Working with industry requires building a culture of trust

Howard Brody, a family physician, recently wrote an article in the Annals of Family Medicine discussing, “Professional Medical Organizations and Commercial Conflicts of Interest: Ethical Issues.”

The article focused on how AAFP has “recently been criticized for accepting a large corporate donation from Coca-Cola to fund patient education and materials on obesity prevention,” and how this money has been called a “conflict of interest.” To that effect, Dr. Brody defines such conflicts when either an “individual or organization enters into arrangements that reasonably tempt one to put aside one’s primary obligations (such as advocacy for the patient and the public health) in favor of a secondary set of interests (the financial well-being of some commercial entity, or their own financial profit).”

Under his definition, Brody claims that “accepting funds from commercial sources that seek to influence physician organizational behavior in a direction that could run counter to the public health represents one of those circumstances and so constitutes a conflict of interest.”

The fact that people can attack the efforts of a commercial entity to help prevent a national epidemic such as obesity is troubling. As Americans, shouldn’t we be wanting and applauding any and every last dollar we can get to help our nation become healthier through patient education programs?

Dr. Brody uses his article to determine whether “the relationship between AAFP and Coca-Cola constitutes a conflict of interest, and whether the conflict, if it exists, is ethically worrisome.” He also does “an analysis of the various defenses for the Coca-Cola arrangement offered by AAFP leadership.” His position accepts the view of Schafer who noted that using the language “conflict of interest, actually understates the moral seriousness of the situation because it makes it sound as if one has two interests and they are in conflict.” To Dr. Brody, “the physician’s or the medical organization’s commitment to patient and public health is a moral duty and not a mere interest.”

Is working with industry to advance science and medicine, discover breakthroughs in treatment, carry out clinical trials, and conduct research not a moral duty of a physician or medical organization? Do those experiences not help emphasize a doctor’s commitment to their patient?

There is no dispute that conflicts of interest in medicine can threaten the trust doctors share with patients, but if it’s true that there can exist a conflict of interest with “no actual unethical behavior that has necessarily arisen,” then what exactly has a doctor done wrong?

There has been no evidence that any medical organization has been influenced by the sources of its support in a way that has prevented it from fulfilling its primary responsibility: helping train doctors so they can continue to help patients. And to that effect, there has been no evidence to suggest that any patient harm as come directly from personal financial ties to commercial entities. Why should we prevent physicians and restrict their freedom when there is only “a strong temptation to serve a competing interest?” The reality is, although this potential exists, physicians are able to uphold their duty to patients while “successfully withstanding the temptation.”

For Brody, those who see the value in commercial support, “neglect the significance of the basic concept—trust in a social role.” He feels that the trust between patients and physicians “depends as much on appearance as on reality.” As a result, he feels that even “the appearance created by an arrangement that could interfere with physician or organizational allegiance to their duty to promote the public health may be as corrosive of public trust as actual unethical behavior.”

Consequently, he wonders “whether any conflict of interest that arises in medical organizations is truly necessary to achieve some important public goal.” One reason why such relationships are necessary is because “financial payment unleashes an entrepreneurial spirit, without which many fewer important scientific discoveries would be made and then developed for wide use.” Even though Brody acknowledges this fact, he asserts that “the same reasoning does not seem to apply to conflicts of interest between medical organizations and industry.”

He explains that while individuals can disclose the existence of a “conflict” and can adopt rules designed to limit any ill effects (i.e. Management Strategy), recent evidence has shown that organizations “tilt toward the stricter Divestment Strategy instead of the looser Management Strategy” to cease receiving income from industry. Brody believes that one reason for such a change is that writers “have documented the pervasive harm caused by these conflicts of interest.” But harm to whom? We have yet to see a patient die or become ill because their doctor spoke for a company.

Those entities that use Management Strategies do so because “conflict of interest is actually ubiquitous in medicine, and it is therefore arbitrary and foolish to single out one particular form (pharmaceutical financial ties) for special condemnation.” This ideology holds that we “cannot eliminate all such intellectual conflicts of interest without eliminating science itself,” because “every investigator believes in his or her pet hypothesis and wishes that the outcome of the experiment will support rather than refute that hypothesis.”

For Brody however, he believes this train of thought confuses conflict of interest with investigator bias. His main argument, however, is problematic because it relies on the weak assertion that investigators are more aware of their own expectations than those of commercial interests. The problem with this claim is that it ignores the simple fact that regardless of what happens at the end of an investigation, removing commercial ties will prevent such research from happening in the first place, and this will truly cause harm to patients waiting for new treatments and clinical data.

Despite the chilling effect on research and innovation that will be caused by hindering physician-industry relationships, Brody goes on to discuss how AAFP may have a conflict of interest for accepting funds from Coca-Cola, even though it is still premature to make such accusations since no one has seen the content of the patient educational materials actually produced. But for Brody, he sees conflict of interest occurring when a “social arrangement is made, not when the final behavioral outcomes become known.” In other words, he wants to eliminate all relationships on the possibility they might cause conflicts of interest.

As Brody sees it, the problem is not whether the company or industry is evil because “we live in a capitalist society, and it is both legal and ethical for companies to market their wares.” Instead, he sees “differing interests (or duties).” For him, companies are out to sell products, while physicians have a duty to prescribe medications or make dietary recommendations based on scientific evidence. In between that process however, there must be a hand-off of information, a collaborative effort in which those who create the products advise those that prescribe them for obvious reasons. Companies need feedback on their products, and physicians need answers to their questions regarding treatments, and to suggest that this trade-off represents “differing interests” is misguided. Only working together can we fight obesity.

