Issue 17(2): Conflicts of interest

Issue 17(2): Conflicts of interest

Journal of Bioethical Inquiry, Volume 17, Issue 2, June 2020

Guest Editors: Miriam Wiersma, Wendy Lipworth, Paul Komesaroff, and Ian Kerridge


Editorial

Michael Ashby

Free Access Life Goes On

Intro
This editor cannot recall a time where you can hear something on the radio news in the morning and find that, not only does the news affect one’s own everyday life immediately, but also that there will be very few people on the planet who are not hearing similar news and facing similar impacts on the same day. In this time everybody and nobody is a Covid-19 expert. We have access to unparalleled quantities of information from multiple sources. It is striking that despite all the accumulating knowledge and experience, few virologists, infectious diseases doctors, or epidemiologists are willing to predict the outcome of the current pandemic. Nearly every publication is substantially devoted to the overwhelming topic of the time, and here at JBI we are no different in wanting to make our contribution. Being a quarterly publication, we are not in a position to respond quickly. However, our editorial group has already had over fifty manuscripts submitted in response to a limited call for papers to past contributors and editorial members of the JBI community. We are therefore planning for one or two subsequent issues to be largely devoted to Covid-19, recognizing that by the time they are published, much will have no doubt changed further.

Recent Developments

Dianne Nicol & Bernadette Richards

Mitochondrial Donation: The Australian Story

Intro
The landscape of healthcare is perpetually changing, with new and innovative treatment techniques constantly emerging. We are also improving the ability to investigate (and prevent) specific inherited conditions through pre-implantation diagnosis and other medical interventions. One such category of medical intervention is mitochondrial donation, which is currently permitted (under strict conditions) in the United Kingdom but is prohibited in Australia. Recently, under the directions of the Hon Greg Hunt, MP (Minister for Health) the National Health and Medical Research Council (NHMRC) opened a dialogue to consider the regulatory, scientific, and ethical issues of mitochondrial donation.

Critical Response

Iñigo de Miguel Beriain & Begoña Sanz

Human Dignity and Gene Editing: Additional Support for Raposo’s Arguments

Abstract
The aim of the present paper is to reinforce some of the affirmations made by Vera Lucia Raposo in a recent paper published by the Journal of Bioethical Inquiry. According to her, germline gene editing does not violate human dignity at all. This article offers some complementary ideas supporting her statement. In particular, four main arguments are stressed. Firstly, not only is the idea of human dignity unclear, but the idea of the human genome suffers from a general lack of concreteness, which has dramatic consequences for the debate. Secondly, it is highlighted that if we believe that the immutability of the human genome underpins human dignity, then it should be our duty to use the tools of genetic modification to reverse any accidental changes that occur in nature. Thirdly, it is showed that if the alteration of germline constitutes an attack on human dignity, then we should also refrain from performing medical practices such as chemotherapy, which cause precisely this effect. Finally, we argue that modification of germline is not contrary to human dignity but an excellent expression of our autonomy.

Symposium: Conflicts of Interest – Lead Essay

Miriam Wiersma, Wendy Lipworth, Paul Komesaroff & Ian Kerridge

Opening Up New Territories

Intro
Over the last few decades, awareness of the importance of managing conflicts of interest among health-related policymaking, professional, research, and clinical institutions has greatly increased. The visibility of the issue—and the widespread use of the expression “conflict of interests”—may give the impression that the underlying concepts have been clearly defined and that there is widespread consensus about processes and practices. Sadly, this is not the case. In reality, conflicts of interests are far more complex than is commonly appreciated and, because of their importance, require ongoing detailed, rigorous analysis and debate.

