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Conflicts about Conflict of Interest

A Comparison of Performance-Based and Trustworthiness Models in the Context of Detailing and Gifts to Physicians

Published online by Cambridge University Press:  27 June 2016

TERRENCE KELLY
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Abstract:

Pharmaceutical representatives use detailing, gift giving, and the donation of free samples as a means to gain access to and influence over physicians. In biomedical ethics, there has been an ongoing debate as to whether these practices constitute an unethical conflict of interest (COI) on the part of the physician. Underlying this debate are the following antecedent questions: (1) what counts as a conflict of interest, (2) when are such conflicts unethical, and (3) how should the ethical physician respond to conflicts? This article distinguishes between two perspectives that have been developed on these issues: a reliable performance model (PM) and a trustworthiness model (TM). PM advocates argue that a conflict of interest can only be established by demonstrating that a particular influence is undermining the reliability of the physician’s judgment, and this requires empirical evidence of negative patient outcomes. TM advocates, on the other hand, argue that because of the fiduciary nature of the patient-physician relationship, physicians have an obligation to develop and be worthy of patient trust. A COI, on this view, is a condition that undermines the warrant for patients to judge a physician as trustworthy. Although there is much that is right in the PM, it is argued that the TM does a better job of responsibly addressing the unique vulnerabilities of the patient. The TM is then applied to the practices of detailing, gift giving, and sample donation. It is concluded that these practices constitute an unethical conflict of interest.

Keywords

conflict of interesttrusttrustworthinessgiftspharmaceutical representative
Type
Departments and Columns
Information
Cambridge Quarterly of Healthcare Ethics , Volume 25 , Issue 3 , July 2016 , pp. 526 - 535
Copyright
Copyright © Cambridge University Press 2016 

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References

Notes

1. Caged strategic data. 2012 U.S. Pharmaceutical Company Promotion Spending; 2013; available at http://www.skainfo.com/health_care_market_reports/2012_promotional_spending.pdf (last accessed 25 July 2014).

2. Dana, J, Loewenstein, G. Social scientific perspective on gifts to physicians. JAMA 2003;290(2):252–5.CrossRefGoogle ScholarPubMed

3. American Medical Association. Opinion 8.061: Gifts to physicians from industry. Code of Medical Ethics; 2014; available at http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion8061.page? (last accessed 12 Oct 2015).

4. Presley H. Vioxx and the Merck team effort. Kenan Center for Ethics at Duke University; available at https://kenan.ethics.duke.edu/wp-content/uploads/2012/07Case-Study-Vioxx.pdf (last accessed 16 June 2014).

5. Davis, M. Conflict of interest. Journal of Business and Professional Ethics 1982;1:17–27.CrossRefGoogle ScholarPubMedDavis, M, Stark, A, eds. Introduction. In: Conflicts of Interest in the Professions. New York: Oxford University Press; 2001:3–22.Google Scholar

6. Institute of Medicine (IOM). Conflict of interest and development of clinical practice guidelines. In: Conflict of Interest in Medical Research, Education, and Practice. Washington, DC: The National Academies Press; 2009:189–215.

7. Hsu B. Clarity on gift-giving. The New Physician 2008 May–June;57; available at http://www.amsa.org/AMSA/Homepage/Publications/TheNewPhysician/2008/tnp434.aspx (last accessed 2 Aug 2014).

8. Stell, L, Stosser, T. Another dip into the muddy waters of COI. American Journal of Bioethics 2011;11:49–50.CrossRefGoogle ScholarPubMed

9. Stosser, T. Regulation of financial conflicts of interest in medical practice and medical research. Perspectives in Biology and Medicine 2007;50(1):54–71.CrossRefGoogle Scholar

10. Heim L. Identifying and addressing potential conflict of interest: A professional medical association’s code of ethics. Annals Family Medicine 2010;8:359–61.

