When Interests Conflict
Relationships between academic medical institutions and medical industry span many years and a spectrum of forms. Whose interests are served, and what is the impact on the work of medical schools, their researchers and physicians? Susan Dorr Goold (M.D. 1987), associate professor of internal medicine and director of the Medical School’s Bioethics Program, explains the nature and some of the complexities of joining science and the profit motive in ethically sound ways.
Q: What is the benefit of relationships between academic medical institutions and medical industry? What are the potential harms?
A: They’ve changed over the years, but there have been relationships between academic medical institutions and industry for a very long time. The idea is that relationships between medical industry and academic medical institutions, which are focused on advancing knowledge and innovation in science and biomedicine, help these innovations reach patients more quickly and effectively.
A definite benefit is that industry support for the advancement of knowledge does unquestionably advance knowledge — some may be in the industry’s self-interest, but some isn’t, either by design or serendipitously. A definite harm is that to the extent that industry funds scientific research, it influences the research agenda. What gets researched is influenced by what is funded, so that the agenda is driven not only by what scientists say would benefit patients, but also by the profit motive.
There’s also evidence that industry relationships with researchers or institutions have, at times, influenced results or reports of results of scientific research. There are some famous cases about this. In one case, the university-based researcher was obligated by contract with the company not to publish results without their approval. The company held the researcher to it, and so a study that was not in the company’s interest but was definitely in the interest of the public and patients was withheld. Such incidents can lead to another risk of these relationships — diminished trust in science and researchers because of the perception that individual scientists or science as a whole are not independent and free of bias and influence. There’s some evidence that there isn’t as much trust in scientific research and scientists as there used to be. The risks or dangers of these relationships are more of the same: that is, more influence on the outcomes of research and less credibility attached to scientific research or scientists.
We know indirectly that industry support of research can influence results and outcomes. But we don’t know to what extent, how it happens, or if there are ways of structuring support that would protect against that influence. I wouldn’t say there’s reason to eliminate industry relationships with academic medicine, but we need to recognize the downside.
Q: Are relationships formed between institutions and industry, or between individual scientists and industry?
A: Both — sometimes together, sometimes separately. For example, research funded by a pharmaceutical company is really a relationship with the institution, because the institution receives the funds to support the research. Of course researchers benefit as well, because they’re able to do their own research which furthers their career through publication, promotion or that important next grant. There’s a whole spectrum of relationships. Folks who train or work at academic medical institutions may go to work for industry, or the industry might send someone to the institution to learn something there — that’s sort of a minimalist relationship. Or it may be that they collaborate on something, or industry provides funding to do something, which is a common model. The relationships aren’t inherently bad, but the potential for conflict of interest needs careful management. If you have equity in a company, for instance, and you’re doing research that is analyzing the effectiveness of that company’s product or potential product, you can bend over backwards to be independent, to be skeptical, and I still think you could be subtly influenced by the fact that if this product works out you win big time.
Q: How common are such relationships, and what forms do they take?
A: A 2007 study we conducted with the Massachusetts General Hospital Institute for Health Policy revealed that almost two-thirds of department chairs had individual relationships with industry, and slightly more than two-thirds of surveyed departments had industry relationships. Individual relationships can range from giving a talk for a $500 honorarium to having equity or stock in a firm or serving as a consultant. Depending on the frequency or size of the financial reward, these may not be problematic — the devil’s in the details. Officer, founder, board of director — those are tighter relationships: potentially more influential, more to gain or lose.
Q: How does the U-M Health System help ensure ethically sound relationships with medical industries?
A: The U-M is well above average in policy and practices. We were one of the first medical institutions in the country to limit interactions on site between doctors (and doctors in training) and drug representatives, and to eliminate use of drug samples in clinics and hospitals. In addition, any investigator with compensation from industry or doing research that could result in personal financial return has to disclose that relationship, and significant relationships are reviewed by a Conflict of Interest Review Board to help the investigator manage or avoid conflict. Dean Woolliscroft has been a leader nationally in generating conversations to chart a move toward some way of handling institutional conflicts, which are not under the purview of the review board.
I’m a member of the American Medical Association’s Council for Ethical and Judicial Affairs which has been working with stakeholders in industry, medical education, and public interest groups to revise a report about industry funding for medical education we first presented at the AMA Annual meeting last June. Our Council’s recommendations were hotly debated at that meeting, yet other national organizations have also been moving toward more stringent guidelines for relationships between medicine and industry.
Fundamentally, we want to train the next generation of physicians and scientists, including entrepreneurial scientists, to reflect the core values of science and medicine; we need to reflect those values ourselves.
Interview conducted and condensed by Rick Krupinski