‘They would say that, wouldn’t they?’ This bon mot has been attributed, not entirely correctly, to Mandy Rice-Davies giving witness in the Profumo affair. During the trial of Stephen Ward, the defence counsel pointed out that Lord Astor denied having had an affair with Mandy, and she laughed it off by replying: ‘Well, he would, wouldn’t he?’ In a way, her rhetorical question aptly highlights some of the issues related to conflicts of interest that abound in medical research.
When a researcher publishes a paper in a medical journal, (s)he must disclose all conflicts of interest that he might have. The aim of this exercise is to be as transparent as possible; if someone has received support from a commercial company, for example, it does not necessarily mean that his/her paper is biased. Yet it is nevertheless important to be transparent so that we can make up our own minds.
The questionnaires that authors are being asked to complete prior to publication of their article focus almost exclusively on financial issues. For instance, one must disclose any sponsorship, fees, travel support or ownership of shares. In conventional medicine, these matters are deemed to be the most important sources for potential conflicts of interest.
In my field, alternative medicine, financial issues are usually thought to be far less critical; it is generally seen as an area where there is so little money that it is hardly worth bothering. Perhaps this is the reason why many journals of alternative medicine do not even insist on declarations of conflicts of interests and few authors disclose them.
After having been a full-time researcher of alternative medicine for more than two decades, I agree that, in this field, financial interests are often negligible. Yet I have become convinced that conflicts of a different nature are at least as prevalent and potentially more powerful. Sure, there is less money at stake, but this fact is more than compensated by non-financial issues. Quasi-evangelical convictions abound in alternative medicine, and it is, I think, obvious that they can amount to significant conflicts of interest.
During their training, alternative practitioners learn many things which are unproven, have no basis in fact or are just plainly wrong. Eventually this education — or is it brain-washing? — creates a belief system to which practitioners adhere, regardless of the scientific evidence, and which they tend to defend at all cost.
Moreover, this belief is indivisibly linked to more existential issues. In alternative medicine, there may not be huge amounts of money at stake, but any criticism or challenge nevertheless has the potential to endanger an alternative practitioner’s livelihood. And this creates a situation which is fundamentally different from conventional medicine. If someone published evidence to show that a new drug is ineffective, most GPs would simply use another one. If, however, someone demonstrates that acupuncture is a placebo, acupuncturists would automatically fear for their cash flow.
In other words, in alternative medicine, such conflicts of interest tend to be very acute, powerful and personal. Consequently, enthusiasts of alternative medicine are often incapable or unwilling to look upon criticism as anything other than an attack on their income, their beliefs, their status, or their person.
When chiropractors deny that neck manipulations carry a risk, when herbalists insist that traditional herbalism is based on good evidence, when homeopaths claim that their remedies are more than placebos, when acupuncturists tell us that meridians, yin and yang are real and evidence-based, we should ask who, in these often fiery and emotional debates, might have a conflict of interest. Who might have an interest that might directly benefit his or her income? Who is more likely to be objective, the person whose belief is being challenged and whose livelihood is endangered, or the independent expert who studied the subject in depth but has no axe to grind? If you ask such questions, you might end up concluding: ‘They would say that, wouldn’t they?’
Edzard Ernst, emeritus professor at the University of Exeter, is the author of Homeopathy: The Undiluted Facts and the awardee of the John Maddox Prize 2015 for standing up for science. He blogs at edzardernst.com.