Medicine, Health Care and Philosophy

, Volume 20, Issue 2, pp 179–186

(Re)disclosing physician financial interests: rebuilding trust or making unreasonable burdens on physicians?

Scientifc Contribution

Abstract

Recent professional guidelines published by the General Medical Council instruct physicians in the UK to be honest and open in any financial agreements they have with their patients and third parties. These guidelines are in addition to a European policy addressing disclosure of physician financial interests in the industry. Similarly, In the US, a national open payments program as well as Federal regulations under the Affordable Care Act re-address the issue of disclosure of physician financial interests in America. These new professional and legal changes make us rethink the fiduciary duties of providers working under new organizational and financial schemes, specifically their clinical fidelity and their moral and professional obligations to act in the best interests of patients. The article describes the legal changes providing the background for such proposals and offers a prima facie ethical analysis of these evolving issues. It is argued that although disclosure of conflicting interest may increase trust it may not necessarily be beneficial to patients nor accord with their expectations and needs. Due to the extra burden associated with disclosure as well as its implications on the medical profession and the therapeutic relationship, it should be held that transparency of physician financial interest should not result in mandatory disclosure of such interest by physicians. It could lead, as some initiatives in Europe and the US already demonstrate, to voluntary or mandatory disclosure schemes carried out by the industry itself. Such schemes should be in addition to medical education and the address of the more general phenomenon of physician conflict of interest in ethical codes and ethical training of the parties involved.

