Thus far, we have discussed social construction of disease, and we turn to marketing and rationality in the field of medicine. One concern in social construction of disease was that medical experts and pharmaceutical companies may make almost every condition into a diseased state. The worry is that interest for public’s health and quality of life becomes less important than interest in financial gain by the companies and medical professionals. For instance, sponsoring drug companies are more or less likely to influence which drugs doctors prescribe and what researchers concentrate on in their research. Patients who suffer from illness and we like to believe there would be no market influence on health-care work, so that patients are not merely means to financial gain. For doctors and researchers, there is conflict of interest, because they not only want to help alleviate suffering, i.e. primary interest, but also need money for various reasons, i.e. secondary interest. We worry that secondary interest will shape primary interest.
This week, we read Dennis F. Thompson (1993), Dana et al. (2003), Katz et al. (2003) Thompson attempts to understand the nature of conflicting interests. Dana and Loewenstein comment on the psychological impact on doctors of gift-receiving in terms of self-serving, yet unconscious bias. Katz and others focus on possibly significant influence of gifts with negligible value in terms of business culture.
For Thompson, conflict of interest is a condition where financial interest is in contest with professional judgments regarding valid research or patient welfare. Such professionalism demands unyielding chief interest in patients, research, students: essentially, some interest that are not only self-centred. On the contrary, secondary interest is not a problem by itself, but a problem when it is greater than the primary interest. Hence, we cannot eradicate secondary interest, but to check that it does not blind primary interest. Of course, there can be many kinds of secondary interests including peer pressure in research to be less critical of colleagues’ work; however, we can focus on money in the meantime, because money is more objective, tangible in terms of effective regulation. One cannot really chase after individual researchers to do a psychological test. In a sense, there is a definite asymmetry between primary and secondary interest.
While professionals may argue that a regulation of conflict is indignant towards professionals, Thompson wants to assure that the rules are meant to guard and foster integrity of the professionals instead of denying it. The reason is that the rules do not indicate most professionals losing integrity, but rather which cases were financially-interested. Especially, only the field experts review the results. Moreover, we do not know what kind of circumstance the author was in during his research. In this way, rules help researchers not to be worried about their circumstances and to focus on the research matter. The rules not only support professionals, but also can ensure public’s confidence in the integrity of the professionals. Generally, professionals have expectations from themselves to be honest on their own accounts and expectations from their patients and others.
Then, the question, “How do we evaluate conflicts of interest?” is important. We know that conflicts are significant according to the likelihood of influence by secondary interest on the professional judgments and to the result of such influence. For instance, if the secondary interest has great value, then we can expect the influence to be great as well. Thompson says that if the secondary interest is of small value, then it is negligible. (However, Dana and Katz will argue that the size of the gift does not matter, and the influence is still present.) Also, if the professional judgment is in accordance with conventional agreement, then we can expect that judgment to be less influenced by secondary interest. The more dependent one is, the less susceptible it is to be influenced, because one is restricted in how much one can judge. On the result of secondary interest influence, it does not only affect immediate patients or research, but may also affect other colleagues or researchers in the field. We also have to make sure the disclosure of a professional judgment, so that they do not escape scrutiny and be assessed more freely.
We could perhaps balance between trusting individual professional’s discretion or collective regulation. Insofar as the economic welfare of the professionals is also a concern, individual discretion may be more efficient and less intrusive, but may not be as effective as collective regulation. The professionals do not address this issue too often. However, we can trust a general physician and a patient who have known each other for long to have forged a mutual trust that the welfare of the patient has more weight than the secondary interest always. On the other hand, increased government intervention is due to the failures on professionals’ part to maintain their integrity. And government intervention does involve more people involved to assess the conflicts of interest. One pitfall may be that inability to understand once the professional judgments are disclosed. Or it may deepen the distrust among patients toward their physicians. This indicates the issue of conflicts of interest is not a simple matter, which deserves more attention.
Dana and Loewenstein (DL hereon) approach from psychological aspect of gift-giving. The conflict of interest is a contest between selfless and selfish interest. These conflicts are present during a test/procedure, referrals for a clinical trial, or prescription. The conflicts which arise during prescription need particular attention, because there is an implicit incentive to receive further sponsoring after a certain period of time. DL makes it clear that bias attained from receiving gifts is seen as deliberate, and therefore, unethical, and suggests that this notion makes physicians feels indignant. Thus, policies are rooted in such understanding, so small gifts are more appropriate than large gifts, believing that small gifts like pens or notes with brand inscription does not influence as much. DL argues that there is a bias, which is unintentional and can be derived from smallest gifts as well, demonstrated by studies in social science. Gifts from the drug companies tend to raise the expenditure on medications. Sales representatives meet with physicians to promote most recent and expensive products, even when those products are not even better than the one we already have.
