Conflict-of-Interest Issues Plague the New England Journal of Medicine

There is no justification for conflicts of interest in any business, but they’re particularly dangerous in medicine, where people’s lives are at stake. A recent airing of differences within the medical community about such conflicts hasn’t gotten much consumer play, but it should.

The prestigious New England Journal of Medicine (NEJM) recently published a series of articles about physicians who have relationships with the medical industry, and who submit their research articles in the hope of being considered for inclusion in the journal. It purported to analyze whether such scientific reviews were acceptable journal material if their writers had financial interests in the subjects they covered.

The series’ conclusion was, basically, that perceived problems with doctor-company ties are overblown.

The NEJM followed up with a poll of the journal’s readers that, as described on HealthNewsReview.org (HNR), asked them to judge the suitability of three hypothetical potential contributors. Each supposed expert had some kind of financial arrangement with the pharmaceutical industry (for example, speaking fees or research funding).

But the readers weren’t given the option to judge a potential author who had no conflict of interest. “This is striking,” said HNR, “considering that during the 1990s and up until 2002, the NEJM would not publish editorials or review articles by authors with any conflict of interest.”

Many reader/physicians weighed in on the poll and the original series, and they weren’t complimentary.

According to HNR, one emergency physician said, “Pharmaceutical company money, and the purchase of influence, has been the single most powerful distorting force in health care in a generation – this is undisputed. This overwhelming and uncontested monetary force has come between guideline panels and recommendations, government agencies and quality markers, health-care policies and subjects, and doctors and patients …. There is a reason more than two-thirds of Americans are taking a prescription drug, an embarrassing statistic,” and he wondered why the poll didn’t offer a nonconflicted contributor as a fourth candidate for review.

“The only reason to choose any of the individuals in these cases would be if there were no available alternatives,” he said.

Other NEJM respondents were concerned that the journal had not given editorial space for people opposed to its conflict-of-interest posture.

As HNR saw it, the reason is because the journal wanted to “frame” the discussion.

That’s sort of what drug companies do when they’re seeking FDA approval of a drug whose clinical trial results aren’t as persuasive as they should be, either in terms of effectiveness or safety; they present consumer witnesses to panels considering approval who speak more from emotion than science, as in the recent hearing about the “female Viagra” drug, for example, and in the worst cases, hide negative study results they know would doom their chances.

A day after HNR’s analysis of the mess at the NEJM, it reported about another journal, BMJ (British Medical Journal) that published the views of three former NEJM editors, who wrote, simply, “Justifying conflicts of interest in medical journals: a very bad idea.”

The three said it was “sad that the medical journal that first called attention to the problem of financial conflicts of interest among physicians would now backtrack so dramatically and indulge in personal attacks on those who disagree.”

They referred to an extensive body of literature the NEJM series mostly ignored that concluded that physician conflicts of interest had measurably negative effects on medicine and medical journals. They offered comparisons of such conflicts in other professions:

Judges are expected to recuse themselves from hearing a case in which there are concerns that they could benefit financially from the outcome. Journalists are expected not to write stories on topics in which they have a financial conflict of interest. The problem, obviously, is that their objectivity might be compromised, either consciously or unconsciously, and there would be no easy way to know whether it had been. Yet [NEJM ] seem[s] to think it is insulting to physicians and medical researchers to suggest that their judgment can be affected in the same way. Doctors might wish it were otherwise, but none of us is immune to human nature.”

The BMJ does not accept educational articles by authors with industry ties. The three former NEJM editors who wrote for it, according to HNR’s follow-up, predicted that the NEJM’s acceptance of these murky associations could either signal a decline in journal quality or galvanize strong opposition to them.

Let’s hope it’s the latter. This isn’t just a closed-club squabble; this is about scientific objectivity, and that affects everybody who will ever need medical care.

To learn more about financial relationships between medical professionals and industry, link to ProPublica’s data base, Dollars for Docs.