Conflicts of interest in science and medicine: the physician's perspective

The various statements and declarations of the World Medical Association that address conflicts of interest on the part of physicians as (1) researchers, and (2) practitioners, are examined, with particular reference to the October 2000 revision of the Declaration of Helsinki. Recent contributions to the literature, notably on conflicts of interest in medical research, are noted. Finally, key provisions of the American Medical Association’s Code of Medical Ethics (2000–2001 Edition) that address the various forms of conflict of interest that can arise in the practice of medicine are outlined. An earlier version of this paper was presented at an International Conference on “Conflict of Interest and its Significance in Science and Medicine” held in Warsaw, Poland on 5–6 April, 2002. The World Medical Association (WMA) is a global federation of National Medical Associations representing the millions of physicians worldwide. Acting on behalf of patients and physicians, the WMA endeavours to achieve the highest possible standards of medical care, ethics, education and health-related human rights for all people.     

The impact of conflict of interest on trust in science

Conflicts of interest have an erosive effect on trust in science, damaging first the attitude of the public toward scientists and their research, but also weakening the trusting interdependence of scientists. Disclosure is recognized as the key tool for management of conflicts, but rules with sanctions must be improved, new techniques for avoidance of financial conflicts by alternative funding of evaluative research must be sought, and there must be new thinking about institutional conflicts of interest. Our profession is education, and both the public and research professionals of all ages would benefit from greater understanding of how science should and does work. An earlier version of this paper was presented at an International Conference on “Conflict of Interest and its Significance in Science and Medicine” held in Warsaw, Poland on 5–6 April, 2002.     

A psychological model that integrates ethics in engineering education

Ethics has become an increasingly important issue within engineering as the profession has become progressively more complex. The need to integrate ethics into an engineering curriculum is well documented, as education does not often sufficiently prepare engineers for the ethical conflicts they experience. Recent research indicates that there is great diversity in the way institutions approach the problem of teaching ethics to undergraduate engineering students; some schools require students to take general ethics courses from philosophical or religious perspectives, while others integrate ethics in existing engineering courses. The purpose of this paper is to propose a method to implement the integration of ethics in engineering education that is pedagogically based on Kohlberg’s stage theory of moral development.     

Conflict or harmony? Clinical research and the medical press in Russia

The author relates conditions for conducting clinical trials in Russia, current experiences of ethics committees, areas where conflicts of interest can occur regarding publishing the results of clinical trials in medical journals and the state of medical journalism in Russia today. An earlier version of this paper was presented at an International Conference on “Conflict of Interest and its Significance in Science and Medicine” held in Warsaw, Poland on 5–6 April, 2002. The author is a science editor of Meditsynskaya Gazeta.     

The protection of patients’ rights in clinical trials

The Helsinki Declaration is a very important document regarding the protection of patients’ rights in clinical trials and one of the fundamental sources of operational principles for every ethics committee. Although they have been updated, the international guidelines for ethics committees continually fail to address certain issues pertaining to the protection of patients’ rights in clinical trials. These issues include, most significantly, the method of electing ethics committees (a free, secret ballot should be preferred to direct appointment), the avoidance of conflict of interest during the election of ethics committee members, and the necessary insurance coverage for the participants of clinical trials. Polish law should, on the other hand, be developed in such way as to not limit the effectiveness of ethics committees in protecting patients’ rights in clinical trials. The ideal solution would be to draft a uniform law concerning not only clinical trials, but all medical experiments. The opinions of experts who have been reviewing medical research projects for several years may prove to be especially valuable in this setting. This paper was presented at the 6th International Bioethics Conference on the subject of ‘The Responsible Conduct of Basic and Clinical Research’, held in Warsaw, Poland, 3–4 June 2005. The author is Chairman, Bioethics Committee of the Warsaw Regional Chamber of Physicians and Dentists.     

Conflict of interest: the importance of potential

The UK Medical Research Council (MRC) takes the issue of conflict of interest very seriously. The overall aim is to preserve a climate in which personal and organisational innovation can flourish while ensuring that potential conflicts are disclosed and identified and conflicts are either avoided or managed with integrity. The approach needs to encompass the MRC’s various responsibilities and the levels at which conflicts might arise: MRC staff (scientists and administrators); the governing Council; research Boards and committees; external peer-reviewers; and applicants for funding. To achieve its goals, the MRC has issued practical guidance on various aspects of conflict of interest. For the future, the MRC has identified the continuing commercialisation of science and the increasing involvement of lay people in scientific decision-making as special challenges in this area. An earlier version of this paper was presented at an International Conference on “Conflict of Interest and its Significance in Science and Medicine” held in Warsaw, Poland on 5–6 April, 2002.     

