Unmasking Special Interest GroupsAuthor(s): Giovanni A.

Fava
Source: Psychotherapy and Psychosomatics , Vol. 79, No. 4 (2010), pp. 203-207
Published by: S. Karger AG

Stable URL: https://www.jstor.org/stable/10.2307/48511265

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Psychotherapy and Psychosomatics

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 Editorial

Psychother Psychosom 2010;79:203–207 Received: September 9, 2009

Accepted: February 11, 2010
DOI: 10.1159/000313688
Published online: April 29, 2010

Unmasking Special Interest Groups:

The Key to Addressing Conflicts of
Interest in Medicine
Giovanni A. Fava 
Department of Psychology, University of Bologna, Bologna, Italy, and Department of Psychiatry,
State University of New York at Buffalo, Buffalo, N.Y., USA

The recent proposal of controlling conflicts of interest
in professional medical associations (PMAs) in the Unit-
ed States apparently represents a bold shift from current
policies [1]. It stems from the recognition of the limita-
tions of disclosure as the sole method for dealing with the
issue. PMAs are now expected to give up all pharmaceu-
tical and medical device industry funding of general bud-
gets – except for income from journal advertising and
exhibition hall fees – and can accept only truly unre-
stricted funds for educational and research purposes.
PMA officers (including members of the practice guide-
line committees) should be completely free from finan-
cial conflicts of interest and PMAs should no longer col-
laborate in or profit from industry marketing activities
[1]. Commercial booths are still allowed at scientific
meetings; however, the proposal states that ‘these booths
should not be in the obligate path to a scientific or educa-
tional session, and must be clearly delineated so that at-
tendees understand that they are entering a marketing
site, and are free to do so or not to do so as they choose’
[1, p. 1369]. Similar restrictions are increasingly reported
in public and private policies [2].
‘Not too much zeal’ warned the 19th century French
diplomat Charles Talleyrand, and his recommendations
seem to apply to the new policies. There are at least two
good reasons for avoiding excessive zeal, aside from not
making life more complicated than it already is. The first,
as Talleyrand feared, is that being overly zealous in advo-
cating a viewpoint might arouse the opposite reaction in
an audience. Indeed, the first sentence of an editorial in
the Journal of Clinical Hypertension announcing the
launch of the Association of Clinical Researchers and Ed-
ucators, which opposes overly stringent rules on conflict
of interest, showed just this kind of resistance. It read:
‘Academic physicians are under attack in the United
States’ [3]. The second is that excessive zeal may also be a
subtle tool for avoiding what would seem to be the mis-
sion and the purpose of an initiative. In The Good Soldier
Švejk by Jaroslav Hašek, Private Švejk avoids going to war
because he pursues his goal of making it to the front line
with such zeal that he is considered insane.
Are the new US rules addressing what matters most?
John Abramson’s book Overdosed America [4] illustrates
how corporate interest has manipulated science, misled
doctors and threatened the health of the community, and
how medical journals and medical societies had a major
role in this, to the extent that a former editor defined
medical journals as ‘an extension of the marketing arm

© 2010 S. Karger AG, Basel G.A. Fava, MD

0033–3190/10/0794–0203$26.00/0 Department of Psychology, University of Bologna
Fax +41 61 306 12 34 Viale Berti Pichat, 5
E-Mail karger@karger.ch Accessible online at: IT–40127 Bologna (Italy)
www.karger.com www.karger.com/pps Tel. +39 051 209 1339, Fax +39 051 243 086, E-Mail giovanniandrea.fava @ unibo.it

