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Conflicts of interest
Definitions
There are at least three categories of definition: medical, legal and business
definitions.
“A conflict of interest (COI) is a set of circumstances that creates a risk that
professional judgment or actions regarding a primary interest will be unduly
influenced by a secondary interest.” (Lo & Field, 2009; MacKenzie & Cronstein,
2006)
“A term used to describe the situation in which a public official or fiduciary who,
contrary to the obligation and absolute duty to act for the benefit of the public or
a designated individual, exploits the relationship for personal benefit, typically
pecuniary.” (http://legal-dictionary.thefreedictionary.com)
“A situation that has the potential to undermine the impartiality of a person
because of the possibility of a clash between the person's self-interest and
professional interest or public interest.” (http://www.businessdictionary.com)
The second and third definitions include reference to personal benefit/ selfinterest but this is not always be involved. The first definition includes three
elements: the primary interest, a secondary interest and conflict (actual or
potential).
Doctors are under an obligation to act on behalf of the best interests of their
patients and, in clinical practice, this is the primary interest. Good Medical
Practice (General Medical Council, 2009) states that a doctor must:
“make the care of your patient your first concern”;
“be honest and trustworthy”, and
“You must act in your patients’ best interests when making referrals and
providing or arranging treatment or care.”
A CoI will arise when a secondary interest influences, or potentially influences,
this primary (clinical) interest. However the activities undertaken by a doctor
are broad and CoIs may arise in other areas of work, eg in work to develop
clinical guidelines, or in academic activities.
What types of conflicts of interest are there?
It has been suggested that CoIs can be categorized into 4 types (Gallagher,
Wainwright, Tompsett, & Atkins, 2012):


Intra-personal
Inter-personal
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

Inter-professional, and
Inter-agency
Gallagher and colleagues (2012) take a broad view of CoIs setting them within an
organizational setting. This paper focuses on CoIs faced by psychiatrists and
ways of dealing with them.
Secondary interests
Monetary reward is recognized as a common and potentially powerful secondary
interest in CoIs, but is not the only factor. The GMC issued guidance on CoIs in
2006 which was withdrawn in 2008 (General Medical Council, 2006): this
focused on financial and commercial conflicts. It included reference to other CoIs
in relation to the trust between patient and doctor:
“Trust may be damaged
by situations in which your financial or other personal
interests affect, or are seen to affect, your professional judgement. Such conflicts
of interest may arise in a variety of circumstances.” (Note: italics added).
Greenberg cites the following secondary interests: personal (including
recognition), job promotion, and religious beliefs (Greenberg, 2012). He also
notes that CoIs may not always be overt and that individual doctors may be
unaware that their judgement is being biased, giving the example of gifts: many
physicians maintain that gifts do not influence their decision-making, whereas
there are studies suggesting the reverse. Categories of secondary interests
include:
Financial/ commercial - well-recognised and common areas of concern.
Academic eg the professional or social relationship between potential reviewers
of papers submitted for publication or grant applications and the authors thereof
(Abdoul et al., 2012; Aleman-Meza et al., 2006)
Relational eg in favouring applicants with whom one has a connection for
employment positions (Howard, 2008)
Clinical eg in caring for a child there may be a conflict between their interests
and the interests of the parent, or in caring for an older adult with dementia
there may be conflict between their interests and those of their family carer.
These are however not conflicts of interest in which the self-interest/ personal
benefit of the psychiatrist is not involved.
Professional eg conflict between one’s work for the College and other duties; or
between time spent on private work and time spent on NHS work; or privileging
some activities above others because they will look better on a curriculum vitae.
Self-interest/ personal benefit may be a factor here. It has been suggested that
Clinical Practice Guideline authors may be influenced by CoIs with the
pharmaceutical industry (Norris, Holmer, Ogden, & Burda, 2011).
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Beliefs/ values – a CoI based on an individual’s deeply held beliefs could bring in
the self-interest/ personal benefit factor if that individual’s decision/s could
potentially influence how other people regarded them or how the decision might
impact on their self-image.
Dealing with CoIs
The common approach to CoIs is to require disclosure. It has been argued that
disclosure as a strategy to mitigate bias is limited if not flawed (PLoS Medicine
Editors, 2012). Three reasons for this have been suggested (Cosgrove & Krimsky,
2012):
1. disclosure simply shifts hidden bias to open bias
2. it sometimes involves a plethora of information, eg about links with the
pharmaceutical industry, so that others are “blinded” by the ‘‘signal to
noise ratio’’
3. disclosure may be regarded as having freed an individual from their
responsibility to manage their CoI
It is important that disclosing a CoI is not seen as removing responsibility to
manage that CoI, and in most cases, particularly those involving a financial CoI,
the individual concerned should remove themselves from any decisions that
involve their conflict. The new commissioning arrangements may increase intraagency conflicts of interest and a psychiatrist involved in commissioning
processes may be put in a position where their advice could carry potential
financial benefits for their employing organization. Although this is not direct
self-interest it could be construed as indirect self-interest.
The personal responsibility of a psychiatrist to manage a CoI clinically should be
driven by what is best for the patient.
Illustrative Queries received by the College
Query 1: transferring NHS psychotherapy patients to private practice
This issue was raised of patients in individual psychotherapy on the NHS on
occasion being transferred to consulting rooms privately. It was discussed
whether this was in the patients best interests, and the Committee agreed that
this was not appropriate. This situation was a conflict of interest, potentially
with financial self-interest being involved.
The Committee advised that an appropriate course of action would be to suggest
private psychotherapy if that seemed appropriate, but that a different therapist
should be sought rather than transfer to the private practice of the NHS
therapist.
Query 2: Dual responsibility and CoI
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The issue of conflicting responsibilities was raised in another query. It related to
a consultant psychiatrist who was Responsible Clinician for a number of patients
but who also conducted therapy with a number of these patients as an EMDR
therapist. The person raising the query asked: can a patient make a true
informed choice regarding
therapy, can they decide whether to engage in
therapy or stop therapy early if they know that their therapist reports to
tribunals and has control over their progression through and out of services.
It could be argued that the best interests of the patient might on occasion be for a
Responsible Clinician to also take on the role of therapist but in most cases it will
be better to separate the two functions.
Conclusions
Disclosure of conflicts of interest does not absolve individuals and organisations
of responsibility for managing those conflicts. It is important to recognize that
there is a wide range of different types of conflicts of interest, of which financial
conflicts are only one category. Other categories of conflicts may distort practice
and/or decisions and may have indirect financial implications for those involved.
In clinical practice the best interests of the patient are paramount.
References
Abdoul, H., Perrey, C., Tubach, F., Amiel, P., Durand-Zaleski, I., & Alberti, C.
(2012). Non-financial conflicts of interest in academic grant evaluation: a
qualitative study of multiple stakeholders in France. [Research Support,
Non-U.S. Gov't]. PLoS ONE [Electronic Resource], 7(4), e35247.
Aleman-Meza, B., Nagarajan, M., Ramakrishnan, C., Ding, L., Kolari, P., Sheth, A. P.,
. . . Finin, T. (2006). Semantic analytics on social networks: experiences in
addressing the problem of conflict of interest detection. Paper presented at
the Proceedings of the 15th international conference on World Wide Web,
Edinburgh, Scotland.
http://www.cs.uga.edu/~wang/8380/files/paper1.pdf
Cosgrove, L., & Krimsky, S. (2012). A Comparison of <italic>DSM</italic>-IV and
<italic>DSM</italic>-5 Panel Members' Financial Associations with
Industry: A Pernicious Problem Persists. PLoS Med, 9(3), e1001190. doi:
10.1371/journal.pmed.1001190
Gallagher, A., Wainwright, P., Tompsett, H., & Atkins, C. (2012). Findings from a
Delphi exercise regarding conflicts of interests, general practitioners and
safeguarding children: 'Listen carefully, judge slowly'. [Research Support,
Non-U.S. Gov't]. Journal of Medical Ethics, 38(2), 87-92.
General Medical Council. (2006). Conflicts of interest Retrieved from
http://www.gmc-uk.org/Conflicts_of_interest.pdf_25416524.pdf
General Medical Council. (2009). Good Medical Practice Retrieved from
http://www.gmc-uk.org/static/documents/content/GMP_0910.pdf
Greenberg, R. D. (2012). Conflicts of Interest: can a physician serve two masters?
[Review]. Clinics in Dermatology, 30(2), 160-173.
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Howard, J. (2008). Balancing Conflicts of Interest when Employing Spouses.
Employee Responsibilities and Rights Journal, 20(1), 29-43. doi:
10.1007/s10672-007-9058-7
Lo, B., & Field, M. J. (Eds.). (2009). Conflict of interest in medical research,
education, and practice. Washington DC: The National Academies Press.
MacKenzie, C., & Cronstein, B. (2006). Conflict of Interest. HSS Journal®, 2(2),
198-201. doi: 10.1007/s11420-006-9016-1
Norris, S. L., Holmer, H. K., Ogden, L. A., & Burda, B. U. (2011). Conflict of interest
in clinical practice guideline development: a systematic review. [Research
Support, U.S. Gov't, P.H.S.
Review]. PLoS ONE [Electronic Resource], 6(10), e25153.
PLoS Medicine Editors. (2012). Does conflict of interest disclosure worsen bias?
[Editorial]. PLoS Medicine / Public Library of Science, 9(4), e1001210.