JAMA Editorial: “Confluence, Not Conflict of Interest”


Yesterday, the Journal of the American Medical Association (JAMA) released an editorial entitled “Confluence, Not Conflict of Interest: Name Change Necessary.” The authors argue that the phrase “conflict of interest is pejorative,” and a better term “would be confluence of interest, implying an alignment of primary and secondary interests.”  “Disclosure is necessary but insufficient,” they write. “It can serve to mitigate, but not to avoid bias.”

The editorial authors, Anne Cappola and Garret Fitzgerald, report that their conclusions are the result of discussions from a recently convened international meeting on conflict of interest held by the Institute for Translational Medicine and Therapeutics at the University of Pennsylvania.

Cappola and Fitzgerald write that conflict of interest is overly “confrontational and presumptive of inappropriate behavior,” while confluence of interest “ represents a complex ecosystem that requires development of a uniform approach to minimize bias in clinical research across the academic sector.”

They explain that many potential sources of bias escape disclosure policies.  For example, researchers may be motivated and biased by academic fame, emotional attachment to their work, and pressure from departments, universities, nonprofit funders, and journals.

They call for a “terrain-mapping approach to potential sources of bias” that “ would express and give weight to elements of fame and fortune on the y-axis, charted against individuals and entities on the x-axis that are likely to gain from the endeavor.”

The authors conclude: “Such a policy must be at once simple and accessible, capturing the complexity of the relationships while being sufficiently flexible at the individual level not to intrude on the process of innovation.”

Both authors report funding from industry and institutional sources in their disclosure statement.


For criticism of this piece click here →


Cappola AR, FitzGerald GA. Confluence, Not Conflict of Interest: Name Change Necessary.JAMA. Published online September 24, 2015. doi:10.1001/jama.2015.12020 (Full Text)


    • A “conflict of interest” is not pejorative – it is just a plain fact! What is insulting about saying to, say, a psychotherapist, “Providing therapy to someone you have a sexual relationship with is unethical because you are likely to lose objectivity” or “you can’t evaluate the drug that you yourself submitted for safety because you’re likely not to see flaws in your own arguments?”

      Humans are not objective about their own work, especially if there is profit or social status to be gained. That’s not pejorative, it’s just the way it is. For them to try to “newspeak” this into something else suggests that they are trying to avoid the real facts and pretend that conflicts of interest don’t affect any of THEIR people…

      They discredited themselves in the first sentence. Ridiculous!

      —- Steve

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  1. Actually the article makes some good points. Namely, that conflicts of interest can include departments, research institutes, universities, nonprofit funders, such as the National Institutes of Health and foundations, and journals. The authors also point out that the pursuit of fame can lead to conflicts of interest, and they discuss the dangers of public-private relationships, although they don’t put it quite that way. Unfortunately, the positive aspects of the authors’ article is overwhelmed by their proposal to replace the rightfully pejorative term conflict of interest with the benign phrase confluence of interest. This absurd wordsmithing exposes the authors’ real motive for their article. Obviously, conflicts of interest have strongly influenced them and, it seems, JAMA.

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    • Don’t get lost in the wording – the whole thing is written up to obscure personal responsibility of individual researchers. You know – I don’t have a conflict of interest, it’s just the system that’s a bit complicated and it’s all confusing and please look the other way now.

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  2. I see problems in the first sentence. Doctor’s, society’s, and the patient’s interests don’t necessary converge. See Szasz. Do we have a doctor for the defense here, or a doctor for the prosecution. I kind of think this one must be a psychiatrist for the prosecution. The patient’s best interests, in other words, are not necessarily the interests of the state. And I would question whether the patient is being served here or the state.

    Confluence is a way of saying influence, and multiple influences at that. I definitely don’t think, for example, the patient’s best interest are necessarily synonymous with the best interests of a pharmaceutical company. Ditto, the state. If this article is saying that psychiatry, as it is practiced today, by and large, is corrupt. Okay. I agree. However I think it is trying to say something else by blurring lines that shouldn’t be blurred. No, sorry. Confluence means multiple influences, and as such, corruption.

    Some interests don’t merge, even if the doctor is under the confluence.

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