Physicians and conflicts of interest
Alexis T. Lama
you L conflicts of interest can arise in any professional activity and, obviously, where they acquire connotations _en medicine especiales_ is not exempt from them. The doctor, in their daily work can be, individually or in groups involved in conflicts of interest both in the care of the sick, and research and education. Although they have always been potentially present in the medical occupation, now seem to be a much more widespread. Also clear that there is a decreased sensitivity to these conflicts, not always appropriate as a response to them. For this reason, it seems appropriate to review this issue, from an ethical perspective, especially when their presence is moving beyond professional circles and is becoming a growing concern of the general public, and the reason for overriding reviews and reports in various media 1, 2 , and even recently addressed in our country, on a specific aspect, the medical journal 3, 4 . Definition
should begin by defining what is a conflict of interest. The word conflict, from the Latin con-flictus indicates struggle, antagonism. Referring to the word interest, limited to the specific struggle that occurs between two or more interest. This referred specifically to the doctor, the concept is close to the situation where two or more interests have become acting struggle the medical professional. Following Thompson, you may note that there is a conflict of interest in the doctor when a secondary interest rate, driven by a group of conditions, may unduly influence their professional opinion in relation to primary or primary interest 5 .
In this definition there are some key elements on which it is appropriate to enter. First, there are two types of interest: one is secondary, and therefore, logically, subject to the primary. And to say that there is a secondary interest is the same as saying that there is a personal or private interest. This secondary interest, personal, can be of various kinds. Most often, that is financial, but as discussed below, includes many other kinds of interests. Should anticipate that in reality there is nothing objectionable in having a personal or private interest in what you do. The problem, and we enter the second key to the definition, is when it enters into antagonism with the primary interest. The latter is the same as saying a professional duty, or what it should be ethically the doctor's primary concern. The third key to the definition is that this conflict can interfere with professional opinion, with their objectivity and independence. The word may is of importance, since it implies the existence of an apparent conflict of interest, apart potential and current. An apparent conflict arises when a reasonable person could conclude that the trial of the doctor may be compromised. One potential involves a situation that can lead to real or actual conflict 6. The last key definition, which is a group of potentially influential. This suggests that having a conflict of interests is an objective situation, and that the problem is only going to unleash on the type of action that freely choose to follow the doctor facing a situation of conflict of interest.
primary duty of the physician
From the above derived clarify what is the primary duty of the physician, which compete against private interests or secondary in a given situation.
In the area of \u200b\u200bdoctor-patient relationship, and following the Hippocratic legacy, the primary duty of the physician to move only in the interest of the patient. The good of the patient is the primary occupation of doctor 7. The medical professional is, and true to what that word means in essence, is obliged to be always biased to serve the patient, not to use it for their own benefit 8. In the research field of duty Primary health care is to seek and transmit the truth. Interest
side can create conflicts of interest
There is a group of situations that may come into conflict with the individual doctor and also for physicians as a group, educational organizations, professional associations and scientific. They can be financial _The more frecuentes_ and other, and variable in their magnitude. Without pretending to exhaust the many possibilities that exist between the interests of a financial side are the links with industry, preferably the pharmaceutical and medical equipment, but not exclusively. Can if any with the food industry, pharmacies, laboratories, etc. and may include payment of conference fees, payment for writing articles in magazines or newspapers, pay to recruit patients for clinical studies investigating payments for a particular product offering of gifts, travel funding, etc.. Also, and very frequent and important in their impact, are derivative financial conflicts of business own physicians, such as sharing fees for the referral of patients or tests, commission for patients referred to other doctors or health professionals, commissions recipes to feed self-reference of patients where medical examinations has financial investments, etc. Self-interest can also exist in order to gain prestige, academic recognition or promotion. Sometimes, there may be conflicts when the same treating clinician is also a researcher funded product, when a physician certifies a patient brain dead to transplant an organ to another of his patients when a doctor does not use the available resources and to decrease costs in the managed care system, etc.
Recently, a new and delicate area of \u200b\u200bconflict of interest is occurring when the private sector rather remuneradas_ _muy request ethics consultations to support their studies or market policies 9, 10 .
Importance of conflicts of interest
To better understand the importance of conflicts of interest may not be well resolved, especially concerning the exercise of individual health and understand the foundation that requires the physician to properly solve it is appropriate to emphasize certain fundamental characteristics that have doctor-patient relationship.
The physician-patient relationship is a fiduciary relationship. That is, a dependent relationship of trust between unequals, in which one party, the physician is powerful. The doctor has the power to heal, but at the same time, the patient, less powerful, he endorses the hope that it will protect your best interests or welfare. The expectation of trust which the patient lays on the doctor requires him to respond appropriately and take no action that could even put into question their actions and undermine this confidence 11. The ethical principle of establishing vulnerability in an unequal relationship of power, knowledge, or material resources, the obligation to respect and protect each other's vulnerability, not exploit it, rests on the strongest. That is, in our case, the doctor. This is else the right way to respond. This is where justice and vulnerability are 7.
Also, conflicts of interest on the part of drivers or clinical trials may compromise the welfare of patients studied and diminish public confidence 12.
Considering the previous comments, we can conclude that anything which might influence our decisions to the effect of postponing the good of the patient or submit their own, or anything that might call into question the confidence that the patient has placed upon us, is ethical failure in our relationship with patients. And I here the risk of conflicts of interest. They threaten to damage the trust between patients and their physicians. And this is essential for the maintenance of medicine as a moral activity. Even the appearance of a conflict of interest is harmful. Patients may lose confidence if only there really perceive influencia_ Even though his doctors are in a state of conflict of interest. And not just at risk of losing confidence and prestige thus _por else curación_ necessary for the doctor as an individual but the profession as a whole.
is in this context that the virtue of prudence of the doctor should be revealed, and therefore should avoid exposure unnecessarily at risk, temptations, which depart from its primary duty professional.
