Professional Medical Organizations and Commercial Conflicts of Interest: Ethical Issues

Dr. Heim does not recognize that it was ethically inappropriate for the American Academy of Family Physicians (AAFP) to make a deal with the Coca Cola Corporation (TCCC) – a deal in which Coke provided her organization with a very large sum of money in support of a project to educate the public about the dangers of obesity.

Sometimes it’s easier to gain a sound ethical perspective by standing back a distance from conduct in which one is personally engaged. So, I invite Dr. Heim to consider the following analogous conflict-of-interest scenarios.

How would she feel about the judicial ethics of a judge who accepted money from one of the litigants in a civil action before him? Would she wait to see how the judge ruled before concluding that the judge’s behaviour was ethically unacceptable? Or: consider the case of a baseball umpire who had accepted money from the owner of a team over whose games he presided. What about a baseball coach or star player who was found to be placing large bets against his own team? Would she say about them, as she does about the AAFP:

"To gauge an individual or organization’s ethics, one must view its behavior over time, define the goal of that behavior, and compare the outcome with the mission and values. Within this context, one can determine whether the assumption or appearance of conflict of interest or ethical lapse was, in fact, correct."

Somehow, I don’t think that she would adopt that stance in any of the above cases. Instead, she would recognize that for a judge to accept money from a litigant is unethical because unprofessional, and she would recognize that the judge’s behaviour - putting herself in a conflict of interest situation - is unprofessional even if the judge subsequently rules against her benefactor. Similarly, Dr. Heim would instantly recognize that it’s wrong for an umpire or referee to accept benefits from anyone associated with the teams over whose games he/she presides. Finally, like everyone else, she would be in no doubt that a player who made bets against his own team was guilty of unprofessional and unethical conduct even if the team subsequently won its match and even if the victory resulted from a stellar performance by the player in question.

Conflicts of interest don’t necessarily lead to corrupt behaviour, but often they do. The key point, which Dr. Brody gets and Dr. Heim misses, is that an ethically conscientious professional should not put herself in a conflict of interest situation even if she is confident that “I can’t be bought for …” (fill in the blank; in the case of the AAFP it would be “$60,000 of corporate sponsorship”). That is, professionals and professional organizations should avoid conflicts of interest even if they sincerely believe that they won’t be corrupted thereby and even if that belief sometimes turns out to be true.

There is a substantial psychological literature demonstrating that when physicians accept gifts from drug companies, even small gifts, their judgement is subtly influenced by biasing factors, such as financial self- interest or feelings of friendship towards the drug company rep. This bias does not usually result from a conscious and deliberate choice but rather operates at a sub-conscious level. Since the physician has a professional duty to exercise her judgement impartially in the best interests of her patient, and since the act of accepting money or gifts which could bias that decision has a marked tendency to undercut the impartiality of the physician’s judgement, it is unprofessional and morally wrong for doctors or other health care professionals to put themselves in a conflict of interest situation. What is true for doctors is also true for bio-medical researchers and medical organizations.

Before concluding, I should say a few words about the meaning of the phrase “conflict of interest”. Howard Brody employs the definition first popularized by Denis Thompson [1], relying on a distinction between primary interests and secondary interests. With respect, I find it misleading to refer to a physicians’ professional orientation to her patient as an “interest”, even a “primary interest”. It’s not an “interest”, it’s an ethical obligation. A more satisfactory definition of the term “conflict of interest” is offered by M.Davis: “A person is in a conflict of interest situation if she is in a relationship with another in which she has a moral obligation to exercise her judgement in that other’s service and, at the same time, she has an interest tending to interfere with the proper exercise of judgement in that relationship.” [2]

Thus, the AAFP put itself into an actual (rather than a merely potential) conflict of interest situation when it decided to accept $60,000 from TCCC to fund patient education materials on obesity. An organization which values professional integrity would not place itself in such a situation, and Dr. Brody is quite right to chastise the organization for setting such a bad example of professional indifference to conflict of interest.

1. Thompson D. Understanding financial conflicts of interest, New England Journal of Medicine. 1993; 329; 573-576.
2. Davis M. Conflict of Interest. Business and Professional Ethics Journal 1 (Summer 1982): 17-27.

For a much more extensive discussion of these issues see: Schafer A. Biomedical conflicts of interest: a defence of the sequestration thesis. Journal of Medical Ethics, 2004;30: 8-24.

Professor Arthur Schafer
Director, Centre for Professional and Applied Ethics, University of Manitoba; schafer@cc.umanitoba.ca

Competing interests:   None declared

I appreciate Dr Brody's sage words so much. He is always an ethical anchor in the storm of controversy. I received the message below from Dr Sundburg in Sweden after my editorial in Family Medicine appeared in January 2010. He supports the fears many have had that all of us in medicine are truly being duped by big money. Even AAFP referring to CocaCola as "TCCC" ("The Coca Cola Corporation") reflects the subliminal message that we (AAFP) think we are not really talking about COKE in this affiliation, but some benign corporation with too long a name to say.

