Thursday, September 05, 2013

Market Fundamentalism and the Denial of Conflicts of Interest, and of Worse Offenses

While we often point out the pervasiveness of conflicts of interest in medicine and health care, and the likely ill effects of this state of affairs, it seems that the powers that be in health care tend to airily dismiss conflicts of interest as at most a minor problem that needs management (e.g., look here.) 

How Market Fundamentalist Ideology Nullifies the Concept of Conflicts of Interest

On the Hooked: Ethics, Medicine and Pharma blog, Dr Howard Brody discussed how application of the reigning orthodoxy in economics, sometimes called neoliberalism, market fundamentalism, or economism, can be used to dismiss the concept of conflicts of interest.

Basically, supporters of market fundamentalism et al seem to assume that all markets are idealized free markets, and that free markets are like a super computer combining all human thought to provide wisdom in the form of price information.  Furthermore, since the market is based on supposedly rational choices made by free individuals, one cannot go back to question such choices.

 So when, for example, an academic physician makes the "free choice" to accept thousands of dollars from a drug company as a "market consultant," and then also gives talks about clinical topics that happen to favor that drug company's products, such choices cannot be questioned.  Therefore, the notion that these choices constitute a conflict of interest, and that the choice to accept the drug company money in particular might increase the likelihood of abuse of the physician's entrusted responsibility to make the best decisions for individual patients, and to teach other physicians honestly and without bias, essentially makes no sense within this framework.

Dr Brody further enlarged on the internal contradictions within the ideology of neliberalism/ market fundamentalism/ economism, in another post on his Economism Scam blog.

Of course, the ideology seems to ignore the possibilities that 1) people's choice may not be free, may not be rational, and may not be based on coldly rational cognition and the best possible knowledge; and 2) one person's economic choice may limit another person's choices, or directly harm another person.

 By Extension, Fraud and Corruption Denialism

Furthermore, not only does neoliberalism et al seem to deny the existence of meaningful conflicts of interest, it also could be used to deny the meaningful existence of deceptive marketing, of market domination through oligopoly or monopoly, and then of outright fraud, bribery, and extortion. 

See for example how former US Federal Reserve chairman Alan Greenspan seemed to deny the existence of fraud, which he asserted would always be nullified by the ideal market.  As we posted here, according to an article in Stanford Magazine,  Greenspan told Ms Brooksley Born, the federal regulatory agency head who tried to develop some effective regulation of financial derivatives,

'Well, you probably will always believe there should be laws against fraud, and I don’t think there is any need for a law against fraud,' she recalls. Greenspan, Born says, believed the market would take care of itself.

By further extension, market fundamentalism could be used to deny the evils of chattel slavery.

The Conflicted as Defenders of Conflicts of Interest

Finally, notice that neoliberalism/ market fundamentalism/ economism ideology seems to have conveniently been adopted by pundits, both in economics and in medicine and health policy who may be personally profiting from conflicts of interest on one hand, and whose conflicts seem to arise from payments from large corporations whose management seem to be personally profiting even more so. 

For example, we have discussed examples of how defenders of existing financial relationships - which in my humble opinion are actually conflicts of interest - employ logical fallacies to make their points.  Some of these defenders seem to have obvious conflicts of their own (for example, this post included examples of physicians rationalizing their financial ties to drug companies,  and this post included fallacies employed by a current medical school leader, but former extremely well paid biotechnology company executive.).  On the other hand, I have yet to find a logical, reality-based defense of these conflicts of interest made by anyone who demonstrably does not have such conflicts of their own.  


Human beings have been wrestling with corruption since the dawn of history.  There are ancient arguments against bribery in the Bible  (e.g., in the Old Testament, in Exodus and Deuteronomy), and fraud (e.g., in Leviticus, the Proverbs, and the Gospel of Mark).  One can argue that a fundamental purpose of civilization is to reduce self-serving misbehavior such as bribery, fraud, and extortion, and other varieties of corruption.  The notion that free markets make the concepts of fraud, and of conflicts of interest (that are risk factors for corruption - look here) meaningless is nothing more than school playground sophistry.

To truly reform health care, we need to return it from its current Wild West mentality to a state more resembling civilization.  We need to reject silly notions that free markets erase the concepts of conflict of interest, or of fraud, or of other aspects of corruption.     


Steve Lucas said...

This provides an interesting counter to how little it takes to influence a doctor:

The Talmud does teach wisdom, the problem is will people listen?

Steve Lucas

Judy B said...

Steve, your link didn't work. I finally found the post but couldn't see the whole paper. Was it taken down?

Steve Lucas said...

Judy B.

I seem to have connected to the wrong link. This is the reference to the Talmud and highlights how little it takes to influence a person:

The link listed was from another comment, but is a very good piece listed on several blogs, I believe first on HCR. Technology works great if you can just keep it all straight, I also was unable to get the link to work properly.

Thank you for catching my error.

Steve Lucas

Anonymous said...

Spot on, Roy.

Perhaps some of these free-market-will-fix-all arguments might have weight if FREE markets actually existed. And in healthcare we have something far from resembling a free market.

Apologist sophistry!

Building Magic said...

"To truly reform health care, we need to return it from its current Wild West mentality to a state more resembling civilization. We need to reject silly notions that free markets erase the concepts of conflict of interest, or of fraud, or of other aspects of corruption."

Who knew that the Wild West had Medicare, Medicaid, the ACA, the FDA, JCAHO, state-by-state health insurance regulations and HIPAA?

To criticize free-market health care in this country, one would need to point out an example of such. I'm afraid that would be no easy task.

What are the best examples? Cosmetic procedures? OTC meds?

Speaking of "civilized" medicine as a departure from the "evils" of our current government/corporatist model, can you see that the evils and failures of EHR are a predictable byproduct of "civilized" regulatory fundamentalism?

And speaking of silly notions, this is a brief but very thoughtful discussion of biased beliefs about economics (starting on page 5):

Roy M. Poses MD said...

Jason Lee,

The whole point is that health care is currently not a free market. In fact, it is hard to conceive of how health care could ever be a true free market. See our post here summarizing the very cogent arguments by Kenneth Arrow in 1963 to this effect: