Consistent Disclosure of Conflict of Interest

In this issue, Bondok et al. examine the concordance between publicly disclosed payments by industry to ophthalmologists and the declarations of conflict of interest of the board members of ophthalmology organisations 1. Their data come from the United States. Correspondence from Baid outlines further measures to address the problems identified by Bondok et al. 2. In this editorial, am I going to say anything new on this topic? Probably not. My motivation is not to break new ground but to assist the authors in keeping this important topic front-of-mind in our scientific, teaching and clinical community. Conflicts of interest, either substantive or perceived, erode trust because they call objectivity into doubt. In research, a declared conflict of interest automatically reduces trust. Industry sponsorship favours the sponsor 3. For decades, clear evidence of the effect of financial conflicts of interest on doctors' research activity, policy development and clinical practice has been available in reviews and primary sources. The final sentence of a review written over a decade ago states, ‘Conflicting interests create substantial distortions in the decisions made by health care professionals’ 4. Denial by doctors of these effects, against the evidence, is also well documented. The feeling that prior knowledge of disease and therapeutic intervention elevates doctors' decision-making above the influence of inducements, small or large, is common and wrong. The combination of objective evidence of influence and subjective denial or minimisation of that influence is characteristic of self-deception 5. In the world of medical scientific communication, we at CEO, in common with other peer-reviewed medical publications, require a ‘declaration of competing/conflicts of interest’ which we publish with each article 6. Cochrane requires at least two-thirds of review authors to be free of relevant financial conflicts, with first and last authors having none, and prohibits authors of industry-funded primary studies from leading reviews on those topics 7. On the other hand, it needs to be recognised that research published by overtly conflicted researchers is not worthless 8. Much innovation would be impossible if innovators who might benefit from their innovation were ostracised by the scientific community. For instance, for inclusion in a Cochrane review, conflict of interest, once declared, in a primary study does not lead to automatic exclusion from a review. Instead, these details are used in risk-of-bias assessments. A declaration of a conflict of interest is aimed not specifically at full restoration of trust but at providing the reader with the tools to weigh the possible bias a study may have. Research, in its best form, translates into improved clinical practice. Patients trust their doctors to make good judgements based on trusted research including research which is derived from conflicted sources but which should not be ignored 9. The key concept is that conflict must be overt, declared and open to the judgement of bias. Although Bondok et al. 1 report on data from the United States, conflict of interest is a matter that concerns all those pursuing the profession of ophthalmology. Everyone publishing research and desiring to influence clinical behaviour and patient treatment must engage with this even if only to ensure their particular data are relevant to the practicing ophthalmic community 10. The Royal Australian and New Zealand College of Ophthalmologists' Professional Code of Conduct states that members, including those in governance roles, must declare all conflicts of interest and ensure they are managed in line with prevailing standards 11. It also states that its board members with a relevant conflict should stand down from decisions where they are conflicted. However, it does not publish a detailed, individual conflict-of-interest register for each board member on its public website. On the basis of what appears in this issue of CEO, perhaps it should. Is publication of conflict of interest among board members of ophthalmology societies necessary? It is undoubtedly best practice but it is not a legal requirement in Australia or anywhere else that I can find. A declaration of conflict of interest, whether it takes place in a research publication or in an organisation, bolsters trust. Medical organisations must inspire trust and uphold the values that support trust because of the unique relationship of doctors with their patients. Caveat emptor can never be a guiding principle in that relationship. No patient, particularly at their most vulnerable moment of ill health, can make a clear judgement of the scientific veracity of what their doctor says. They take it on trust. In fact, by contrast, they come to trust us by making judgements based on many superficialities such as our manner, our dress, the welcome they receive from our staff and so many other matters of little concern to the outcome of their therapeutic interaction 12. Our professional institutions must reflect this and specifically those involved in teaching must ensure that its members uphold and teach the principles of open disclosure and its relationship to trust. All our endeavours, clinical, teaching and research, survive and thrive on trust. Declaration of conflicts of interest, in all these forums, is a prime component of that trust and not just a box to be ticked on a governance checklist. The author has nothing to report. The author declares no conflicts of interest. Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.