Individual and institutional conflict of interest: policy review by research universities in the United States

This paper is a discussion of efforts to manage real and potential conflicts of interest in university research in the United States. The focus is on the report by an Association of American Universities (AAU) task force that addresses both individual and institutional conflict of interest issues. An earlier version of this paper was presented at an International Conference on “Conflict of Interest and its Significance in Science and Medicine” held in Warsaw, Poland on 5–6 April, 2002.     

Brief Report: Promoting Postformal Thinking on the Job: A Protocol for Interpersonal Conflict Resolution Training

In this paper, we discuss the relevance of training in the constructive resolution of interpersonal conflicts that occur at work. Research indicates that such conflicts may be a source of stress for adults, particularly young adults who have just entered the workforce. We present a training protocol in constructive conflict resolution that has been adapted for application to work-related conflicts. Most conflict resolution training protocols for use in the workplace focus on resolving company-wide problems. We do not know of any that focus on individual conflicts between employees, while emphasizing skills that may offer some benefits for the development of postformal thinking. Postformal thinking has been postulated as relevant to becoming an expert in one’s chosen profession. We present this protocol to stimulate ideas on how to further develop and refine training efforts for working adults in conflict resolution.     

Applying evidence to support ethical decisions: Is the placebo really powerless?

Using placebos in day-to-day practice is an ethical problem. This paper summarises the available epidemiological evidence to support this difficult decision. Based on these data we propose to differentiate between placebo and “knowledge framing”. While the use of placebo should be confined to experimental settings in clinical trials, knowledge framing — which is only conceptually different from placebo — is a desired, expected and necessary component of any doctor-patient encounter. Examples from daily practice demonstrate both, the need to investigate the effects of knowledge framing and its impact on ethical, medical, economical and legal decisions. An earlier version of this paper was presented at an international conference, “Placebo: Its Action and Place in Health Research Today,” held in Warsaw, Poland on 12–13 April, 2003.     

A comparison of conflict of interest policies at peer-reviewed journals in different scientific disciplines

Scientific journals can promote ethical publication practices through policies on conflicts of interest. However, the prevalence of conflict of interest policies and the definition of conflict of interest appear to vary across scientific disciplines. This survey of high-impact, peer-reviewed journals in 12 different scientific disciplines was conducted to assess these variations. The survey identified published conflict of interest policies in 28 of 84 journals (33%). However, when representatives of 49 of the 84 journals (58%) completed a Web-based survey about journal conflict of interest policies, 39 (80%) reported having such a policy. Frequency of policies (including those not published) varied by discipline, from 100% among general medical journals to none among physics journals. Financial interests were most frequently addressed with relation to authors; policies for reviewers most often addressed non-financial conflicts. Twenty-two of the 39 journals with policies (56%) had policies about editors’ conflicts. The highest impact journals in each category were most likely to have a published policy, and the frequency of policies fell linearly with rank; for example, policies were published by 58% of journals ranked 1 in their category, 42% of journals ranked third, and 8% of journals ranked seventh (test for trend, p = 0.003). Having a conflict of interest policy was also associated with a self-reported history of problems with conflict of interest. The prevalence of published conflict of interest policies was higher than that reported in a 1997 study, an increase that might be attributable to heightened awareness of conflict of interest issues. However, many of the journals with policies do not make them readily available and many of those policies that were available lacked clear definitions of conflict of interest or details about how disclosures would be managed during peer review and publication.     

Political and interpersonal aspects of ethics consultation

Previous papers on ethics consultation in medicine have taken a positivistic approach and lack critical scrutiny of the psychosocial, political, and moral contexts in which consultations occur. This paper discusses some of the contextual factors that require more careful research. We need to know more about what prompts and inhibits consultation, especially what factors effectively prevent house officers and nonphysicians from requesting consultation despite perceived moral conflict in cases. The attitudes and institutional power of attending medical staff seem important, especially where innovative interventions raise ethical questions. Ethics consultants also need to address the thorny problems of the origin(s) of the consultant's authority, whistleblowing, conflicts of interest that affect the consultant, persistently poor communications in hospitals, systemic inequity in the availability or quality of services for some, and the standing of the consultant's recommendations, including their appearance in the patient's medical record.     

