveraging ties with diverse individuals, institutions, and activities to influence others beyond industry’s immediate reach, and on and on, with none of these participants (or those overseeing conflicts of interest) grasping their part in a vast influence network that inflicted profound harm on patients and the public.

If the opioid epidemic taught us anything, it is that our current approach to conflicts of interest is woefully unable to control the worst excesses of the profit motive, enabling them to flourish within the healthcare ecosystem and threaten patient safety and public health. To correct the course, we need full transparency and oversight across the system—including for patient advocacy groups, public officials, foundations, and other parties that shape clinical research, education, and care, but are often exempt from regulatory measures like Open Payments.2 And we should immediately eliminate all industry gifts, meals, speakers bureau payments, and other marketing “perks” that serve no legitimate scientific, educational, or clinical purpose. Direct to consumer advertising, too, is harmful and unnecessary and should be disallowed. We should also consider alternatives for developing new tests and treatments, as through prizes and other strategies that would “delink” inventions from profit-seeking organisations.

But even beyond these steps, what is urgently needed is a new, structural approach that considers the complex web of interrelationships that industry deploys to develop and market its products. We need more research to understand the ways in which bias may travel and amplify through the system, so we can bolster or reinvent our safeguards accordingly. And that means we need a way to fund such efforts, perhaps through a nominal “tax” on industry profits, managed by a group of objective arbiters to finance worthy research on this vital topic. Companies understand very well how the structure works—indeed, they were clever enough to create it. Our approach to conflicts of interest must be equally sophisticated if we are to protect patients and ensure public trust in the healthcare system.


  • Competing interests: for a full COI statement, please see the linked research paper

  • Provenance and peer review: Commissioned, not peer reviewed