Conflicts of Interest in Healthcare
Conflict of interest (COI) is defined as a situation in which a person is—or appears to be—at risk of acting in a biased way due to personal interests.1 COI can occur in many settings, including medicine and anesthesiology. Though physicians’ most important duty is to heal patients, they often participate in activities above and beyond patient care, such as teaching medical students, conducting research studies, developing new drugs or medical devices, investing in biotechnology companies and owning testing facilities or treatment centers.1 Through these activities, physicians may develop relationships with people, businesses and organizations, sometimes benefitting financially from these relationships.1 From these financial transactions arises the potential for COI.1
Due to the particular complexity of the specialty of anesthesiology, any situation involving COI in this field can create suspicion among the public and patients.2 In reality, however, COI is not as unambiguous as it may seem. COI follows a continuum ranging from potential to apparent to actual, in that the risk for COI does not always mean it is occurring.2 It can also be categorized into “tangible” COI, which involves financial gain and monetary relationships, and “intangible” COI, which involves academics/research activity leading to fame and influence.2 COI is also context-dependent, and its severity depends on the harm to the recipient.2 The main component of a COI situation is the physician’s secondary interest, which may influence decisions about the primary interest (i.e., patient care).2 When the physician has a secondary interest, she or he may show bias, make inappropriate decisions or cause harm to patients.2 Yet COI also varies based on authority type, such as an individual or an institution; motivation, be it financial or non-financial; and other factors such as conflict of commitment (when time spent on secondary work competes with patient care), conflict of conscience (when personal morals or prejudice influence patient-related decisions), confluence of interest (when many interests are at play) and competing interests (when there is more than one primary interest).2
The history of COI in medicine and anesthesiology can be traced as far back as the 1920s, when Eli Lilly and Company helped researchers at the University of Toronto produce insulin that could be commercially manufactured and sold.3 Perhaps one of the most famous examples of COI in science and medicine was the manipulation by the tobacco industry in the 1950s.4 Led by John Hill of the public relations firm Hill & Knowlton, prominent tobacco companies used financial and non-financial means to recruit academic researchers to their Scientific Advisory Board (SAB).4 The SAB and Tobacco Industry Research Committee (TIRC) worked to control public discourse about smoking and health by convincing others that tobacco smoking was not harmful.4 These researchers were clearly engaged in COI, in that they were compensated by the tobacco industry to alter scientific discussion that was antithetical to patients’ health. Later on, COI became more commonplace with the Bayh-Dole Act of 1980, which—through granting universities the rights to sell their patents to private industry—allowed for pecuniary collaborations between researchers and businesspeople.5 To this day, COI remains an issue in medical research and practice.
Contemporary examples of potential COI in medicine and anesthesiology are numerous and varied. In a survey study of almost 2,000 physicians in the American Medical Association (AMA), 70.8 percent of respondents believed that physicians are more likely to perform unnecessary procedures when they profit from them, suggesting that financial gain remains a prominent secondary interest in medicine.6 COI reporting by authors of medical journal articles is highly studied and prioritized,7 and organizations such as the International Committee of Medical Journal Editors (ICMJE) have made efforts to standardize such reporting.8 While some researchers argue that simple disclosure of COI is not enough,9 others offer specific recommendations for prevention and disclosure of COI that are specific and thorough.10 One set of authors made explicit efforts to reduce COI by managing pharmaceutical sales activities in their anesthesiology department, through encouraging ethics discussions, banning sales representatives from bringing food into the department and adopting The American Medical Association Guidelines on Gifts.11 Evidently, COI is a frequent topic of discussion and research in contemporary medicine.
COI is highly complex and nuanced, and not all potential COI situations should cause fear. However, today’s physician organizations generally agree that it must be regulated.12 Many researchers give suggestions for the management of COI,1,10 while organizations such as the AMA create and update guidelines on collaborations between medical professionals and industry.13 Future research should explore the utility of publicly communicating the specificities of COI, such as the extent of industry involvement and the actual amounts of monetary exchange.9
1. Muth CC. Conflict of Interest in Medicine. JAMA. 2017;317(17):1812.
2. Dutta A, Choudhary P. Conflict-of-Interest in Anesthesiology. Yearbook of Anesthesiology-7. New Delhi, India: JP Medical; 2018.
3. Rosenfeld L. Insulin: Discovery and Controversy. Clinical Chemistry. 2002;48(12):2270–2288.
4. Brandt AM. Inventing conflicts of interest: A history of tobacco industry tactics. American Journal of Public Health. 2012;102(1):63–71.
5. Levenson D. Consequences of the Bayh-Dole Act. Cambridge, MA: Massachusetts Institute of Technology; December 12, 2005:1–13.
6. Lyu H, Xu T, Brotman D, et al. Overtreatment in the United States. PLoS One. 2017;12(9):e0181970.
7. Krimsky S, Rothenberg LS. Conflict of interest policies in science and medical journals: Editorial practices and author disclosures. Science and Engineering Ethics. 2001;7(2):205–218.
8. Drazen JM, de Leeuw PW, Laine C, et al. Toward More Uniform Conflict Disclosures: The Updated ICMJE Conflict of Interest Reporting Form. JAMA. 2010;304(2):212–213.
9. Kofke WA. Disclosure of industry relationships by anesthesiologists: Is the conflict of interest resolved? Current Opinion in Anesthesiology. 2010;23(2):177–183.
10. Lo B, Field MJ. Conflict of Interest in Medical Research, Education, and Practice. Washington, DC: National Academies Press; 2009.
11. Johnstone RE, Valenzuela RC, Sullivan D. Managing pharmaceutical sales activities in an academic anesthesiology department. Journal of Clinical Anesthesia. 1995;7(6):544–548.
12. Thompson DF. The Challenge of Conflict of Interest in Medicine. Journal of Evidence, Training and Quality in Health Care. 2009;103(3):136–140.
13. American Medical Association. Gifts to Physicians from Industry: Code of Medical Ethics Opinion 9.6.2. Ethics 2019.