Beyond Money: Conscientious Objection in Medicine as a Conflict of Interests.

"Financial Conflict of Interest and Non-Financial Conflict of Interest According to current guidelines regulating healthcare practice and biomedical research and scholarly debate on this issue, in the scenarios described above, the only problematic interactions between the doctors’ personal lives and their patient care arise for John’s doctor in the antibiotics scenario and perhaps Mark’s doctor in the vaccination scenario (see, e.g., Rodwin 1993; Topol and Blumenthal 2005; Brennan et al. 2006; Brody 2011; Rodwin 2011; Rodwin 2012; Stamatakis et al. 2013; Kelly 2016). This is because they involve financial interests, which are typically taken to generate either the only or the most problematic type of conflict of interest (COI) in healthcare. The U.S. National Institutes of Health rules for dealing with conflict of interest in medical research and the U.K. General Medical Council guidelines on the subject only address financial conflict of interest (FCOI) (Department of Health and Human Services 2011; GMC 2013). The NHS definition of “interests” in its document regulating COI management, while including non-financial interests, understands them merely in terms of material gains or of some form of personal benefit, such as professional reputation (NHS England 2017). Where the possibility of non-financial conflict of interest is acknowledged (e.g., Institute of Medicine 2009), the tendency is to think that non-financial interests affecting professional healthcare practice should not (Bero and Grundy 2016) or cannot (Institute of Medicine 2009) be regulated. In the scholarly debate, only recently have some started to include non-financial interests among the possible sources of COI that might need to be prevented, constrained, or somehow regulated in the same way as financial interests, both in biomedical research (Saver 2012) and in healthcare (Wiersma et al. 2018a and 2018b; Smith and Blazeby 2018). It is noteworthy that some of the interests that we have mentioned in the above scenarios, namely those having to do with certain moral beliefs, are not only considered permissible but are often supported in academic and professional contexts, including through legislation in the form of “conscientious objection” provision. Nonetheless, as some of the scenarios above suggest, personal moral or religious beliefs can affect one’s professional practice to the same extent as, if not to a greater extent than, financial interests. In this paper, we will argue that ethical issues arising from conflicts of interest in healthcare are not limited to financial interests, and that the same ethical and regulatory perspective currently adopted with regard to FCOI should be extended to non-financial conflict of interest (NFCOI). Not all the situations in the scenarios above constitute a conflict of interest, and not all COIs in healthcare give rise to an ethically impermissible outcome. However, we argue that the issue of whether a COI is financial or non-financial in nature is not the criterion by which to determine whether a certain interest generates a conflict of interest or whether that conflict led to unethical behaviour. NFCOIs have the potential to lead to ethically impermissible or ethically problematic behaviours just as FCOIs can, and they should be managed to avoid this outcome to the same degree as FCOIs, if doing so is feasible. In order to argue for this claim, we need first to clearly define what is meant by “conflict of interest,” which requires some preliminary analysis of the concepts of “interest” and of “conflict.” We will turn to this task in the next section. Interests, Conflicts, and Conflicts of Interest InterestsFrom a philosophical point of view, an interest can be defined in terms of having a stake in something, or, as Joel Feinberg puts it,[o]ne’s interests (…) taken as a miscellaneous collection, consist of all those things in which one has a stake, whereas one’s interest in the singular, one’s personal interest or self-interest, consists in the harmonious advancement of all one’s interests in the plural. (Feinberg 1987, 34)An alternative but equivalent characterization, still inspired by Feinberg, is the one according to which “to have an interest in something is to have a stake in it, and to have a stake in X is to stand to lose or gain depending on what happens to X” (Weale 1998).The interests in question when we discuss COI in healthcare are specific interests that can conflict with either other individuals’ interests (most notably, patients’ interests) or with specific professional obligations. The reference to professional obligations is important. An understanding of COI in healthcare that focuses only on the conflict between a physician’s personal interests and the interests of patients is too narrow to capture the ethically relevant aspects of conflicts of interest in healthcare. Brody’s definition of conflict of interest, based on Erde’s influential analysis (1996), seems to imply this narrow understanding when he writes that an interest that gives rise