Conflict of interest or just confluence?

Recently, the prominent experts involved in drafting blood pressure treatment guidelines for the American College of Cardiology/American Heart Association were excoriated for undisclosed industry ties by an opinion writer in the Baltimore Sun. I sympathize with the writer to some extent; he is a preventive medicine resident who seemed to be advocating for more use of lifestyle to manage blood pressure in lieu of drugs. I could not agree more.

But the guidelines in question clearly situate lifestyle intervention as the primary response in blood pressure control. To date, that tends to be sadly rare in practice, but not for want of emphasis in these guidelines. In addition, the writer was simply wrong about many of his allegations. This zeal for discerning and exposing potential conflict, at times where none exists, and all too often by those with greater undisclosed conflict of their own, has expansive implications and inevitably invokes the law of unintended consequences. We clearly do not want blood pressure guidelines from doctors peddling some proprietary drug any more than we want dietary guidelines from those selling coconuts or doughnuts . On the other hand, we do want guidelines from leading experts. The question becomes, then, who do we want advising industry or overseeing the study of their proprietary products?

My answer would be: leading experts. After all, the entire modern pharmacopeia, including the occasional game-changing advance like immunotherapy for lung cancer, reaches us via FDA-regulated research, the vast bulk of it industry funded. I much prefer that research to be conducted by genuinely qualified colleagues rather than whomever is left after all the credible candidates decline for fear of being tainted. Let’s be clear that if we did not have industry funded research, pharmacy shelves would be empty.

The matter extends beyond research to all manner of consulting and advising. I am aware of many instances where experts declined to consult for some effort in the private sector despite fully supporting its aims to avoid the risk not of actual conflict, but of a conflict allegation. Just consider, though, that innovations in disease and health care, as in almost every other domain, occur overwhelmingly in the private sector. Do we prefer all of this innovation to be guided only by those with lesser expertise, and, perhaps, lesser scruples, too, as the highly expert and highly scrupulous decline en masse to satisfy the current standard of professional chastity?

I do not. I want the momentum of biomedical advance overseen by the most qualified, conscientious, and sedulous. Sure, I want transparency and disclosure. But if the elite all demur when industry asks for expertise, the less qualified will take their place.

We must more thoughtfully differentiate between conflict, and confluence, of interest. A conflict is present whenever truth and best efforts to find it are subordinate to any other agenda. A confluence may be present when a professional interaction serves the pursuit of truth and is constrained by both mission and methods from doing otherwise. Expert interaction with industry is neither reliably innocent nor preemptively compromising; it depends on who does what and how.

Whatever entity is paying the bills, the defense against bias is robust methods designed to serve truth, and allowing for it to be a truth that disappoints. To make this personal: I have hoped for a specific outcome in every study I have ever run, those funded by the NIH, those funded by the CDC, and those funded by industry. In every instance, I have relied on the same methods to produce the right result, rather than the one I “wanted.” Bias, then, is not a real factor in honest results; integrity is.

True conflicts of interest, and opacity about them, are enemies to truth, and thus to us all. But confluences are salient, too, and neglecting to distinguish these may append personal insult to public health injury. Nobody expects the Spanish Inquisition to recur, but something like it does when sanctimony and the presumption of guilt displace reason and informed judgment. If the current version of conflict precludes expert guidance when it matters most, from the most qualified experts, we may all come to rue the consequences.