Transparency as a means to conquer conflicts of interest is illusory
BMJ 2024; 386 doi: https://doi.org/10.1136/bmj.q2092 (Published 24 September 2024) Cite this as: BMJ 2024;386:q2092
Spectacles, suits, Taylor Swift, and Old Trafford. The register of interests of the UK prime minister, Keir Starmer, has now precipitated a reverse turn.1 The newspapers swooped on the shopping list for the newly elected prime minister, along with his colleagues—including, for the deputy prime minister, Angela Rayner, over £2500 from a rather nice clothing company. The chancellor, Rachel Reeves, told the Sunday Times that she took a £7500 donation from a friend to make sure that she looked the part in the election campaign.23 Following criticism, Starmer, Reeves, and Rayner have now said that they’ll no longer accept donations of money for clothes.
It’s interesting to ask why this reaction, and why now? Gifts to politicians from wealthy donors are nothing new. We have had decades of this. And the rules have been followed! As Rayner told the BBC, “Transparency is really important . . . the transparency is there so people can see that.” Declarations are placed on a central register, and anyone can check them. This has been done. And yet the public reaction is one of annoyance (“Aren’t they well off enough to buy their own stuff?”), anger (“They’ve cut winter fuel allowance but are feathering their own nests”), and disappointment (“We thought we were going to see a change in the way politics are done”).
I’ve spent the past few years researching conflicts of interest in medicine.4 And I wonder what the public reaction would be to what’s hiding in plain sight: doctors being paid thousands to advise pharma while also advising the NHS on what drugs to put in formularies; declarations of payments by “industry,” with no further details at all; and educational programmes funded by companies that have a particular interest in doctors prescribing more of their drugs.
Transparency as a means to conquer conflicts of interest is illusory. It makes it all seem fine, because as long as the rules are followed, and declarations are made, then everyone’s behaving ethically and morally, etc. But rather than ridding ourselves of the impacts of conflicts, this just embeds them: there’s no incentive for people to decrease their potential for conflicted interests when they’re told that declarations are the way to deal with it.
The unintended consequence of transparency may be that it increases the number of conflicts of interest. It’s telling to note that the politicians told the public that they’d discharged their responsibility by being transparent and following the rules. They can claim that nothing wrong was done. It’s members of the public who are saying that the rules are void. And they’re right: we know that even small gifts can corrupt.5 Being open and honest just exposes the conflict—it doesn’t take it away.
Transferred responsibility
I feel quite guilty about this, as I’ve campaigned for decades for transparency, naively thinking that it would sort out most problems. After all, embarrassment is unpleasant. But a senior NHS consultant took me aside and told me that after Disclosure UK was set up (a voluntary system run by the Association of the British Pharmaceutical Industry) his colleagues started looking at what the others were being paid. I was told that a lot of “willy waving” was going on—alpha males believing that they should be paid more than their colleagues. This was an unintended consequence of what would seem like an obviously good thing.
And what are we meant to do with this transparency? It simply transfers the responsibility of managing the conflict onto the patient or the voter. We’re somehow meant to incorporate this knowledge into our reckoning. The public clearly reckons that it expected something better from Labour. When it comes to doctors, however, patients hardly know that this information exists, let alone have the resources to deal with it. Instead, it just adds to the burden of patienthood, while doctors think that fessing up means the conflict has been dealt with. It hasn’t.
The public—currently—trusts doctors more than politicians. That may mean that we think doctors are less corruptible, or it may mean that doctors will be held to a higher standard. Whatever. But I’d suggest that if we’re relying on transparency to solve the problem of conflicts of interest, we’ll be corrupted for a long time to come.
Footnotes
Competing interests: See whopaysthisdoctor.org
Provenance and peer review: Commissioned; not externally peer reviewed.