Since last fall I have been conducting my debate with the leaders of my own medical professional society, the American Academy of Family Physicians, within full sight of the readers of this blog. I submitted a long article (just out this week) to the AAFP academic journal, the Annals of Family Medicine, explaining at some length my disagreement with the leaders' decision to accept funding from Coca-Cola for patient education materials on obesity prevention:
Not unreasonably, the Annals elected to offer the AAFP leadership, namely President Lori Heim, a chance to respond, which she did:
I was not able to review the contents of Dr. Heim's rebuttal until the publication date earlier in the week. I then prepared my response which I have submitted to the journal's on-line TRACK discussion feature (meaning that if there is further give and take you can follow it on the Annals website, which has free open access). As the journal has to make up its mind before they decide whether to publish my response, I append it below.
A Reply to Dr. Heim
Dr. Heim (1) takes issue with my criticism of the AAFP and its leadership for accepting Cola-Cola funding for patient education materials (2) on the following grounds: It cannot be the case that appearance of a conflict of interest (COI)—“a person’s perception of another’s behavior—even absent relevant information related to the behavior or its outcome” (1, p. 359), is ethically the same as an actual COI. It must be the case that an appearance creates nothing more than a rebuttable presumption of possible ethical misdeeds. In the AAFP’s case, the careful and responsible way that the organization went about dealing with the funds—full disclosure, demanding editorial independence, etc.—successfully rebuts any presumption of unethical action. So, in accusing the AAFP of an ethical lapse, my criticism is not suitably evidence-based (“Dr. Brody has failed to bring forth evidence that the TCCC contract interfered with the AAFP’s ability to meet its mission”; (1, p. 360)).
On its surface this rejoinder appears quite reasonable, so it will require a bit of stepwise analysis to show why I believe that it ultimately fails to prove the point that Dr. Heim wishes to argue.
In my essay (2) I offered a definition of COI: that it arises “when individuals or organizations enter into a set of arrangements which under usual circumstances would lead to the reasonable presumption that they will be tempted to put aside their primary interests…” (2, p. 355, emphasis added). If this happens, according to the definition, we have not an apparent COI but an actual COI. Notice that part of what makes it a COI is that a reasonable onlooker would reasonably judge that the arrangements entered into by the organization would normally and naturally tempt it to forgo its primary commitments (in this case, to promoting the public health). It is not enough that the onlooker has a mere uninformed “perception” as Dr. Heim puts it (1, p. 359).
The majority of the people I am aware of outside of the AAFP leadership who have heard about the Coca-Cola deal concluded immediately that the arrangement could not pass what would vulgarly be called the sniff test. That is, they decided that receiving a “strong six figure” sum from Coca-Cola would reasonably be expected to cause an organization like AAFP to deviate from its mission of strong advocacy for the public’s health. Put another way, they wondered why Coca-Cola would spend that much money to support a patient-education program that AAFP supervised. Coca-Cola is not, after all, a non-profit or a charitable foundation. One could argue that the company is obligated to its shareholders not to spend that sort of money unless they could be quite sure that something of benefit to company sales was going to result. In effect, Coca-Cola was saying through their corporate behavior that they expected commercial benefit from this deal, whereas AAFP was insisting that no such benefit would accrue and that the result would be strictly a contribution to the public’s health. The onlooker might well decide that of these two accounts, Coca-Cola’s was the more plausible.
I assert that the fact that the AAFP entered into this arrangement with Coca-Cola, when reasonable onlookers would reasonably have this reaction, constitutes an actual COI. The reason is because of the link that I described between COI and one’s ability to maintain public trust (2). By entering into this deal, AAFP knew or should have known that it was placing itself in a position where the public’s trust could easily be compromised.
To risk public trust in this fashion is to take a serious gamble. We next need to ask what prompted AAFP to take such a gamble. If the only way to secure support for patient education materials was to get the funding from Coca-Cola, then we might have a reasonable rebuttal to the charge of COI. But the AAFP has come nowhere close to showing that it had no other choices of where to raise the funds.
Dr. Heim goes on in her commentary to list things that AAFP has since said about the dangers of drinking beverages that contain too much sugar. Presumably those statements count as actual “evidence” on the basis of which AAFP should be judged, while the criticisms lodged against AAFP last fall, when the deal was first announced, count only as “early, uninformed reaction” (1, p. 360). She adds that I “[offer] no evidence of long-term harm resulting from” those “uninformed” reactions (1, p. 360).
As a long-time member of AAFP, I am frankly delighted that I can offer no hard evidence of long-term harm to the trust that the public presumably feels toward AAFP. In the past year or so we have had two examples of organizations that have discovered “evidence of long-term harm” in terms of widespread public distrust created by their actions—Toyota and BP. I presume that Toyota and BP have each discovered what most of us already know, that it takes much less time and effort to lose public trust than to regain it once it is lost.
Last fall AAFP took a gamble with its reserve of public trust by signing the “six-figure” deal with a soft drink company. So far, the gamble appears to have worked out all right. Could one have been so sure, back in the fall, that this would have been the outcome? What sort of pressing need could have justified AAFP taking this sort of gamble with its most precious resource? Since it has been lucky so far, what sorts of even riskier gambles will it decide that it can take in the future? My argument is that AAFP is ethically accountable for such decisions, and that its ethical reasons are wanting thus far.
1. Heim L. Identifying and addressing potential conflict of interest: a professional medical organization’s code of ethics. Ann Fam Med. 2010; 8:359-361.
2. Brody H. Professional medical organizations and commercial conflicts of interest: ethical issues. Ann Fam Med. 2010;8:354-358.