"For the last four years I have been investigating the ties between food and pharmaceutical industry and policy-making expert groups, such as the ADA , AHA and similar groups in Europe . If one penetrates the nutritional guidelines by the ADA , it is not only full of contradictions to basic physiology and biochemistry, but moreover it is full of misquotations of the literature it refers to. Two years ago I published a critique of these, along with criticism of the guidelines from the European Association for the Study of Diabetes. When I looked into the individuals in this European expert group I found that they were sponsored by sugar and margarine industry, and their latest meeting was financed by Coca-Cola. I have also found that the initiatve to issue to publish dietary guidelines at all comes from the food, pharmaceutical and agro- chemical industry, examplified by a protocol from the International Life Sciences Institute, whose president was the co-chairman of Coca-Cola at that time. As Lord Acton said, history is not woven by innocent hands."

-Ralf Sundburg, MD, PhD - Malmoe, Sweden

I too have decided that my membership dues will not go to the AAFP until they swear off these affiliations. I have been a member for over 30 years, and at one time was an AAFP staff member. I am saddened that my professional society thinks only of money. My only option was to not give them mine.

Competing interests:   None declared

To the Editor:

Having previously written to both the AAFP and NYSAFP (my state chapter) in protest of AAFP’s “consumer alliance” with The Coca-Cola Company (TCCC), I was pleased to read Dr. Brody’s penetrating analysis of the issue,(1) and Dr. Heim’s reply.(2) I very much resonated with Dr. Brody’s perspective of a conflict of interest – or more pointedly, a breach of “moral duty” – being not only “apparent”, but “real”, despite AAFPs “rationalizations”.(1) Where I disagree with Dr. Brody is in his assertion that “the argument against AAFP’s accepting funding from Coca-Cola does not hinge in any way upon an assertion that the company is evil.” I think the argument is informed by the company’s “evil”.

It would not be a stretch to make an analogy between TCCC and Phillip Morris – another company producing a flagship product for consumer enjoyment having no health benefits and demonstrable, devastating harms. Both companies have aggressively marketed their unhealthy products to vulnerable consumers (e.g. children, minorities, citizens of developing countries), have exploited workers, and have been accused of various labor, human-rights, and environmental abuses.(3-5) Are these the kinds of companies we want affiliated with AAFP?

The analogy to Phillip Morris goes further. Advertisements for Coca Cola on familydoctor.org (e.g. “This content was developed with general underwriting support from The Coca-Cola Company”),(6) are reminiscent of mid-century ads for Philip Morris in prominent medical journals.(7) In both cases, preceding information is presented about the health harms of product categories (i.e. soda or cigarettes) with final statements creating the impression, “but our product is different”. While an online editorialist called this kind of messaging “subliminal” in the case of TCCC (see Dr. Backman’s comments), I believe such messages amount to no less than an open endorsement for Coca Cola. Such endorsement runs completely counter to AAFP’s mission of “improving the health of patients, families, and communities”.(2)

Dr. Heim defends AAFP’s position, noting familydoctor.org content that details the serious health consequences of added sugars and sugar-sweetened beverages as evidence of AAFP’s editorial independence form corporate influence.(2) But, as another online editorialist notes, the anti-sugar/anti-soda messages could be stronger (see Dr. Lesser’s comments). Did AAFP water down its statements? As Dr. Brody mentions in his piece, we can never be sure.(1)

What we can be sure of is that TCCC would never pay AAFP any sum if it were not sure that doing so would generate a worthwhile return on investment. As Dr. Brody points out in his online comments, TCCC is not a “non-profit or charitable foundation”; it is a corporation expecting “commercial benefit from this deal”. AAFP would do well to divest from its alliance with a for-profit, ethically-questionable, toxic-food company, and re-invest in the public’s trust. Only through responsible partnerships can AAFP repair its damaged reputation, and that of the blameless physicians it represents.

Sean C. Lucan, MD, MPH, MS
Department of Family and Social Medicine, Montefiore Medical Center / Albert Einstein College of Medicine
1300 Morris Park Ave, Mazer Building, Room 410, Bronx, NY 10461, Tel: (718) 430-3667, Fax: (718) 430-8645, slucan@yahoo.com

References
1. Brody H. Professional medical organizations and commercial conflicts of interest: ethical issues. Ann Fam Med. 2010 Jul-Aug;8(4):354-8.
2. Heim L. Identifying and Addressing Potential Conflict of Interest: A Professional Medical Organization's Code of Ethics. Ann Fam Med. 2010 Jul-Aug;8(4):359-61.
3. Tracy Samilton. National Public Radio Broadcast: "Coca-Cola Deal Dumped Amid Labor Abuse Charges". January 24, 2006; Available from: http://www.npr.org/templates/story/story.php?storyId=5170745.
4. Corinna Hawkes. Marketing Activities of Global Soft Drink and Fast Food Companies in Emerging Markets: A Review. Chapter in World Health Organization Report Globalization, Diets and Noncommunicable Diseases. 2002.
5. Andrew E. Kramer. Philip Morris Is Said to Benefit From Child Labor. The New York Times. 2010 July 14;Sect. B2.
6. American Academy of Family Physicians. Added Sugar: What You Need To Know. 2010 [cited 2010 July 22]; Available from: http://familydoctor.org/online/famdocen/home/healthy/food/general-nutrition/1005.html.
7. Phillip Morris. Cigarette advertisement: "How irritation varies from different cigarettes". New York State Journal of Medicine. 1944 April(April).

Competing interests:   Nothing to disclose. I am a member of AAFP (but not proud of it).