Conflicts of interest in critical care partnerships: are we living up to our values?
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Conflicts of interest in critical care partnerships: are we living up to our values? Robert D. Truog1,2* and J. Randall Curtis3,4 © 2018 Springer-Verlag GmbH Germany, part of Springer Nature and ESICM
Throughout the twentieth century, conflicts of interest in medicine were largely tolerated as inevitable and unavoidable [1]. Since about the middle of the last decade, however, they have come under greater scrutiny and criticism [1, 2]. The problems have been compounded by a lack of clarity about how these conflicts should be defined and analyzed. A clear understanding of what constitutes a conflict of interest leads to insights about how they can be managed when necessary and eliminated whenever possible. A conflict of interest (COI) exists when a primary interest (such as the patient’s welfare or the integrity of research) may be influenced by a secondary interest (such as financial gain) [3]. Consider that physicians working in a fee-for-service environment have a COI because of the risk that they may overtreat patients, putting their financial interests ahead of the patient’s. Physicians working in a managed care environment also have a COI, since they may undertreat patients for the same reasons. In many European countries, these financial conflicts may be less apparent, but there may be other types of COI related to keeping the ICU beds full to ensure ongoing resources to the ICU. COIs are ubiquitous in medicine. The tendency to label COIs as only “potential” or “perceived” has further confused the issue [4]. For example, physicians working in either a fee-for-service or a
*Correspondence: [email protected] 1 Frances Glessner Lee Professor of Medical Ethics, Anaesthesia, & Pediatrics, Center for Bioethics, Harvard Medical School, 641 Huntington Ave., Boston, MA 02115, USA Full author information is available at the end of the article
managed care environment may argue that the financial model does not impact their decision-making, and they may indeed be correct, but this misses the point. These situations do not represent a “potential” COI that could become a “real” COI, but rather simply a COI that could result in real bias or harm [4]. The degree to which a COI needs to be managed or eliminated depends upon two factors: (1) the likelihood that the secondary interest will influence the primary interest, and (2) the magnitude of the harm that could come from this undue influence. The likelihood of the undue influence is often evaluated in terms of the amount of money or other resources involved, and this is indeed relevant, but research shows that even small gifts, such as providing lunch for a continuing medical education (CME) activity, predictably lead to significant but unrecognized biases in physicians’ decisions and judgment [5]. The harms of COIs are often evaluated in terms of medical harms to patients. The pharmaceutical industry points out that such harms are rarely reported [1]. But our ability to detect such harms is extremely limited, and this is a case w
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