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Conflicts of Interest

When an article is published in a medical journal, the authors must disclose any conflicts of interest. This is important, because even if they think owning stock in the drug company won’t influence their scientific judgment, we know that subtle biases can creep in to somehow affect the findings of studies. It has been shown that studies funded by drug companies are more likely to get positive results for their drug than studies funded by independent sources. Andrew Wakefield, author of the infamous retracted Lancet study suggesting a relationship between MMR vaccine and autism, was severely chastised for not disclosing that he received money from autism litigators and expected to earn a fortune from his own patented products if the MMR vaccine could be discredited.

I was recently contacted by an acupuncturist who plans to critique an article I wrote. It was a commentary in the journal Pain that accompanied a systematic review of systematic reviews of acupuncture by Ernst et al. For details of Ernst’s and my articles, see my previous post. He challenged my statement that I had no conflicts of interest to report. He apparently thinks I should have said I have a conflict of interest in that I am anti-CAM and anti-acupuncture. When he writes about my article, he plans to attack me for not declaring this alleged conflict of interest and he plans to set a good example with a conflict of interest statement of his own, divulging that he makes his living practicing acupuncture, has financial investments in it and many personal relationships, that his self-identity and prestige are dependent on his belief in acupuncture’s efficacy, and that he is biased towards constructivism and away from positivism. (I think this is a fancy way of saying he favors experience over the scientific method.) I agree that he has conflicts of interest, but was I wrong to say I had no conflicts of interest? I don’t think so.

He cited the International Committee of Medical Journal Editors (ICMJE) criteria on conflict of interest:

Public trust in the peer-review process and the credibility of published articles depends in part on how well conflict of interest is handled during writing, peer review, and editorial decision making….Conflict of interest exists when an author … has financial or personal relationships that inappropriately influence (bias) his or her actions… Financial relationships (such as employment, consultancies, stock ownership, honoraria, and paid expert testimony) are the most easily identifiable conflicts of interest and the most likely to undermine the credibility of the journal, the authors, and of science itself. However, conflicts can occur for other reasons, such as personal relationships, academic competition, and intellectual passion.

Financial relationships? Something that would make it financially advantageous for me to disparage acupuncture? Employment, consultancies, stock ownership, honoraria, paid expert testimony? Nope, nope, nope, nope, and nope. None of these apply to me. I’m retired, so I can’t even be accused of competing for patients with acupuncturists. I would have nothing to gain financially if acupuncture vanished from the earth overnight.

Personal relationships? Should Dr. Oz should divulge that his wife is a Reiki master before he pontificates about the wonders of Reiki on national television? I think he should; if it hasn’t influenced his views, I can’t imagine what his marriage is like.  Do I need to state that I associate in cyberspace with other science-based writers who have questioned the evidence for acupuncture? Do I need to say that I have 3 friends who accept acupuncture and 6 who reject it? I don’t think so.  Does a scientist doing a drug study need to divulge that his cousin or his next-door neighbor or one of his Facebook friends works for the drug company? I don’t think so.

Academic competition? I am not and have never been an academic. I’m a retired family physician with no ties to any academic institution.

Intellectual passion? My passion is for science and reason, not for or against acupuncture or any other particular treatment. I have no brief against acupuncture. I have had no personal experiences, good or bad, that would tend to prejudice me for or against it. My initial opinion of acupuncture was favorable. When I was in med school, the head of anesthesia, Dr. John Bonica, was enthusiastic about acupuncture and was actively investigating it as a possibly worthwhile addition to his field. He thought it worked by the gate control theory of pain. (As he studied it, his initial enthusiasm soon waned.)  I believed the first reports I heard about its effectiveness for surgical anesthesia and pain relief. Through the years, I read the reports that came out in the medical literature and I perceived that the weight of evidence was gradually turning against it. I also learned about the psychology of how patients and doctors can come to believe that a treatment works when it really doesn’t, and I learned some of the things that can go wrong in research to produce results that are not valid. Eventually I came to the provisional conclusion that acupuncture probably has no specific effects but is very good at eliciting non-specific effects of treatment. I don’t say that acupuncture doesn’t work: I only say that the entire body of published evidence is compatible with the hypothesis that it doesn’t work better than placebo.

