BJD
E DI TO R IA L
Interests and their conflicts
DOI: 10.1111/bjd.15710
I cannot knock my shins severely without forcing on
some surgeon the difficult question, ‘Could I not make a
better use of a pocketful of guineas than this man is
making of his leg? Could he not write as well – or even
better – on one leg than on two? And the guineas would
make all the difference in the world to me just now. My
wife – my pretty ones – the leg may mortify – it is
always safer to operate – he will be well in a fortnight –
artificial legs are now so well made that they are really
better than natural ones – evolution is towards motors
and leglessness, &c., &c., &c’1
George Bernard Shaw (1856–1950), the Anglo-Irish dramatist
and an excoriating wit, here sets up the temptations of money
to the doctor against his unstated duties to his patient. The
surgeon’s interest is in wealth. What Shaw exposes is the
rationalizing hypocrisies that he indulges to justify a course of
action that will promote that interest. We can note that there
is no third party, no institutional pressure and no other
expressed motivation, beyond the implication of not ignoring
the victim altogether. It’s personal.
The editor of the British Journal of Dermatology has taken the
interesting initiative of inviting views on conflicts of interest
in the specialty, while conceding that dermatology is no more
likely to raise these issues than any other area of medicine.2
What is striking in subsequent contributions is how frequently
discussion has focused on the relationships between doctors
and the pharmaceutical industry. An example is the otherwise
excellent collection of views by Williams et al.3 However, as
Anstey points out in his BJD editorial, the breadth of conflicts
extends beyond the familiar culprit of industry or indeed our
professional lives. There has certainly been no shortage of
publications offering a critique of relations between doctors
and industry. In the U.K., for example, editorial4 and personal
opinions5 and a themed issue of the BMJ5 advocating that it
was ‘time to untangle doctors from drug companies’ go back
many years. In the U.S.A., the role of ‘Big Pharma’ has been
more exhaustively examined in a medical culture where finan-
cial gain appears far more prominent in a fee-for-service sys-
tem. The much-quoted views of the editor of the New England
Journal of Medicine6 stimulated an ongoing discussion, and
another former editor-in-chief has given a fiercely critical view
of the industry.7
‘Interest’ is an ambiguous term. For someone to have an
interest, we often mean that they take an interest in it; or alter-
natively they have an interest if something is in their interest,
i.e. beneficial for them.8 This has been expressed as ‘those
© 2017 British Association of Dermatologists
British Journal of Dermatology
things that a person needs or that are conducive to his or her
flourishing’.9 We may link ‘flourishing’ to some kind of satis-
faction or happiness, the fulfilment of some inclination: some-
thing that we all desire. Against this lie the demands of our
morality. Our inclinations are often in conflict with our moral
sensibilities. Our problem is further complicated by our igno-
rance of even our own, often mixed, motivations. ‘We can
never, even by the most strenuous self-examination, get
entirely behind our covert incentives, since, when moral
worth is at issue, what counts is not actions, which one sees,
but those inner principles of actions that one does not see.’10
We should strive to do right things gladly, but we cannot be
commanded to have this disposition, which is an ‘archetype
we should strive to approach and resemble in an uninter-
rupted but endless progress’. We can try, and morality tells us
that we should: but we know we shall never be more than
partially successful. We shall often be conflicted between what
we would like to do and what we should do in our personal
and our professional lives. Therein lies the value of profes-
sional guidance. Often too, we know what we should do but
lack the will to do it – what philosophers term ‘akrasia’.11
If an interest is (merely) something conducive to flourish-
ing, then in what way is a ‘conflict of interest’ different from
any other prospective moral failing? I think that there is no
real distinction, while noting that secondary interests in con-
flicts of interest are not usually illegitimate in themselves: all
moral decision making involves a choice between alternatives.
We judge that one of them is right in a conflict of priority
between inclination (which should be our secondary interest)
and moral action (or duty, our primary interest). There may
be a satisfaction in pursuing the right course: morality can be
satisfying, but hedonic temptations are often overwhelming.
These factors lead to the suspicions of others and the hypoc-
risies that we all indulge. We like to see ourselves in the best
possible light. It follows that we may not be the best judges
of how our actions will be considered by others.
Conflicts of interest are thought to be bad things, problem-
atic and preferably to be avoided. It is more sensible to see
such conflicts as inevitable, simply part of human interactions
like the moral life itself. Their influence on decision making,
perceived or real, stems from a suspicion, by public or indi-
viduals, that unfair gains are the result. As Anstey points out,
the perception of a conflict may be as damaging as wrongful
action in response to one. At the individual level, both patient
and doctor should be committed to the patient’s welfare, even
if the doctor has a legitimate interest in remuneration for the
services provided – or perhaps just in getting home earlier.
Thus, we can define a conflict of interest12 as a set of condi-
tions in which professional judgement concerning a primary
British Journal of Dermatology (2017) 177, pp331–333 331
332 Editorial
interest (such as a patient’s welfare or the validity of research)
tends to be unduly influenced by a secondary interest (such as
financial gain or getting home early).
