Conflicts of Interest

When an article is published in a medical journal, the authors must disclose any conflicts of interest. This is important, because even if they think owning stock in the drug company won’t influence their scientific judgment, we know that subtle biases can creep in to somehow affect the findings of studies. It has been shown that studies funded by drug companies are more likely to get positive results for their drug than studies funded by independent sources. Andrew Wakefield, author of the infamous retracted Lancet study suggesting a relationship between MMR vaccine and autism, was severely chastised for not disclosing that he received money from autism litigators and expected to earn a fortune from his own patented products if the MMR vaccine could be discredited.

I was recently contacted by an acupuncturist who plans to critique an article I wrote. It was a commentary in the journal Pain that accompanied a systematic review of systematic reviews of acupuncture by Ernst et al. For details of Ernst’s and my articles, see my previous post. He challenged my statement that I had no conflicts of interest to report. He apparently thinks I should have said I have a conflict of interest in that I am anti-CAM and anti-acupuncture. When he writes about my article, he plans to attack me for not declaring this alleged conflict of interest and he plans to set a good example with a conflict of interest statement of his own, divulging that he makes his living practicing acupuncture, has financial investments in it and many personal relationships, that his self-identity and prestige are dependent on his belief in acupuncture’s efficacy, and that he is biased towards constructivism and away from positivism. (I think this is a fancy way of saying he favors experience over the scientific method.) I agree that he has conflicts of interest, but was I wrong to say I had no conflicts of interest? I don’t think so.

He cited the International Committee of Medical Journal Editors (ICMJE) criteria on conflict of interest:

Public trust in the peer-review process and the credibility of published articles depends in part on how well conflict of interest is handled during writing, peer review, and editorial decision making….Conflict of interest exists when an author … has financial or personal relationships that inappropriately influence (bias) his or her actions… Financial relationships (such as employment, consultancies, stock ownership, honoraria, and paid expert testimony) are the most easily identifiable conflicts of interest and the most likely to undermine the credibility of the journal, the authors, and of science itself. However, conflicts can occur for other reasons, such as personal relationships, academic competition, and intellectual passion.

Financial relationships? Something that would make it financially advantageous for me to disparage acupuncture? Employment, consultancies, stock ownership, honoraria, paid expert testimony? Nope, nope, nope, nope, and nope. None of these apply to me. I’m retired, so I can’t even be accused of competing for patients with acupuncturists. I would have nothing to gain financially if acupuncture vanished from the earth overnight.

Personal relationships? Should Dr. Oz should divulge that his wife is a Reiki master before he pontificates about the wonders of Reiki on national television? I think he should; if it hasn’t influenced his views, I can’t imagine what his marriage is like.  Do I need to state that I associate in cyberspace with other science-based writers who have questioned the evidence for acupuncture? Do I need to say that I have 3 friends who accept acupuncture and 6 who reject it? I don’t think so.  Does a scientist doing a drug study need to divulge that his cousin or his next-door neighbor or one of his Facebook friends works for the drug company? I don’t think so.

Academic competition? I am not and have never been an academic. I’m a retired family physician with no ties to any academic institution.

Intellectual passion? My passion is for science and reason, not for or against acupuncture or any other particular treatment. I have no brief against acupuncture. I have had no personal experiences, good or bad, that would tend to prejudice me for or against it. My initial opinion of acupuncture was favorable. When I was in med school, the head of anesthesia, Dr. John Bonica, was enthusiastic about acupuncture and was actively investigating it as a possibly worthwhile addition to his field. He thought it worked by the gate control theory of pain. (As he studied it, his initial enthusiasm soon waned.)  I believed the first reports I heard about its effectiveness for surgical anesthesia and pain relief. Through the years, I read the reports that came out in the medical literature and I perceived that the weight of evidence was gradually turning against it. I also learned about the psychology of how patients and doctors can come to believe that a treatment works when it really doesn’t, and I learned some of the things that can go wrong in research to produce results that are not valid. Eventually I came to the provisional conclusion that acupuncture probably has no specific effects but is very good at eliciting non-specific effects of treatment. I don’t say that acupuncture doesn’t work: I only say that the entire body of published evidence is compatible with the hypothesis that it doesn’t work better than placebo.

I have never seen a conflict of interest statement that mentioned the authors’ worldview. No prayer study lists “I believe in God” as a conflict of interest. No scientist is expected to state “I believe the scientific method is the best way to evaluate claims.”

If conflicts of interest make an article less credible, should we also be required to disclose factors that would tend to make it more credible?  When Ernst writes an article critical of homeopathy, should he divulge that he was trained as a homeopath and used to work in a homeopathic hospital? Should we be more disposed to believe his criticisms of homeopathy because he is a “convert”? No, the content of the article can be judged on its own merits. Only significant conflicts of interest need be reported. We can keep them in the back of our mind to moderate our confidence in the study’s findings but we can never assume they mean the study is not credible.

I have no particular attachment to my provisional conclusion about acupuncture. It really makes no difference to me personally whether it works or not. Really. I would welcome proof that acupuncture works, as it would give me another option for treating any pains of my own. I am always ready to change my mind and have done so innumerable times in my career in response to better evidence. As Emerson said, “A foolish consistency is the hobgoblin of little minds.” It can’t hurt my pride to change my mind as long as I change it in response to evidence and reason; I am proud when I have learned that I was wrong about something and was able to correct my error.

If new evidence convinced me that acupuncture worked, I would write about it and explain the evidence and my reasoning. This wouldn’t hurt my reputation. If anything, it would enhance my prestige in the skeptical community. It would demonstrate that I didn’t have an ax to grind, that I was willing to follow the evidence wherever it led.

The acupuncturist’s arguments for more complete disclosure remind me of a “complete” informed consent for surgery that was written as a joke. It advised patients of everything that could possibly happen, including an earthquake during surgery and the chance that the surgeon could die suddenly of a heart attack and fall on top of the patient. Informed consent and disclosing conflicts of interest are both important, but it’s possible to get too carried away.

In summary, the acupuncturist would have a great deal to lose if he rejected acupuncture, while I would have nothing to lose if I accepted it. He has a conflict of interest. I don’t.

This article was originally published in the Science-Based Medicine Blog

Dr. Hall is a contributing editor to both Skeptic magazine and the Skeptical Inquirer. She is a weekly contributor to the Science-Based Medicine Blog and is one of its editors. She has also contributed to Quackwatch and to a number of other respected journals and publications. She is the author of Women Aren’t Supposed to Fly: The Memoirs of a Female Flight Surgeon and co-author of the textbook, Consumer Health: A Guide to Intelligent Decisions.

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