Symposium: Conflicts of Interest – Original Research

Jonathan H. Marks

Lessons from Corporate Influence in the Opioid Epidemic: Toward a Norm of Separation

Abstract
There is overwhelming evidence that the opioid crisis—which has cost hundreds of thousands of lives and trillions of dollars (and counting)—has been created or exacerbated by webs of influence woven by several pharmaceutical companies. These webs involve health professionals, patient advocacy groups, medical professional societies, research universities, teaching hospitals, public health agencies, policymakers, and legislators. Opioid companies built these webs as part of corporate strategies of influence that were designed to expand the opioid market from cancer patients to larger groups of patients with acute or chronic pain, to increase dosage as well as opioid use, to downplay the risks of addiction and abuse, and to characterize physicians’ concerns about the addiction and abuse risks as “opiophobia.” In the face of these pervasive strategies, conflict of interest policies have proven insufficient for addressing corporate influence in medical practice, medical research, and public health policy. Governments, the academy, and civil society need to develop counterstrategies to insulate themselves from corporate influence and to preserve their integrity and public trust. These strategies require a paradigm shift—from partnerships with the private sector, which are ordinarily vehicles for corporate influence, to a norm of separation.

Symposium: Conflicts of Interest – Original Research

Jing-Bao Nie, Guangkuan Xie, Hua Chen & Yali Cong

Conflict of Interest in Scientific Research in China: A Socio-ethical Analysis of He Jiankui’s Human Genome-editing Experiment

Abstract
Extensive conflicts of interest (COI) at both individual and institutional levels are identifiable in scientific research and healthcare in China, as in many other parts of the world. A prominent new case from China is He Jiankui’s experiment that produced the world’s first gene-edited babies and that raises numerous ethical, political, socio-cultural, and transnational questions. Serious financial and other COI were involved in He’s genetic adventure. Using He’s infamous experiment as a case study, this paper explores the wider issue of financial and other COI in scientific research and healthcare in China, especially institutional conflict of interest (ICOI) and policy-related COI. Taking a socio-ethical perspective, it examines China’s state policies and its massive efforts to transform and commercialize scientific research, the lack of policies and oversight mechanisms for regulating COI, as well as major ethical issues arising from COI including the undermining of public trust. Some practical suggestions are offered for institutional reform and institutional development so that COI, particularly ICOI, can be avoided or more effectively managed in scientific research in China.

Symposium: Conflicts of Interest – Original Research

Miriam Wiersma, Ian Kerridge & Wendy Lipworth

Status, Respect, and Stigma: A Qualitative Study of Non-financial Interests in Medicine

Abstract
Conflicts of interest (COI) in health and medicine have been the source of considerable public and professional debate. Much of this debate has focused on financial, rather than non-financial COI, which is a significant lacuna because non-financial COI can be just as influential as financial COI. In an effort to explore the nature and effects of non-financial, as well as financial COI, we conducted semi-structured interviews with eleven Australian medical professionals regarding their experiences of, and attitudes towards, COI. We found that this group of medical professionals saw non-financial interests—most notably the pursuit of status and respect and the avoidance of stigma—as potentially conflicting with other important interests (such as patient care).

Symposium: Conflicts of Interest – Original Research

Daniel S. Goldberg

Financial Conflicts of Interest are of Higher Ethical Priority than “Intellectual” Conflicts of Interest

Abstract
The primary claim of this paper is that intellectual conflicts of interest (COIs) exist but are of lower ethical priority than COIs flowing from relationships between health professionals and commercial industry characterized by financial exchange. The paper begins by defining intellectual COIs and framing them in the context of scholarship on non-financial COIs. However, the paper explains that the crucial distinction is not between financial and non-financial COIs but is rather between motivations for bias that flow from relationships and those that do not. While commitments to particular ideas or perspectives can cause all manner of cognitive bias, that fact does not justify denying the enormous power that relationships featuring pecuniary gain have on professional behaviour in term of care, policy, or both. Sufficient reason exists to take both intellectual COIs and financial COIs seriously, but this paper demonstrates why the latter is of higher ethical priority. Multiple reasons will be provided, but the primary rationale grounding the claim is that intellectual COIs may provide reasons to suspect cognitive bias but they do not typically involve a loss of trust in a social role. The same cannot be said for COIs flowing from relationships between health professionals and commercial industries involving financial exchange. The paper then assumes arguendo that the primary rationale is mistaken and proceeds to show why the claims that intellectual COIs are more significant than relationship-based COIs are dubious on their own merits. The final section of the paper summarizes and concludes.

