Conflicting views on conflicts of interest in medicine.
Authors: Wolfgang W Fleischhacker
Journal: World Psychiatry (2007)

I would like to divide my commentary on Giovanni Fava's paper into two parts. Firstly, I will discuss style and tone and secondly content.

As scientists - and Fava, I am sure, fits this category - we should be guided by the principle sine ira et studio. At least the former is not adhered to in Fava's remarks. I understand that he has  strong opinion regarding the issue of conflicts of interest, but I feel that  more balanced and less affectively charged manuscript would have helped his cause more. Merely repeating accusations and unfounded insinuations, which have been unfairly generalized to the whole field in the past, will only jeopardize  rational discussion of the problem. Consequently, those of us, and I  we are many, who believe that the field needs to actively tackle the issue, will be taken aback and disengage from discussing the matter. As I firmly believe that we need this discussion, from both the perspectives of scientific ethics and integrity and of the distorted public view of it, I find the style and tone of Fava's comments regrettable.

The 1850 edition of the Webster Dictionary defines  of interest as a  between private interests and official responsibilities of  person in  position of trust (I believe this was cited by Ira Glick at the 2006 Meeting of the American College of Neuropsychopharmacology). This nicely outlines the point that I would like to make in the following, namely that the issue goes way beyond financial interests, although most of the public discussion, especially in the lay media, has focused on these. All of us face conflicts of interest regularly in our professional lives. For instance, we may see  manuscript sent to us for review in  more favourable light if it approvingly cites our own work. When writing up scientific papers, we may be more eager to report data which support our hypotheses than those who do not. As journal editors, we could be more willing to accept  manuscript which is likely to drive up the impact factor of the journal. As conference organisers, we may put more emphasis on topics which suit our own interests. As librarians, given the choice to spend the rest of the library budget on  book on the same topic written by  friend or by  stranger, we may favour our friend's book. As clinicians, deciding among drugs of similar efficacy and safety profile, we may recommend the one that the company representative has just left  package of, and so on.

These few examples dealing with various aspects of  clinician/scientist's job represent an incomplete list of everyday challenges to our work ethics. Many of them are much more subtle than financial conflicts of interest, but yet of at least comparable relevance. In addition, monitoring these types of conflicts is considerably more difficult than the tracking of financial relationships, which may be one of the reasons why the latter have become much more the focus of the debate.

The field is charged with  challenge that, I believe, must be targeted from within the scientific community. While declarations of financial conflicts of interests on publications, during scientific meeting, etc. help to enhance transparency, all the other potential conflicts call for additional measures. I am convinced that the concept of peer review, if taken really seriously, can be the strongest force in this struggle. Peer review can function as  continuous selfmonitoring instrument. We have to revive the skill of reading between the lines of manuscripts we are reviewing and point out potential conflicts of interests to editors, who need to make such remarks part of their decision process. Journal editors should explicitly ask their reviewers to look at manuscripts under this aspect, just as they require to judge the ethical standards of studies under review. (As  bynote, open access publishing and open peer review will not make the task easier). Similar rules should apply to the grant review process and to program committees of scientific meetings. Conflicts of interest have to be identified in such settings and individuals affected by them must be excused from the decision process.

Some international societies have already established committees to provide guidance regarding these matters. Again, the scope must go beyond the relationships between scientists and the pharmaceutical industry. Clearly, such rules should not be buried in the minutes of the relevant committees, but actively communicated to the field and the public. Societies should not only set up rules but also suggest means to oversee compliance with these standards. Let us not leave this important business to self-appointed watchdogs, but assume  leading role ourselves, as  strong responsibility of and for our field.

At the 2006 meeting of the American College of Neuropsychopharmacology, David Braff stated that conflict of interest is the entry of wrongdoing not wrongdoing in itself, and I would submit that we all need to be sitting near the entryway to make sure that nobody harms the field by crossing the line.