Monday, April 6, 2009

Conflicts of Interest in Science and Medicine

There has been a small uproar in the medical community over how the editors of JAMA responded to a criticism of one of their articles. (For details see the WSJ Health Blog from 13-Mar-09 ).

The JAMA editors behaved shamefully when Dr. Jonathan Leo revealed in a letter to the BMJ not only the analytical weaknesses of a Lexapro study, but that these weaknesses were in the context of the author's undisclosed conflict of interest. Incredibly, rather than using the incident to improve their editorial process, the JAMA editors are seeking as a matter of policy to silence those who would publicly reveal their lapses.

They feel justified because they are mistakenly applying the model of the Protected Forum which facilitates discovery, and whereby physicians and hospitals seek causes and remedies for medical errors. However, an international, weekly publication is the opposite of a protected forum. Suppose a reporter publicized a story that a local hospital had removed the wrong kidney from a patient, and that witnesses believed the surgeon to be impaired. Should the hospital respond by telling the reporter that his family can no longer get care there? Should the hospital administrator call the publisher and ask that the reporter be disciplined or fired? No, the hospital should call the paper first, explain that there has been an incident, explain their internal procedures, and inform the public that the surgeon's privileges are suspended pending a complete review to determine where their patient safety procedures failed and how to improve them. There should be an apology to those harmed. They also have a duty to explain how hospitals that are transparent about their quality measures make patients safer. These actions by the JAMA editors are an affront to all of us in the truth-telling professions, physicians and journalists in particular.

However, I think people become confused when they elevate the absence of conflicts of interest to the status of a "purity test" that substitutes for the genuine scientific quality of a work. In scientific circles, legitimate disagreement over the merits of one treatment over another should not devolve into ad hominem attacks in the form of an accusation of some real or perceived conflict of interest. Plenty of good science is done with integrity by people with financial, academic, or emotional stakes in the outcome, and patients are harmed if this work is dismissed thoughtlessly. Conversely, plenty of bad science is done by people with little to gain or lose.

In some quarters there is an obsessive concern over conflicts of interest, however defined, that can become distorted into a cult of scientific asceticism. The truth is that in all fields of human creativity, money, power and sex have proven to be great motivators, both for good and ill. We should be open about this. I want the people who make major medical advances to accrue wealth, authority and emotional satisfaction. They've earned it. We should sleep much less soundly if those with the ability to improve our lives somehow had these motivations taken away.

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