Commentary Conflicted by conflicts of interest Kurt J. Matushek, DVM, MS
I
n a recent commentary,1 Dr. Michael Kotlikoff argues that the AVMA should divest itself of the Council on Education (COE) not because of any concerns with the policies or procedures the council uses in accrediting colleges of veterinary medicine, but simply because of “obvious real and apparent conflicts of interest.” His argument rests on three main premises: that conflicts of interest are evidence of bias or wrongdoing, that individual COE members share the same conflicts held by the AVMA or Association of American Veterinary Medical Colleges (AAVMC) as a whole, and that conflicts of interest can be eliminated. However, all three of these premises are demonstrably false. The term conflict of interest is frequently used, but often in inconsistent ways. In 2009, the Institute of Medicine (IOM) released its comprehensive review on conflicts of interest and conflict of interest policies in medicine.2 The definition adopted for that review was that “a conflict of interest is a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest.” Notice, then, that a conflict of interest represents a certain set of circumstances. It is not a behavior; is not indicative of improper actions, wrongdoing, or misconduct; and is not a judgment about the individual who finds himself or herself in that situation. From this definition, it follows that it does no good simply to state that a conflict of interest exists or to argue that the AVMA should divest itself of the COE because the association has conflicts of interest. The same logic would lead to the conclusion that one should never ride in an automobile simply because there is a possibility of being involved in a deadly crash. The crucial factor, both in assessing whether to drive an automobile and whether to be concerned about a conflict of interest, is the magnitude of the risk (or, the severity of the conflict). In this regard, the IOM has recommended that the severity of a conflict be assessed on the basis of the likelihood that professional decisions would be unduly influenced by a secondary interest and the seriousness of the harm or wrong that could result from such influence. Even if we were to stipulate that allowing accreditation decisions to be influenced by financial considerations would cause great harm, we must still evaluate whether any of the financial arrangements the AVMA has with outside entities would be likely to affect those decisions. If, as Dr. Kotlikoff alleges, the Dr. Matushek is Editor-in-Chief of JAVMA and Director of the Publications Division, AVMA, Schaumburg, IL 60173. Address correspondence to Dr. Matushek ([email protected]). JAVMA, Vol 246, No. 6, March 15, 2015
AVMA has financial arrangements both with entities that want to weaken accreditation standards and with entities that want to enhance them, then the overall risk must be quite small. Note also that the IOM specifically recommended against categorizing conflicts of interest as actual versus perceived, warning that “the contrast suggests that there is no conflict (only an appearance of a conflict) unless the decision maker actually favors secondary interests over primary interests.”2 Characterizing certain conflicts as real while others are only perceived results in an unstated assumption that individuals with real conflicts of interest are guilty of wrongdoing. Such an assumption is, of course, patently unfair. In developing its conflict of interest definition, the IOM stressed that any such conflict requires three elements: the primary interest, the secondary interest, and the conflict itself. In this instance, the primary interest is maintaining the integrity of the accreditation process. In identifying the secondary interest, Dr. Kotlikoff warns that financial considerations present a risk that the AVMA may attempt to unduly influence the accreditation process. But, he makes no distinction between institution-wide conflicts of interest (ie, AVMA interests) and conflicts of interest for individual COE members, who are the ones making accreditation decisions. Members of the COE are unpaid volunteers who freely contribute substantial amounts of their own time to ensure that the accreditation process is rigorous and fair. Although it is possible that a council member could have a financial conflict of interest (eg, a paid consultancy with a college under consideration), this would be a set of circumstances related to that individual member and not to the council as a whole. Similarly, individual council members could have conflicts of interest other than financial conflicts (eg, professional advancement, personal recognition, or even favors for friends or family), but these again would be unique to individual members and would be a concern regardless of whether the COE were to remain a part of the AVMA or become an independent entity. Finally, as the IOM report2 makes clear, “conflicts of interest are, to some degree, both ubiquitous and difficult to avoid.” In his proposal for an independent accrediting body, Dr. Kotlikoff argues for a board of trustees selected by presidents of universities that include veterinary colleges. However, such individuals would have financial interests in ensuring both that the veterinary colleges associated with their universities continue to be accredited and that competing colleges, Views: Commentary
601
