Friday, December 9, 2011

"Intellectual Conflict of Interest" Rides Again

Dr. Roy Poses posted on his Health Care Renewal blog about Pharma critic Dr. Sidney Wolfe being denied a place on an FDA advisory committee--
--which prompted a response by a "Melissa Raven" and a reply from Dr. Poses (see same URL).

Dr. Poses was kind enough to reference two former posts on this site about "intellectual conflict of interest," of which the more pertinent and complete is:

I was about to add my proverbial 2 cents in the form of a comment on Health Care Renewal, but decided it would become too wordy, and I save wordy for this blog and the few long-suffering readers thereof, so here goes.

Mr. Raven sees value in excluding people with "intellectual conflicts of interest" from advisory panels and similar groups, and instead looking for methods experts who understand what counts as good and bad evidence, but who have not previously taken stands on the particular issue under review. Dr. Poses quotes objectors to the FDA action in the Wolfe case who say that eliminating "intellectual conflict of interest" amounts to excluding anyone who has previously thought carefully about an issue, which seems to be overkill on a scientific matter.

It seems to me that underlying this discussion is a possible confusion among three concepts-- disinterested; conflict of interest; and disclosure of conflict of interest.

Ms. Raven invokes the goal of the "disinterested" advisory panelist as her argument against seating somebody like Dr. Wolfe (whose specific sin, by the way, was having previously issued warnings, on behalf of the consumer organization Public Citizen, against the type of birth control pill that the panel was supposed to review). Now, there may be something to be said for this goal, and even taking it to the extreme of excluding academic types who have formed opinions on a matter previously. After all, a reason to exclude potential jurors is that they have preconceived ideas about the guilt or innocence of the defendant. But my point right now is that "disinterested" and "conflict of interest" are rather different concepts.

As I discussed in HOOKED, and in a subsequent publication referenced below, 'conflict of interest' is hard to define succinctly, but a good approximation is, "One has become party to social arrangements that would tempt a person of normal psychological makeup to neglect a duty to protect the interests of a person or group in favor of a secondary interest, in such a manner as to create a risk of loss of trust in one's social role." Illustrative example:

  • Medical scientist undertakes clinical study of a drug.

  • The medical scientist also becames a paid speaker and consultant to the company.

  • The company wants to publish data that would promote the use of the drug and suppress data hinting at problems with the drug.

  • A medical scientist has a (primary) duty to publish the scientific truth for the benefit of future patients.

  • The scientist now has a (secondary) interest in serving the goals of the company, which conflict with the goals of good science and patient benefit.

  • The secondary interest is of the sort that would lead a person of normal human psychology to be tempted to ignore the primary duty in favor of the secondary interest.

  • This social arrangement (accepting speaker fees etc.) is of the sort that could lead reasonable onlookers to lose trust in medical science.

Notice that this describes a pretty specific set of circumstances. On the other hand. "disinterested" is a much broader term, which does not necessarily implicate any conflict of interest or threaten loss of trust in a social role. Because I know somebody is interested and not disinterested, I may distrust a particular opinion that person offers, but that is not the same as losing trust in a social role.

The sorts of financial conflicts of interest that us pharmascolds have focused on are relatively easily avoided. One does not have to fill one's own pockets with Pharma cash to practice good medicine or do good science. On the other hand, in an academic venue or in medical practice, being truly disinterested may be well-nigh impossible.

Suppose that as a medical practitioner I tell my male patients that they should have PSA tests routinely. Studies now come out showing that PSA testing may be more harmful than helpful. I am hardly disinterested when I read those studies. If their conclusions are true I have been exposing my patients to potential harm out of proportion to their benefits. Of course I am "interested" in how I interpret those studies, how hard I try to find flaws in their design, and so forth. So find me a "disinterested" medical practitioner, let alone scientist.

I have previously stated, ad nauseam in fact, that disclosure of conflicts of interest is a necessary but often hardly sufficient response to the ethical problem posed by COI. But it is in the nature of financial conflicts of interest not to be generally known unless disclosed. On the other hand, the fact that an academic has taken a certain point of view on a scientific topic is usually self-disclosing. (Just listen to the guy for about 5 minutes.) Anyone wondering whether I have an opinion on most matters can easily do a PubMed search and see what I have published on the topic. Dr. Wolfe certainly does not keep his Public Citizen advocacy activities secret.

So I suggest we keep these distinctions in mind as we discuss such matters as whether the FDA was silly to exclude Dr. Wolfe, which I vote that they were.

Brody H. Clarifying conflicts of interest. American Journal of Bioethics 11(1):23-28, January 2011.

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