When it comes to conflicts of interest, moral huffing is in plentiful supply, whereas careful analysis and ethical insight are scarce. Conflict of Interest in the Professions, a collection of 17 chapters edited by Michael Davis and Andrew Stark, is a welcome attempt to even the balance. The book soars across a wide range of professions including the law, anthropology, literary and art criticism, investment banking, and medicine. It critically considers practices as varied as "reciping" by bank trust departments, forcibly testing a prison tattooist for hepatitis B, and the Hollywood casting couch. Had the editors waited a few more months to publish, they could have added a subtitle: "From Enron to HMOs, with a Brief Stop at Folsom Prison" (for the chapter on "correctional health systems"). The fundamental idea behind the book is that examining how conflicts of interest arise and are dealt with in diverse professions yields insight into their underlying structure. The execution of the idea is often informative, sometimes brilliant, and occasionally flat. There are surprises. Did you know that the familiar representation of justice as a goddess with a sword and scales acquired a blindfold denoting impartiality only in the 16th century? Or that, in its contemporary form, the concept of conflict of interest is only half a century old? Davis suggests that our recent interest in such conflicts arose from sweeping social changes in the 20th century, which rendered us ever more vulnerable to experts who were also strangers: "We are now much more dependent on the judgment of others, much less able to evaluate their judgment decision by decision, and indeed generally know much less about those individuals than we would have even fifty years ago." To say that someone has a conflict of interest sounds like an accusation. Although the chapter authors use different definitions of conflict of interest, they agree overwhelmingly that such conflicts are common and occasionally perilous but often either insignificant or manageable. A conflict of interest refers to a situation or set of circumstances that creates the possibility that a professional may provide a judgment or take an action motivated by something other than the interests or well-being of a patient, client, or the like -- someone owed a professional duty. Three chapters deal specifically with health professionals. Physicians are likely to find Stephen R. Latham's chapter on conflict of interest in medical practice particularly interesting. Latham worked on ethical and legal matters at the American Medical Association for several years and writes with authority and sophistication. He calls attention to questionable practices, such as physicians' selling "neutraceuticals" to their patients and fee-splitting with practitioners of alternative and complementary medicine. For the same reasons that physicians are not permitted to sell drugs to their patients, they should not be selling vitamins or supplements. And although ethics codes and laws, for historical reasons, prohibit splitting fees only with licensed medical professionals, again the moral logic is the same: there is a conflict of interest between physicians' duty to their patients and their desire to make more money. If a physician honestly believes patients can benefit from supplements or alternative therapy, then he or she should tell them so -- but send them to an appropriate vendor. A frequent complaint in contemporary medicine is that managed care creates conflicts of interest by pitting physicians' income against patients' welfare through financial-incentive schemes such as bonuses, referral budgets, and "withholds." The complaints are correct, but the inference that such conflicts of interest are inherently iniquitous is mistaken. Our lives are rife with conflicts of interest, and we manage, mostly, to navigate through them without great damage to others or to our own character and self-respect. The particulars of the conflict matter greatly. For one thing, although managed-care incentive schemes can have baleful effects on patient care, it is possible to design incentives that do not. A common alternative to financial incentives is the use of strategies that second-guess physicians' clinical judgments, such as "prospective approval." Latham notes that such practices infuriate physicians and frustrate patients, in addition to resulting in delays and inappropriate denials of care. Financial incentives that pit physicians' interests squarely against the welfare of their individual patients are bad ideas. Instead, Latham advocates "intensity-reduction techniques" that minimize the likelihood of inappropriate clinical decisions. He offers a provocative and persuasive analysis of such incentive schemes, one that concerned physicians and managers should read. The introductory and concluding chapters are excellent conceptual guides to conflict of interest in general, although neither is for the casual reader. This is serious philosophical analysis that is worth reading. Some chapters are elegant, such as David Luban's discussion of judges. Some are mildly entertaining, if unconvincing, such as the two chapters by economists on, respectively, criticism and the Hollywood film industry. Even Voltaire's Candide would be impressed by these economic "just-so" stories explaining how "praise for sale" and the infamous casting couch are the natural and acceptable outcomes of our economic system. Neither chapter has much of use to say about conflicts of interest. Jane Gallop, a professor of English, defends sexual relationships between faculty and students against the charge that such relationships create conflicts of interest. This is perhaps the least illuminating chapter in the book, because the analysis overlooks so much and the arguments are breathtakingly flimsy. In contrast, John R. Boatright's discussion of conflicts of interest in the financial-services industry is packed with surprising information and thoughtful analysis. Investors would be well advised to read his chapter. Taken as a whole, Conflict of Interest in the Professions provides insights into the structure of conflicts, how and why they are dangerous -- and when they are not -- and the best ways to escape or manage them. The book deepens our understanding of conflicts of interest and clearly lays out the choices we face.
Thomas H. Murray, Ph.D.Copyright © 2002 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