which might draw applicants away, not be established. Similarly, Dr. Kotlikoff suggests that individuals serving on a new accreditation committee be chosen on the basis of “a lack of any apparent conflicts of interest.” Any individual with sufficient experience and expertise to serve on such a committee, however, could never be considered completely free from conflicts. And, of course, any independent accrediting body would need to financially support itself and, therefore, would be subject to its own financial conflicts of interest. Establishing an independent accrediting body without its own conflicts of interest is simply not possible. All of this is not to say that conflicts of interest are unimportant. They are a concern. But, they will always be a concern, and trying to eliminate them is an impossible task. Rather, the key is to manage them in such a way that they do not influence accreditation decisions. And, the AVMA has done this. Members of the AVMA Board of Directors do not serve on the COE, do not participate in site visits (although they currently may attend as an observer) or COE accreditation discussions, and do not select members of the COE, having turned this duty over to the COE Selection Committee. Members of the COE are themselves required to disclose any conflicts of interest and to recuse themselves when they have conflicts. Dr. Kotlikoff’s point that conflicts of interest should not be allowed to influence accreditation decisions is well-taken, and it appears to be an opportune time
602
Views: Commentary
for both the AVMA and COE to review their current conflict of interest policies to ensure that these policies are comprehensive while still being proportional (ie, directed at the most important conflicts), transparent (ie, comprehensible and accessible to all affected individuals and institutions), accountable (ie, providing clear guidelines for who is responsible for enforcing and revising them), and fair (ie, applying equally to all relevant individuals and institutions). The perception that conflicts of interest could affect the accreditation process is a problem, but this is more a problem of image than substance. Perhaps the AVMA could do more to make it clear that conflicts of interest have been managed appropriately, but to throw over a process that has served the profession well for many decades in favor of an untested one that will itself be faced with conflicts of interest makes little sense. References 1. 2.
Kotlikoff MI. Why the AVMA’s Council on Education should be an independent entity. J Am Vet Med Assoc 2015;246:599–600. Committee on Conflict of Interest in Medical Research, Education, and Practice; Board on Health Sciences Policy; Institute of Medicine. Principles for identifying and assessing conflicts of interest. In: Lo B, Field MJ, eds. Conflict of interest in medical research, education, and practice. Washington, DC: The National Academies Press, 2009;44–61. For all commentaries, views expressed are those of the authors and do not necessarily reflect the official policy of the AVMA.
JAVMA, Vol 246, No. 6, March 15, 2015
I
n a recent commentary,1 Dr. Michael Kotlikoff argues that the AVMA should divest itself of the Council on Education (COE) not because of any concerns with the policies or procedures the council uses in accrediting colleges of veterinary medicine, but simply because of “obvious real and apparent conflicts of interest.” His argument rests on three main premises: that conflicts of interest are evidence of bias or wrongdoing, that individual COE members share the same conflicts held by the AVMA or Association of American Veterinary Medical Colleges (AAVMC) as a whole, and that conflicts of interest can be eliminated. However, all three of these premises are demonstrably false. The term conflict of interest is frequently used, but often in inconsistent ways. In 2009, the Institute of Medicine (IOM) released its comprehensive review on conflicts of interest and conflict of interest policies in medicine.2 The definition adopted for that review was that “a conflict of interest is a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest.” Notice, then, that a conflict of interest represents a certain set of circumstances. It is not a behavior; is not indicative of improper actions, wrongdoing, or misconduct; and is not a judgment about the individual who finds himself or herself in that situation. From this definition, it follows that it does no good simply to state that a conflict of interest exists or to argue that the AVMA should divest itself of the COE because the association has conflicts of interest. The same logic would lead to the conclusion that one should never ride in an automobile simply because there is a possibility of being involved in a deadly crash. The crucial factor, both in assessing whether to drive an automobile and whether to be concerned about a conflict of interest, is the magnitude of the risk (or, the severity of the conflict). In this regard, the IOM has recommended that the severity of a conflict be assessed on the basis of the likelihood that professional decisions would be unduly influenced by a secondary interest and the seriousness of the harm or wrong that could result from such influence. Even if we were to stipulate that allowing accreditation decisions to be influenced by financial considerations would cause great harm, we must still evaluate whether any of the financial arrangements the AVMA has with outside entities would be likely to affect those decisions. If, as Dr. Kotlikoff alleges, the Dr. Matushek is Editor-in-Chief of JAVMA and Director of the Publications Division, AVMA, Schaumburg, IL 60173. Address correspondence to Dr. Matushek ([email protected]). JAVMA, Vol 246, No. 6, March 15, 2015
