Sunshine disinfects nothing

I seem to remember Jon Stewart once playing a clip of a politician declaring that sunshine is the best disinfectant. After the clip, Stewart warned viewers that using sunshine as a disinfectant could lead to a nasty infection. In response to the Sunshine (Open Payments) Act, bioethicist Mark Wilson sounds a similar alarm in a recent paper.

For years, many people, including myself, have argued that industry payments to physicians should be disclosed to the public, so that we will all be aware of possible financial conflicts of interest (FCOI). My hope was that disclosing conflicts of interest might help actually reduce corruption or even simple bias in medical practice, but Wilson points to our experience of Wall Street before and after the 2008 financial collapse to show that knowledge of conflicts of interest does not prevent them. Rather, disclosure only shifts the burden for reducing FCOI to patients, who are least empowered to eliminate them. Rather than fixing the problem, Wilson claims the Sunshine Act only “mythologizes transparency.”

Wilson pointed me to a paper (“Tripartite Conflicts of Interest and High Stakes Patent Extensions in the DSM-5”) in Psychotherapy and Psychosomatics that illustrates the problem. If you want the details, you can read the paper yourself, but I will skip right to the conclusion, which I admit is how I read most papers anyway:

[I]t is critical that the APA recognize that transparency alone is an insufficient response for mitigating implicit bias in diagnostic and treatment decision-making. Specifically, and in keeping with the Institute of Medicine’s most recent standards, we recommend that DSM panel members be free of FCOI.

Telling people about FCOI does not reduce bias and corruption; it only offers an opportunity for people to be aware that bias and corruption exist. I think it is valuable that the Sunshine Act is making people aware of FCOI. In response, though, I hope we will take steps to reduce FCOI. Unfortunately, the burden is indeed shifted to voters and consumers. The most disturbing and obviously true statement Wilson makes in his paper is this: “Until politicians end their own commercial COIs, the Sunshine Act will likely remain the governance order of the day.”

We can’t hope the experts will solve this problem. We must demand that FCOI are eliminated.

5 thoughts on “Sunshine disinfects nothing

  1. John H Noble Jr 12/02/2014 / 1:00 pm

    To understand the dynamics of FCOIs is to know about how pack animals like dogs and human beings behave. Look for the alpha male (or female) and the pecking order. Material and symbolic rewards are distributed accordingly. Dogs sniff at each other’s butts to establish identity–the equivalent of a friendly “hello” and handshake in humankind. Transparency about pack animal identities and power differences does not ipso facto alter anything about the members of the pack. Clearly, politicians in legislatures or top executive branch positions are the alphas of the pack. They can and do use their power to alter the status of others. But why should they lower their own preferential status for any purpose–no matter how lofty? To do so would threaten their continuing survival as a pack leader. Thus, Mark Wilson’s conclusion that politicians must end their own commercial FCOIs to achieve meaningful reform through transparency is to point out its impossibility. Lobbyists in the pack pay homage (and money) to politicians after sniffing a friendly “hello” and handshake. Everybody in the pack understands the way of things and accepts it one way or another.

  2. ethicsbeyondcompliance 12/02/2014 / 1:14 pm

    Yes. Unfortunately, the responsibility rests on the shoulders of voters and consumers. Those who have conflicts of interest are not the ones who will guide the way to ending bias and corruption. Often, we ask patients why they might go to a doctor when they are aware of FCOI or other problems, and the answer is, “I was sick, and I needed a doctor.” Adding additional burdens to those who are injured or ill is obscenely unjust in my mind.

    • John H Noble Jr 12/02/2014 / 1:20 pm

      We share the same wave length. Long ago in The Prince, Machiavelli laid out the rules of engagement: “We must bear in mind, then, that there is nothing more difficult and dangerous, or more doubtful of success, than an attempt to introduce a new order of things in any state. For the innovator has for enemies all those who derived advantages from the old order of things, whilst those who expect to be benefited by the new institutions will be but lukewarm defenders.”

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