I have never seen a conflict of interest statement that mentioned the authors’ worldview. No prayer study lists “I believe in God” as a conflict of interest. No scientist is expected to state “I believe the scientific method is the best way to evaluate claims.”

If conflicts of interest make an article less credible, should we also be required to disclose factors that would tend to make it more credible?  When Ernst writes an article critical of homeopathy, should he divulge that he was trained as a homeopath and used to work in a homeopathic hospital? Should we be more disposed to believe his criticisms of homeopathy because he is a “convert”? No, the content of the article can be judged on its own merits. Only significant conflicts of interest need be reported. We can keep them in the back of our mind to moderate our confidence in the study’s findings but we can never assume they mean the study is not credible.

I have no particular attachment to my provisional conclusion about acupuncture. It really makes no difference to me personally whether it works or not. Really. I would welcome proof that acupuncture works, as it would give me another option for treating any pains of my own. I am always ready to change my mind and have done so innumerable times in my career in response to better evidence. As Emerson said, “A foolish consistency is the hobgoblin of little minds.” It can’t hurt my pride to change my mind as long as I change it in response to evidence and reason; I am proud when I have learned that I was wrong about something and was able to correct my error.

If new evidence convinced me that acupuncture worked, I would write about it and explain the evidence and my reasoning. This wouldn’t hurt my reputation. If anything, it would enhance my prestige in the skeptical community. It would demonstrate that I didn’t have an ax to grind, that I was willing to follow the evidence wherever it led.

The acupuncturist’s arguments for more complete disclosure remind me of a “complete” informed consent for surgery that was written as a joke. It advised patients of everything that could possibly happen, including an earthquake during surgery and the chance that the surgeon could die suddenly of a heart attack and fall on top of the patient. Informed consent and disclosing conflicts of interest are both important, but it’s possible to get too carried away.

In summary, the acupuncturist would have a great deal to lose if he rejected acupuncture, while I would have nothing to lose if I accepted it. He has a conflict of interest. I don’t.

Posted in: Science and Medicine

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39 thoughts on “Conflicts of Interest

  1. Jan Willem Nienhuys says:

    Very good. But the example of Oz is incorrect. The moral obligation to truthfully declare conflicts of interest applies to articles in the scientific literature, not tv shows.

    The ICMJE criteria mention ‘intellectual passion’. That is a vague concept and conceivably the only thing to discuss in this case. Dr. Hall gives a good example of what might be called intellecual passion (religious belief) but is not commonly regarded as conflict of interest.

    But what type of intellectual passion did the ICMJE have in mind, more specifically, what intellectual passion that would not be intimately connected with other and more tangible conflicts of interest? The ICMJE doesn’t specify it at all.

    An example that might be considered as ‘conflict of interest’ is the following. Suppose someone is very active (as volunteer) in an organisation such as 10:23 . ( http://www.1023.org.uk/ )
    This organisation is dedicated to explaining to the public that homeopathic preparations contain nothing except ordinary water, lactose or alcohol. A chairperson of such an organisation might not be considered neutral. The Glossary of terms accompanying the ICMJE statement mentions in point 17 being on the board of an organisation. I am not certain whether this would apply in this particular example.

    The quoted explanation of the ICMJE does not contain anything that can be easily construed as applicable to this case. As Dr. Hall says, belief in the scientific method (to the extent that one puts effort in educating the public about it) cannot be seen as a conflict of interest in a scientific journal.

    Of course, Harriet Hall is listed as Associate Editor of SBM and as Fellow of CSI, but it is not clear how that falls under the scope of what the ICMJE defines as conflict of interest.