Consequently, the AAFP correctly recognizes the importance of commercial support in at least one area, continuing medical education. In fact, AAFP asserted that they have been “very successful in disclosing and managing any potential conflicts,” and have never accepted the line of thinking that “even the appearance of a conflict means that a conflict exists and that it is irresolvable.” Instead, AAFP follows the belief that “conflicts need to be disclosed and then dealt with because an “apparent” conflict of interest is ethically unimportant, and the Management Strategy always suffices, so the Divestment Strategy need never be invoked.” Contrary to what Brody believes, AAFP’s use of this balanced and reasonable approach for CME funding creates the best outcomes for patients and doctors, while still maintaining trust from the public, and such a policy would be beneficial to medical organizations as well.

In fact, the Coca-Cola funding is a good example of how industry would like to work with professional organizations “to develop educational materials to help consumers make informed decisions so they can include the products they love in a balanced diet and healthy lifestyle.” Although we may not know exactly what the materials will say restricting the involvement of this funding and their ideas seems like restricting free speech. And at a time when the numbers of obese adults and children continue to climb each day, and treatments are becoming more difficult to develop, why would anyone want to turn away support for this valuable issue for what may “appear” as a “conflict?”

The role of AAFP and its members, who are widely trusted family physicians, is crucial to the health of our society. In order to provide solutions to patients and communities, especially regarding issues like obesity, partnerships between academia, government and industry are desirable and necessary. Since “no one is suggesting that the AAFP not engage Coca-Cola if the engagement avoids conflicts of interest,” then it seems fair we should allow such important work to happen without hyperbole and criticism. What will critics say when “the result of the engagement improves public health?” If we stigmatize this funding and those involved now, we may never know the outcome, and that would be harmful to all.

We need to build a culture of trust.  To begin that culture, we need to trust that the leadership at the AAFP is motivated to conduct this program to help children and families.  Trust the physicians participating in the program who are almost desperate for tools to help these children and families.  In the end we are all trying to do what is best for patients; working with industry resources to accomplish this goal is good for everyone.

In the end, our efforts and energy should not be concerned “about the development of a corporate culture within a medical professional society,” because doctors and physicians are trained to avoid such motivations. For the overwhelming majority of doctors, especially those in family medicine, the only role corporate culture plays is helping physicians conduct the research, training and education needed to make families healthier. As such, we should be encouraging the funding from and collaboration with industry to help physicians carry out their moral duty to their patients, which includes working with industry to find new ways that can help treat diseases like obesity.

Thomas Sullivan is founder of Rockpointe who blogs at Policy and Medicine.

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  • Michael F. Mirochna, MD

    I’m so exhausted after reading this lengthy post, I think I’ll have to drink a coke.

    Bottomline, coke needs to make money to exist. Selling coke and coke products makes them money. That’s the conflict of interest.

    Perhaps coke benefits by somehow controlling the very literature and education that is meant to limit its sales and use. Somewhere it seems that the material will say that coke in moderation is okay and that lowcal or no-cal beverages are great alternatives.

    We’ve already let the soda companies infiltrate the education system, why do we need them to sponsor the education doctors are trying to provide?

  • r watkins

    Unfortunately, the AAFP lost all professional respectability when they chose to become (without being bought off) a public relations firm for the EMR industry, rather than represent the interests of practicing docs.

  • doc99

    Anyone wish to comment on the AMA’s Code Book Monopoly, especially in light of the imminent arrival of the mandated ICD10?

  • Milan Moore MD, MPH

    Perhaps the author should review and remember the funding relationship between the tobacco industry and medical organizations such as the AMA in the days when it was unpopular for a practitioner to suggest that smoking might pose a danger to health….. the pro-tobacco position – no double blind randomized clinical trials to prove that smoking was harmful. Those who ignore history….. you know how it goes.

    • gzuckier

      You took the posting right out of my mouth. I can only add that the quid pro that particular quo was the tobacco industry’s aid in fighting that dread enemy of the medical industry, Medicare. Take home lesson; pacts with the Devil really never work out well.

  • Marc Gorayeb, MD

    Dr. Moore;
    Please provide detail about how the AMA did Tobacco’s bidding. I wasn’t around then, and your comment provides no detail. I believe that physicians as a group made a concerted and organized effort to quit smoking around 1960 or so. The link between smoking and cancer was first published in 1950.
    There is no justification to declare that relationships with profit-making companies are de facto bad. Let the educational campaign proceed; the critics will be vigilant and loud if the results are unbalanced.

  • Kimbo slice

    Being in the health field (not as a MD) and having done my graduate degree in the health field, I feel that there is a lack of funding both promotion, education, equipment etc but both the health professionals and the clients/patients. In other words, trying to change societal trends without any money, marketing, consistent messaging is impossible. Look at how much good research is published in scientific papers and the general pop. never even knows about it. If you want change to happen, you need ppl that knows how to influence trends….unfortunately, big corporations are the only one’s with the funds, dedication and research to make these kinds of things happen. Corporations needs to reach sales quotas to be successful so they need to know their target demographics. Health professional get paid regardless to their clients/patients success. In that regard, you could even say that health professionals don’t even have to care if clients/patients even have success in the management of obesity….if anything, failure to achieve success guaranties a returning client/patient. So the conflict of interest can be looked at from this opposite perspective.

    Bottom line, health professionals like big corp. have moral responsibilities, I think private/public partnerships are needed, who you partner with and the terms of agreements between organizations need to have integrity and a passion for the greater good of society. reply is almost as long at the oriniginal post!

  • doctor

    My question would be whether by giving this money the educational program gives any favoritism to coca cola/related products in terms of not relating how consumption of them causes obesity. Also, what type of visibility/endorsements is coca cola allowed? (i.e. does each sponsored material have their logo?) Is the donation entirely “strings free”? I don’t know- but that’s what I would like to know more about.

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