A social science research was conducted where the subjects showed that when they worked more in terms of effort or results, they wanted to receive more than what their partner would receive. This indicates that whenever people face the choice between effort and results, they would refer to whichever one they have evidently achieved more and call it fair. People also tend to have difficult time being objective and unbiased when they have learned about some supporting arguments for their position when they took a part in model court cases. If they did not know about those arguments, they would reach settlement with the other party more quickly. When told about bias, the subject mostly believed it would be present in the other party, but not in themselves. Like these subjects, physicians report to have no bias themselves, but convinced that other physicians are biased. What is interesting is patients are not exception: they think that their physicians would be less biased and interested in financial gain than other physicians for other patients.
These informative studies allow us to rethink intervening regulations such as gift size limit and disclosure do not really affect present bias much. The physicians would not admit it even when they are told about this. So it is better to enforce regulation without assuming that large gifts create more bias than the small ones. The worry with disclosure is that patients do not know what the information mean or how to react to it. Patients would be willing to pay more even if they were told about the financial gain their physicians would have. Therefore, gifts, small or large, have influence on engendering bias among the receivers.
Katz, Caplan, and Merz (KCM hereon) also calls for re-evaluation of the policies regarding gift-giving from a perspective of business culture. When in the 80’s the integrity of the physicians were susceptible to commercial influence by receiving large gifts, American government decided to put a limit on what can be received: products which enforce the well-being of patients, and not only doctors. It was prevalent thinking around 90’s that size of the gift is directly proportional to the potential of its influence. Nearly all doctors receive gifts from companies, and doctors would not meet the representatives without them. They receive gifts as a badge of achievement and stature. As all advertisements, these gifts raise awareness about the company and its products. If the doctors rely on commercial information, then they would not concentrate on patient as much, focusing on the prescription instead of patient condition. Most doctors do not admit the influence of gifts, but evidences accumulate that more gifts corresponds to more denial in their influence. Gifts are a way to lower the receiver’s guard. As usual in business world, gifts act as promoting partnership. From a socio-cultural perspective, a gift puts the receiver in a indebted position and expects some obligation to comply since reciprocity is our nature to foster human societies. This feeling of obligation is not limited to gifts of high monetary value. Any gift works as a sign of respect and appreciation. Moreover, offering a free meal is often held to be effective persuasion method among business people as meals often give us satisfaction. A general rule that there must be some form of returning a favour; otherwise, it is socially uncomfortable, because the receiver is perceived to be free-loader in a negative way. And it is more problematic especially when refusal of gifts means total departure from any cooperation. Gift-giving is worrying because the giver as initiating a partnership decides what kinds of favours to be exchanged.
When people are educated about these norms, they found some gifts to be more inappropriate than others. Patients who are aware of gift-giving find it less appropriate than their doctors would. The gift-giving is not really a balanced exchange, because it has its incentives as to achieve more profit regardless of the excuse that it is a compensation for physicians to set aside some time to learn about the new drugs. Furthermore, companies take the cost of gifts as marketing expenses, which means it is not free. This gift-giving seeks to create interest of physicians which goes in conflict with their primary obligation to the well-being of their patients: even small gifts do influence without physicians admitting its influence on their decision. Even though there may be some measures to require physicians for disclosure in order to inform patients about the potential bias, patients have no power to limit bias, but to rely on physicians. If we could limit the frequency and the amount together, we may have a chance to tackle bias. Particularly, physicians are not business people, but the public demands professional integrity before their selfish desires. These anti-gift rules can be perceived to stifle the freedom of individual physicians, but as long as physicians do not regard themselves as a business person, they would feel less stifled. The gift-giving is an ambiguous case in this context, because we cannot really figure when it is commercial purposeful or merely is a sign of personal gratitude. It is important to recognize the need for separating common culture and medicine for the reasons above. The context in which physicians encounters drug companies has significant impact on the physicians’ prescription behaviour.
Thus far, the key issue for three authors is how to evaluate the significance of gift with regards to its influence on the conflicts of interest in professionals. Although there is much still to develop regulations and policies which will guard against bias, currently it seems that bias is inevitable as an instance of social phenomena.