Unmasking Special Interest Groups: The Key to Addressing Conflicts of Interest in Medicine
Authors: Giovanni A. Fava
Journal: Psychotherapy and Psychosomatics (2010)

The recent proposal of controlling conflicts of interest in professional medical associations (PMAs) in the United States apparently represents a bold shift from current policies [1]. It stems from the recognition of the limitations of disclosure as the sole method for dealing with the issue. PMAs are now expected to give up all pharmaceutical and medical device industry funding of general budgets – except for income from journal advertising and exhibition hall fees – and can accept only truly unrestricted funds for educational and research purposes. PMA officers (including members of the practice guideline committees) should be completely free from financial conflicts of interest and PMAs should no longer collaborate in or profit from industry marketing activities [1]. Commercial booths are still allowed at scientific meetings; however, the proposal states that 'these booths should not be in the obligate path to a scientific or educational session, and must be clearly delineated so that attendees understand that they are entering a marketing site, and are free to do so or not to do so as they choose' [[1], p. 1369]. Similar restrictions are increasingly reported in public and private policies [2].'Not too much zeal' warned the 19th century French diplomat Charles Talleyrand, and his recommendations seem to apply to the new policies. There are at least two good reasons for avoiding excessive zeal, aside from not making life more complicated than it already is. The first, as Talleyrand feared, is that being overly zealous in advocating a viewpoint might arouse the opposite reaction in an audience. Indeed, the first sentence of an editorial in the Journal of Clinical Hypertension announcing the launch of the Association of Clinical Researchers and Educators, which opposes overly stringent rules on conflict of interest, showed just this kind of resistance. It read: 'Academic physicians are under attack in the United States' [3]. The second is that excessive zeal may also be a subtle tool for avoiding what would seem to be the mission and the purpose of an initiative. In The Good Soldier Švejk by Jaroslav Hašek, Private Švejk avoids going to war because he pursues his goal of making it to the front line with such zeal that he is considered insane.Are the new US rules addressing what matters most? John Abramson's book Overdosed America [4] illustrates how corporate interest has manipulated science, misled doctors and threatened the health of the community, and how medical journals and medical societies had a major role in this, to the extent that a former editor defined medical journals as 'an extension of the marketing arm of the pharmaceutical companies' [5]. When our journal published the first investigation which gave an idea of the extent and dangerousness of conflict of interest in science [6], this took place in a stage of massive denial by major medical journals [7]. The issue was whether specific episodes that emerged were the unavoidable drawbacks of a scientific system that functioned in a substantially independent way, or whether they were simply the tip of the iceberg. What iceberg? Corporate interest which results in self-selected academic oligarchies (special interest groups) that influence clinical and scientific information [7]. Members of special interest groups, by virtue of their financial power and close ties with other members of the group, have the task of systematically preventing dissemination of data which may be in conflict with their interests. The first target is to undermine the critical individual judgment of the physicians. George Engel [8] differentiated between 'scientific physicians' (clinicians who fully apply the scientific method in their care of patients and in their understanding of the disease) and 'physician-scientists' (physicians whose primary commitment is to scientific research pertaining to medicine, with no obligation to be involved with patients). Clinical practice is the source of fundamental scientific challenges for scientific physicians, whereas the application of basic (including pharmaceutical) research is the preferred focus of physician-scientists. The intellectual freedom portrayed by scientific physicians is the worst enemy of special interest groups, and thus requires massive doses of censorship. Censorship may take different forms: direct suppression of information by special interest groups who act as editors and reviewers or make choices in scientific programs, careful selection of the literature in a biased direction and manipulated interpretation of clinical trials (including those supported by public sources), and self-censorship (when an investigator omits raising questions and criticism for the fear of retaliation) [9]. Other instrumental methods are the substitution of critical reviews with meta-analyses whose data could be easily manipulated by excluding censored (unpublished) studies [10], the emphasis on clinical guidelines by experts with major conflicts of interest [11], full control of medical societies, their journals and their meetings [12], and keeping medical literature as distant as possible from the clinical problems of daily practice. An editor who is personally devoid of financial conflicts of interest but is inclined to focus on issues that have no overt relationship to clinical phenomena is functional to these strategies. Special interest groups are ready to modify their approach if circumstances require it. In the US the call against conflicts of interest took place essentially to counteract the increasing loss of credibility of clinical medicine, engendered by the work of the Senate Finance Committee, chaired by Senator Charles Grassely, on failures to disclose conflicts by prominent physicians and by corporate actions that placed profit over health and became regular news in the media [2], with the ensuing withdrawal of pharmaceutical support to PMAs.Chomsky's [13] mechanisms of propaganda may apply to what has occurred in medicine in the past two decades. Corporate interests have fused with academic medicine to create an unhealthy alliance that works against objective reporting of clinical research (censorship), sets up meetings and symposia with the specific purpose of selling the participants to