Conflict of interest
“The need for justice grows out of the conflict of human interests.” — John Rawls.
WE were sitting in a committee room in the National Assembly building, participating in a meeting of the National Assembly Standing Committee on Health. The subject under discussion was the regulation of private medical colleges in Pakistan because of serious concerns about their performance.
At least three members of this committee owned private medical colleges and two others were on the board of different colleges in Pakistan. They were loudly justifying the working of private medical institutions. Nobody pointed out the conflict of interest. The meeting ended without concluding anything on the stringency of regulation.
The above example is repeated every day in different forms, with different people, and during different meetings on different topics, and those who have a direct interest in the subject usually prevail. Nobody talks about it, nobody takes it up, and if ever there is a mention by anybody, that person becomes persona non grata, a troublemaker, and is portrayed as somebody who doesn’t understand the ‘realities’ of the world. As happened in the above-mentioned meeting!
Recently, the owner of a medical college, a teaching hospital, and a number of other health-related organisations was made chairman of the Board of Authority of Islamabad Healthcare Regulatory Authority. Nothing personal, but it is against common ethical sense. Those who are to be regulated must not head the regulatory body which is going to regulate them.
In a society suffering a moral crisis, conflict of interest is on the lower rung of the ladder. It comprises a faded shade on the ethics spectrum, which people hardly ever see. There are much bigger issues — such as disrespecting the Constitution, and the lack of rule of law; hence, few care about discussions on conflict of interest. However, in healthcare, ignorance or lack of attention to a conflict of interest can be a matter of life and death, directly or indirectly. So, it is indeed very important.
There are many definitions and descriptions of conflict of interest from the legal, moral and technical perspectives. One that I really like is picked from a World Health Organisation publication. It describes a two-day meeting on the subject, where experts discussed and agreed on this definition: “An actual conflict of interest arises when a vested interest has the potential to unduly influence official or agency judgement/action through the monetary or material benefits it confers on the official or agency.” I think this is it.
Those who are to be regulated must not head the body which is going to regulate them.
In 2021, a major scoping review was published in the British Medical Journal by Susan Chimonas et al on mapping all known ties between the medical product industry and the healthcare ecosystem. They developed a map through the synthesis of 538 articles from 37 countries showing the extensive network of medical product industry ties to activities and parties in the healthcare system. They identified activities in health research, healthcare education, guideline development, formulary selection, and clinical care.
The medical product industry was found to have direct ties to almost all parties in the healthcare ecosystem, including non-profit entities, the healthcare profession, the market supply chain, and government. The most frequently identified parties were individual health professionals described in 422 (78 per cent) of the included studies.
More than half (303 or 56pc) of the publications documented the medical product industry ties to research, with clinical care (156 or 29pc), health professional education (145 or 27pc), guideline development (33 or 6pc), and formulary selection (eight or 1pc). Policies for conflicts of interest existed for some financial and a few non-financial ties.
Nothing is interest-free though. We all have legitimate professional and personal interests. The issue arises when opposing interests combine in one person or an entity and when private interests are pursued through a position of power by undermining professional or public interest.
Situations of conflict of interest are ubiquitous and natural. The real point of the discussion should be how to deal with conflicts of interest. First of all, the system should be sensitive to such situations and it should be able to recognise it. Secondly, there should be an institutional framework to manage a conflict of interest. A proper system of declaration and management of conflict of interest blunts the interest to the extent required in the conflict situation.
I have sat in many international meetings where all participants had to sign an elaborate conflict of interest form before the beginning of the meeting and some participants had to recuse themselves on certain points of discussion which had to do with their direct interest. And all this is recorded in the minutes of the meeting.
Institutions that believe in and practise good governance usually have explicit, written-down policies on conflict of interest. The best definition of a policy is that it helps people avoid becoming hostage to events. Getting caught in a situation and not knowing what to do about it or how to handle it lands the organisation in a position of arbitrariness.
Power, instead of principle, then prevails. Once a policy is made, there should be a mechanism and well-defined responsibilities for the implementation of the policy. The members of the organisation should be made aware of the policy; they must be trained and then monitored for their conduct, and reported in a transparent way; appropriate well-laid-out accountability procedures must take their course.
True, even with all the above in place it doesn’t mean that everything will be sorted out and everybody will live happily thereafter. The key is to continue to work in the loop of practice, learning, monitoring, course correction and continuity of practice.
In Pakistan, conflict of interest is generally not seen as a conflict or even a milder form of the problem; hence it has permeated our body politic at every level and every sector and organisation. When people stop feeling guilty about an unethical act, it becomes normalised, and this is the most dangerous situation.
The writer is a former health minister and currently a professor of health systems & population health at the Shifa Tameer-i-Millat University.
Published in Dawn, February 22nd, 2025