Symposium: Conflicts of Interest – Original Research

Alberto Giubilini & Julian Savulescu

Open Access Beyond Money: Conscientious Objection in Medicine as a Conflict of Interests

Abstract
Conflict of interests (COIs) in medicine are typically taken to be financial in nature: it is often assumed that a COI occurs when a healthcare practitioner’s financial interest conflicts with patients’ interests, public health interests, or professional obligations more generally. Even when non-financial COIs are acknowledged, ethical concerns are almost exclusively reserved for financial COIs. However, the notion of “interests” cannot be reduced to its financial component. Individuals in general, and medical professionals in particular, have different types of interests, many of which are non-financial in nature but can still conflict with professional obligations. The debate about healthcare delivery has largely overlooked this broader notion of interests. Here, we will focus on health practitioners’ moral or religious values as particular types of personal interests involved in healthcare delivery that can generate COIs and on conscientious objection in healthcare as the expression of a particular type of COI. We argue that, in the healthcare context, the COIs generated by interests of conscience can be as ethically problematic, and therefore should be treated in the same way, as financial COIs.

Symposium: Conflicts of Interest – Original Research

Christopher Mayes

After Conflicts of Interest: From Procedural Short-Cut to Ethico-Political Debate

Abstract
This paper critically examines the proliferation of conflicts of interest (COI) discourse and how the most common conceptions of COI presuppose a hierarchy of primary and secondary interests. I show that a form of professional virtue or duty is commonly employed to give the primary interest normative force. However, I argue that in the context of increasingly commercialized healthcare neither virtue nor duty can do the normative work expected of them. Furthermore, I suggest that COI discourse is symptom of rather than solution to the problems of market forces in contemporary medicine. I contend that COI, as it is commonly conceived, is an inadequate concept through which to attend to these problems. It is used as a procedural short-cut to address ethico-political problems. That is, it is an economic and policy concept expected to do significant moral and political work. Like most short-cuts, this one also leads to entanglements and winding roads that fail to reach the destination. As such, I suggest that we need a different set of ethico-political tools to address normative fluidity of medical practice in the absence on a primary interest.

Original Research

Samuel H. LiPuma & Allyson L. Robichaud

Deliver Us From Injustice: Reforming the U.S. Healthcare System

Abstract
For the last fifty years, the United States healthcare system has done an extremely poor job of delivering healthcare in a just and fair manner. The United States holds the dubious distinction of being the only industrialized nation in the world lacking provisions to ensure universal coverage. We attempt to provide some of the reasons this dysfunctional system has persisted and show that healthcare should not be a commodity. We begin with a brief historical overview of healthcare delivery in the United States since WWII. This is followed by a critical analysis of the for-profit model including reasons to support the view that healthcare should not be a free market commodity. We also demonstrate how special interest groups have been able to win support for their practices based on propaganda rather than fact. A brief analysis of the Affordable Care Act is offered along with critical comments regarding its ineffectiveness. We conclude with a brief overview of international approaches that have resulted in universal coverage and suggest the United States ought to adopt an approach similar to those outlined so that it no longer stands as the only industrialized nation to ignore the glaring problems that exist.