the sponsors (engineering opinions), gets its prodigal experts into leading roles in journals, medical associations and non-profit research organizations (using the public relations industry) and provides the appropriate degree of retaliation to outliers (marginalizing dissident cultures). Examples of the spectacular achievements of propaganda that took place in psychiatry are as follows: • the denial of the link between selective serotonin reuptake inhibitors and suicidal risk before the publication of a critical review in our journal [14]; • overprescribing of antidepressants based on removal of negative studies and findings [15,16]; • the use of the term 'antidepressant discontinuation syndrome' for withdrawal syndromes which entail important clinical implications, such as misinterpretation of these reactions as signs of impending relapse [10]; • the prolongation of antidepressant drug treatment for preventing relapse based on meta-analyses of published studies, such as the one by Geddes et al. [17], that failed to take publication bias into account [18]; • the switch from benzodiazepines to newer antidepressants in anxiety disorders without any evidence to support it [19]; • the prescription of atypical antipsychotics for the treatment of behavioral problems in dementia despite lack of supporting data [20]. Prescribers may claim to be following the evidence, but are primarily influenced by the eminence of the authorities they listen to in meetings and read in journals [21] or by the framing of the risk of medication side effects by the pharmaceutical industry [22]. This occurs also because of the control of special interest groups over diagnostic classification [23] and clinical guidelines committees [24]. It is certainly not because of a few bad apples or a couple of Bernie Madoffs [2] that the medical field is being punished. The clinician who wants to retain a cautious and balanced attitude feels like the person whom Chomsky depicts as sitting alone in front of the TV, thinking he/she must be crazy or outdated for not buying what comes out of the tube [13]. The same clinician now feels like a criminal if he/she drinks fruit juice at a commercial stand in a meeting, while leaders of scientific societies, medical journals and academic medicine who were actively involved in the propaganda or looked the other way, ignoring the few who did speak up years ago, are teaching us how to behave as to conflict of interest.A proposal for an operational definition of substantial conflict of interest, based on the work by Krimsky et al. [6], was recently presented [25], with the task of increasing intellectual freedom. This proposal underscores the dangers of the continuity of a financial relationship with a private company as outlined in table 1. Occasional consultancies, grants for performing an investigation, or receiving honoraria or refunds on specific occasions would not be a source of substantial conflict of interest. Indeed, it would be perfectly legitimate and essential for the progress of science to collaborate with the industry on specific scientific projects.Rothman et al. [1] suggested that authors of clinical practice guidelines should be free from any financial conflict of interest, mainly as an aftermath of the scandals that took place over many guidelines. But what about authors of review articles and meta-analyses? And priority for obtaining grants from public agencies supported by taxpayer money? These and other suggestions are described in table 2[25].Mario Maj [26] has recently summarized several issues concerned with non-financial conflicts of interest and has expanded the notion of 'special interest groups' to academic, political and personal ties. Table 3 outlines several steps to address non-financial conflicts of interest in medical research, as discussed in detail elsewhere [27]. The rationale behind this strategy is to increase and support the reservoir of disinterested experts who can be called upon to advise government policy makers and physicians on the safety and efficacy of treatments and on the hazards of chemicals [6] and the dangers of restrictive ideology leading to 'trivial variations on tired themes' in grant and journal selections [28]. The crisis of credibility in the medical profession has not yielded a reformulation of the missions and goals of PMAs. Table 4 indicates some priorities in an agenda for fostering creativity and independence.While Rothman et al. [1] pay zealous attention to the location of commercial stands in scientific meetings, there is no mention to the need for substantial changes in structure and characteristics of these events. Society meetings are still held on an annual basis, causing major ecological wastage due to thousands of people travelling to reach the sites, and reflect a 20th century communication paradigm, where meetings were of the main source of scientific novelties compared to printed journals. At a time when information is available to the scientific community through the internet, scientific meetings should offer the opportunity for in depth discussions among scientists with no substantial conflict of interest; a pause from information overload. Medical journals and meetings tend to be blind to the psychosocial issues of clinical research. At present almost all health care spending is directed at biomedically oriented care. Still, half of the deaths that take place in the USA can be attributed to largely preventable behaviors and exposure, such as tobacco smoking, obesity and physical inactivity [29]. Not surprisingly, psychosomatic medicine does not seem to find room in the present medical establishment, since it challenges the reductionism which paves the ground for pharmaceutical propaganda. Quite appropriately, Hirsch [30] argues that many journals and editors have compromised their credibility, have double standards as to judging integrity, and ignore major positive changes that have occurred in the pharmaceutical industry in the past decade. In an accompanying editorial, Lanier [31] wonders whether journal editors who published flawed industry-funded research, to save their own personal brand integrity and that of their journals, are leading us to an era of scientific McCarthyism.Will the new rules on conflict of interest [1] give medicine its credibility back? Probably not. They may even further decrease intellectual freedom. Only a true change in leadership will do.