Competing interests: The need to control conflict of interests in biomedical research

Individual and institutional conflict of interests in biomedical research have becomes matters of increasing concern in recent years. In the United States, the growth in relationships — sponsored research agreements, consultancies, memberships on boards, licensing agreements, and equity ownership — between for-profit corporations and research universities and their scientists has made the problem of conflicts, particularly financial conflicts, more acute. Conflicts can interfere with or compromise important principles and obligations of researchers and their institutions, e.g., adherence to accepted research norms, duty of care to patients, and open exchange of information. Disclosure is a key component of a successful conflict policy. Commitments which conflict with a faculty member's primary obligations to teaching, research, administrative responsibilities, or patient care also need attention. Institutional conflict of interests present different problems, some of which are discussed in an analysis of an actual problem posed by two proposed clinical trials. This paper is adapted from a lecture presented to a Symposium on Scientific Integrity, Warsaw, Poland, 23 November 1995. Daniel Steiner was Vice-President and General Counsel of Harvard University (1972–92) and in that capacity became familiar with conflict of interest issues. He is currently Counsel to the Boston law firm. Ropes and Gray, and is Adjunct Lecturer in Public Policy at the John F. Kennedy School of Government. Harvard University.     

Medical journals' conflicts of interest in the publication of book reviews

The purpose of the study was to assess medical journals’ conflicts of interest in the publication of book reviews. We examined book reviews published in 1999, 2000, and 2001 (N=1,876) in five leading medical journals: Annals of Internal Medicine, British Medical Journal (BMJ), Journal of the American Medical Association (JAMA), Lancet, and New England Journal of Medicine. The main outcome measure was journal publication of reviews of books that had been published by the journal’s own publisher, that had been edited or authored by a lead editor of the journal, or that posed another conflict of interest. We also surveyed the editors-in-chief of the five journals about their policies on these conflicts of interests. During the study period, four of the five journals published 30 book reviews presenting a conflict of interest: nineteen by the BMJ, five by the Annals, four by JAMA, and two by the Lancet. These reviews represent 5.8%, 2.7%, 0.7%, and 0.7%, respectively, of all book reviews published by the journals. These four journals, respectively, published reviews of 11.9%, 25.0%, 0.9%, and 1.0% of all medical books published by the journals’ publishers. Only one of the 30 book reviews included a disclosure statement addressing the conflict of interest. None of the journals had a written policy pertaining to the conflicts of interest assessed in this study, although four reported having unwritten policies. We recommend that scientific journals and associations representing journal editors develop policies on conflicts of interest pertaining to book reviews. Disclosure: R.M. Davis was North American editor of the BMJ from 1998 to 2001, and is a member of the Board of Trustees of the American Medical Association, which publishes JAMA. The opinions expressed in this paper are those of the authors and do not reflect the official policy of any organization with which the authors have been affiliated.     

Conflict of interest from a Romanian geneticist’s perspective

This paper examines Romanian bioethics regulations for biomedical sciences, looking in particular at the genetics area as a source for conflict of interest. The analysis is focused on the organizational level, national regulations, the sources for generating conflicts of interest, and management of conflicts. Modern biotechnology and gene technology are among the key technologies of the twenty-first century. The application of gene technology for medical and pharmaceutical purposes is widely accepted by society, but the same cannot be said of the development and application of gene technology in agriculture and food processing. Because the use of a technology in the production and processing of food is regarded more sceptically than in the production of biomedical products, there can be areas of conflict in many cases when communication is undertaken about gene technology in the agro-food sector. Ethical concerns play an important factor in this, but a society’s attitude to a developing technology is an amalgam of many effects which are beyond ethics as such. This paper contains a study carried out by the author for the Romanian Association for Consumer Protection about the attitudes of consumers towards genetically modified (GM) foods. This study revealed that in Romania more than 98% of consumers did not know anything about GM foods and frequently were confused about the definitions of these terms. In conclusion, it is necessary to say that there is a low level of knowledge regarding biotechnology in Romania and this is an important reason why there is neither public acceptance of gene technology products nor is there a rejection. An earlier version of this paper was presented at an International Conference on “Conflict of Interest and its Significance in Science and Medicine” held in Warsaw, Poland on 5–6 April, 2002. Ioana Ispas, MD in Molecular Biology, is a scientific researcher and Member of the Romanian Association for Consumer Protection, NCP for FP5-Quality of life and management of living resources.     

Welfare Rights and Conflicts of Rights

The fact that welfare rights – rights to food, shelter and medical care – will conflict with one another is often taken to be good reason to exclude welfare rights from the catalogue of genuine rights. Rather than respond to this objection by pointing out that all rights conflict, welfare rights proponents need to take the conflicts objection seriously. The existence of potentially conflicting and more weighty normative considerations counts against a claim’s status as a genuine right. To think otherwise would be to threaten the peremptory force – and hence the analytical integrity – of rights. The conflicts objection is made more pressing once we have conceded that welfare rights give people entitlements to what are potentially scarce goods. I argue that welfare rights can survive the conflicts objection if, and only if, we take scarcity into account in the framing of a given welfare right. Earlier versions of this paper were presented at the Nuffield Political Theory Workshop in Oxford and the Canadian Philosophical Association Congress 2006 at York University. I am grateful to Adam Swift, David Miller, Idil Boran, Sarah McCallum and two anonymous referees for their comments, and to the Economic and Social Research Council for research funding.     