AVMA has financial arrangements both with entities that want to weaken accreditation standards and with entities that want to enhance them, then the overall risk must be quite small. Note also that the IOM specifically recommended against categorizing conflicts of interest as actual versus perceived, warning that “the contrast suggests that there is no conflict (only an appearance of a conflict) unless the decision maker actually favors secondary interests over primary interests.”2 Characterizing certain conflicts as real while others are only perceived results in an unstated assumption that individuals with real conflicts of interest are guilty of wrongdoing. Such an assumption is, of course, patently unfair. In developing its conflict of interest definition, the IOM stressed that any such conflict requires three elements: the primary interest, the secondary interest, and the conflict itself. In this instance, the primary interest is maintaining the integrity of the accreditation process. In identifying the secondary interest, Dr. Kotlikoff warns that financial considerations present a risk that the AVMA may attempt to unduly influence the accreditation process. But, he makes no distinction between institution-wide conflicts of interest (ie, AVMA interests) and conflicts of interest for individual COE members, who are the ones making accreditation decisions. Members of the COE are unpaid volunteers who freely contribute substantial amounts of their own time to ensure that the accreditation process is rigorous and fair. Although it is possible that a council member could have a financial conflict of interest (eg, a paid consultancy with a college under consideration), this would be a set of circumstances related to that individual member and not to the council as a whole. Similarly, individual council members could have conflicts of interest other than financial conflicts (eg, professional advancement, personal recognition, or even favors for friends or family), but these again would be unique to individual members and would be a concern regardless of whether the COE were to remain a part of the AVMA or become an independent entity. Finally, as the IOM report2 makes clear, “conflicts of interest are, to some degree, both ubiquitous and difficult to avoid.” In his proposal for an independent accrediting body, Dr. Kotlikoff argues for a board of trustees selected by presidents of universities that include veterinary colleges. However, such individuals would have financial interests in ensuring both that the veterinary colleges associated with their universities continue to be accredited and that competing colleges, Views: Commentary
601
which might draw applicants away, not be established. Similarly, Dr. Kotlikoff suggests that individuals serving on a new accreditation committee be chosen on the basis of “a lack of any apparent conflicts of interest.” Any individual with sufficient experience and expertise to serve on such a committee, however, could never be considered completely free from conflicts. And, of course, any independent accrediting body would need to financially support itself and, therefore, would be subject to its own financial conflicts of interest. Establishing an independent accrediting body without its own conflicts of interest is simply not possible. All of this is not to say that conflicts of interest are unimportant. They are a concern. But, they will always be a concern, and trying to eliminate them is an impossible task. Rather, the key is to manage them in such a way that they do not influence accreditation decisions. And, the AVMA has done this. Members of the AVMA Board of Directors do not serve on the COE, do not participate in site visits (although they currently may attend as an observer) or COE accreditation discussions, and do not select members of the COE, having turned this duty over to the COE Selection Committee. Members of the COE are themselves required to disclose any conflicts of interest and to recuse themselves when they have conflicts. Dr. Kotlikoff’s point that conflicts of interest should not be allowed to influence accreditation decisions is well-taken, and it appears to be an opportune time
602
Views: Commentary
for both the AVMA and COE to review their current conflict of interest policies to ensure that these policies are comprehensive while still being proportional (ie, directed at the most important conflicts), transparent (ie, comprehensible and accessible to all affected individuals and institutions), accountable (ie, providing clear guidelines for who is responsible for enforcing and revising them), and fair (ie, applying equally to all relevant individuals and institutions). The perception that conflicts of interest could affect the accreditation process is a problem, but this is more a problem of image than substance. Perhaps the AVMA could do more to make it clear that conflicts of interest have been managed appropriately, but to throw over a process that has served the profession well for many decades in favor of an untested one that will itself be faced with conflicts of interest makes little sense. References 1. 2.
Kotlikoff MI. Why the AVMA’s Council on Education should be an independent entity. J Am Vet Med Assoc 2015;246:599–600. Committee on Conflict of Interest in Medical Research, Education, and Practice; Board on Health Sciences Policy; Institute of Medicine. Principles for identifying and assessing conflicts of interest. In: Lo B, Field MJ, eds. Conflict of interest in medical research, education, and practice. Washington, DC: The National Academies Press, 2009;44–61. For all commentaries, views expressed are those of the authors and do not necessarily reflect the official policy of the AVMA.
JAVMA, Vol 246, No. 6, March 15, 2015
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