The primary claim of this paper is that intellectual conflicts of interest (COIs) exist but are of lower ethical priority than COIs flowing from relationships between health professionals and commercial industry characterized by financial exchange. The paper begins by defining intellectual COIs and framing them in the context of scholarship on non-financial COIs. However, the paper explains that the crucial distinction is not between financial and non-financial COIs but is rather between motivations for bias that flow from relationships and those that do not. While commitments to particular ideas or perspectives can cause all manner of cognitive bias, that fact does not justify denying the enormous power that relationships featuring pecuniary gain have on professional behaviour in term of care, policy, or both. Sufficient reason exists to take both intellectual COIs and financial COIs seriously, but this paper demonstrates why the latter is of higher ethical priority. Multiple reasons will be provided, but the primary rationale grounding the claim is that intellectual COIs may provide reasons to suspect cognitive bias but they do not typically involve a loss of trust in a social role. The same cannot be said for COIs flowing from relationships between health professionals and commercial industries involving financial exchange. The paper then assumes arguendo that the primary rationale is mistaken and proceeds to show why the claims that intellectual COIs are more significant than relationship-based COIs are dubious on their own merits. The final section of the paper summarizes and concludes.
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Of course, simply establishing ethical obligations and priorities does not indicate which actors are primarily responsible for relevant action. This question merits its own independent analysis, which time and space here do not permit. Nevertheless, it is likely that a variety of actors bear responsibility for intervening on COIs, including but not limited to individual health professionals, health agencies and organizations, and policymakers.
Some non-financial COIs also have the ability to diminish trust in a social role (Lipworth et al. 2019); whether in so doing their level of ethical concern more closely resembles fCOIs or that of iCOIs is a question reserved for future work.
Admittedly, not all fCOIs are practically avoidable. As Brody notes,
… [a]ll known ways of paying physicians create temptations to act in ways that fail to serve the patient’s health—fee-for-service rewards overtreatment whereas managed care capitation rewards undertreatment, for example. But we have discovered no way to deliver health care without paying physicians. (2010, 355)
Given the analysis above, it is reasonable to claim that consistency demands that fCOIs that satisfy the unavoidability criterion should be deprioritized relative to those that are avoidable. While this is plausible, I would still maintain that a very large proportion of the relationships that providers and/or healthcare organizations maintain with commercial entities are practically avoidable.
I am indebted to an anonymous reviewer for this point.
Note, of course, that the fact that iCOIs can generate ethical concern is entirely consistent with the claim that intellectual commitments are morally desirable as part of a virtue-based commitment to evidence-based practice. Many morally desirable acts and practices may not be unqualified goods; theorists of nonideal models of justice frequently emphasize the trade-offs that inevitably attend any effort to craft a just social order (Powers and Faden 2006; Venkatapuram 2011).
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Goldberg, D.S. Financial Conflicts of Interest are of Higher Ethical Priority than “Intellectual” Conflicts of Interest. Bioethical Inquiry 17, 217–227 (2020). https://doi.org/10.1007/s11673-020-09989-4
- Conflicts of interest
- Public health ethics