Keywords

Informed consent Physician financial interest Disclosure Conflict of interest 

References

  1. American Medical Association. 2013. The American Medical Association Code of Medical Ethics opinions on the physician as businessperson. Virtual Mentor 15 (2): 136–140.Google Scholar
  2. Association of British Pharmaceutical Industry. 2016. Disclosure UK. http://www.abpi.org.uk/our-work/disclosure/Pages/disclosure.aspx.
  3. Blum, J. 2014. CMS Modifies policy on disclosure of physician payment information. http://blog.cms.gov/2014/01/14/cms-modifies-policy-on-disclosure-of-physician-reimbursement-information/. Accessed 22 November 2016.
  4. Camp, M. W., D. A. Mattingly, A. E. Gross, M. T. Nousiainen, B. A. Alman, and M. F. McKneally 2013. Patient’s views on surgeons’ financial conflicts of interest. The Journal of Bone & Joint Surgery 95 (2): e9.CrossRefGoogle Scholar
  5. Carlsen, B., and O. F. Norheim. 2005. “Saying No is No Easy Matter”: A qualitative study of competing concerns in rationing decisions in general practice. BMC Health Services Research 5: 70.CrossRefGoogle Scholar
  6. Code of Federal Regulations. Title 42 § 425.312(a); 76 Fed. Reg. 67982. https://www.law.cornell.edu/cfr/text/42/425.312. Accessed 22 November 2016
  7. Cohen, S. 2012. The nocebo effect of informed consent. Bioethics 28 (3): 147–154.CrossRefGoogle Scholar
  8. Colla, C. H., V. A. Lewis, S. M. Shortell, and E. S. Fisher. 2014. First national survey of ACOs finds that physicians are playing strong leadership and ownership roles. Health Affairs 33 (6): 964–971.CrossRefGoogle Scholar
  9. Corrigan, O. 2003. Empty ethics: The problem with informed consent. Sociology of Health & Illness 25 (3): 768–792.CrossRefGoogle Scholar
  10. Crisp, R. 2015. The duty to do the best for one’s patient. Journal of Medical Ethics 31: 220–223.CrossRefGoogle Scholar
  11. DeAngels, C. D. 2015. The importance of physicians’ financial disclosure for public’s health. Milbank Quarterly 93 (4): 679–682.CrossRefGoogle Scholar
  12. Dyer, C. 2014. UK needs database of payments from industry to doctors, conference hears. BMJ, 349, g6197.CrossRefGoogle Scholar
  13. Emmanuel, E. J. 2012. Why accountable care organizations are not 1990s managed care redux. Journal of American Medical Association 307 (21): 2263–2264.Google Scholar
  14. European Federation of Pharmaceutical Industries and Associations. 2016. The EFPIA Code. http://transparency.efpia.eu/the-efpia-code-2.
  15. Faden, R. 1997. Managed care and informed consent. Kennedy Institute of Ethics Journal 7 (4): 377–379.CrossRefGoogle Scholar
  16. General Medical Council. Financial and commercial arrangements and conflict of interests. 2013. http://www.gmc-uk.org/guidance/ethical_guidance/21161.asp, Accessed 7 June 2016.
  17. Goldacre, B. 2014. Problems with ABPI proposals to release data on payments to doctors. BMJ 348, g236.CrossRefGoogle Scholar
  18. Gorawara-Bhat, R., T. H. Gallagher, and W. Levinson. 2003. Patient-provider discussions about conflicts of interest in managed care: Physicians’ perceptions. American Journal of Managed Care 9 (8): 564–571.Google Scholar
  19. Hall, M. A., and R. A. Berenson. 1998. Ethical practice in managed care: A dose of realism. Annals of Internal Medicine 128 (5): 395–402.CrossRefGoogle Scholar
  20. Haywood, T. T., and K. C. Kosel. 2011. The ACO model—a three-year financial loss? New England Journal of Medicine 364: e27.CrossRefGoogle Scholar
  21. Hoeyer, K., and N. Lynoe. 2009. An organizational perspective on ethics as a form of regulation. 2009. Medicine, Healthcare & Philosophy 12 (4): 385–392.CrossRefGoogle Scholar
  22. Jacobson, P. D. 2002. Strangers in the night: Law and medicine in the managed care era. New York: Oxford University Press.Google Scholar
  23. Johnson, J., and W. Rogers. 2014. Joint issues—conflicts of interest, the ASR hip and suggestions for managing surgical conflicts of interest. BMC Medical Ethics doi: 10.1186/1472-6939-15-63.Google Scholar
  24. Jost T.S. 2001. Pegram v. Herdrich: The supreme court confronts managed care. Yale Journal of Health Policy. Law & Ethics 1 (1): 187–193.Google Scholar
  25. Kassirer, J. P. 2007. By financial disclosures, we’re fixing the wrong problem. Medscape General Medicine 9 (3): 61.Google Scholar
  26. Katz, D., A. L. Caplan, and J. F. Merz. 2003. All gifts large and small: Towards an understanding of the ethics of pharmaceutical industry gift-giving. American Journal of Bioethics 3 (3): 39–46.CrossRefGoogle Scholar
  27. Kukla, R. 2007. How do patients know? Hastings Center Report 37 (5): 27–35.CrossRefGoogle Scholar
  28. Loewenstein, G., and D. Moore. 2005. The dirt on coming clean: Perverse effects of disclosing conflicts of interest. Journal of Legal Studies 34: 1–25.CrossRefGoogle Scholar
  29. Loewenstein, G., S. Sah, and D. M. Cain. 2012. The unintended consequences of conflict of interest disclosure. JAMA: The Journal of the American Medical Association 307 (7): 669–670.CrossRefGoogle Scholar
  30. Mayes, C., W. Lipworth, and I. Kerridge. 2016. Declarations, accusations and judgment: Examining conflict of interest discourses as performative speech-acts. Medicine, Healthcare and Philosophy 19 (3): 455–462.CrossRefGoogle Scholar
  31. McCartney, M. et al. 2014. Letter: Why the GMC should set up a central registry of doctors’ competing interests. British Medical Journal, 348: g236.CrossRefGoogle Scholar