    For journalists this is different. Membership in any organisation with points of view that might be considered as controversial or partial can affect their credibility, both for their readers and the people they interview. But we are dealing here with the ICMJE. So: what exactly does the ICMJE mean by intellectual passion? Any examples?

  2. Ian says:

    @Nienhuys erm, ethics don’t apply to TV? o.O

  3. BillyJoe says:

    “If new evidence convinced me that acupuncture worked, I would write about it…”

    …on the side of my…

    :D

  4. weing says:

    I have an intellectual passion for science and applying the scientific method for studying the world and effecting change. I gladly admit to this bias and conflict of interest, if you want to call it that. If someone has passion for fairy tales and make believe, they should state it so. They should also state that their bias is for using magic carpets to fly and not airplanes. That way people can more readily decide whether to follow them or science.

  5. Jan Willem Nienhuys says:

    ethics don’t apply to TV?

    Harriet Hall is accused of not reporting a conflict of interest where it is required, namely in a scientific journal that uses a specific definition the meaning of which is generally agreed upon. The readers of the journal know that all authors have been required to make such a statement, and also that if the author has stated such a conflict of interest, it will be reported by the editors of the journal.

    This is totally different from what happens on TV (and in ordinary newspapers). And if the readers of Pain had no idea why an apparently retired physician, writing not from an academic institution, was asked to write an editorial, they could have googled.

  6. Jan Willem Nienhuys says:

    If someone has passion for fairy tales and make believe, they should state it so.

    Do you seriously mean that this was the intention of the ICMJE?

  7. Epinephrine says:

    I think it is reasonable to say that you have a “conflict of interest.” The term has been used far too often to refer solely to financial matters, or as you describe it, a matter of what you have to lose. Cognitive dissonance crops up whenever we dedicate time and effort to something, and it wouldn’t be at all surprising if we have cognitive biases about quackery when we devote much time to reading up on it and dispelling it. I certainly would say that I have a conflict of interest when it comes to natural health products, even though I have no financial involvement with them, nor does my work revolve around them. And while you may not feel that it is true, most of use have the belief that things in which we have invested our time are worthwhile. While you might change your mind when presented with sufficient evidence, the amount required may well have been altered by your time spent arguing against it.

  8. WilliamLawrenceUtridge says:

    So essentially this guy is saying “anyone who disagrees with me must declare a conflict of interest”. There are some cases in even scientific debates where there are extremely strident disagreements and there is merit to saying “I’m the primary proponent of the other theory”. Disagreeing on the basis of the totality of evidence including biology, anatomy and history isn’t a conflict of interest it’s good science. And as Ernst and Barker-Bausell have indicated, there’s very little good science in the “pro-” camp which is why most of the positive studies done by proponents are of such poor quality.

  9. windriven says:

    @ Jan Willem Nienhuys

    “The moral obligation to truthfully declare conflicts of interest applies to articles in the scientific literature, not tv shows. ”

    I would disagree. The professional obligation may apply only to articles in the scientific literature but the moral and ethical obligation extends to all efforts to influence thoughts and actions.

  10. ebohlman says:

    Interesting timing: just the other day the proponents of California’s Proposition 8 filed a motion asking that the verdict in the case that struck it down be vacated because the judge who decided it was gay and therefore had a conflict of interest (taken to its logical conclusion, this line of reasoning demands that human judges be replaced with science-fiction style justice robots).

    I’m reminded of a vaccine-autism fracass where a pro-science poster observed that to one particular anti-vaxer, “conflict of interest” meant “ever did work you got paid for”.

  11. qetzal says:

    @Epinephrine,

    I strongly disagree with your characterization of conflict of interest. Obviously, any writer has an intellectual and emotional stake in the truth of what they claim, but that’s not a conflict of interest according to any normal definition of the term.

