Conflict of Interest
Every physician-patient encounter is a conflict of interest. Every physician-payer encounter is also a conflict of interest. (Todd 1991)
Incentive misalignments are ubiquitous (Langbein 2005). In every relationship, the parties face incentives, varying in strength, to act contrary to and without regard for the interests of the other(s). Relationships are always “conflicted” to some degree: husbands with wives, parents with children, siblings with each other, friend with friend, partner with partner, lawyers with clients, research subjects with investigators, and physicians with patients. Indeed, the relationship we each have with ourselves is “conflicted.” Self-help books are premised on the conflicts between the motivating effects of what we take an interest in and what is in our own best interests. Each of us makes most of our own trouble. Each is his own worst enemy. But the COI frame, by emphasizing relationship risk, ignores convergent interests which may be predominant, deeper, more persistent, and stronger. The COI frame creates a biased picture, inviting the false belief that non-conflicted relationships exist. Hence it has been observed that conflict of interest is “an epithet” (Langbein 2005).
There are several conceptions of COI but two are most common in the medical literature. One says that a physician is conflicted when a reasonable person/observer would [should?] perceive the physician’s relationships or circumstances as role compromising (Erde 1996; Brody 2007; Brennan et al. 2006).
Conflicts of interest occur when “...motives that caregivers have and/or situations in which we could reasonably think caregivers’ responsibilities to observe, judge, and act according to the moral requirements of their role are or will be compromised to an unacceptable degree” (Shimm and Spece 1996).
The other conception says that a physician is conflicted when a second party or third party or a relationship or a situation [to a high degree of medical certainty?] has exerted, is exerting, or will exert “undue influence” on the physician’s actions (e.g., prescribing) adverse to the interests of a second party (e.g., a patient) or third party (e.g., a payer or society) (Thompson 1993; IOM 2009). Each conception sometimes adds a proviso, “potentially” conflicted, a nuance I ignore.