Physicians are required to complete conflicts of interest (COI) disclosures for a variety of activities, such as providing continuing medical education, submitting an article to a journal for publication, or considering financial relationships with industry. If completing COI disclosures sometimes feels like a tiresome bureaucratic exercise or if it is not always entirely clear what constitutes a COI, why they are relevant, or why they should be disclosed, you are probably not alone. Good reasons exist for disclosing COIs, notably that such disclosure promotes the good of patients and the profession. In this and future articles, I will address the basics of COI in medicine.
With regard to practicing physicians, a COI refers to a situation in which a physician’s judgment regarding a patient’s well-being—the primary interest—is at risk of being biased by a secondary interest that can harm patients.1 Secondary interests could include financial gain, but they can also refer to an interest in career advancement, ability to obtain grant funding, professional recognition, and personal interests like work-life balance. This is relevant because rules and policies for COI disclosures in some health systems may be limited to financial matters.
A COI does not require that a patient be harmed or proven that a physician’s professional judgment is or was biased. It only requires that the judgment regarding a patient’s well-being is at risk of being biased by a secondary interest. Using this definition, scholars and others have thus broadened the perspective on what is considered a COI. Unfortunately, some physicians may be apprehensive that this suggests that one’s professional judgment can be impugned simply by association.
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Having a COI, however, is not necessarily ethically problematic, but having a COI and not disclosing or managing it can be. This gets to the reason why disclosing COI is so important. Fundamentally, failure to identify and manage a COI adequately may undermine the trust that patients have in their physicians and the medical profession. In other words, if patients believe physicians are making decisions that promote other interests over their own, they will lose what is arguably a central aspect of the patient-physician relationship: trust.2 Furthermore, in some health systems, failing to disclose COIs may have legal implications when existing rules and regulation prohibit financial COIs.
COIs vary by the likelihood and magnitude of harm that might occur if they are not managed adequately. For example, consider the situation in which a physician has been asked to serve on the board of a start-up pharmaceutical company because the physician has significant experience with the patient population that would be served by a drug the company is developing. The company has offered to pay the physician $20,000 over the next 6 months to review development materials and attend board meetings. The physician is eager to consider this opportunity because it provides an opportunity to learn about running complex organizations and to translate professional work into treatment.
The likelihood and magnitude of the harm from either serving on the board or accepting financial compensation are likely to be different. In both cases, because the time, attention, or reimbursement may risk biasing the physician’s professional judgment regarding patient care, both situations represent a COI. Serving on the board, however, may not have the same likelihood or magnitude of risk of biasing a physician’s judgment, and thus could be managed and ethically justifiable. In other words, serving on a board may still be a COI that should be disclosed, but it may not necessarily be prohibited.3 (Physicians should consult with their ethics committee or legal counsel if they have specific questions about their particular situations.)
Financial compensation for serving on the board presents a more significant, ethically problematic COI that may be more likely to bias professional judgment and be more difficult to manage. In accepting money, a physician establishes an implicit “quid pro quo” relationship (already well-established in the social science literature)4 that may, for example, lead to the physician to be more likely to recommend the class of medication the company is developing or medication in general.
Disclosing COIs is part of a physician’s professional and ethical responsibility to ensure that patients trust that their medical needs and well-being are their physicians’ top concern. Having a COI does not necessarily pose an ethical concern if it is managed adequately and is not likely to harm patients or impair judgment. Physicians need not feel defensive for having such a COI. Having a COI that has a high likelihood and magnitude of harm to patients can be problematic, however. Figuring out the difference between the two (often with help from an ethics and/or legal consultation) helps protect the integrity of the profession and may help the physician to sleep better at night.
In the next column, I will discuss managing COIs.
David J. Alfandre MD, MSPH, is a health care ethicist for the National Center for Ethics in Health Care (NCEHC) at the Department of Veterans Affairs (VA) and an Associate Professor in the Department of Medicine and the Department of Population Health at the NYU School of Medicine in New York. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the NCEHC or the VA.
References
- McCoy MS, Emanuel E. Why there are no “potential” conflicts of interest. JAMA. 2017;317:1721-1722.
- Fineberg HV. Conflict of interest: Why does it matter? JAMA. 2017;317:1717-1718.
- Lo B. Serving two masters—conflicts of interest in academic medicine. N Engl J Med. 2010;362:669-671.
- Dana J, Loewenstein G. A social science perspective on gifts to physicians from industry. JAMA. 2003;290:252-255.