to a COI in healthcare is one that “would tempt a person of normal human psychology to neglect the patient’s/public’s interests in favor of the physician’s (or third party’s)” (Brody 2011, 24).Sometimes, however, physicians have personal interests that do not conflict with individual patients’ interests or the public interest but that do conflict with their obligations to the profession. One example is an obligation to act according to a certain standard of fairness, for example in the distribution of the burdens required by certain professional roles amongst the workforce. These professional obligations can be taken to be “interests,” or “professional interests,” according to a different, and broader, definition of “interest,” such as the one provided by the Royal Australasian College of Physicians, according to which an interest is to be understood as “a value, goal or obligation associated with a social relationship or practice” (The Royal Australasian College of Physicians 2018, 7). The word “associated” here can be understood either in a descriptive sense (as a matter of fact, certain relationships or practices do generate interests for the physicians, such as receiving gifts from pharmaceutical companies in exchange for promoting certain drugs) or in a normative sense (certain practices, such as the healthcare profession, should generate interests for professionals to fulfil certain professional requirements). In other words, the normative sense suggests there is something wrong when one has an interest in practising within a profession but does not have an interest in fulfilling the requirements of that profession. In fact, in most professions, failing to fulfil professional obligations is a reason for dismissing a person from their role.We have thus distinguished what we might call “personal interests” from what we might call “professional interests.” A general definition provided by Lipworth et al. (2019) is broad enough to include both types of interests; as they define them, interests are “people’s concerns for themselves or perceived duties to others that are relevant to the social role or roles they assume.” However, it is useful to keep the two kinds of interest distinct in order to more easily see how they can conflict with each other in healthcare. The scenarios described at the beginning contain clear examples.Below, we will return to the issue of how professional obligations should be defined on the basis of the “four principles” of biomedical ethics: respect for autonomy, beneficence, non-maleficence, and justice (Beauchamp and Childress 2012). Self-InterestWhen a conflict does arise, one factor which differentiates the FCOIs and NFCOIs might be the question of self-interest. A doctor with an FCOI is clearly party to a self-interested benefit by prescribing, for example, unnecessary antibiotics from a company the doctor holds shares in. On the other hand, an NFCOI is harder to connect to self-interest.However, there may be directly analogous self-interested benefits arising from non-financial interests also. Status and recognition are one example, as are doctors’ personal moral or religious views—what we might call “moral interests.” Importantly, moral interests also have implications for one’s status and standing to others and oneself. Someone’s conscientious objection to abortion might help them gain social recognition among colleagues or superiors who share the underlying moral beliefs. Thus, moral interests may be a more potent source of conflict than money, both because of a professional’s interest in preserving their own moral integrity and because of their interest in gaining some form of recognition within a certain group (say, colleagues or superiors with the same moral convictions, their religious community, and so on).However, even if we assume that the doctor does not receive a self-interested benefit in this way, or even if the doctor experiences a social or professional cost for their behaviour, the problem that a COI poses is not that the doctor receives a self-interested benefit in itself. After all, we tend to pay doctors well for their work, and it would be perfectly acceptable for a doctor to choose one arm of the profession over another for its better rate of remuneration. A problem arises if and when, due to the COI, the patient’s care was affected by the interest, or was seen to be affected.Consider a COI in the legal profession. A solicitor cannot act for both parties in a house purchase. This is not to avoid self-interested behaviour. It is because a solicitor has a duty to put each client’s interests first. It is not possible to commit to this for both clients. Each time she meets a client, there is the potential that her consultation will be affected by her other client’s interests. Conflicted CareOf course, in professional settings, and in the healthcare profession in particular, not all personal "

"AG and JS were funded by the Wellcome Centre for Ethics and Humanities, University of Oxford, which is supported by a Wellcome Centre Grant (203132/Z/16/Z), and by the Wellcome Trust grant 104848/Z/14/Z. "