11. See note 9, Stosser 2007.

12. Epstein, R. Conflicts of interest in health care: Who guards the guardians? Perspectives in Biology and Medicine 2007;50(1):72–88.CrossRefGoogle Scholar

13. Brody H. Clarifying conflict of interest. American Journal of Bioethics 2011;11(1):23–8.

14. See note 13, Brody 2011.

15. Wazana A. Physicians and the pharmaceutical industry: Is a gift ever just a gift? JAMA 2000;283:375.

16. Luebke N. Conflict of interest as a moral category. Business and Professional Ethics Journal 1987;6:66–81.

17. Hui EC. Doctors as fiduciaries: A legal construct of the patient-physician relationship. Hong Kong Journal of Medicine 2005;11(6):527–9.

18. Garfinkel H. A conception of, and experiments with “trust” as a condition of stable concerted action. In: Harvey OJ, ed. Motivation and Human Action. New York: The Ronald Press; 1963:187–238.

19. Baier A. Trust and antitrust. Ethics 1986:231–60. Baier A. Trust and its vulnerabilities. In: The Tanner Lectures on Human Values. Vol. 13. Salt Lake City: University of Utah Press; 1992.

20. See note 18, Garfinkel 1963. See also Jones K. Trust as affective attitude. Ethics 1996:4–25.

21. Nickel P. Trust and obligation ascription. Ethical Theory and Moral Practice 2007;10(3):309–19.

22. Hall M, Dugan E, Zheng B, Mishra A. Trust in physicians and medical institutions: What is it? Can it be measured? And does it matter? The Milbank Quarterly 2001;79(4):613–39.

23. Schütz A. The stranger: An essay in social psychology. American Journal of Sociology 1944;49(6):505.

24. See note 22, Hall et al. 2001.

25. Pellegrino, E, Thomasma, D. The Virtues in Medical Practice. New York: Oxford University Press; 1993.Google Scholar

26. Buber M. I and Thou. New York: Scribner; 1958.

27. See note 22, Hall et al. 2001.

28. Rawls J. A Theory of Justice. Cambridge, MA: Harvard University Press; 1971, at 112.

29. See note 13, Brody 2011, at 24, emphasis added.

30. Brennan T, Rothman D, Blank L, Blumenthal D, Chimonas S, Cohen J, et al. Health industry practices that create conflicts of interest. JAMA 2006;295(4):429–33, at 430, emphasis added.

31. Morreim E. Taking a lesson from the lawyers: Defining and addressing conflict of interest. American Journal of Bioethics 2011;11(1):33–4.

32. See note 3, American Medical Association 2014, emphasis added.

33. Mauss M. The Gift. New York: W. W. Norton; 1954; see note 2, Dana, Loewenstein 2003; Cialdini R. Influence: The Psychology of Persuasion. New York: Collins; 2007.

34. American College of Emergency Physicians. Gifts to Emergency Physicians from the Pharmaceutical Industry; 2005; available at http://www.acep.org/content.aspx?id=30106 (last accessed 16 Apr 2013).

35. Shimm D, Spece Jr R. Conflicts of interest in relationships between physicians and the pharmaceutical industry. In: Spece R, Shimm D, Buchanan A, eds. Conflict of Interest in Clinical Practice and Research. New York: Oxford University Press; 1996:321–61.

36. Grande D, Shea J, Armstrong K. Pharmaceutical industry gifts to physicians: Patient beliefs and trust in physicians and the health care system. Journal of General Internal Medicine 2012:274–9.

37. Katz D, Caplan A, Merz JF. All gifts large and small. American Journal of Bioethics 2003;3(3):39–46.

38. See note 4, Presley.

39. See note 36, Grande et al. 2012. I also thank a CQ reviewer for this observation.

40. See note 10, Heim 2010; Stossel T. Regulation of financial conflicts of interest in medical practice and medical research: A damaging solution in search of a problem. Perspectives in Biology and Medicine 2007;50(1):54–71.

41. See note 13, Brody 2011, at 26. Brody H. Professional medical associations and commercial conflicts of interest. Annals of Family Medicine 2010;8(4):354–8.

42. Harter T. Answering Brody’s challenge from a pharmapologist perspective. American Journal of Bioethics 2011;11(1):30.