Managing Conflicts of Interest: Who is Responsible?

The new American Society for Aesthetic Plastic Surgery/Aesthetic Surgery Education and Research Foundation Policy 

The American Society for Aesthetic Plastic Surgery (ASAPS) is one of many professional groups that has tackled this issue head-on. Consistent with requirements mandated by the Accreditation Council for Continuing Medical Education (ACCME), ASAPS has a clearly-articulated conflicts of interest disclosure and resolution policy for faculty participating in ASAPS-sponsored programs. In May 2009, however, the Boards of Directors of ASAPS and the Aesthetic Surgery Education and Research Foundation (ASERF) adopted a new Unified Conflict of Interest Policy that specifically addresses potential conflicts of interest among individuals in positions of leadership.1 This policy requires full disclosure, on an annual basis, of potential conflicts of interest by all members of the organizations' Boards of Directors, committee chairs, Trustees, and spokespersons, including traveling professors, all employees, and all members of official publication editorial boards, including Aesthetic Surgery Journal and Aesthetic Society News.

Remedies for managing conflicts of interest most often involve some form of public disclosure, so that those receiving information from an individual with real or perceived conflicts of interest can take such potential conflicts into consideration when evaluating data or expressed opinions. According to the ASAPS/ASERF policy, additional remedies (such as recusal from specific activities or severing of relationships that present a conflict) may be considered in some cases, if warranted. Application of these policies is critical for individuals in key leadership positions— particularly for the president and president-elect as the organization's most visible and responsible representatives.

An independent ad hoc committee appointed by the president will evaluate conflicts of interest and publish its findings. Generally, privacy is warranted in the case of economic disclosures; specific dollar amounts will not be publicly disclosed. It is important to note, however, that conflicts of interest do not necessarily involve economic benefit. In the ASAPS/ASERF policy, a conflict of interest is defined as “a relationship held by a discloser or the discloser's immediate family that could influence the discloser, or be perceived as influencing the discloser, to act contrary to the interests of the Society.”

AESTHETIC SURGERY JOURNAL's EDITORIAL POLICIES 

As mentioned above, the Journal's Editorial Board is included in the newly adopted ASAPS/ASERF United Conflict of Interest Policy. Speaking on behalf of the Editorial Board, we welcome this additional measure of transparency. We are proud, however, that the Journal has previously and independently instituted many conflict of interest safeguards into our editorial process.

As a scientific journal indexed by the National Library of Medicine (MEDLINE, PubMed), ASJ is committed to the integrity of its peer-review process. Every paper published within the Journal is evaluated by at least two independent reviewers, each of whom is queried in advance as to any potential conflicts of interest relevant to the paper under consideration. Every effort is made to avoid even the possibility of compromising the objectivity of manuscript reviews.

Recently, the Journal voluntarily expanded the criteria and scope of disclosures associated with published articles. While a relationship between an author and a public or private commercial or noncommercial entity was previously noted in conjunction with an article only if the editors felt such a disclosure was important in judging the manuscript, new procedures instituted in January 2008 called for a disclosure statement with every published article regardless of whether any conflicts of interest were felt to exist. Our policy on disclosure statements has been generally expanded to include not only financial relationships, but also the identification of specific assistance (if any) by a study sponsor in research design, analysis, or interpretation of data. We also specifically state when no such assistance was provided. (As of June 2009, our Information for Authors has also been updated to reflect the policies now in effect.) These principles are advocated by the Society for Scholarly Publishing2 and the International Committee of Medical Journal Editors.3

The National Library of Medicine (NLM), while recognizing that “journals indexed for MEDLINE sometimes publish supplements devoted to a specific topic and that may be financed by profit-making organizations or by organizations representing for-profit interests,” addresses specific standards for conflict of interest disclosure in such supplements.4 ASJ's editorial policies meet (and even exceed) those standards with regard to peer-review and disclosures.

Ultimate responsibility 

There is no question that science has been enriched by the contributions of physicians who, by virtue of their particular talent and expertise, have developed research and advisory (or other) relationships with industry. Nevertheless, there are some in the medical community who feel that once money changes hands, objectivity and credibility go out the window. There are certainly instances in which these concerns have been substantiated by inappropriate behavior on the part of organizations and individual physicians. With increasing awareness of the potential for abuse, however, I believe that such problems can be effectively addressed and the benefits of industry support for worthy educational and research goals do not have to be sacrificed. With regard to research, there is much valuable data that have been derived from industry-sponsored studies conducted by responsible physicians, whether they were paid or unpaid for their efforts. The critical factors are how the studies are designed and how such data are gathered, analyzed, interpreted, and presented. When intelligent research, honest evaluation, and complete disclosure of relationships are all part of the equation, science can be very well served.

Leading institutions, professional societies, and journals (including ASJ), have taken an increasingly proactive stance on the issue of conflicts of interest and disclosure, but the story does not end there. Ultimately, the responsibility for transparency comes back around to the individual—to each one of us.

Disclosures can only be as complete as the information provided by the individuals involved. While most authors submitting their work to the Journal intend to be forthcoming about any conflicts of interest, as specified in the Information for Authors,5 there is the danger of carelessness in this regard. Some authors fail to recognize the existence of a real or perceived conflict. For example, an author who does not benefit directly but whose institution benefits from his or her relationship with a commercial or noncommercial entity does, indeed, have a potential conflict of interest to disclose. It is important for all matters of potential conflicts of interest to be carefully considered and appropriately disclosed by authors submitting manuscripts, as well as by presenters on panels, teaching course instructors, and public advocates of particular treatments and techniques.

Finally, each of us has a responsibility to remain aware of the subtleties and implications of conflicts of interest when evaluating articles, presentations, and other public statements by our esteemed colleagues who have openly disclosed their relevant relationships. The point is not that we should expect to find evidence of bias in the work of these individuals; on the contrary, we hope that every inclination toward bias has been systematically rooted out before data are developed and presented. Nevertheless, the purpose of disclosure is to better enable the recipient of information to judge its validity in light of the potential for bias.

If we look hard enough, there are many examples of conflicts of interest that really cannot be documented or disclosed. I am referring to colleagues who may have built their reputations, to some degree, on a specific surgical technique. Is it possible that their public presentations continue to highlight the positive aspects of their preferred approach, while omitting or downplaying any negative results? Call it human nature or call it conflict of interest. In any case, such instances are generally beyond the reach of institutional policy (though ASAPS does encourage presenters at its meetings to discuss both positive and negative outcomes) and are mostly a matter of objectivity and conscience. Here, again, the recipient of the information needs to engage in critical thinking to determine what is meaningful and verifiable.

Aesthetic Surgery Journal is meeting its responsibility to readers by requiring full disclosure from its Editorial Board, reviewers, and authors, and by alerting readers to conflicts of interest (or lack thereof) in conjunction with each and every published article, including sponsored supplements to the Journal. ASJ's Editorial Board continues to monitor the changing landscape of conflict of interest disclosure as it applies to scholarly publications. It is our commitment to you, the readers, that ASJ will always reflect the highest standards of integrity and transparency.