{"id":428,"date":"2011-04-21T20:39:12","date_gmt":"2011-04-22T03:39:12","guid":{"rendered":"http:\/\/blog.stevenreidbordmd.com\/?p=428"},"modified":"2011-04-28T12:05:51","modified_gmt":"2011-04-28T19:05:51","slug":"conflicts-of-interest-in-medical-education-disclosure-may-not-help","status":"publish","type":"post","link":"http:\/\/blog.stevenreidbordmd.com\/?p=428","title":{"rendered":"Conflicts of interest in medical education: Disclosure may not help"},"content":{"rendered":"

\"\"Yesterday’s New York Times<\/em> had an interesting op-ed<\/a>, “Stumbling into Bad Behavior,” about corruption and unethical conduct in corporate and financial settings. \u00a0The authors, Max H. Bazerman and Ann E. Tenbrunsel, are\u00a0academics who wrote a book about ethical blind spots. \u00a0They note that\u00a0regulators, prosecutors, and journalists tend to focus on corruption caused by willful actions or ignorance, but this overlooks unintentional lapses: \u00a0“Our legal system often focuses on whether unethical behavior represents ‘willful misconduct’ or ‘gross negligence.’ Typically people are only held accountable if their unethical decisions appear to have been intentional \u2014 and of course, if they consciously make such decisions, they should be. But unintentional influences on unethical behavior can have equally damaging outcomes.”<\/p>\n

This caught my attention as it relates to conflicts of interest in medicine. \u00a0For example, I have long expressed ethical concerns regarding the willful participation of physicians in pharmaceutical promotion. \u00a0It is a clear conflict of interest to purport to be an unbiased advisor to patients, while at the same time choosing to attend (or deliver) overtly slanted marketing presentations. \u00a0However, defenders of such participation say they deserve more credit: They cannot be corrupted, and would never willingly deliver biased medical advice no matter how drug or device manufacturers reward them.<\/p>\n

These positions are reconcilable given that bias is often unconscious and unwilled. \u00a0Bazerman and\u00a0Tenbrunsel note: \u00a0“[M]uch unethical conduct that goes on, whether in social life or work life, happens because people are unconsciously fooling themselves. They overlook transgressions … because it is in their interest to do so.”<\/p>\n

Psychiatry, of course, has a lot to say about how people fool themselves. \u00a0We discount our own lapses to maintain our self-esteem. \u00a0We may employ psychological denial to make our troubling inconsistencies disappear, or utilize projection to attribute our faults to others. \u00a0We may reframe liabilities to look like assets \u2014 and we may do all of these outside of our own awareness. \u00a0Thus, it is entirely consistent sincerely to consider oneself principled, ethical, and unbiased, and yet to be undermined by one’s own unconscious mind.<\/p>\n

To me, the most striking paragraph of the op-ed questioned the value of disclosing<\/em> conflicts of interest, an issue I’ve raised<\/a> in the past. \u00a0As chair of Continuing Medical Education (CME) at my medical center, I am forever badgering CME speakers to provide a “disclosure slide” at the start of their talks. \u00a0(CME is required to maintain medical licensure and stay up to date, so all physicians must attend many hours of CME annually.) \u00a0This disclosure of financial ties to industry, and other potential sources of bias, is required by state and national CME oversight bodies; the medical center risks its CME accreditation if this rule is not followed. \u00a0Yet the value of disclosure has always felt tenuous to me. \u00a0Maybe it’s better than nothing, I thought, but simply disclosing potential conflicts of interest hardly guarantees that the talk will not be biased anyway, nor that the physician audience will know how to evaluate the imparted information given the disclosure.<\/p>\n

The New York Times<\/em> op-ed cites a 2005 study<\/a> that clarifies this matter of disclosure in a very useful if sobering way. \u00a0“The Dirt on Coming Clean: Perverse Effects of Disclosing Conflicts of Interest” by\u00a0Daylian M. Cain, George Loewenstein, and Don A. Moore discusses what disclosure intends to remedy, versus what it may actually do given unconscious as well as conscious factors. \u00a0The authors point out that\u00a0people generally do not discount advice from biased advisors as much as they should, even when advisors\u2019 conflicts of interest are disclosed. \u00a0Moreover,\u00a0disclosure can actually increase the bias in the delivered information\u00a0because it leads the disclosers to feel morally licensed and strategically encouraged to exaggerate their advice even further. \u00a0The paper reports an empirical study conducted with Carnegie Mellon University undergraduates that supports these concerns. \u00a0The authors conclude:<\/p>\n

[D]isclosure cannot be assumed to protect recipients of advice from the dangers posed by conflicts of interest. Disclosure can fail because it (1) gives advisors strategic reason and moral license to further exaggerate their advice and (2) it may not lead to sufficient discounting to counteract this effect. The evidence presented here casts doubt on the effectiveness of disclosure as a solution to the problems created by conflicts of interest. When possible, the more lasting solution to these problems is to eliminate the conflicts of interest.<\/p><\/blockquote>\n

I couldn’t have said it better myself. \u00a0The op-ed likewise concludes that, “Good people unknowingly contribute to unethical actions, so reforms need to address the often hidden influences on our behavior.” \u00a0When it comes to unbiased medical education, neither good intentions nor disclosure of potential bias is sufficient. \u00a0The solution is to admit we are fallible humans, and to avoid sources of bias, conscious and unconscious. \u00a0Psychiatry could help \u2014 if it weren’t so complicit itself.<\/p>\n","protected":false},"excerpt":{"rendered":"

Yesterday’s New York Times had an interesting op-ed, “Stumbling into Bad Behavior,” about corruption and unethical conduct in corporate and financial settings. The authors, Max H. Bazerman and Ann E. Tenbrunsel, are academics who wrote a book about ethical blind spots. They note that regulators, prosecutors, and journalists tend to focus on corruption caused by […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[34,5],"tags":[13,16],"class_list":["post-428","post","type-post","status-publish","format-standard","hentry","category-human-nature","category-medicalpsychiatric-education","tag-ethics","tag-pharmaceutical-marketing","odd"],"aioseo_notices":[],"_links":{"self":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/428","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=428"}],"version-history":[{"count":6,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/428\/revisions"}],"predecessor-version":[{"id":435,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/428\/revisions\/435"}],"wp:attachment":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=428"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=428"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=428"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}