    There’s no dispute that people are emotionally invested in their beliefs, and that this might bias how they interpret the available evidence. But that’s true for everyone, and we all know it. We don’t need to have that disclosed as a “conflict of interest” and it would be absurd to do so.

    What would you suggest? Dr. Hall writes a commentary arguing that acupuncture is no better than placebo, and at the end discloses as a “conflict of interest” that for some years now, she has indeed believed (based on her reading of the evidence) that acupuncture is no better than placebo?

    @Dr. Hall,

    You wrote:

    I don’t say that acupuncture doesn’t work: I only say that the entire body of published evidence is compatible with the hypothesis that it doesn’t work better than placebo.

    I don’t think that goes far enough. The evidence clearly favors that hypothesis, and disfavors the hypothesis that acupuncture works by any mechanism other than placebo.

    I prefer your wording from the original commentary:

    In fact, taken as a whole, the published (and scientifically rigorous) evidence leads to the conclusion that acupuncture is no more effective than placebo.

  12. Jan Willem Nienhuys says:

    I have a conflict of interest when it comes to natural health products, even though I have no financial involvement with them

    Apart from what the ICMJE thinks what should count as COI, there is what the general reader of a scientific journal expects to be stated and how the general editor of the journal interprets this. These COI statements are meant to inform the reader, after all.

    In the case of Harriet Hall the editors knew quite well why they had asked her to write an editorial (I presume), and if they thought it had any relevance for the COI they would have asked her to correct het form.

    There is a kind of intellectual passion that would make sense to state: if one writes about homeopathy and is a practicing homeopath and if this fact is not clear from one’s affiliation.

  13. vicki says:

    Epinephrine–

    By your definition, is there anyone who could write a worthwhile article without a conflict of interest? You’re drawing a circle so broad that the simple act of learning about a topic would make a person biased. It sounds as though you want people to say “I have studied this subject and have opinions. Not everyone agrees with me.”

    There is a difference between the sort of cognitive bias you allude to, and having something significant to gain: reputation counts. Salary or even speaking fees might count. But you don’t expect a conflict of interest note on a newspaper article saying “Conflict of interest notice: Dr. Whoever is paid a fee for every article of theirs we publish, so they have an incentive to write things we like.”

  14. trrll says:

    Proposed revised conflict of information statement: “Dr. [insert name] has [studied the scientific literature/carried out research/published] on [insert topic(s)] and may have formed opinions regarding [insert topic(s)]

  15. Epinephrine says:

    I know that I have seen presentations in which the conflict of interest slides stated no CoI, but the presenter made note of the fact that they have been working in the area and have the following beliefs; most recently at the Canadian Immunization Conference, some speakers were health care workers with no CoI in terms of honoraria, consulting fees, grants, etc., and their CoI slide was empty, but they would include commentary to indicate that they are believers in vaccination programs and deal with vaccine preventable disease in their work. I appreciated knowing what each speaker’s background was, and that they acknowledge that it may influence how they view the field or interpret data.

    I guess I just figure it’s important information. Sure, maybe not necessary, but important. I’m not necessarily right, either.

  16. Ed Whitney says:

    The ICMJE has a “glossary of terms” for conflict of interest http://www.icmje.org/coi_glossary.pdf , but “intellectual passion” is undefined. Item #13, “Relevant relationship,” is pretty vague also; it is “substantial enough to have a potential bearing on the matter in hand.”

    A diatribe of some sort would be suspect in this context, but it is hardly a diatribe to say “Overall the evidence is inconsistent, and among those studies judged to be of the highest quality, the results tend to be negative.” This would be tough to classify as evidence of “intellectual passion” that would have a substantial bearing on the matter in hand.

  17. weing says:

    Do you seriously mean that this was the intention of the ICMJE?

    No. But it appears that this idiot interprets it thus.

  18. ConspicuousCarl says:

    By their standard, anyone who expresses the same opinion more than once has a conflict of interest to report.

