Senator Grassley, Psychiatric Ethics, and Conflict of Interest

Senator Charles Grassley, ranking Republican on the Senate Finance Committee, is on the warpath about conflict of interest in psychiatry.

More power to him. My profession and the public should thank him and his staff.

Senator Grassley and his committee have pursued conflict of interest inquiries for many academic leaders in psychiatry - most recently Dr. Charles Nemeroff, who, until he stepped down this week, was chair of psychiatry at Emory.

In each case the issue is essentially the same: (1) the psychiatrist in question was paid substantial sums by drug companies; (2) the psychiatrist in question wrote, spoke and did research about the company's products; and (3) the psychiatrist's disclosures of the financial arrangements were incomplete at best and, possibly, deliberately inaccurate.

The basic response has been, essentially - "my judgment has not been corrupted, trust me."

This isn't adequate, and neither is disclosure.

For contrast, take an area of psychiatric ethics about which the American Psychiatric Association is unambiguous - "sexual activity with a current or former patient is unethical." Why is this the case?

The most common rationale is that the patient will be harmed. This is probably true almost all the time. But there are well known examples of decades long happy marriages between psychiatrists and former patients. Why don't these examples undermine the absolute ethical prohibition?

The reasons are (1) trust and (2) the ancient roots of the medical profession in religious healing. When we're ill we turn to members of the health professions. As professionals they "profess" basic commitments, most notably, that they will always seek our well-being and will not exploit us. Even if there have been some happy marriages between psychiatrists and former patients, any ambiguity about the attitudes and values on something as basic as having sex with their patients will diminish overall trust in a profession we count on when we're in some of life's toughest moments. Medicine won't work if patients have to wonder if the physical exam is leading to diagnosis and treatment or to sex.

Just so with the revelations about Dr. Nemeroff. Even if his research papers are scientifically impeccable and his clinical recommendations have been unbiased, the revelation that he earned $2.8 million from drug company consultation between 2000 - 2007 (and failed to report at least $1.2 million) undermines the trust the profession needs.

Medicine needs to reformulate the way it manages conflicts of interest. Disclosure is necessary, but it's not sufficient, even if it is done well. (And from Senator Grassley's inquiry we know just how poorly it's actually done.) The expectations will be more complex to articulate than "no sex with current or former patients," but we need better behavioral guidelines as to what is acceptable and what isn't.

(If you want more on this topic, see articles in the New York Times and Wall Street Journal, and Senator Grassley's October 2 letter to Emory. And, see previous posts here and here.)