Original Research

Veljko Dubljević

The Principle of Autonomy and Behavioural Variant Frontotemporal Dementia

Abstract
Behavioural variant frontotemporal dementia (bvFTD) is characterized by an absence of obvious cognitive impairment and presence of symptoms such as disinhibition, social inappropriateness, personality changes, hyper-sexuality, and hyper-orality. Affected individuals do not feel concerned enough about their actions to be deterred from violating social norms, and their antisocial behaviours are most likely caused by the neurodegenerative processes in the frontal and anterior temporal lobes. BvFTD patients present a challenge for the traditional notion of autonomy and the medical and criminal justice systems. Antisocial behaviour is often the earliest recognized manifestation of bvFTD. Given that the symptoms are not specific and that atrophy of the frontal lobes is only observable with structural neuroimaging in the later stages of the disease, it is hard to ascertain their autonomy. Recently proposed re-conceptualizations of autonomy (Dworkin’s, Jaworska’s, and Dubljević’s) can, however, be sufficiently redefined to provide explicit rules and offer nuanced guidance in such cases. A combination of notions of autonomy gives the most nuanced guidance with three modifications: 1) including socio-moral judgement in the notion of “normal cognitive competence,” 2) excluding in-principle un-endorsable ideals from the notion of “capacity to value,” and 3) redefining ideal-typical degrees of compulsion (mild, severe, and total).

Original Research

Michelle Greason

Ethical Reasoning and Moral Distress in Social Care Among Long-Term Care Staff

Abstract
There are studies on the normative ethical frameworks used by long-term care staff and studies proposing how staff should reason, but few studies explore how staff actually reason. This study reports on the ethical reasoning process and experiences of moral distress of long-term care staff in the provision of social care. Seven interdisciplinary focus groups were conducted with twenty front-line staff. Staff typically did not have difficulty determining the ethical decision and/or action; however, they frequently experience moral distress. To manage these experiences of moral distress in making ethical decisions, staff 1) comply with being told what to do out of fear of consequences, 2) defer decisions to family, 3) “have a meeting,” 4) socialization into and acceptance of workplace culture. Findings suggest that to better understand how and why staff make ethical decisions and improve quality and ethical care, we must explore the interaction between front-line practice and organizational and public policy.

Original Research

K.M. Saulnier

Telling, Hearing, and Believing: A Critical Analysis of Narrative Bioethics

Abstract
Narrative ethics taps into an inherent human need to tell our own stories centred on our own moral values and to have those stories heard and acknowledged. However, not everyone’s words are afforded equal power. The use of narrative ethics in bioethical decision-making is problematized by a disparity in whose stories are told, whose stories are heard, and whose stories are believed. Here, I conduct an analysis of narrative ethics through a critical theory lens to show how entrenched patterns of narrative neglect in medicine are harming not only our capacity to make use of narrative ethics but also our capacity to deliver effective healthcare. To illustrate this point, I use three examples where the patient’s gender affects how their stories unfold: autism, weight, and pain management. From these, I argue that the use of narrative ethics without the application of a critical theory lens risks the exacerbation of what Miranda Fricker refers to as “testimonial injustice,” the prima facie harm experienced by individuals whose credibility is undermined by others’ prejudices. Finally, I suggest that narrative ethics can be a powerful tool for mitigating oppressive practices in medicine if we couple it with critical analysis that enables us to understand the power dynamics at play in storytelling.

Original Research

C.S. Wareham

Genome Editing for Longer Lives: The Problem of Loneliness

Abstract
The development of gene-editing technologies, such as the clustered regularly interspaced short palindromic repeats and associated Cas9 endonuclease (CRISPR/Cas9) system, coincides with a rapidly expanding knowledge of the role of genes in the human ageing process. This raises the prospect that, in addition to the treatment of genetic diseases and disorders, it may become possible to use gene-editing technologies to alter the ageing process and significantly extend the maximum human lifespan. Germline editing poses distinctive problems due to its implications for individual members of future, unborn generations. In this essay, I wish to home in, narrowly, on a single ethical objection to extending the lifespan of future generations by editing the human germline. The objection suggests that to extend lifespans is to unethically inflict the harm of loneliness on future people. I claim that the argument rests on assumptions that ought to be rejected.