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Journal fuels conflict-of-interest debate The prestigious New England Journal of Medicine has the toughest conflict-of-interest policy of any science publication - and the toughest to enforce. Just how difficult has become apparent during the last two weeks. First, the Journal acknowledged it shouldn't have run a book review downplaying the risks of chemical carcinogens because the review was written by the medical chief at chemical giant W.R. Grace & Co. Since then, however, Journal editors have defended their decision to publish an editorial arguing that environmental estrogens do not cause breast cancer, even though it was written by a researcher who until recently got 20 percent of his funding from a trade group representing firms that produced those estrogens. Readers weren't told of either author's affiliations. The two cases are spawning a debate among medical journalists and ethicists nationwide over how to protect the public from conflicts of interest and the distorted judgments they can yield, while at the same time protecting scientists from a political correctness that can stifle the exchange of ideas. At the center of that debate is the Boston-based New England Journal, the world's most esteemed medical publication. Arthur Caplan, who runs the Center for Bioethics at the University of Pennsylvania, says the controversy is useful if it gets the public to focus on how science is supported and how it sustains its integrity. While tough judgment calls are required, Caplan added, ''I'd rather see us err on the side of picking up on the potential conflict rather than minimizing it. ''Conflict-of-interest standards are the thin blue line of morality,'' he said. Editors at the New England Journal agree, and say that's why in 1990 they tightened their policy on conflicts of interest. Rather than simply requiring authors to disclose potential conflicts the way other medical publications do, the Journal said it no longer would accept reviews or editorials from anyone connected to firms with a financial stake in the drug or device being discussed. In November, however, that policy was breached when the New England Journal let Dr. Jerry H. Berke of W.R. Grace review Sandra Steingraber's book, ''Living Downstream: An Ecologist Looks at Cancer and the Environment.'' The Journal recently apologized for the breach, saying that the editor who handled the review inexplicably had not recognized Berke's conflict of interest, and promised to run a ''complete explanation'' in an upcoming issue. Since then another, less clear-cut case has come to light. In October the Journal editorialized that environmental estrogens like PCBs and DDT are not causing breast cancer. The editorial was written by Stephen H. Safe, a toxicologist at Texas A&M University who for three years had accepted grants of up to $150,000 a year from the Chemical Manufacturers Association. Was that a conflict? Safe doesn't think so. He said he didn't tell the Journal about his ties to CMA because he had formed and stated his views on environmental estrogens before accepting CMA funding, had stopped taking industry money five months before his editorial ran, and ''there's hardly any life scientist in the country who hasn't had funding from the industry.'' Still, while he doesn't perceive a problem, he said, ''I can see why people would bring it up. ''I felt a little twinge'' about the potential for a conflict, he added, ''but it was not much of a twinge.'' Dr. Jerome P. Kassirer, the Journal's editor-in-chief, says that while he didn't know about Safe's CMA funding when the editorial ran, that wouldn't have stopped him from publishing it. That's because Safe's funding had stopped several months earlier, he also was getting money from neutral sources like the National Institutes of Health and the US Environmental Protection Agency, and, most important, because CMA funds made up just 20 percent of Safe's research budget. ''You could argue that 20 percent is too much, or $150,000 is too much, but we have to have some cutoff,'' said Kassirer. ''In my perspective Safe doesn't qualify as a case of conflict of interest.'' Others are less sure. George Annas, professor of health law at Boston University School of Public Health, said that CMA would seem to pose a conflict, and yet ''almost all experts in the field at some point have taken grant money or an honorarium from someone. It's a very, very difficult area that's fraught with land mines.'' Annas, who writes a column on legal issues for the New England Journal, applauds the publication for going further than any other in guarding against conflicts, but he adds that implementing the policy ''has turned out to be much harder than they thought it would be.'' Dr. George D. Lundberg, editor of the esteemed Journal of the American Medical Association, says the New England Journal has boxed itself in with its all-or-nothing policy banning anyone from writing an editorial who has a potential conflict of interest. JAMA, he explained, is like most other technical journals in letting people with financial stakes write reviews and editorials ''as long as we know about that, and as long as we disclose that to the reader.'' ''If we were to eliminate all such people we would be depriving our readers of the knowledge of the best people in the field,'' said Lundberg. ''Our readers are not children. They're physicians, scientists, health policy experts, and medical reporters. They can figure this thing out so long as we give them the information.'' As for Safe's ties to CMA, ''I would see that as a financial disclosure necessary for the author to provide us, and useful for us to provide readers,'' the JAMA editor added, but such ties would not disqualify Safe from writing an editorial. Even with disclosure, however, there are questions of how much is too much. Brookline author Eve LaPlante wrote a book in 1993 called ''Seized,'' about temporal lobe epilepsy, that was panned in a May 1994 New England Journal. She is still angry that the Journal never mentioned that thereviewer, Dr. Gregory Bergey, was president of the Maryland chapter of the Epilepsy Foundation of America. The foundation, LaPlante says, ''has made a practice of not publicizing the form of epilepsy my book dealt with ... it's a conflict of interest and, at the very least, I would have liked the Journal to point this out.'' But Bergey, a professor of neurology at the University of Maryland School of Medicine, says there is a point where you can ''go overboard with political correctness.'' |