Conflicts of Interest in Clinical Practice and Research

Our society has long sanctioned, at least tactily, a degree of conflict ofinterest in medical practice and clinical research as an unavoidable consequenceof the different interests of the physician or clinical investigator, thepatient or clinical research subject, third party payers or research sponsors,the government, and society as a whole, to name a few. In the past, resolutionof these conflicts has been left to the conscience of the individual physicianor clinical investigator and to professional organizations. The public is nolonger willing to allow health care providers to wholly govern their ownconflicts of interest because of: new forms of health care financing anddelivery that provide innovative and lucrative opportunities for physician orinsurer enrichment at patient expense; the increased importance of commercialresearch support as peer-reviewed governmental research support has decreased;evidence that physicians and clinical investigators too frequenctly resolveconflicts of interest in their own favour; and a general societal mistrust ofauthority.This volume represents a multidisciplinary effort, drawing from philosophy,medicine, law, economics and public policy to identify and categorize conflictsof interest in medical practice and clinical research, and, where possible, tooffer a mechanism for resolving them. Part I addresses conflicts of interestfrom a theoretical perspective, offering basic concepts and analyticalframeworks. Part II discusses two topics priminent in current health carepolicy debates - self-referral and financial incentives to limit care. Part IIIexamines conflicts of interest generated by pharmaceutical industry involvementin clinical practice and research. Part IV deals with conflicts of interest inclinical research in several contexts, including institutional review boards,clinical trials, Cooperative Research and Development Agreements betweengovernment and private researchers, brokerage of research subjects by ContractResearch Organizations, and cost-effectiveness studies.