Institutional Conflict of Interest: Not Just a Relationship, but a Set of Circumstances

Looking at the pros and cons of working with industry

Do financial relationships between medical institutions and industry automatically represent a wrongful conflict of interest?

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“Not necessarily,” says Susannah Rose, PhD, Director of Bioethics Research and Policy in the Department of Bioethics and a member of the Innovation Management and Conflict of Interest Committee at Cleveland Clinic.

“Those relationships may in fact benefit patients, enhance medical research and help advance patient care,” she says. Yet these financial relationships are complex, she notes, and the nuances of different types of relationships among physicians, hospitals, researchers and for-profit industries must be evaluated closely and managed properly by hospitals and universities.

How industry relationships impact patient care

“The tension lies in weighing the potential benefits of connections with industry against the potential risk of harm to patients and to the research,” Dr. Rose says. “We want to make sure it’s not just money exchanged but that a true benefit may be realized.”

For example, to improve patient outcomes, the joint-replacement device industry must work with a joint replacement surgeon who knows how to improve a device. Unless the surgeon is involved in design and testing, the new device might never be created.

Conversely, some types of industry relationships may increase the risk of harm to patients, such as when physicians rely solely on industry for funding and information about drug products. Not only might the money unconsciously bias clinical decision-making, but the situation also may bias the information the physician receives about the drug’s risks and benefits.

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How transparency affects patient trust

Preserving patient trust is central to patient care and to medical research, says Dr. Rose. She believes that institutions should be fully transparent about financial relationships, possibly even disclosing the amount of money involved and why it was provided.

“However, we need more research on what type of information is necessary for transparency, and how, when and by whom it should be presented,” she says.

“Truth-telling is a critical component of developing patient-physician trust,” notes Dr. Rose. Research suggests that disclosure may indicate trust and has positive effects. However, transparency can create a false sense of trust that may lead patients to trust people who might not be trustworthy.

“Several studies show that patients may falsely trust a professional who discloses a conflict but does not act in their best interest,” Dr. Rose says.

Furthermore, such disclosure may merely shift responsibility to the patient, who may not know how to use the information in medical decision-making, she says.

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Analyzing data nationwide

Dr. Rose is analyzing national disclosure data related to conflict of interest at academic medical centers across the country. “We really don’t know much about disclosure practices or their effects on clinical decision-making,” she notes.

Most academic medical centers have a conflict of interest management committee, but policies throughout the nation vary widely in levels of restrictiveness, permissions and transparency.

“The point of future research is to understand how disclosure of conflict of interest can help or hinder patient care,” she says. “We need to create institutional protections and management plans that protect the integrity of patient care and medical research.”

Dr. Rose, Director of Bioethics Research and Policy in Cleveland Clinic’s Department of Bioethics, conducts research on conflict of interest in healthcare and patient decision-making at the end of life.