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of the pharmaceutical companies’ [5]. When our journal
published the first investigation which gave an idea of the
extent and dangerousness of conflict of interest in science
[6], this took place in a stage of massive denial by major
medical journals [7]. The issue was whether specific epi-
sodes that emerged were the unavoidable drawbacks of a
scientific system that functioned in a substantially inde-
pendent way, or whether they were simply the tip of the
iceberg. What iceberg? Corporate interest which results
in self-selected academic oligarchies (special interest
groups) that influence clinical and scientific information
[7]. Members of special interest groups, by virtue of their
financial power and close ties with other members of the
group, have the task of systematically preventing dissem-
ination of data which may be in conflict with their inter-
ests. The first target is to undermine the critical individ-
ual judgment of the physicians. George Engel [8] differ-
entiated between ‘scientific physicians’ (clinicians who
fully apply the scientific method in their care of patients
and in their understanding of the disease) and ‘physician-
scientists’ (physicians whose primary commitment is to
scientific research pertaining to medicine, with no obli-
gation to be involved with patients). Clinical practice is
the source of fundamental scientific challenges for scien-
tific physicians, whereas the application of basic (includ-
ing pharmaceutical) research is the preferred focus of
physician-scientists. The intellectual freedom portrayed
by scientific physicians is the worst enemy of special in-
terest groups, and thus requires massive doses of censor-
ship. Censorship may take different forms: direct sup-
pression of information by special interest groups who act
as editors and reviewers or make choices in scientific pro-
grams, careful selection of the literature in a biased direc-
tion and manipulated interpretation of clinical trials (in-
cluding those supported by public sources), and self-cen-
sorship (when an investigator omits raising questions and
criticism for the fear of retaliation) [9].
Other instrumental methods are the substitution of
critical reviews with meta-analyses whose data could be
easily manipulated by excluding censored (unpublished)
studies [10], the emphasis on clinical guidelines by ex-
perts with major conflicts of interest [11], full control of
medical societies, their journals and their meetings [12],
and keeping medical literature as distant as possible from
the clinical problems of daily practice. An editor who is
personally devoid of financial conflicts of interest but is
inclined to focus on issues that have no overt relationship
to clinical phenomena is functional to these strategies.
Special interest groups are ready to modify their ap-
proach if circumstances require it. In the US the call
204 Psychother Psychosom 2010;79:203–207
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against conflicts of interest took place essentially to coun-
teract the increasing loss of credibility of clinical medi-
cine, engendered by the work of the Senate Finance Com-
mittee, chaired by Senator Charles Grassely, on failures
to disclose conflicts by prominent physicians and by cor-
porate actions that placed profit over health and became
regular news in the media [2], with the ensuing with-
drawal of pharmaceutical support to PMAs.
Chomsky’s [13] mechanisms of propaganda may apply
to what has occurred in medicine in the past two decades.
Corporate interests have fused with academic medicine
to create an unhealthy alliance that works against objec-
tive reporting of clinical research (censorship), sets up
meetings and symposia with the specific purpose of sell-
ing the participants to the sponsors (engineering opin-
ions), gets its prodigal experts into leading roles in jour-
nals, medical associations and non-profit research or-
ganizations (using the public relations industry) and
provides the appropriate degree of retaliation to outliers
(marginalizing dissident cultures). Examples of the spec-
tacular achievements of propaganda that took place in
psychiatry are as follows:
• the denial of the link between selective serotonin reup-
take inhibitors and suicidal risk before the publication
of a critical review in our journal [14];
• overprescribing of antidepressants based on removal
of negative studies and findings [15, 16];
• the use of the term ‘antidepressant discontinuation
syndrome’ for withdrawal syndromes which entail
important clinical implications, such as misinterpre-
tation of these reactions as signs of impending relapse
[10];
• the prolongation of antidepressant drug treatment for
preventing relapse based on meta-analyses of pub-
lished studies, such as the one by Geddes et al. [17], that
failed to take publication bias into account [18];
• the switch from benzodiazepines to newer antidepres-
sants in anxiety disorders without any evidence to
support it [19];
• the prescription of atypical antipsychotics for the
treatment of behavioral problems in dementia despite
lack of supporting data [20].
Prescribers may claim to be following the evidence,
but are primarily influenced by the eminence of the au-
thorities they listen to in meetings and read in journals
[21] or by the framing of the risk of medication side ef-
fects by the pharmaceutical industry [22]. This occurs
also because of the control of special interest groups over
diagnostic classification [23] and clinical guidelines
committees [24]. It is certainly not because of a few bad
Fava
apples or a couple of Bernie Madoffs [2] that the medical
field is being punished. The clinician who wants to retain
a cautious and balanced attitude feels like the person
whom Chomsky depicts as sitting alone in front of the
TV, thinking he/she must be crazy or outdated for not
buying what comes out of the tube [13]. The same clini-
cian now feels like a criminal if he/she drinks fruit juice
at a commercial stand in a meeting, while leaders of sci-
entific societies, medical journals and academic medi-
cine who were actively involved in the propaganda or
looked the other way, ignoring the few who did speak up
years ago, are teaching us how to behave as to conflict of
interest.
A proposal for an operational definition of substantial
conflict of interest, based on the work by Krimsky et al.
[6], was recently presented [25], with the task of increas-
ing intellectual freedom. This proposal underscores the
dangers of the continuity of a financial relationship with
a private company as outlined in table 1. Occasional con-
