The Age of Conflicts—of Interest

"Careers, money, and fame are at stake." J. Willwerth¹

Long before he became a saint, Augustine of Hippo (354-430 AD) knew something about temptation. “. . . when [Augustine] reached Carthage, towards the end of the year 370, every circumstance tended to draw him from his true course: the many seductions of the great city that was still half pagan, the licentiousness of other students, the theatres, the intoxication of his literary success, and a proud desire always to be first, even in evil.”² Although Augustine was eventually to overcome such temptations—becoming Bishop of Hippo at age 42—I will always identify with the poignant plea of Augustine’s wilder days:

“Lord, grant me chastity and continence, but not yet.”

In our own time, many so-called conflicts of interest (COI) boil down to temptation, as James DuBois,³ professor and department chair of health care ethics at Saint Louis University, notes in his excellent chapter on this subject. A physician-researcher is tempted to slant the results of his or her study in order to maintain funding from a medical technology company. A psychiatrist is tempted to write a glowing opinion piece on a new antipsychotic in order to remain on the pharmaceutical company’s “speaker’s bureau.” A cardiologist is tempted to order coronary CT angiography on all his patients with angina in order to pay off the cost of the expensive new equipment—despite the unclear benefits of this technology.

But the words “in order to” are a bit misleading. For in each instance, the physician or researcher may not even be aware of his real motivation. We are all quite capable of rationalizing our own self-interest in the name of “the patient’s well-being,” “the need for the latest technology,” and so on.

As DuBois puts it, “One reason that COI can be so insidious is that individuals are often unaware of their biases and the ways their biases influence their behavior, often in self-serving manners.”^3,4

Indeed, the opprobrium we may reflexively attach to the term “conflict of interest” is unjustified. The term means simply, “a situation in which financial or other personal considerations have the potential to compromise or bias professional judgment and objectivity.”⁵ As DuBois points out, a conflict of interest “does not imply that a professional intends to put his or her personal interests first; it does not in itself imply any wrong-doing.”³

Why, then, has the issue of COI stirred up so much emotion and consternation in recent months, particularly in the field of psychiatry? It probably doesn’t help that Sen Charles E. Grassley (R, Iowa) has been holding hearings looking into possible COI in the psychiatry departments of Harvard and Stanford medical schools.^6,7 The details of the allegations—involving underreporting of consulting fees in the Harvard case and underreporting of stock ownership in the Stanford case—are still unfolding. It is clear, however, that the public trust has been damaged by these reports, particularly since the integrity and validity of some research done at Massachusetts General Hospital (on pediatric bipolar disorder) has now been called into question.⁶ And when physicians lose the trust of the general public, they have begun to lose the soul of their profession.

Psychiatric Times is not in a position to investigate or judge the psychiatrists involved in Senator Grassley’s hearings or to gauge the integrity of the research in question. Until all the facts are known, I am inclined to give these psychiatrists the benefit of the doubt. But I am also aware of my own conflicted feelings in this matter: my instinct is to rally behind those I regard as friends and colleagues. Thus, the need for a rigorous, independent investigation is clear. It will not be enough for an internal committee at Massachusetts General Hospital or at Stanford University to render a verdict. Objective reviewers from outside these institutions must be a part of any credible investigation.

For now, we at Psychiatric Times must ensure that our own house is in order. This begins with our editorial board—which includes some of the most respected names in the field of psychiatry. With the exception of the editor-in-chief, who receives a monthly stipend, members of the board are not paid for their editorial work with Psychiatric Times, nor do they make executive decisions regarding what we do or do not publish. They serve as unpaid advisors and consultants to the editor-in-chief and the editor. However, we do sometimes ask board members to review submissions for relevance and accuracy and to recommend potential topics and authors. There is clearly room for COI. For example, a board member with substantial stock in a pharmaceutical company might—consciously or not—tend to favor an article that praised a drug made by that company.

Yet the job of the editor-in-chief is not to banish any psychiatrist—however brilliant and informed—who may have a potential COI. Rather, it is the editor-in-chief’s job to know of potential conflicts and to make executive decisions accordingly. One very experienced journal editor told me that in certain cases, it is useful to have a controversial article reviewed by someone who is known to have a strongly opposing view—maybe even an “axe to grind”—in order to ferret out weaknesses in the article. This amounts to using someone’s bias in service of the truth—so long as the bias is known, weighed carefully, and not allowed to determine the article’s fate.

Accordingly, Psychiatric Times will ask all members of our editorial board to submit a detailed disclosure form, involving such items as:

• Membership on a pharmaceutical company speaker’s bureau.
• Major stockholdings in a drug or medical device company.
• Receipt of funding for research, or of frequent honoraria, from such companies.

I believe that this policy will help ensure fair and accurate reporting, as well as balanced and scientifically grounded opinion and commentary. So far as I’m aware, Psychiatric Times will be one of a very few psychiatric publications requiring such disclosure by its editorial board.

But what about the readers of Psychiatric Times? Should they have the right to know of potential COI among editorial board members? After considerable discussion with our board members, I believe the answer is yes. Therefore, Psychiatric Times will make the disclosures of board members available to our readers, either in print, online, or both—we are still working out the logistics. In addition, we will move toward a similar policy of detailed disclosure for the authors of our major clinical and CME pieces.

Arguably, every editor whose publication relies on advertising revenues from major pharmaceutical companies has a potential conflict of interest. That said, in my time as both Science Content Editor and Editor-in-Chief, I have never once been asked to reconsider or revise any articles, owing to concerns on the part of an advertiser or corporate officer. Furthermore, we have at least 3 “lines of defense” that help us keep our writing scientifically objective: our outside peer reviewers; our Editorial Board members; and—perhaps most important—our readers. Indeed, without the continued confidence of our readership, there would likely be no advertisers willing to put up money for ads.

Professor DuBois suggests—only half-facetiously, I think—that in order to prevent COI entirely, we would need to develop a “vaccination” against temptation. He is probably right. In the meantime, we can at least avoid falling into the self-serving mind-set that says, “Lord, grant me integrity and honesty—but not yet.”