What is a conflict of interest?
Each of the articles begins with a definition of conflict of interest. It should be noted that these definitions of conflict of interest can be applied across a wide variety of situations and that the authors have chosen to restrict themselves to specific circumstances, with the pharmaceutical industry and physician relationship. Thompson has the more complex definition stating that a conflict of interest is “a set of conditions in which professional judgement concerning primary interest (…) tends to be influenced by a secondary interest” (Thompson 573). Thompson uses the examples of a physician who should have a primary interest in a patient’s well-being and care and a conflict with the physician’s financial gain (Thompson 573). Dana and Loewenstein define conflict of interest as a “primary ethical or professional interest clash[ing] with financial self-interest, a situation that arises commonly in medical practice” (Dana and Loewenstein 252). Dana and Loewenstein then go on to provide examples of the various conflicts between patient welfare and financial self-interest that can arise in clinical practice, including recommending tests and procedures that the physician is paid for and being paid for referrals to research studies (Dana and Loewenstein 252).
The Thompson article provides a more fulsome discussion on assessing conflicts of interest. This article also sheds some light on the gradients of conflicts of interest. Thompson provides his readers with a discussion of the “scope of the conflict” (Thompson 574). Thompson states, “[l]onger and closer associations increase the problem” (Thompson 574). Thompson’s example is particularly illustrative, saying that a position on the board of an industry partner creates a more serious conflict than a one-time gift (Thompson 574). Thompson also discusses the “extent of discretion” (Thompson 574) which can allow for greater and lesser conflicts of interest depending on how closely the decision follows convention or procedure. Thompson’s example here is illustrative of professional and positional discretion, in that it is less likely for the laboratory technician to have a conflict of interest than it is for primary investigator (Thompson 574).
Current Policies on Gift Giving from Industry to Physicians:
The discussion in these articles focuses on American policies relating to industry gift giving and physicians. Dana and Loewenstein provide a brief discussion on the current policies surrounding conflicts of interest. They state that policies “seem to be premised on the understanding of bias” (Dana and Loewenstein 252) and offer policies concerning the size of gifts as examples. Katz, Caplan, and Merz provide a more detailed discussion of the policy surrounding gifts. In 1991, the policy was that the gifts or exchanges could not exceed $100 (Katz, Caplan and Merz 39). In 2002, the guidelines changed to “items of minimal value” (Katz, Caplan and Merz 40) are still allowable and can be “given with any frequency” (Katz, Caplan and Merz 40). Larger gifts under $100 must benefit patients and be given only occasionally (Katz, Caplan and Merz 40).
Gifts from Industry and Conflict of Interest:
Dana and Loewenstein discuss gifts from industry in the context of pharmaceutical sales representatives but the discussion should and could be expanded to include the manufacturers of the equipment and supplies that physicians use and prostheses or implants for surgical purposes. The discussion focuses on the “biasing effect of accepting gifts” (Dana and Loewenstein 252). Dana and Lowenstein state that there has be a positive correlation made between “the cost of physicians’ treatment choices and their amount of contact with pharmaceutical representatives” (Dana and Loewenstein 253). The article then goes on to provide a discussion concerning the idea of self-serving bias, which is important in this case, as it means that individual physicians look at themselves as not being able to be influenced by small gifts but that other physicians may be (Dana and Loewenstein 253). One of the examples provided in the article speaks to prescription practices after contact with sales representatives: “Orlowski and Wateska tracked pharmacy inventory usage reports of 2 drugs after 20 physicians at their institutions were sponsored to attend continuing medical education seminars sponsored by the companies producing drugs” (Dana and Loewenstein 254). There was a marked increase in the use of these drugs after the education event (Dana and Loewenstein 254).
The article written by Katz, Caplan, and Merz, “All Gifts Large and Small” (which seems to be a play on words of a James Herriot’s collected stories All Creatures Great and Small), provides a more fulsome discussion concerning the one sided gift exchange between the pharmaceutical industry and physicians. This article discusses the self-serving bias in a similar manner to the Dana and Loewenstein article, providing different research papers to support the point. However, the Katz, Caplan, and Merz article takes the research further for self-serving bias: “researchers have found that the more gifts a physician receives, the more likely he or she is to believe that they do not influence behaviour” (Katz, Caplan and Merz 40). The article moves forward to discuss the effects that these small gifts of have on the behaviour of physicians, including the ideas and values surrounding reciprocity. This is perhaps the most concerning part of the article as it states that gifts create an obligation to return the favour, which in this case means that physicians will feel obligated to prescribe the interventions manufactured by the particular company providing gifts (Katz, Caplan and Merz 41).
Responses and Considerations:
Thompson states that while disclosure is an option to remedy the situation it is often ineffective and generates more problems (Thompson 575). Thompson provides a list of other remedies he thinks may work – mediation, abstention, divestiture, and prohibition (Thompson 575-576). However, these were the remedies proposed in 1993. In the articles published in 2003 there are different remedies proposed. Dana and Loewenstein state that current interventions have not worked (Dana and Loewenstein 254) and that the current policies should be taken further and should not be limited to large gifts (Dana and Loewenstein 254) In fact, all gifts should be “prohibited” (Dana and Loewenstein 254). Katz, Caplan, and Merz state the “obvious and compelling policy option (…) is to restrict gift-giving and gift-acceptance” (Katz, Caplan and Merz 43). Katz, Caplan, and Merz look to the Department of Health and Human Services to shed light on the direction that the government is taking in situations like these: “[t]he federal government has already indicated that gift-giving practices may be criminalized because of the presumable effects on governmental drug expenditures” (Katz, Caplan and Merz 254). The overwhelming implication, if not explicit comments, in these articles is that practices and policies need to change in order to ensure that the patient and the healthcare consumer are protected.
Impediments to Change:
Given the self-serving bias, it is worth mentioning the discussion in the Dana and Loewenstein article and the Katz, Caplan, and Merz article concerning what physicians might think of the public calling this relationship into question and seeking to regulate it. Dana and Loewenstein state that physicians report that they are not “biased by financial arrangements with pharmaceutical companies, although a large body of research suggests that they are” (Dana and Loewenstein 254). Katz, Caplan, and Merz discuss what this restriction based on the research mentioned above and their own research may do; “psychology research suggests that any imposed restrictions on physicians’ professional behaviour are likely to be ill-received and viewed as an affront to their personal integrity and professional freedom” (Katz, Caplan and Merz 43). The article goes further to state that once freedoms are threatened they are desired even more (Katz, Caplan and Merz 43). This may make it difficult to implement the proposed changes as physicians may start to view themselves in different contexts, such as business professionals (Katz, Caplan and Merz 43-44).