A diagnosis of conflict: theoretical barriers to integration in mental health services &; their philosophical undercurrents

This paper examines the philosophical substructure to the theoretical conflicts that permeate contemporary mental health care in the UK. Theoretical conflicts are treated here as those that arise among practitioners holding divergent theoretical orientations towards the phenomena being treated. Such conflicts, although steeped in history, have become revitalized by recent attempts at integrating mental health services that have forced diversely trained practitioners to work collaboratively together, often under one roof. Part I of this paper examines how the history of these conflicts can be understood as a tension between, on the one hand, the medical model and its use by the dominant profession of psychiatry, and on the other, those alternative models and practitioners in some way differentiated from the medical model camp. Examples will be given from recent policy and research to highlight the prevalence of this tension in contemporary practice. Part II of this paper explores the deeper commonalities that lay beneath the theoretical conflict outlined in Part I. These commonalities will be shown to be apart of a captivating framework that has continued to grip the conflict since its inception. By exposing this underlying framework--and the motivations inherent therein--the topic of integration appears in wholly different light, allowing a renewed philosophical basis for integration to emerge.     

The ethics activities of the World Medical Association

Since its formation in 1947, the World Medical Association (WMA) has been a leading voice in international medical ethics. The WMA’s principal ethics activity over the years has been policy development on a wide variety of issues in medical research, medical practice and health care delivery. With the establishment of a dedicated Ethics Unit in 2003, the WMA’s ethics activities have intensified in the areas of liaison, outreach and product development. Initial priorities for the Ethics Unit have been the review of paragraph 30 of the Declaration of Helsinki, the expansion of the Ethics Unit section of the WMA website and the development of an ethics manual for medical students everywhere. An earlier version of this paper was presented at an international conference, “The Ethics of Intellectual Property Rights and Patents,” held in Warsaw, Poland on 23–24 April, 2004.     

Conflict of interest in medical research in Estonia

An area where conflicts of interest can take place in Estonia is in the conduct of clinical trials. The paper lists the main areas where such conflicts of interest can occur. The author also briefly discusses Estonia’s current position with regard to regulating genetic information and the commencement of the Estonian Genome Project. An earlier version of this paper was presented at an International Conference on “Conflict of Interest and its Significance in Science and Medicine” held in Warsaw, Poland on 5–6 April, 2002.     

Ethical issues in graduate education

Concern about the employment prospects of Ph.D.’s in the sciences and engineering has prompted overdue interest in the ethical aspects of graduate education. It is not possible to isolate an ethical inquiry that focuses solely on job-related issues. The ethical problems in graduate education are each related to employment, but none is related to employment only. We can illuminate potential ethical problems by considering conflicts of interest at each point from the decision to offer a graduate program through the treatment of its alumni. Such consideration prompts reassessment of program content, relations with students, and the objectives of graduate programs. This paper is a revised and expanded version of a presentation given at the American Association for the Advancement of Science meeting in Seattle, WA, February, 1997, during a program organized by the National Science Foundation (“Ethics, Employment, and Graduate Education in Science and Engineering,” Rachelle Hollander, Organizer). Samuel Gorovitz is Professor of Philosophy and of Public Administration at Syracuse University.     

Ethical and legal aspects in teaching students of medicine

Due to the rapid advances in medical technology, medical students are now being faced with increasingly complex and unparalleled ethical and practical dilemmas during their training. The new and future challenges of high-tech medicine demand improvements in current medical education, not only by meeting the needs of students through humanized training programs, but also by involving them in finding solutions to the ethical and legal quandaries they encounter. Today’s students of medical universities must acquire knowledge and understanding of the ethical and legal issues relevant to the practice of medicine, and we have to do everything possible to introduce these students to the current discussions on more or less controversial ethical and legal topics. Although final answers may not be found, the very discussion, argumentation, and awakening of students’ interest should become an essential part of the core curriculum of every doctor. An earlier version of this paper was presented at an international conference, “The Ethics of Intellectual Property Rights and Patents,” held in Warsaw, Poland on 23–24 April, 2004. The author is a student and member of the Senate Committee on Teaching.