sultancies, grants for performing an investigation, or re-
ceiving honoraria or refunds on specific occasions would
not be a source of substantial conflict of interest. Indeed,
it would be perfectly legitimate and essential for the prog-
ress of science to collaborate with the industry on spe-
cific scientific projects.
Rothman et al. [1] suggested that authors of clinical
practice guidelines should be free from any financial con-
flict of interest, mainly as an aftermath of the scandals
that took place over many guidelines. But what about au-
thors of review articles and meta-analyses? And priority
for obtaining grants from public agencies supported by
taxpayer money? These and other suggestions are de-
scribed in table 2 [25].
Mario Maj [26] has recently summarized several is-
sues concerned with non-financial conflicts of interest
and has expanded the notion of ‘special interest groups’
to academic, political and personal ties. Table 3 outlines
several steps to address non-financial conflicts of interest
in medical research, as discussed in detail elsewhere [27].
The rationale behind this strategy is to increase and sup-
port the reservoir of disinterested experts who can be
called upon to advise government policy makers and
physicians on the safety and efficacy of treatments and on
the hazards of chemicals [6] and the dangers of restrictive
ideology leading to ‘trivial variations on tired themes’ in
grant and journal selections [28].
The crisis of credibility in the medical profession has
not yielded a reformulation of the missions and goals of
PMAs. Table 4 indicates some priorities in an agenda for
fostering creativity and independence.
Special Interest Groups
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Table 1. Criteria for the presence of substantial conflict of interest
of a researcher
The researcher meets at least one of the following:
1 Being an employee of a private firm
2 Being a regular consultant or on the board of directors of a
firm
3 Being a stockholder of a firm related to the field of research
4 Owning a patent directly related to the published work
Table 2. Lines of support for independent researchers who are free
of substantial conflict of interest
1 Priority for obtaining grants from public agencies supported
by taxpayer money
2 Priority for scientific society and medical journal editorship
positions
3 Adequate visibility in scientific society meeting programs
4 Inclusion only of researchers with no substantial conflict of
interest in clinical practice guidelines groups
5 Conflict-free investigations and critical reviews should be
emphasized in training and continuing medical education
and should have priority in medical journals
6 Priority for conflict-free meta-analyses in medical journals
Table 3. Steps to addressing non-financial conflicts of interest in
medical research
1 Disclosure of both non-financial and financial conflicts of
interest should be performed by the editor and reviewers of a
scientific journal
2 The request by the submitting author to exclude specific
experts from the review process should be granted by the
editor, whereas assignment to suggested reviewers may be
discretional
3 Members of a committee in granting agencies and external
experts cannot act as reviewers if they share previous
publications and research projects or belong to the same
institution or are a relative of the grant applicant
4 All grant application reviewers should provide full disclosure
of both non-financial and financial conflicts of interest
5 Increased input from the general public, patients’ associations
and scientists whose main field is outside of the one which is
the target of grant applications
6 Inclusion of people who represent the perspectives of research
subjects and are not academic researchers on institutional
review boards
7 Independent review bodies (within each field) for examining
the issues concerned with non-financial conflict of interest
Psychother Psychosom 2010;79:203–207 205
Table 4. Agenda for fostering creativity and independence in
PMAs
1 PMAs should reformulate their missions and goals with the
help of the general public and patients’ associations
2 A complete change of leadership of PMAs, including
editorship of affiliated journals, should occur
3 Society meetings should be held every other year to avoid the
ecological wastage of annual events
4 The structure of the meetings should be reformulated,
giving priority to in depth discussions of scientists with no
substantial conflict of interest
5 PMAs should be boycotted by members who are dissatisfied
as to the handling of conflict of interest
While Rothman et al. [1] pay zealous attention to the
location of commercial stands in scientific meetings,
there is no mention to the need for substantial changes
in structure and characteristics of these events. Society
meetings are still held on an annual basis, causing major
ecological wastage due to thousands of people travelling
to reach the sites, and reflect a 20th century communica-
tion paradigm, where meetings were of the main source
of scientific novelties compared to printed journals. At a
time when information is available to the scientific com-
munity through the internet, scientific meetings should
offer the opportunity for in depth discussions among sci-
entists with no substantial conflict of interest; a pause
from information overload.
Medical journals and meetings tend to be blind to the
psychosocial issues of clinical research. At present al-
most all health care spending is directed at biomedical-
ly oriented care. Still, half of the deaths that take place
in the USA can be attributed to largely preventable be-
haviors and exposure, such as tobacco smoking, obesity
and physical inactivity [29]. Not surprisingly, psychoso-
matic medicine does not seem to find room in the pres-
ent medical establishment, since it challenges the reduc-
tionism which paves the ground for pharmaceutical
propaganda.
Quite appropriately, Hirsch [30] argues that many
journals and editors have compromised their credibility,
have double standards as to judging integrity, and ignore
major positive changes that have occurred in the pharma-
ceutical industry in the past decade. In an accompanying
editorial, Lanier [31] wonders whether journal editors
who published flawed industry-funded research, to save
their own personal brand integrity and that of their jour-
nals, are leading us to an era of scientific McCarthyism.
Will the new rules on conflict of interest [1] give med-
icine its credibility back? Probably not. They may even
further decrease intellectual freedom. Only a true change
in leadership will do.

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