Medicine itself has been defined as a ‘set of conversational
and relational skills, rooted in but not confined by knowledge
of the material organism’.13 That is to remind ourselves that it
is essentially a moral enterprise. Its practitioners and its orga-
nizations must therefore be grounded on sound moral founda-
tions. We have to acknowledge those foundations have not
always been apparent at the institutional level or by individual
practitioners. Despite a series of scandals in the U.K., trust in
the profession remains high. For all our interests, it is best for
it to stay that way. Nobody lives without trust: trust in materi-
als, trust in systems, trust in organizations, trust in other peo-
ple, trust in ourselves. An ethos of mistrust leads to a
contractual relationship with an infinite regress as to where
one places trust,14 coupled with increasing suspicion that
specification by contractual attitudes is only necessitated
because there must be an underlying problem. If conflicts of
interest demand further action, that will require a focus upon
medicine’s values and not just ‘the material organism’.
These concerns include the drug industry but also the pub-
lic pursuit of science, research in the higher education sector,
the organization and institutions of health care, the willing-
ness of individuals to sacrifice livelihood for conscience when
a morally unacceptable course of action is proposed and more.
As described by Krimsky,15 ‘modern governments have
become inordinately dependent on expert knowledge for their
decisions’ and their expert decision makers or advisers may,
for reasons of prestige or income, go beyond their expertise.
The culture, norms and values of some academic science may
have changed, becoming entangled with entrepreneurship.
Corporate cash can taint the integrity of academic science at
all levels of institutions. Scholarly journals cannot find inde-
pendent reviewers and institutional integrity evolves into
something different. The temptation of research fraud16
becomes more rewarding, financially and professionally.
Others comment that ‘privatisation and commercialisation are
threatening the objectivity of clinical research and the avail-
ability of health care because uncontrolled market mechanisms
focussed on profit are nurturing conflict of interest that gener-
ate bias and unreliability into research and medicine’.17
Another states that ‘members of corporate driven special inter-
est groups, in virtue of their financial power and close ties
with other members of the group, often get leading roles in
editing medical journals and in advising no-profit research
organization. They act as reviewers and consultants with the
task of systematically preventing dissemination of data which
may be in conflict with their special interests.’18
Public trust in science will require open disclosures of con-
flicts of interest.
Rodwin writes that ‘conflicts of interest are endemic in pri-
vate practice in countries with very different medical, legal, and
political systems. Yet there are also big differences among coun-
tries in the extent and kind of conflicts of interest that exist in
private practice, the measures used to cope with them, and the
British Journal of Dermatology (2017) 177, pp331–333
alternatives to private practice that are available. Each country’s
laws, insurance, and medical institutions shape medical practice;
and within each country, different forms of practice affect clini-
cal choices.’19 Conflicts are more likely in some jurisdictions
than others. The allegations of conflicts of interest against Don-
ald Trump or Francois Fillon and his Welsh wife are difficult to
imagine in the U.K. On the other hand, from a U.K. perspective,
I would have guessed that the ability to earn substantial fees in
private (independent) practice as a supplement to employment
in the U.K.’s National Health Service (NHS) creates a bigger
conflict than the occasional fees from the pharmaceutical indus-
try. The arrangement in the U.K. in which one can work both in
salaried and fee-earning practice is an incentive to maintain a
long waiting list in the former in order to increase business in
the latter. It is a sign of the sensitivities in this area that I have
never seen reliable data to either support or refute these sugges-
tions. (The now outdated investigation by Yates noted the
strength of allegations but reported no evidence.20) Changes in
the organization of care in the English health service has inevita-
bly led to concerns of conflicts of interest between patients and
the (institutional) interests of hospitals.21 Conflicts of interest
occur at all levels of the service including management, govern-
ment and its advisers – not just individuals. One response has
been comprehensive statutory guidance for those involved in
commissioning services.22 It runs to 73 pages of 153 paragraphs
and 10 annexes. It has already been noted that it excludes gen-
eral practices, dentists, community pharmacies, optical provi-
ders and social enterprises.23
Rodwin19 poses these questions: ‘The future of the medical
profession will be shaped largely by how society (sic) answers
these key questions: In what context can physicians be trusted
to act in their patients’ interests? How can medical practice be
organized to minimize physicians’ conflicts of interest? How
can society promote what is best in medical professionalism?
What roles should physicians and organized medicine play in
the medical economy? What roles should insurers, the state,
and markets play in medical care?’
The answer will be: imperfectly. In the U.K., doctors are
already unhappy about the extent and burden of regulatory
controls. In its report on professionalism, the U.K.’s Royal Col-
lege of Physicians of London argued against more regula-
tion.24,25 Against this, resistance to regulation will threaten
trust in an increasingly demanding and suspicious society.
Openness carries a price: this was argued before publishing sur-
gical outcomes, but, as in that case, the gains should be worth-
while. The U.K.’s General Medical Council has issued guidance.
Knowledge and training in this should surely be included in
specialist examinations, such as the MRCP diploma – an essen-
tial passport for those training in medical specialties such as
dermatology. Disclosure of aggregated external earnings and
their source should become routine for all salaried NHS staff as
part of contractual responsibilities, similar to the publicly avail-
able register of interests of parliamentarians. Professional bodies
such as specialist societies or medical royal colleges should
address conflicts of interest in their guidance; and the lengthy
guidance produced for clinical commissioning could be
© 2017 British Association of Dermatologists

markedly shortened, issued in print and online, and discussed
at annual appraisals. These are relatively modest practical mea-
sures, which should be more effective than publishing wordy
reports on ‘professionalism’ which few read. Finally, we should
remember that conflicts of interest are not only about money
and that the integrity of the profession ultimately depends on
the ethical conduct of its individual members, not its managers
or government.
Conflicts of interest
None declared.
Swansea University, Swansea, U.K. J. SAUNDERS
E-mail: SaundersJ19@cardiff.ac.uk
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