Book Review

Conflicts of Interest in Clinical Practice and Research

N Engl J Med 1997; 336:518-519February 13, 1997

Article

Conflicts of Interest in Clinical Practice and Research
Edited by Roy G. Spece, Jr., David S. Shimm, and Allen E. Buchanan. 453 pp. New York, Oxford University Press, 1996. $49.95. ISBN: 0-19-508024-6

In its 19 chapters, this book examines a broad set of issues involving conflicts of interest in medicine, and it does so from an even broader set of perspectives. Often a book of contributed chapters is an uncertain proposition, particularly when the authors come from very different fields. Such works often fail because the chapters are poorly chosen or badly coordinated, but this one succeeds.

The editors — a law professor, a professor of radiation oncology, and an ethicist — tie the chapters together with discussions introducing each section. In addition, many of the contributions show signs that the authors have seen, and reacted to, the chapters written by the other authors. The contributions represent a wide range of well-argued views. Every reader is likely to respond to some chapters eagerly and reject others out of hand, but different readers will make different choices.

The book has four parts. The first comprises six chapters that try to provide a conceptual overview of conflicts of interest, in medicine and elsewhere. Two chapters, by law professors Hazard and Wolfram, discuss how other fields handle such conflicts, pointing out both the parallels with medicine and the important differences. Erde's rigorous philosophical analysis of conflicts of interest is particularly valuable. Buchanan's attack on the very idea of an American medical “profession” is provocative; I suspect it will infuriate most readers and delight a few.

The second part is the heart of the book. Its seven chapters include rigorous and intelligent discussions of conflicts of interest in medical practice. Some chapters focus on issues of self-referral, but others look beyond at the conflicts inherent in prepaid care — and fee-for-service practice. Although (or perhaps because) they reach very different conclusions, the chapters by Rodwin and Hall are particularly strong. Morreim's chapter is also interesting, although her legal analysis needs to be taken very cautiously. Katz's skeptical view of informed consent, though no surprise to followers of his work, is, as always, worthwhile; so is Mitchell's review of the empirical evidence on physician self-referral and joint ventures.

The book's third part contains a single chapter that discusses at length the many potential conflicts of interest involving physicians and the pharmaceutical industry. Its highlight is a detailed — and chilling — case study of the American blood-products industry and AIDS in the early 1980s. Although strong, the discussion would have benefited from international comparisons; in many countries, the events of the same era led to criminal prosecutions. The final section looks usefully at conflicts of interest affecting physicians involved in research. The chapters by Huth and Brody on conflicts of interest in clinical trials both analyze the problems insightfully and make helpful suggestions for change.

The territory this book tries to cover is broad, and its contours are changing rapidly, but the editors give us a coherent and comprehensive look at the issues.

Henry T. Greely, J.D.
Stanford Law School, Stanford, CA 94305-8610