  32. Mehlman, M. J. 2006. Dishonest medical mistakes. Vanderblit Law Review 59: 1137–1173.Google Scholar
  33. Moore, V.1990 Regents of the University of California 51 Cal. 3d. 120.Google Scholar
  34. Morain, S. R., C. Flexner, N. E. Kass, and J. Sugarman. 2014. Forecast for the physician payment sunshine act: Partly to mostly cloudy? Annals of Internal Medicine, 161(12): 915–916.CrossRefGoogle Scholar
  35. Morreim, E. H. 2006. High-deductible health plans: New twists on old challenges from tort and contract. Vanderblit Law Review 59: 1207–1261.Google Scholar
  36. Movsas, T. Z., E. Wells, A. Mongoven, and V. Grigorescu. 2012. Does medical insurance type (private vs. public) influence the physician’s decision to perform caesarean delivery? Journal of Medical Ethics 38 (8): 470–473.CrossRefGoogle Scholar
  37. Neade v. Portes et al. 193 Ill. 2d 433. 2000.Google Scholar
  38. Oakes, J. M., H. K. Whitham, A. B. Spaulding, L. A. Zentner, and S. R. Beccard. 2015. How should doctors disclose conflicts of interest to patients? A focus group investigation. Minnesota Medicine 98 (1): 38–41.Google Scholar
  39. O’Neil, O. 2003. Some limits of informed consent. Journal of medical ethics 29: 4–7.Google Scholar
  40. Pacarini,P.A. 2012. The financial aspects of accountable care organizations. In Pavarini P.A., C.I. McGinty and M.E. Schaff (Eds.), The ACO handbook: A guide to accountable care organizations. Washington, DC: American Health Lawyers Association. (1st ed.) (pp. 17–27).Google Scholar
  41. Pearson, S. D., and T. Hyams. 2002. Talking about money: How primary care physicians respond to a patient’s question about financial incentives. Journal of General Internal Medicine 17: 75–78.CrossRefGoogle Scholar
  42. Pearson, S. D., K. Kleinman, D. Rusinak, and W. Levinson. 2006. A Trial of disclosing physicians’ financial incentives to patients. Archives of Internal Medicine 166: 623–628.CrossRefGoogle Scholar
  43. Pegram v. Herdrich 530 U.S. 211. 2000.Google Scholar
  44. Pellegrino, E. D. 1997. “Managed care at the bedside: How do we look in the moral mirror?” Kennedy Institute of Ethics Journal 7 (4): 321–330.CrossRefGoogle Scholar
  45. Rittenhouse D.R., S.M. Shortell, and E.S. Fisher. 2009 Primary care and accountable care – two essential elements of delivery system reform. New England Journal of Medicine, 361, 2301–2303.CrossRefGoogle Scholar
  46. Sade, R. M. 2011. Full disclosure: Where is the evidence for nefarious conflicts of interest? Annals of Thoracic Surgery 92 (2): 417–420.CrossRefGoogle Scholar
  47. Sah, S., and G. Lowenstein. 2014. Nothing to declare: Mandatory and voluntary disclosure leads advisors to avoid conflicts of interest. Psychological Science 25 (2): 575–584.CrossRefGoogle Scholar
  48. Sah, S., G. Loewenstein, and D. Cain. 2013. The burden of disclosure: Increased compliance with distrusted advise. Journal of Personality and Social Psychology 104 (2): 289–304.CrossRefGoogle Scholar
  49. Sahm, S. 2013. Of mugs, meals and more: The intricate relations between physicians and the medical industry. Medicine, Healthcare and Philosophy 16 (2): 265–273.CrossRefGoogle Scholar
  50. Shea v. Esensten 107 F. 3d 625, 629 (8th Cir. 1997).Google Scholar
  51. Sommers, R., S. D. Goold, E. A. McGlynn, S. D. Pearson, and M. Danis. 2013. Focus groups highlight that many patients object to clinicians’ focusing on cost. Health Affairs 32 (2): 338–346.CrossRefGoogle Scholar
  52. Spece, R. G., D. V. Yokum, A. G. Okoro, and C. T. Robertson. 2014. An empirical method for materiality: Would conflict of interest disclosures change patients decisions. American Journal of Law & Medicine 40: 253–274.CrossRefGoogle Scholar
  53. Sperling, D. 2017. Revising the requirement of informed consent in an era of privatization, managed care and ACOs: Implications for bioethics and the connection between law and ethics. Journal of International Aging Law & Policy, 10.Google Scholar
  54. Sulmasy, D. P. 1992. Physicians, cost control, and ethics. Annals of Internal Medicine 116 (11): 920–926.CrossRefGoogle Scholar
  55. Thompson, D. 1993. Understanding financial conflicts of interest. New England Journal of Medicine 329: 573–576.CrossRefGoogle Scholar
  56. Transparantieregister zorg. 2016. Raadpleeg het Transparantieregister. http://www.transparantieregister.nl/nl-NL/Raadpleeg-het-Transparantieregister.
  57. Trostorff, D.L. 2012. Certification and Licensure. In Pavarini P.A., C.I. McGinty and M.E. Schaff. (Eds.) The ACO Handbook: A Guide to Accountable Care Organizations, 137–158. Washington, DC: American Health Lawyers Association.Google Scholar
  58. Veatch, R. M. 1995. Abandoning informed consent. Hastings Center Report 25 (2): 5–12.CrossRefGoogle Scholar
  59. Wen L. 2014. Patients can’t trust doctors’ advice if we hide our financial connections with drug companies. British Medical Journal, 348: g167.CrossRefGoogle Scholar
  60. Whitehead, S. 2014. ABPI efforts to increase transparency about competing interests. BMJ, 348, g1300.CrossRefGoogle Scholar
  61. Wilson, M.H. 2014. The need to eliminate commercial conflicts of interest from medicine. BMJ, 348, g1735.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2017

Authors and Affiliations

  1. 1.University of HaifaHaifaIsrael

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