In recent days, our media have covered two “scandals” involving allegations against public figures of failing to adequately address identifiable conflicts of interest.
Our Prime Minister is under attack for accepting upgraded flights from Qantas and thereby placing himself in scenarios where later political decisions may have been influenced by the largesse of Qantas. The inaugural head of the National Anti-Corruption Commission, Justice Paul Brereton, has been criticised for not recognising that, in declaring a conflict of interest, his response lacked judgement as he failed to remove himself fully from the making of a controversial decision to decline to further investigate several people involved in the “Robodebt” catastrophe. Of these two instances, the latter surprises me more as I had long imagined that persons trained in law would have a strong appreciation of the seriousness of avoiding conflicts of interest and being seen to strictly avoid them.
These two instances raise matters of public importance as conflicts of interest pervade community, political and commercial life. As a minimum, any discussion of conflicts of interest should encompass its definition and advice as to what should be done when a conflict is identified. In both domains, problems immediately arise. Thus, for example, definitions of conflict of interest may be influenced by conflicts of interest. And advice on how to address a conflict of interest almost never emphasises the impact of the subconscious mind on an individual’s perception as to whether a conflict of interest actually exists. Much of the research into conflicts of interest and the impact of competing interests is based on well-designed studies of the effect of drug company promotions on the prescribing patterns of medical practitioners.
Here I first examine how conflicts of interest are defined (and at times, are undermined). Then I seek to explain both the subconscious impact of drug company interactions with medical practitioners and the equally important subconscious impact of self-interest. A closely related subject is the giving of gifts and the resultant subconscious effect of reciprocity. While much of this data about subconscious influences relate to the medical profession, it should be apparent that these observations must surely apply to all the conflicts of interest that arise in our daily lives, whether one is a politician, a regulator or an ordinary citizen.
One definition of a conflict of interest from the Oxford dictionary reads: “a situation in which a person is in a position to derive personal benefit from actions or decisions made in their official capacity”. Another definition is “a set of circumstances that creates a risk that professional judgement or actions regarding a primary interest will be unduly influenced by a secondary interest”. Secondary or multiple interests should automatically raise a red flag but sadly this seems not to be the view of one of the leading medical colleges in Australia, the Royal Australasian College of Physicians, which chose in its 2018 guidelines to describe such situations as “dualities of interest”, thereby risking denial or minimisation of the ethical issues involved. In addition, the 92-page guidelines make only passing mention of subconscious influences and do not provide relevant references.
The impact of drug company interactions with medical practitioners have been extensively researched and the findings are unequivocal. Drug companies interact with medical practitioners in many ways, all designed to promote the company’s products. These interactions include the use of trained representatives who bring a spiel, copies of studies of their drugs, samples of new drugs and small gifts for the medical practitioner. Over 80 per cent of Australian medical practitioners regularly accept visits from these representatives. Drug companies advertise to medical practitioners directly and through advertising in medical journals. They also provide financial assistance for the educational meetings held in our major public hospitals and for the national conferences of the medical colleges and medical societies. The industry invests heavily in “key opinion leaders”; i.e. expert medical practitioners who sit on the advisory boards of the companies and who are available to speak positively about the drugs they have been researching.
There are studies from multiple countries that show that the more often a medical practitioner sees a company representative, the more likely they are to prescribe unnecessarily or inappropriately. In addition, these visits can lead to medical practitioners lobbying their hospital pharmacy to stock a new drug. What is both alarming and depressing is that when confronted with this evidence, most medical practitioners deny that they could possibly be so influenced; instead, to make sense of the evidence, they blame colleagues. Their denial (sometimes angry) can only be explained by the subconscious impact of the promotion by the drug industry. This evidence of subconscious influences has been available for at least three decades but it was only in 2018 that the guidelines of the Australian Medical Association at last acknowledged that the drug industry influenced prescribing behaviour with the words “…industry marketing can influence behaviour. Doctors need to be aware of this influence and take appropriate steps to minimise it”. What the updated guidelines lacked was any reference to the subconscious mind; it is difficult to minimise an influence of which one is unaware. It should also be noted that responses to these subconscious influences are unintentional; hence the anger of some doctors accused of being biased – they were genuinely unaware of the influences.
There are two other important influences at work in the subject of conflicts of interest. These are the subconscious influence of self-interest and the concept of reciprocity that results from the giving of gifts. Both influences have been well-documented. Social studies research confirms that even when participants in a study are alert to the possible impact of self-interest, its subconscious influence remains unabated. Equally the feeling of a need to reciprocate when a gift is received, even a small gift, plays a big part in the science of marketing. In the instance of medical practitioners, reciprocation is only practicable via prescribing the drug marketed by the gift giver. Politicians have a broader range of reciprocities open to them.
If all or most of the above information is accepted as relevant and accurate, there remain complex situations for persons in positions of authority as to if, how, or when to declare and respond appropriately to a conflict of interest. This dilemma seems to have entrapped Justice Brereton but may have not crossed the mind of our Prime Minister.
Dr Kerry Breen AO is a retired physician whose career spanned roles in clinical medicine, medical ethics, regulation of the medical profession and the health of doctors. His long-term interest in medical ethics is reflected in his 2018 publication, Memoir of an Accidental Ethicist.
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