Where the sun never shines

Are Brean About the author

Trust in authors and journals depends on openness about financial conflicts of interest

Photo: Einar Nilsen

When the editors of two of the world’s leading general medical journals come to blows in what may seem like an academic dogfight, there is reason to pay attention. It all started when the New England Journal of Medicine (NEJM) recently published three commentary articles by Lisa Rosenbaum, accompanied by an editorial written by Jeffrey M. Drazen, editor-in-chief (1 – 4). Simply put, the message was that the concerns over authors’ financial conflicts of interest are often exaggerated and a hindrance to the best interests of the profession.

The responses from the other side of the Atlantic were not slow in coming and did not mince words: «We don’t find much to agree with in NEJM’s anecdotal analysis,» wrote Fiona Godlee, editor-in-chief of the BMJ (5). Three former editors of the NEJM described the articles as «a seriously flawed and inflammatory attack», and used words such as «rambling», «silliness», «fear mongering» and «fanciful» in referring to Rosenbaum’s analysis (6).

To understand the unusually strident reactions, we need to know the underlying story: During the 1970s and 80s, the connections between doctors and pharmaceutical companies became increasingly complex and problematic. On several occasions, drug studies published in the NEJM had caused the share prices of the manufacturers involved to soar (7). Something had to be done to prevent medical publishing from falling into serious disrepute. In 1984, Arnold Relman, editor-in-chief, introduced a measure: all authors of scientific studies were requested to report their financial ties and conflicts of interest (7). Since then, increasingly rigorous requirements have been introduced. In 1990, a rule was introduced saying that no authors of review articles or editorials were permitted to have ties to manufacturers of drugs referred to in the articles in question (8). The BMJ, on the other hand, maintained its emphasis on openness rather than restrictions, but in 2014 the journal introduced restrictions that were even more stringent than those of the NEJM: No authors of review articles or editorials are permitted to have any ties to the industry (9).

Now, however, Jeffrey M. Drazen appears to think that the fear of the pharmaceutical industry has gone too far. Figures from the USA may elucidate why so many are in disagreement: The Physician Payments Sunshine Act, which came into force in 2010, requires all manufacturers of drugs and medical equipment to report their contributions to individual doctors and hospitals. Over the last five months of 2013, a total of 4.45 million such transactions were registered, and the total value for 2014 may exceed USD 9 billion (10). In other words, there is no reason to believe that the problematic interactions described by Relman in 1984 have abated over the years (7). One juicy detail, however, is that a significant part of NEJM’s own financial conflicts of interest is exempt from public access – there is reason to assume that a significant proportion of the journal’s revenues stem from the sale of offprints of drug studies, but the journal has refused to comment on this allegation (11).

The problem is not a moral, but a practical one, as noted by Fiona Godlee in the BMJ (12). There are many good reasons for doctors and pharmaceutical companies to collaborate, and receiving money is not equivalent to «having sold out to the industry». The point, however, is a simple one: there is no such thing as a free lunch. The pharmaceutical companies are not charitable organisations, they are commercial enterprises with a legitimate need to exert influence. Doctors and researchers, on the other hand, are dependent on the trust of the public that they are unbiased in the fulfilment of their social mandate. Therefore, all financial and material ties must withstand the bright sunlight of public scrutiny.

In the Journal of the Norwegian Medical Association we place weight on openness rather than restrictions. In 2001 we introduced requirements for reporting of financial conflicts of interest (13), and since 2010 we have required all authors to sign the international form developed by the Vancouver group for reporting of these (14). Our policy in this area will continue to develop in the years to come. This is necessary for ensuring that the journal and our authors enjoy the trust on which we depend. The most important job, however, must be shared by us all: to always remain critical readers (15). No matter what requirements for openness are brought to bear, there will always be places where the sun does not penetrate.


Rosenbaum L. Conflicts of interest: part 1: Reconnecting the dots – reinterpreting industry-physician relations. N Engl J Med 2015; 372: 1860 – 4. [PubMed] [CrossRef]


Rosenbaum L. Understanding bias – the case for careful study. N Engl J Med 2015; 372: 1959 – 63. [PubMed] [CrossRef]


Rosenbaum L. Beyond moral outrage–weighing the trade-offs of COI regulation. N Engl J Med 2015; 372: 2064 – 8. [PubMed] [CrossRef]


Drazen JM. Revisiting the commercial-academic interface. N Engl J Med 2015; 372: 1853 – 4. [PubMed] [CrossRef]


Loder E, Brizzell C, Godlee F. Revisiting the commercial-academic interface in medical journals. BMJ 2015; 350: h2957. [PubMed] [CrossRef]


Steinbrook R, Kassirer JP, Angell M. Justifying conflicts of interest in medical journals: a very bad idea. BMJ 2015; 350: h2942. [PubMed] [CrossRef]


Relman AS. Dealing with conflicts of interest. N Engl J Med 1984; 310: 1182 – 3. [PubMed] [CrossRef]


Relman AS. New «Information for authors» – and readers. N Engl J Med 1990; 323: 56. [PubMed] [CrossRef]


Chew M, Brizzell C, Abbasi K et al. Medical journals and industry ties. BMJ 2014; 349: g7197. [PubMed] [CrossRef]


Department of Health and Human Services, Centers for Medicare and Medicaid Services. Annual report to Congress on the open payments program for fiscal year 2014. www.cms.gov/OpenPayments/Downloads/Open-Payments-April-2015-Report-to-Congress.pdf (23.6.2015).


Callaway E. Questions raised over medical journals’ financial ties to industry. Nature 2010. www.nature.com/news/2010/101026/full/news.2010.564.html (23.6.2015).


Godlee F. Conflict of interest: forward not backward. BMJ 2015; 350: h3176. [CrossRef]


Nylenna M. Interessekonflikter. Tidsskr Nor Lægeforen 2001; 16: 121.


Haug C. Nytt og bedre. Tidsskr Nor Legeforen 2010; 130: 2325.


Brean A. Hva er en medisinsk sannhet? Tidsskr Nor Legeforen 2013; 133: 381. [PubMed]


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