Thought experiment: Financial Conflicts of Interest

Believe it or not, many people see no problem with financial conflicts of interest in health care. People who receive payments say they are only doing the same job they would do otherwise, except with more resources. This, they say, enables them to provide better health care. People who make the payments will claim that they are only trying to ensure that their beneficial products are able to improve the lives of as many consumers as possible. Even patients defend conflicts, saying they don’t mind their doctors making a few extra dollars in order to provide efficient, state-of-the-art service. Patients see these financial ties as a way to ensure groundbreaking treatments reach consumers.

Slippery Slope
A rather beautiful example of a slippery slope.

I’m not a doctor, but there are analogies for me. If we look at financial ties in another industry, it may be easier to see the problem. In education, the stakes are lower, but some parallels to the medical industry remain. I will begin with actual practices and then ask you to imagine further practices that parallel the medical industry.

First, instructors are commonly asked to review books for publishers seeking feedback on manuscripts or new textbooks. This gives the publisher an opportunity to get feedback from potential customers while also enabling instructors to provide input to publishers. Instructors get better books, and publishers are able to improve both their products and their marketing. The instructor is, of course, paid a small honorarium for the time invested in reading and reviewing the book.

Second, once instructors have given feedback, publishers may invite them to be more involved in the production of the textbook. They may be asked to write an instructor’s manual to accompany the text or participate in developing workbooks or online supporting materials for students. (Disclosure: I know that these first two items are practiced because I have reviewed textbooks and written an instructor’s manual for pay.) Instructors, of course, know the most about what instructors need and how students may use various materials. Improving the product benefits publishers, instructors, and students.

Now, imagine that an instructor sees an improvement in students’ success rates and general aptitude. The instructor begins to collect data and may even present at a teaching and learning conference on how these materials have benefited students. A publisher might (I don’t know of this happening in real life) offer to pay the instructor to give the same presentation at additional conferences. On the surface, this does not seem harmful. After all, the students really did improve using these materials, and the presentation was not developed with the aim of getting payouts from the publisher. Certainly, no students will be harmed by these presentations.

Finally, imagine this instructor begins to accept regular invitations from the publisher to present on the benefits of the products and encourages others to adopt the same materials for their classes. The instructor notes that most of her or his students are now earning A’s and B’s when the class averages were usually a B or C before the materials were adopted. To reward the instructor for this amazing success, the publisher begins to pay the instructor $100 for each A awarded and $80 for each B awarded. Soon, this instructor is widely hailed for improving student success and completion rates at a college that struggles with generally high rates of failure and incompletion.

Now, these payments to the instructor come to the attention of the student newspaper, which publishes the amounts paid to the instructor and the increase in high grades in the classes. The public is outraged, but enrollments in the class continue to increase. The instructor counters that no one has shown that even one student who received an A did not deserve an A. Further, the instructor says that the improvements in student success were documented even before the payments began. The publisher responds by saying that the materials it produces are of the highest quality and that it is proud of the success rates of the students using the products. Without the relationship between the publisher and instructor, fewer students would have benefited from these outstanding educational materials and that would be a real tragedy.

Questions to consider: 1. Did students really benefit from the relationship? 2. Were cheaper alternative materials available that were equally beneficial? 3. Is it possible that students received inflated grades, even if proving it so is impossible? 4. What would it take to identify this relationship as a moral problem? 5. Are all financial relationships with industry unethical? 6. If not, when does the relationship become unethical?

I think it is extremely rare for someone to go into a job with criminal intent to capitalize on the system and take home as much money as possible regardless of possible harm. No, everyone begins with the best intentions and becomes blinded to the possible effects of their actions. And, precisely because each person has no malevolent intentions, each person feels insulted by even a hint of judgment and defends her or his practices vehemently. Because good people do X or Y, it is easy to think it is impossible that X or Y is a bad thing, especially when we can show that many people have benefited from these practices.

åIt is easy to be blinded by the fog of good intentions and financial influence, and ethicists are not immune. The job of the ethicist is not to be perfect but to be on guard. The job of the ethicists is to constantly strive to get a clear view through the fog and to help others stay on the paved path running alongside that slippery slope.

 

It is Time to Shed Sunshine on Informed Consent

Most patients realize doctors receive gifts from the pharmaceutical and device-

A patient having his blood pressure taken by a...
A patient having his blood pressure taken by a physician. (Photo credit: Wikipedia)

manufacturing industry. When we see industry logos on pens, clocks and posters, we don’t assume the doctors ordered these items from the merch page of these companies, but most of us aren’t aware of how lucrative the payments to doctors can be.

A story that ran in the New York Times described the experience of Dr. Alfred J. Tria, who made $940,857 in about two years for promoting products and training doctors in Asia to use them. The article notes that Tria’s experience may be exceptional, but in two and a half years, industry paid out $76 million to doctors practicing in Massachusetts alone.  I’ve been reading about this subject for a while, and even I was surprised that someone could make half a million dollars in a year on a side job.

In a slightly different type of payout, Oregon recently concluded a court case against two doctors who “put heart implants into patients without telling them that a manufacturer’s training program put a sales representative into the operating room.” The doctors would receive between $400 and $1,250 each time they completed a surgery using Biotronik defibrillators and pacemakers. The state argued that patients should know when doctors’ recommendations may not be based entirely on the needs of the patient. One of the doctors in the case earned more than $131,000 from 2007 to 2011 through implant surgeries. Doctors also received speaking fees, expensive meals, and other gifts.

As part of the Affordable Care Act (Obamacare), the Sunshine Act now requires industry to start collecting data on payments to doctors now, and the information will be made available to the public next year on a government website. This will enable patients to learn how much their doctor receives from the industry each year, though there may still be hidden incentives.

For example, doctors may be in profit-sharing arrangements with facilities or they may actually be the owners of the facility. A recent study by Dr. Matthew Lungren found that doctors who had a financial stake at an imaging facility ordered tests with negative results at a much higher rate (33 percent) than doctors with no financial stake. In other words, it appears that doctors order unneeded tests because they are making money off of them, not because the patients need them. Lundgren suggests that patients should ask whether they are being referred to a facility in which the doctor has a financial stake. I say the doctor should volunteer the information.

Beginning next year, the Sunshine Act will make it much easier for patients to discover their doctors’ financial relationships with industry, and I’m thrilled for this development. For those who think Obamacare is a complete disaster, just take a minute to relish this one positive development.  Still, I think the movement should go further. I think financial disclosure should be part of the informed consent process. When your doctor is telling you all the risks and benefits of treatment, I think he or she should also say, “I get paid $1,000 to do this surgery,” “I will make $100 off this MRI,” or “I own stock in the company conducting this medical research.”

I believe patients want this information, and I don’t think they feel it is their responsibility to search for it. True informed consent is only possible in light of complete financial disclosure.