Letter to the Editor
In “Are Conflict of Interest Policies Fair and Effective?” (Mar. 20, page 4) by Drs. Kimford J. Meador and Jacqueline A. French, we are informed that people act in their own self-interest, and that bias can result not only from financial inducements by industry, but also for reasons of research funding, professional or personal advancement, or self-aggrandizement, among others, which need to be policed.
Trying to find someone knowledgeable without some personal interest can be difficult, and sometimes counterproductive. To quote an 1873 speech by Mark Twain on similar concerns in the criminal jury system: (it) “…is only marred by the difficulty of finding twelve men every day who don't know anything and can't read.”
A logical alternative would be to have committees that are willing to act against their own self-interest. A commendable example is the AAN Quality Standards Subcommittee. Why else would they keep publishing practice parameters that don't recommend what neurologists practice? Examples include epidural steroid injections for radicular pain (Neurology 2007;68:723–729), or administering intravenous gammaglobulins (IVIg) to children with Guillain-Barre syndrome, before the disease becomes severe (Neurology 2003;61:736–740). As the parameters are soon to be incorporated into pay-for-performance guidelines, however, a bit more self-interest might not have been such a bad thing.
Those who believe that transparency is the answer might take a look at the world of finance, where people tend to be more savvy about these matters. According to “A Little Bit of Blow,” an article in the April 9 Barron's (pages 10–12), a prospectus by a going-public company, the Blackstone Group, states: “Our general partners have limited fiduciary duties, which may permit them to favor their own interests, to the detriment of us and our common unit holders.”
Admitting that bias is unavoidable is the first step towards developing a decision-making process that can limit damage resulting from conflicts of interest. Attempting to eliminate all forms of bias or self-interest can only lead to more elaborate regulations, witch-hunts, and a stifling bureaucracy that paralyzes decision-making.
Other solutions can be found. For example, including a larger number of experts in the decision-making process could effectively dilute or cancel out the occasionally biased vote. Maintaining anonymity during deliberations, by communicating electronically, would also limit any undue influence that any one participant might exert. Other than eliminating more obvious conflicts, a more appropriate use of our resources might then be to challenge the authority of medical insurance companies to limit care, while enriching their coffers, in the name of their own best self-interest, and against ours and our patients'.
Norman Latov, MD
Weill Medical College of Cornell University, New York, NY