The New England Journal of Medicine (NEJM) spent the month of May with an artillery barrage against the idea that conflicts of interest in medicine are at all problematic, with a series of three longish opinion pieces (here’s one) by Lisa Rosenbaum, amounting to nearly 10,000 words of text overall, plus an editorial by Jeffrey Drazen. At the very least, this format and sheer commitment of pages signals that changes are on the horizon for NEJM, rolling back at least some of the 25-years of regulations about conflicts of interest. In substance, the papers careen between skepticism about whether commercial bias exists at all, and the cynical view that there is so much bias from so many commercial and non-commercial sources that resistance is futile.
This week, three former NEJM editors (Robert Steinbrook, Jerome Kassirer, and Marcia Angell) fire back from across the Atlantic in the BMJ. In the 1400 words allowed in the essay format, the rebuttal cannot meet the onslaught in sheer volume, but it does call out some of the excesses, including Rosenbaum’s strange suggestion that “honest debate” has been “stifled” and the sky-is-falling notion that regulation of COIs “prevent the dissemination of expertise.” If the Rosenbaum papers had been submitted to traditional peer review procedures, engaging subject-matter experts from the fields of psychology, law, and ethics, I think that the worst of these could have been avoided.
The BMJ authors also call out the burden-shifting on the core empirical questions about whether conflicts of interest are problematic and whether they can be effectively regulated. In my view, there is plenty of basic science research to show how COIs can create biases and undermine trust. The remaining questions are just cost-benefit analyses about how best to regulate.
I am not sure that I would follow the BMJ authors all the way to their own unqualified thesis that, “Put simply, financial conflicts of interest in medicine are not beneficial, despite strained attempts to justify them and to make a virtue of self interest.” The relationship between profit and health is contingent. In some instances, profit-seeking behavior does in fact promote health. When profit-seeking detracts from health, that’s when we need thoughtful regulation.
“The relationship between profit and health is contingent.” Possibly, but if so, for the sake of argument, in some more progressive countries where the two have been to a certain extent decoupled or minimized, the result, by WHO indices, has been an almost across the board improvement in health which would seem to contradict the idea that there is any benefit to profit and contingent COI being allowed without contest. And shame on the NEJM for going over to the dark side!