  19. I think they are confusing ‘interest’ with ‘conflict of interest’.

  20. Mark Crislip says:

    I like to read about war, so for openess I admit to an interest in conflicts.

  21. Your critic has said just this: “Only people who agree with me are unbiased!” Epic intellectual maturity fail.

  22. Skeptic says:

    It seems like the acupuncturist is arguing that a commitment to sound science is a conflict of interest to the study of acupuncture. Good grief…

  23. Conflict of interest disclosure regarding this comment:

    I believe in the truth of what I am commenting, so you should take this comment with a grain of salt because I may be biased in my opinion regarding this comment.

  24. Jan Willem Nienhuys says:

    Now seriously, what did the ICMJE mean by intellectual passion? What could they possibly have meant?

  25. By the way, is that the best ammunition the acupuncturist has for his critique, a misunderstanding of what constitutes a legitimate conflict of interest in scientific publications?

    Good luck to him in building his castle on that foundation of swampy sand, but as an acupuncturist, he must be used to building on flimsy foundations.

    Where does he intend to publish this intense crucible of scientific and ethical critique? (Calling the Huffington Post…you have a submission to consider for publication…)

  26. Ed Whitney says:

    Jan—I was trying to figure that out that bit about intellectual passion, but that glossary was no use. At first I thought it might be an expression of wariness about polemical articles, but perhaps it refers to the inability to let go of a particular viewpoint or perspective on things, regardless of your commercial interests.

    I think we may be seeing it in the reaction of the birthers today to the release of the long form of the Obama birth certificate. They are saying that it still is headed “Certificate of live birth” and that it gives the fathers race as “African” instead of “Negro.” And, not to be deterred, they now want his school records. That is an intellectual passion (or fixation). The immortal Onion summed it up so well a couple of years ago: http://www.theonion.com/articles/afterbirthers-demand-to-see-obamas-placenta,6866/ .

    Just a guess.

  27. Harriet Hall says:

    Where does he intend to publish? In an acupuncture publication.

  28. BillyJoe says:

    Epinephrine

    “…but they would include commentary to indicate that they are believers in vaccination programs and deal with vaccine preventable disease in their work. I appreciated knowing what each speaker’s background was…”

    Then look up their BACKGROUND, not the section headed CONFLICT OT INTEREST.

    Good grief!

  29. Ken Hamer says:

    Notwithstanding all the argument about what is or is not a “conflict of interest,” even if it were, wouldn’t the alleged “conflict” be self-evident from the article?

  30. weing says:

    “Now seriously, what did the ICMJE mean by intellectual passion? What could they possibly have meant?”

    Just guessing, but, I think they meant that there may be situations when a group is passionate about, let’s say, global warming. They will tend to publish and praise articles that are in agreement with their passion and not publish and criticize articles that are not in agreement with their intellectual passion.

  31. GLaDOS says:

    I once suspected that acupuncturists were wankers. That was my opinion or my bias.

    Then I came across real evidence of wanking –an acupuncturist pretending that conclusions based upon evidence are just the same as personal opinions no one can corroborate, and a big acupuncturist journal playing right along with the lie.

    The evidence of wank that I see can be corroborated by others. Therefore acupuncturists are, indeed, wankers. Not just my opinion or bias but trufax. QED.

  32. Jan Willem Nienhuys says:

    situations when a group is passionate about, let’s say, global warming.

    I find it hard to believe that this is what the International Committee of Medical Journal Editors (ICMJE) had in mind.

    The Lancet published
    Music, imagery, touch, and prayer as adjuncts to interventional cardiac care: the Monitoring and Actualisation of Noetic Trainings (MANTRA) II randomised study.

    vol 366 (2005), p. 211-217
    The authors were:
    Mitchell W Krucoff, Suzanne W Crater, Dianne Gallup, James C Blankenship, Michael Cuffe, Mimi Guarneri, Richard A Krieger, Vib R Kshettry,
    Kenneth Morris, Mehmet Oz, Augusto Pichard, Michael H Sketch Jr, Harold G Koenig, Daniel Mark, Kerry L Lee

    Who is Krucoff? On http://www.adventisthealthcare.com/pdf/WAH-2008-SIM.pdf we find: Dr. Krucoff has served on the Board of Directors of the Sri Satya Sai Institute of Higher Medical Sciences in Puttaparthi, India since 1990.

