Conflicts of interest don’t always involve money

Conflicts of interest in medical research are extremely common – one recent study found that 52% of the experts involved in developing clinical practice guidelines for the management of diabetes in the United States and Canada had a financial conflict of interest.  Although doctors and researchers often declare financial conflicts of interests when they make presentations and publish papers, there are many who argue that declaring financial conflicts is no longer enough, and that other conflicts, such an intellectual conflicts, may be more important to manage.

Typically, attention has been focused on easily identifiable financial conflicts of interest – most commonly when researchers receive funds from industry.  But conflicts of interest are not just about money.  According to Gordon Guyatt, a Professor in the Faculty of Medicine at McMaster University, “intellectual conflicts of interest are completely ubiquitous” and have generally been ignored.

Intellectual conflicts occur when clinicians or researchers may be too deeply embedded in their own area of expertise to objectively look at a research question “with an open mind”. Guyatt argues that “even when money is not involved … we [scientists] get very attached to our ideas.”  This is compounded by university culture, which rewards researchers if their work is highly referenced by others and is perceived to be influential. This environment creates an incentive for those participating in guideline development to highlight their own research in clinical practice guidelines.

Arthur Slutsky, Vice President of Research at St. Michael’s Hospital in Toronto, believes intellectual conflicts can be even stronger than financial ones.  He argues “researchers are motivated by the opportunity to profile their work” and that the opportunity to “publish in a prestigious journal can influence decision making more than a payment from industry, unless the payments are substantial.”

The trouble is that while disclosure of financial conflicts of interest has become standard practice, few disclose their intellectual conflicts.  This, however, may be about to change.  The American College of Chest Physicians recently adopted a new method of guideline development in an attempt to better mitigate financial and intellectual conflicts in developing their guidelines about the management of clotting disorders. Experts will have input into the development of the guidelines, but will not have a final say.  In addition, the editors for each chapter will be physicians who are experts in clinical epidemiology and research methods, with no financial or content-specific intellectual conflicts. The researchers who led this process were motivated by the argument that “clinical experts who write guidelines are influenced by (usually) declared financial conflicts and by equally important undeclared intellectual conflicts of interest”.

The American College of Chest Physicians is the first group to attempt this approach, and it is not without its critics.  Some argue there needs to be greater involvement of experts even if they have conflicts, because only they can understand the nuances of the research findings and the diseases being treated.

Time will tell if the ACCP approach is adopted on a wider scale, and whether the guidelines developed by this group are perceived as both free of conflicts and clinically credible.  If nothing else, the ACCP has helped draw attention to the largely unrecognized danger posed by ignoring conflicts that don’t have to do with money.

Andreas Laupacis is an internal medicine physician.  Both he and Karen Born write at Healthy Debate.

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