Conflict of interest conundrums
Authors: Harriet Vickers
Publication date: 05 May 2012
Julian Sheather, the BMA’s ethics manager, answers some questions on situations you might find yourself in
Doctors and students can be invited to conferences by their corporate sponsors, with the offer of a nice hotel and reimbursed travel thrown in. Is it okay to take up these invitations?
It is widely recognised that the drug industry does have a role to play in some forms of training for health professionals. The question is how to ensure that this benefit can be realised without potential conflicts of interest—perceived or real—undermining trust in the profession.
In its guidance, the Association of the British Pharmaceutical Industry (ABPI) sets out stringent guidelines in relation to conferences and meetings. The critical issues are purpose and proportionality: the conference has to have a legitimate educational purpose, and levels of subsistence must not be disproportionate to the purposes of the meeting.
In addition to ensuring that the conference meets these criteria, doctors also need to ensure that they are aware of the possibility that conflicts of interest might arise and ensure that any prescribing decisions are made on the basis of an assessment of the best clinical interests of patients.
Should GPs give informal advice to employees such as receptionists?
Informal medical advice cannot be a substitute for the proper care and supervision of the patient’s named GP. Informal consultations present several potential problems. They risk giving patients the impression that they have taken appropriate medical advice. Good medical care can also require appropriate investigation and follow-up, and obviously these will not be available in a “corridor consultation.” Conflicts of interest can also arise where employees are requesting informal advice—medical staff can risk blurring the boundaries between their obligations as an employer and any perceived obligations that might arise in relation to their employee’s health problems.
Students are forever being enticed to pharma sponsored lunchtime meetings. What should they do if they don’t feel comfortable about the drug promotion?
The provision of sponsorship by drug companies is closely regulated—as are the type and value of gifts and the nature of the subsistence that is provided at meetings. It is important for the individual to identify the reasons for feeling uncomfortable—does he or she feel, for example, that the lunches are likely to influence, or to be seen to influence, prescribing or referral patterns in ways that might not be in the best interests of patients? This in itself should be a spur to acknowledging the potential for any conflicts of interest and to ensure that they are appropriately managed.
What should doctors do if they are left money in a patient’s will?
NHS employees are prohibited from accepting substantial gifts or bequests from patients or from other individuals with whom they are professionally involved. If the doctor is employed directly by the NHS then he or she should speak to the employing trust to discuss how best to handle the bequest. Private doctors and GPs can accept unsolicited gifts, but great care has to be exercised, and doctors must make it clear that gifts will have no impact on the quality of the care that is offered. The Health and Social Care Act 2001 made provision for a reporting and recording system for gifts. Subsequent regulations specify that GPs should keep a register of gifts for patients or their relatives if the gifts have a value of £100 or more.
Researchers trialling drugs are sometimes linked to the manufacturer, including financially. If all the authors on a research article declare a conflict of interest of this sort, how suspicious should readers be of the results?
There is no straightforward answer to this. Important questions to consider will include whether it is published in a reputable, peer reviewed journal and whether the authors have declared their conflicts of interest. Practising doctors are inevitably dependent on the intellectual and ethical rigour of journal editors, and trust in them is critical to medicine.
Can doctors recommend private surgeons or other providers who are their friends to patients?
Treatment and referral decisions should be made in accordance with the best clinical interests of patients. Financial conflicts of interest should be avoided—there must, for example, be no payment or other inducement for referral to a specific service provider. Where a choice of referrals is available it is important that objective impartial advice is given to patients. A doctor’s primary obligation is to ensure that referral is made to an appropriately qualified professional, and doctors should not permit personal relationships to have an impact on this judgment.
Additional sources of advice:
BMA. Medical Ethics Today: The BMA’s Handbook of Ethics and Law. BMA, 2012. [Link]
BMA. The interface between NHS and private treatment: a practical guide for doctors in England, Wales and Northern Ireland. 2009. [Link] .
Association of the British Pharmaceutical Industry (ABPI). Code of Practice for the British Pharmaceutical Industry 2012. [Link] .
General Medical Council. Good Medical Practice. GMC, 2006. [Link] .
Competing interests: None declared.
From the Student BMJ.
Harriet Vickers assistant multimedia producer, BMJ