Multiple facets of conflict of interest

May 2022

EDITORIAL: Multiple facets of conflict of interest

Vol. 34. No. 2
Richard Balon, MD

Departments of Psychiatry and Behavioral Neurosciences and Anesthesiology
Wayne State University School of Medicine
Detroit, Michigan, USA

For most physicians, the phrase “conflict of interest” (COI) usually refers to a financial COI, such as physicians receiving payments from a pharmaceutical company. Financial COI is the most frequently discussed COI, and the one disclosed at the end of articles in professional journals.

However, financial COI is not the only COI an individual may have. The recent debate about the origin of the virus that causes COVID-19 and the possibility that it escaped from a laboratory in Wuhan, China, revealed another facet of COI—the impact of ideology and personal belief. Some researchers strongly opposed the lab leak theory and attacked those who proposed it. For many, the fact that President Donald J. Trump proposed the virus originated in China was argument enough to label the lab leak theory as yet another conspiracy theory.

Additionally, there is what I call “ideological bias” or “ideological COI,” eg, some of the opponents of the lab leak theory were probably impacted by the fact that their reputation would be ruined if it turned out to be true. Unbelievably, Facebook and Wikipedia initially banned any suggestion that the virus may had leaked from the Wuhan laboratory. Interestingly, with President Trump’s departure from office, more people were willing to entertain the possibility that the virus that causes COVID-19 escaped from the laboratory and were willing to investigate this theory. I believe this tale does not paint a very laudatory picture of many scientists and the state of present-day science. It also raises serious questions about nonfinancial COIs.

I believe that compared to financial COIs, nonfinancial COIs have a similar, if not worse, impact on scientific conduct. As a profession, psychiatry has focused on discussing and disclosing financial COIs. Yet, there are numerous nonfinancial pressures and COIs. As Korn1 wrote, “These pressures … include the desire for faculty advancement, to compete successfully and repetitively for sponsored research funding, to receive academic accolades from professional peers and win prestigious research prizes, and to alleviate pain and suffering … All of these nonfinancial pressures may generate conflicts by creating strong bias toward positive results, and all of them may more powerfully influence faculty behavior than any prospect of financial enrichment.” Cappola and FitzGerald2 mentioned the same, adding, “in academia, the prospect of fame may be even more seductive than fortune.”

In their debate on whether we should try to manage nonfinancial COIs, Wiersma et al3 emphasized that nonfinancial COIs are of political, ideological, individual, or religious nature, and that dismissing them is naïve, empirically unfounded, and dangerous. They mentioned similar issues as Korn,1 adding to his list of nonfinancial COIs an interest in a positive outcome in a study that may support one’s previous findings and intellectual property in fruits of research. I would also add to this list of COIs the interest in suppressing results of studies that do not support one’s previous results or beliefs.

Others warned of various consequences of nonfinancial COIs. Saver4 suggested that secondary interests can compromise the design, conduct, and reporting of research, and that intellectual or political predispositions can bias research conduct. Viswanathan et al5 warned that the risk of nonfinancial COIs can be heightened for systematic reviews and could be intertwined with other COIs, and thus when ignored, can call into question the impartiality of systematic reviews. Importantly, as Abdoul et al6 found in their qualitative study, nonfinancial COIs (eg, rivalry, cronyism, geographic and academic biases) may influence allocation of finances in the grant review process.

Three areas of COI are outlined by the Office of Research Integrity (ORI) of the United States Department of Health & Human Services7: financial gain, work commitments, and intellectual and personal matters. The ORI stated, “Personal conflicts are usually the easiest to identify and resolve. Researchers generally should not serve as reviewers for grants and publications submitted by close colleagues and students … Most granting agencies require reviewers to disclose conflict of interest, including personal conflicts, as a condition of service.”7 The text continues, “Intellectual conflicts are more difficult to identify, but are nonetheless important. If a researcher holds strong personal views on the importance of a particular area of research or set of research findings, those views should be disclosed so that others can take them into consideration when judging the researcher’s statements. The same is true for strong moral convictions that could influence a researcher’s scientific opinions.”7

One would hope that people adhere to these policies— but do they? The debate over the origin of the virus that causes COVID-19 does not attest that they do. Ideological and other nonfinancial COIs seem to permeate science on many fronts. The nonfinancial COIs (namely the ideological COIs) have a serious impact on debates—some issues are not properly debated or even allowed to be debated due to the prevailing ideological atmosphere and lack of disclosure of ideological and other COIs. We have to realize that “The politicization of science leads to a loss of confidence in science as an institution. The distrust may be justified but leaves a vacuum, often filled by a ‘much more superstitious approach to knowledge.’”8 This might help explain public resistance to technologies such as genetically modified food or vaccines.8 Some scientists “seem to fall prey to groupthink, and the process of peer reviewing and publishing allows dogmatic gate-keeping to get in the way of new ideas and openminded challenge.”8

We need to address all nonfinancial COIs and the politicization of science as diligently, if not more so, than financial COIs (those should include COIs related to psychological treatments). We need to educate ourselves and our trainees about all facets of COIs. Cappola and FitzGerald2 suggested that we abandon the term COI as it is pejorative and replace it with “confluence of interest,” which implies alignment of primary and secondary interests. They also proposed a complicated strategy of terrainmapping or a dashboard of COIs, eg, “a dashboard 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.”2

Those are interesting ideas for medicine to consider in the future. At this time, we should realize that many of the scientists, promoters, and prophets of science are as human as we are and are ridden by various nonfinancial COIs that should be acknowledged and addressed on multiple levels, starting in open scientific debates.


Richard Balon, MD
Departments of Psychiatry and Behavioral Neurosciences and Anesthesiology
Wayne State University
Tolan Park Building, 3rd floor
3901 Chrysler Service Dr
Detroit, MI 48201 USA

[email protected]


  1. Korn D. Conflicts of interest in biomedical research. JAMA. 2000;284:2234-2237.
  2. Cappola AR, FitzGerald GA. Confluence, not conflict of interest: name change necessary. JAMA. 2015;314:1791-1792.
  3. Wiersma M, Kerridge I, Lipworth W, et al. Should we try to manage non-financial interests? BMJ. 2018;361k1240. doi:10.1136/bmj.k1240
  4. Saver RS. Is it really all about the money? Reconsidering non-financial interest in medical research. J Law Med Ethics. 2012;40:467-481.
  5. Viswanathan M, Carey TS, Belinson SE, et al. A proposed approach may help systematic reviews retain needed expertise while minimizing bias from nonfinancial conflicts of interest. J Clin Epidemiol. 2014;67:1229-1238.
  6. Abdoul H, Perrey C, Tubach F, et al. Non-financial conflict of interest in academic grant evaluation: a qualitative study of multiple stakeholders in France. PLoS One. 2012;7:e35247. doi:10.1371/journal. pone.0035247
  7. Steneck NH. ORI introduction to the responsible conduct of research. Revised edition. The Office of Research Integrity, U.S. Department of Health and Human Services. August 2007. Accessed November 14, 2021.
  8. Varadarajan T. How science lost the public’s trust. The Wall Street Journal. July 23, 2021. Opinion. Accessed March 4, 2022.