Abstain, disclose, or step aside? The answers can be as complicated as the ethical questions they address.
COLUMBIA, 7/11/11 (Beat Byte) -- The old practice of taking pens and coffee mugs from pharmaceutical sales representatives has disappeared from many clinics, as physicians worry about the appearance of impropriety -- taking gifts, no matter how simple, in exchange for prescribing certain medications. Ethical concerns are driving a nationwide debate about the need for full disclosure anytime drug companies fund or otherwise support research in human medicine.
Animal doctors are taking note.
"Dr. George Glanzberg, like many veterinarians, reads human as well as veterinary medical literature," reported a January 2010 Veterinary Information News Service story, Scrutiny emerges concerning conflicts of interest in veterinary literature. "Glanzberg, a small-animal practitioner in Vermont, surmises that if unreported conflicts are of concern in human medical literature, they're likely to be a problem in veterinary literature as well, even if the stakes are not as high."
Disclosure and avoidance
Although the Nathan Voris-Pfizer issue (see Pharma Fright) involves policy-making rather than research, "there is indeed potential for a conflict of interest," said Lisa Cosgrove, Ph.D., a fellow at the Edmond J. Safra Center for Ethics at Harvard University whose research on conflicts of interest has been cited and discussed in The New York Times, Washington Post, USA Today, U.S News and World Report, New Scientist, the Boston Globe, NPR, and the BBC.
Citing a 1993 definition in the New England Journal of Medicine, a conflict of interest is a set of conditions in which professional judgment could be unduly influenced by a secondary interest, such as financial gain, said Cosgrove -- who authored a recent article for the American Association of University Professors about Big Pharma's role in psychiatric research.
"Conflict-of-interest rules, informal and formal, regulate the disclosure and avoidance of these conditions," Cosgrove told the Heart Beat.
Though Voris is almost certainly not directly benefitting from the new cat testing mandates -- he's an equine, or horse medicine specialist -- full disclosure, as a Board of Health director making legally-enforceable, community-wide animal care policy, serves transparency, explained animal health journalist and San Francisco Chronicle pet columnist Christie Keith.
"Any legislator should disclose his or her own conflicts, potential or actual, financial or simply relationship-based," said Keith, who recently explored Big Pharma-driven conflicts of interest in veterinary medicine and veterinarian trustworthiness. "Conflicts of interest should be disclosed in all areas of legislation, including human or veterinary medicine, landlord/tenant law, or the zoning of the local ice cream store," she told the Heart Beat.
An offer from Voris to step out of Board deliberations and votes on the new feral cat ordinance would have been an "antidote" to the potential conflict of interest issue, veterinarian Paul Pion explained. At this point, however, "if Dr. Voris believes in the feral cat program – and moreso if Pfizer believes in it, and isn't looking to profit from it – then I suggest they agree to either not participate in the sale of any of the supplies for it, or they should donate them," Pion told the Heart Beat.
Often-discussed elements of the Missouri Sunshine Law, transparency and disclosure are important -- but also complicated. It's never a given that potential conflicts will be disclosed, and blaming people for lack of disclosure isn't always fair. For instance, Nathan Voris makes no secret of his employment with Pfizer. It appears on at least one version of his blog, and on Linked In.
But his employment came part way into his term on the Board of Health, and midway into the feral cat debate. Should he have disclosed it officially and publicly at the time, then stepped aside, or at least, out of Board votes and ordinance deliberations?
SNAP board member Christina McCullen thinks so. "We expect judges, physicians and attorneys to recuse themselves in similar legal matters," she said. "Why is he exempt from these accepted practices?"
Other experts say the answer can depend on complex considerations and individual understanding.
"The problem is not getting people to agree that transparency and disclosure are important; it's getting them to understand the pervasive nature of influence," Christie Keith said.
Most colleagues, Paul Pion told the Heart Beat, "do not intend to deceive or let their bias affect their judgment. But time and again, studies show that, while we all think we are immune, we are all subject to these biases."
Biases in favor of potential pocketbook interests can be so powerful that often, "transparency is not enough," Harvard's Cosgrove said. This March, she explained, the National Academy of Sciences Institute of Medicine issued a report stating that industry-affiliated individuals should not be creating treatment guidelines -- period -- regardless of how much they disclose their industry relationships.
"Everyone says they are against conflicts of interest going undisclosed," the Chronicle's Keith explained. "The problem is everyone defines 'conflict of interest' differently, and very often, believes they are not being influenced by their relationships, nor even by who signs their paychecks."