    Another author was Harold G. Koenig. The same source states Dr. Koenig is
    co-director of the Center for Spirituality,
    Theology and Health at Duke University
    Medical Center
    (which is immediately apparent if one googles his name), and author of a whole stack of books on spirituality and medicine (also apparent by googling). I think it is fair to say that if someone writes two dozen books about a subject, it constitutes an intellectual passion similar to the one of Dr. Hall.

    We cannot find this information from the affiliations of the authors. There are no conflict of interests listed for any author.

    Dr. Hall may have been thinking of this example when she wrote “No prayer study lists ‘I believe in God’ as a conflict of interest.” Actually the above example goes a bit further than merely believe. These people fulfill functions comparable to being on the board of an organisation dedicated to one particular outlook that has some relevance to the study outcome.

    These affiliations must have been known to the editors of the Lancet. They didn’t think it necessary to demand that these things were listed as COI. So this is an example of how at least one group of editors has decided about the interpretation of ‘intellectual passion’.

    I start to doubt that the ICMJE had any concrete ideas about what they meant by this. Maybe I am wrong. But if this intellectual passion clause had any practical meaning, then somebody must have seen concrete COI-statements where an intellectual passion explicitly is mentioned.

    I have given a concrete example of an article where something that looks like an intellectual passion is not listed. Who provides a counterexample to the statement “Intellectual passions are never listed in COI-statements in serious medical journals”?

  33. weing says:

    I think that was put in to help avoid confirmation bias. Good scientists tend to be the severest critics of their own theories. They try to disprove them instead of confirming them. I refer you to Science Vol 257 page 620 pubished July 31 1992.

  34. Epinephrine says:

    I have given a concrete example of an article where something that looks like an intellectual passion is not listed. Who provides a counterexample to the statement “Intellectual passions are never listed in COI-statements in serious medical journals”?

    I figured I’d look for an example; Edzard Ernst is known for taking on CAM claims, so I figured he might mention something.

    Baum, M. & Ernst, E. (2009). Should We Maintain an Open Mind about Homeopathy? The American Journal of Medicine,
    Vol. 122
    (11) , 973-974.

    “Funding: No relevant funding source for this commentary.

    Conflict of Interest: None, other than our commitment to evidence-based medicine.”

  35. Scott says:

    This seems quite ridiculous to me. The acupuncturist is essentially claiming that “I believe what I just wrote” is a conflict of interest which must be disclosed. Well, gee. I tend to assume that anyway.

    The reverse would be relevant, but come on. A supposed COI which virtually every author has is irrelevant even if, by some contortions, it can be claimed to fit the definition.

  36. Epinephrine
    “Baum, M. & Ernst, E. (2009). Should We Maintain an Open Mind about Homeopathy? The American Journal of Medicine,
    Vol. 122(11) , 973-974.
    “Funding: No relevant funding source for this commentary.
    Conflict of Interest: None, other than our commitment to evidence-based medicine.”

    That seems odds to me. It sounds like a Judge saying he has a conflict of interest because of his commitment to uphold the law.

  37. Epinephrine says:

    micheleinmichigan:

    For some tongue in cheek “competing interest” comments, you should check out the replies to the article “Effects of remote, retroactive intercessory prayer on outcomes in patients with bloodstream infection: randomised controlled trial” mentioned by Dr. Atwood in the “Cochrane is Starting to ‘Get’ SBM!” thread, above. Sample competing interests are:

    Evangelical Christian
    Member of National Secular Society
    Atheist medical Doctor
    Logic

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