Monday, January 09, 2006

A Multi-Disciplinary Approach to Conflicts of Interest

My colleague Prof. Joachim Krueger, from the Psychology Department at Brown, recently reviewed a book on conflicts of interest that may help inform the discussion of conflicted leadership in health care.

Joachim wrote: "Many items posted on this blog have been concerned with conflicts of interest in the medical field. I recently came across a volume edited by Moore, Cain, Loewenstein, and Bazerman that brings together relevant research from several behavioral sciences. One section of the book is dedicated to conflicts of interests faced by physicians and medical researchers. Because the book also contains sections on conflicts of interests in other domains, as well as the role of psychological processes and organizational responses, it does a lot to put the current discussion in a broader context."

His review, entitled "And Lead Us Not Into Temptation," will be available on PsychCRITIQUES - Contemporary Psychology, although a subscription is required. The book is entitled Conflicts of Interest: Challenges and Solutions in Business, Law, Medicine, and Public Policy.

Piecing together quotes summarizing Joachim's main points:

Conflicts of interests, or COIs, arise when personal motives, especially of a financial nature, are at odds with professional obligations. Many academics are only dimly aware of such conflicts, as when they sign the yearly disclosure form for their employing institution or when they sign a contract for a publisher. This dimness of awareness might result from the lowness of the stakes.
The damage potential is greater when the stakes are higher, a situation most likely faced by powerful players. When this power goes unchecked, the temptation to abuse it must be terrific.
Conflicts of interests pervade the professional world. They play out in individual minds, thereby making large swaths of psychological research relevant. They also unfold in institutional arrangements and policy, thereby creating a need for interdisciplinary study.
The tenor of the book, though not unanimous, is that COIs are more widespread than casual observation suggests, that basic psychological processes contribute to and exacerbate COIs, and that many of the standard remedies backfire, resulting in some 'perverse' effects.
The point is that the line separating corruption from regular COIs is very fine indeed.
COIs do not necessarily lead to corruption, but they might.
To the psychological readership, the question of why people succumb to COIs is the most interesting. The simple answer, given by Dawes, Messick, and especially Chugh et al. and MacCoun, is that people are selfish and irrational. According to this view, the mind either by its own limitations or by its devious design inflates the self, diminishes concern for others, shuts out inconvenient information, and rationalizes unethical action.
Tyler and Dana propose that people can reason about COIs at two levels. At one level, thinking is controlled by self-interest and its attendant calculations of benefits and risks; at another level, thinking is concerned with generic (i.e., 'selfless') social norms and procedural justice. These two levels of thinking need not be in conflict.
Tyler notes that people will not act selfishly if they construe a situation as one that mandates moral behavior. Dana notes that people may act morally, not necessarily out of a deep-seated personal sense of morality, but because they understand that moral rules apply and that their own behaviors will be judged against these rules.
What should be done about COIs? disclosures are not only ineffective, they can be counterproductive. Cain et al. argue that disclosure can heighten egotism by undercutting moral self-control. Lowenstein observes another perverse effect when control is passed from conscience to law. Redefining a formerly immoral behavior as illegal, transgressors are tempted to redefine the fine as an added cost (and bear it if they can).
After so many votes of no confidence on consequentialism, a more categorical 'thou-shalt-not' approach has some appeal. This approach has been around for a long time, even foreseeing critical psychological pitfalls. 'Don’t take bribes, for bribery blinds the sighted and distorts the words of the righteous' (Exodus 23:8). For such exhortations to work, they must enter the conscience of individuals and corporations. Tyler’s work on procedural justice, Dana’s work on the modified dictator game, and Loewenstein’s review of professional identity suggest that conscience matters.
The review is worth reading in its entirety, and much of this book may be of interest to Health Care Renewal readers.

The final point is of particular interest. Physicians swear oaths when they graduate medical school, and are exposed to codes of conduct promulgated by medical organizations. However, non-physician leaders of health care organizations are not often subject to such rules, and few health care organizations display their codes of ethical behavior. Maybe it's time for a change.

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