Managing Conflict of Interest in Anesthesiology
Conflict of interest (COI) in medicine, in which a physician, researcher or other health professional may be influenced by motives other than patient care, can be highly complex.1 Both financial and non-financial COI situations must first be identified, quantified and evaluated for harm. Only then can COI be restricted, managed and ultimately eliminated.2 While it is relatively simple to implement policies preventing financial COI, non-financial COI can be difficult to identify, analyze and manage.2 However, non-financial COI can be equally—if not more—damaging than financial COI, and health professionals see the rapid development of COI guidelines and regulations as crucial to maintaining integrity in health care.2
The solution to handling COI in medicine, and in anesthesiology in particular, begins with evaluation of the situation. For one, the expected benefit from the secondary interest must be weighed against the bias it entails.2 If the advantages of the secondary interest contribute to the primary interest, it may be possible to justify the COI situation. Also, the size and value of the secondary interest should be evaluated to gauge its influence over the health professional. Even small gifts, if valuable and given frequently, can unduly (i.e., unwittingly) sway a recipient’s decisions.3 Additionally, professionals need to assess the seriousness of harm caused by the COI situation. COI that affects multiple patients is larger in scope, and thus has the potential to cause more harm.4 Finally, health professionals’ accountability for their actions can change the way COI situations are evaluated. COI is more likely to cause harm if health professionals and researchers are not held responsible for decisions they make about patients or participants.2 Taken together, these factors show that COI situations can vary widely depending on the proportionality of benefits from a secondary interest, the extent to which bias is unintentional, the harm of the COI and the accountability of the decision-maker.
After COI is evaluated, it can be properly managed. Disclosure is considered the best way to manage financial COI in medicine.5-7 However, disclosure is not a panacea for COI management. For one, its usefulness in research is limited, as the release of seemingly unnecessary information to participants may do more damage than good.8 Additionally, disclosure requirements do not eliminate financial COI completely.2 Some professionals have gone so far as to argue for a zero-tolerance policy regarding financial COI, claiming that any monetary exchange whatsoever should be eliminated.9,10 In these zero-tolerance contexts, disclosure of financial COI is not enough; rather, COI must be abolished entirely. For non-financial COI, however, management or elimination may be more difficult. Given that humans are imperfect and subjective, it can be almost impossible to separate COI-related secondary interests from general interests or biases.11 Bero and Grundy suggest using “reflexivity” to differentiate non-financial COI from general interests and to manage non-financial COI.11 Usually, an interest is considered COI if it could be eliminated from the situation entirely, if the bias cannot change direction within the circumstances or if the bias is widespread and has unlimited impact.11 Another aspect of reflexivity for non-financial COI includes “heightened disclosure,” which entails a health professional’s disclosure of not only financial interests, but also professional identity and motivations.11 This allows for the identification of possible influences on a professional’s decision, and can inform policy on non-financial COI.2 Management of non-financial COI focuses on enforcing standards of research conduct, reducing natural bias, publishing research in a timely manner, developing evidence-based practice guidelines and sustaining public confidence in professional judgment.2
In anesthesiology, professionals can take many approaches to COI management, including disclosure, resignation, substitution or termination of the relationship.2 The anesthesiologist’s proactive approach to COI involves vowing to follow principles such as autonomy, beneficence, non-maleficence and justice.2 In addition, anesthesiologists can take COI into consideration while retaining primary responsibility to the patient, analyzing the risks and benefits of COI and always disclosing financial COI.2 After the fact, anesthesiologists can acknowledge COI by reporting it, giving solutions, suggesting changes in practice and research, working towards awareness of COI and proposing new policies.2
While COI situations can vary widely in complexity and harm, there are several concrete approaches to COI evaluation and management. Circumstances should be evaluated according to the risks and benefits of a secondary interest, undue influence on the professional, potential harm of the COI and accountability of the decision-maker.2 While financial COI may be managed with disclosure,5 non-financial COI may require health professionals to reveal many of their general interests and identities. In anesthesiology, professionals can make efforts to prevent COI, to identify its presence and to manage it after it has occurred. Future research must address the ability of these strategies to limit and reduce the harm of COI.
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