Another poorly argued article trying to minimize the reality of conflicts of interest in medical research. Cappola AR, FitzGerald GA. Confluence, not conflict of interest: Name change necessary. JAMA. 2015;314(17):1791-2.

If someone stands to have a personal advantage as a result of their research, or their recommendation of a course of therapy, then that is necessarily in conflict with the need to be objective and to analyze data, perform meticulous trials, and objectively review publications.

First, the term conflict of interest is pejorative. It is confrontational and presumptive of inappropriate behavior. Rather, the focus should be on the objective, which is to align secondary interests with the primary objective of the endeavor—to benefit patients and society—in a way that minimizes the risk of bias. A better term—indicative of the objective—would be confluence of interest, implying an alignment of primary and secondary interests. In this regard, the individuals and entities liable to bias extend far beyond the investigator and the sponsor; they include departments, research institutes, and universities.

I don’t think calling a spade a spade is pejorative. It is just accurate. If I am a medical research scientist my primary interest should  be to perform the research to the highest standards, without bias. Any personal advantage that accrues from that research is in conflict with that goal. It also does not presume inappropriate behaviour; to say that someone has a conflict of interest does not mean that they cheated, exaggerated or misled the public. What it does mean is that there is risk that the results of their academic endeavour might benefit them personally, so watch out! There are so many examples that prove the power of such conflicts, which are not necessarily conscious.

The article does, however, point out the importance of other non-financial conflicts of interest.

For example researchers involved in a large multi-center trial for which they have invested much time and public money, may be very reluctant to stop such a trial even when the results of other similar trials become conclusive. This has happened more than once, including in neonatology. It is entirely understandable, and I do not believe necessarily a conscious bias. It is usually possible to find a reason why “the science is not yet settled” and continue a trial, even when it has become crystal clear that the science actually is settled to clinicians outside the trial.

This is partly why Iain Chalmers wrote an article a couple of years back that data-monitoring committees of similar trials should share data (Chalmers I, et al. Data sharing among data monitoring committees and responsibilities to patients and science. Trials. 2013;14(1):102.)

The JAMA article refers to his pressure as being “the prospect of fame”, which I don’t actually think is that big an issue, depending on what you mean by “fame”. Neonatologists do not become celebrities, in general, but the recognition of your peers, the satisfaction of getting an article published in a high profile journal, the feeling that you have performed the best, most complete research, adding to your total of entries in PubMed, getting promoted at your university, and so on, are drivers of academic conflicts of interest. Such conflicts are not often revealed, and indeed are hard to define.

It has happened many times in neonatology that several simultaneous trials investigating the same issues have been performed almost simultaneously. Whereas one larger trial could answer the questions with more precision, and do so faster. Sometimes this has been because of funding issues, but it has sometimes been because of academic conflicts of interest.

I think the answer to such conflicts is transparency, and finding ways to work together. Co-funding of trials from multiple agencies could get us much further, but has been hard to organize as yet. The CIHR ha been very open to allowing inclusion of non-Canadian centers in research projects, but that doesn’t increase the funding available. Hopefully in the future we will be able to perform larger trials, co-funded by several agencies, and everyone involved will get appropriate recognition of their contributions, without having to be first author on the article, and that we can work for the good of our patients and their families, with fewer conflicts of interest.

Yes conflicts, not confluences.