Health service researchers – are we blind to our own conflicts of interest?
Ritika Goel’s recent commentary on Healthy Debate about the pharmaceutical industry’s influence on physicians got me thinking about other kinds of conflict of interest within the health care system, particularly related to health services researchers.
There is a great need for researchers to be independent when conducting their work, and to be able to speak freely about research-related issues.
I think those of us who are health services researchers tend to under-appreciate the potential impact that government funding has upon our willingness to speak entirely freely in public about health policy issues.
Let’s compare the criticisms of those researchers who receive funding from industry, with those health services researchers whose salaries are paid by government and sometimes advise government.
Legitimate criticisms of the pharmaceutical industry are that they do not publicly release all relevant information about their products, and that their marketing materials are often not balanced.
However, very similar criticisms can be levelled at government and other major actors in the health care system. The Centre for Law and Democracy recently ranked Canada 55th of 99 countries in regard to “right-to-know” legislation. Kevin Donovan of the Toronto Star has described the difficulty he has had accessing important information that the public has a right to know from numerous public or quasi-public actors within the health care system including ministries of health, hospitals and regulatory colleges.
The pharmaceutical industry also often requires their academic and clinical consultants to sign confidentiality agreements (thus inhibiting them from speaking freely about the company’s products), and they usually pay these consultants well (which may affect their ability to be unbiased).
Again, it’s not that different with government, although they tend not to pay as much as pharma. A recent report from University of Victoria researchers has documented the restrictions Canadian governments place on their scientists’ ability to speak freely about their work. A recent article in Macleans documented worrisome instances of the muzzling of federal scientists working in ministries relevant to the environment and climate change – I would not be surprised if this also extends to scientists working in federal health-related ministries. These examples of censorship and message control seem particularly egregious, because the funds to support this research come from tax-payers.
Most of us who have functioned as advisors to government have signed confidentiality agreements, which are similar to those signed by consultants to industry.
Many health service researchers who are not directly employed by government still receive some or all of their salaries from government, and they often work in research institutes substantially funded by government. It seems to me that this can put us in a similar potential conflict of interest as industry funding places those who consult for industry. However, many of my colleagues do not appear to agree with me.
For example, Evidencenetwork.ca, a web site that provides journalists and others with access to “non-partisan health policy experts and evidence” removed me from their list of experts because I received about $15,000 per year for work I did for three pharmaceutical companies (being a member of Data Monitoring Committees and providing advice about the design of clinical trials). However, my guess is that they would not have seen any significant conflict of interest with my previous role as CEO of the Institute for Clinical Evaluative Sciences (a health services research institute that receives millions of dollars of funding from the government of Ontario), even though the personal payment I received from public provincial funds was much greater than what I received from pharma, and when I was CEO I had a clear interest in not criticising the Ontario government publicly about their health policies, because government support was essential for the survival of ICES. (Click here for evidencenetwork.ca’s COI policy.)
To be clear, the government never pressured me to change the design of any studies or to bury the results of any study (but neither has pharma tried to muzzle me). However, I think I would be naïve to think that being the CEO of ICES had absolutely no impact on my willingness to speak freely about all politically charged health policy issues. If I was approached by the press for comment, would I be willing to publicly strongly criticize a prominent new government health system strategy that I thought was misguided in the middle of a contract negotiation with the government? I suspect I would find a way of slightly tempering my views (without being dishonest) or being unavailable for comment.
At this point, it is important to make the distinction between funding for research that goes directly from government to researchers or the research institutes they work in, and government funding that is given to “peer-reviewed” granting agencies such as the Canadian Institutes for Health Research and Alberta Innovates – Health Solutions. Because the government has no say in the selection of the scientists or projects that receive peer-reviewed funding, scientists are very likely to feel totally free to speak their mind about their research.
It might be worthwhile articulating different degrees of conflict of interest. One scheme might go as follows, in order of increasing conflict of interest: 1) receipt of only operating funds to conduct the research from the payor, 2) receipt of personal salary or consulting fees, 3) receipt of funds for a research group or institute, so many individuals are dependent upon those funds for all or part of their salary and/or projects, and 4) potential to derive entrepreneurial profits in partnership with the payor. An important point here is that, except for the fourth conflict, the others pertain to both industry and the public sector.
So, what to do? Many of the people I respect the most within health care, and who have the most to offer, are highly connected – with government, health care institutions, organized medicine, the pharmaceutical and device industry, academia, patient advocacy organizations, and others. Interactions with each of these groups influences the way these people think. Does that make them more biased, or does it make them more knowledgeable? I suspect both.
I have a lot of time for thoughtful, well connected people with multiple biases, provided they recognize them, and publicly identify them. My issue right now is that some health services researchers seem blind to the potential conflict of interest associated with government funding.
Andreas Laupacis is a general internist, the Executive Director of the Li Ka Shing Knowledge Institute of St. Michael’s Hospital and the Editor-in-Chief of Healthy Debate. Follow Andreas on Twitter @AndreasLaupacis