However, one major problem with this type of conflict is that doctors usually do not recognize it, even deny the possibility that they may be influenced by this type of situation. They think they are impervious _especialmente in industria_ referred to the potential influence on their decisions. However, evidence has been contrary to this perception, and has been shown that the huge amount of money the pharmaceutical industry invests in and please visit doctors, eventually resulting in some influence 13, 14 . Thus, it has found in the case of scientific and clinical guidelines development, a strong association between financial ties to the pharmaceutical industry and the recommendation of its products 15, 16 . Studies show that physicians who accept gifts, hospitality, services may compromise the objectivity of its professional opinion in relation to medical information and therefore its subsequent decisions in the care of patients 17, 18 .
The other problem is that there is great sensitivity on the part of doctors against the possibility of facing a conflict of interest, and most seriously, there is usually no adequate response from the doctor when you are inside. Therefore, it is important to understand recommendations about how to address these problems and ethical foundations that exist in this regard. Showdown
conflicts of interest
The best way to deal with a conflict of interest is prevention. For that, the clinician should be very attentive and sensitive to their appearance. This awareness, through the discussion of these issues should begin in the last years of medical student training and during training medical trainees, since they are also the focus of interest to the pharmaceutical industry. We must be vigilant and aware of the so-called perverse relationship that has now produced between it and the doctor who tends to blur his work and academic assistance in the field of research and education 19, and should discuss the issue of businesses' own physicians. Alongside this, greater concern is fundamental in the formative stage of the medical professional for their moral integrity.
If there was conflict, recognize this is the second step. This is not always easy. For revealing the existence of a conflict, and considering that self-interest can obscure the objectivity of the people, and can be easier to recognize when others are in conflict when it is self 20 , some authors recommend what they call the "test of Confidence ': could my colleagues, my patients, my students, general public rely on my opinion, if they know that I'm in this situation? Once it recognized a conflict should be disclosed to the parties that may be affected. This is a very important step, and in any circumstances should be omitted 10 . Unfortunately, it has been observed that often hides 21, 22 . However, reveal only provided does not solve the problem. Third, in cases where conflict may markedly affect the confidence, the physician should simply refuse to participate. Concerning ethical
address the conflicts of interest
In our country there is a very general and indirect reference to mention the phrase _without intereses_ conflict in Article 49 of Title IV, the relationship of physicians with the Company Code of Ethics of the Colegio Médico de Chile AG "are forbidden to physicians accept and receive any kind of payments it might mean commercial collusion professional care ... "23 . On the other hand, our country's Health Code, Article 120 states that "it may work and have business interests that say their business relationship with ....» 24. Very recently the editors of Revista Medica de Chile have published guidelines for the case of medical journals 3, 4 .
However, at present, the most ethical references on the topic from foreign standards, and refer more wide and specific to the various conflicts of interest, such as physicians' own business, its relationship with industry, its relationship with research, education, use of medical samples 25 - 27 , etc. Thus, the fourth edition of Ethics of the American College of Physicians refer explicitly in one of his titles to financial conflicts of interest and other recomendaciones_ _enter notes that "physicians should not refer patients to outside facilities, which have investments and those that do not directly provide care " 28. In another paragraph, referred specifically to the relations of physicians with the pharmaceutical industry states that it "strongly discourages a doctor accepts individual gifts of hospitality, travel and / or subsidies of any kind of chemical-pharmaceutical industry." In relation to this point, on which there is also an extensive and interesting literature that advocates _en good medicine and urgent pacientes_ a distance from the current physician-industry 19, 29 - 33 , the American Society of Internal Medicine, also says that "no gift should be accepted if there are conditions that tie" 34. Canadian Medical Association states that "any medical practitioner must accept personal gifts from the pharmaceutical industry or similar institutions" 35 . For the sake of this issue, the position of the Royal London Medical College: "A physician shall not accept excessive or extraordinary hospitality of any pharmaceutical company ..." 36. Some specific scientific societies such as American Association of Dermatologists have also been expressed on the subject: "Gifts of minimal value are permissible only to the extent they are related to medical work " 37.
For events organized by scientific societies and supported by the industry it is recommended that "the organizers should ensure that promotional activities are separated from the health information fair. The presentation of products in the industry should be undertaken only in areas designed for that purpose and in the case of conferences, the program must clearly identify them as organized independently and separately from the official scientific sessions " 38.
have also been developed ethical framework for the industry in relation to medical 39, 40 .
Moreover, members of ethical societies have published their opinions on how to face their own conflicts of interest with the private sector 9.
Conclusion Conflicts of interest are common in medical practice. The coming of the relationship with the pharmaceutical industry have become very relevant today.
are of different type and magnitude, and are generally not recognized by the doctors themselves.
important because they can threaten patients' trust their doctors and the medical profession. This is the core of the problem.
The resolution, passed eventually and inevitably by virtue of the doctor, is his honesty and integrity. Medical Schools must ensure the moral education of future physicians.
urgent need is to discuss the issue extensively, especially from the ethical point of view, within the scientific unions and medical groups, including, as appropriate to industry representatives _no ruled out in some cases representatives of the comunidad_ and conclude in number of recommendations appropriate to the realities of our country, to guide more explicit internal medicine doctors in training, clinicians and researchers, medical educators, medical associations and scientific unions in the best way to resolve such conflicts in order to protect those medical professionals to serve and safeguard confidence of patients and the general public and the medical profession itself. References
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