It is uncommon to see an ethics page on the website of a physician, university hospital, treatment center, or clinic. Yet problems involving conflict of interest in medicine and psychiatry have grown so pervasive—and have so eroded the public trust in doctors—that the practice should be a standard.
In a society where paid lobbying, influence buying, and revolving doors are widespread, patients and family members deserve upfront transparency and full disclosure. They deserve to know to what extent a physician’s financial ties, including speaking fees, research and writing fees, referral fees, and other sources of supplemental income, might influence the advice and treatment recommendations their doctor provides.
This page briefly describes conflicts of interest in medicine and psychiatry and discloses one area of potential conflict of interest of Merritt Mental Health.
Conflicts of Interest
Conflicts of interest in medicine can take many forms. A pharmaceutical or medical device company might pay a physician to conduct a study, write an article, give a presentation, or serve on a board. Stock or stock options may be offered in return for consulting services or for the promotion of a product through educational lectures. A diagnostic or treatment center might express its gratitude to a doctor for sending recurring referrals with direct payments of money or gifts. Alternately, in a conflict of interest known as “self-referral,” doctors may steer patients to treatment or testing centers in which they themselves possess undisclosed financial interest.
Drug and medical device companies sometimes sponsor physician continuing education, courses required by state law. Or they may underwrite educational lecture series given by universities and professional societies or even fund academic posts and fellowships.
There is cause for concern because each major method of paying doctors or medical institutions has the potential to put physicians’ primary duty of providing the best care possible to patients at odds with secondary extracurricular financial gain. That secondary interest (i.e., income from drug companies, device companies, treatment centers, and diagnostic centers) may distort physicians’ judgments, hindering them from clearly prioritizing patients’ needs and putting their best interests and welfare before all else.
Over the past two decades, hundreds of articles on conflicts of interests in medicine have been published in the New York Times and other major national newspapers. Dozens of well-researched books have revealed the problem to be a real crisis. These works include notable titles such as Bradford Gray’s The Profit Motive and Patient Care; Marc Rodwin’s Medicine, Money, and Morals: Physicians’ Conflicts of Interest; Jerome Kassirer’s On the Take: How Medicine’s Complicity with Big Business Can Endanger Your Health; Marcia Angell’s The Truth About the Drug Companies: How They Deceive Us and What to Do About It; Derek Bok’s Universities in the Marketplace; David Healy’s The Antidepressant Era.
These books reveal how much today’s models of treatment in medicine are driven by the profit motives of doctors, drug and device companies, and, most concerning of all, doctors and companies working in close collaboration.
Of the aforementioned book titles, two of the most instructive and valuable for patients and families navigating the mental health care system are David Healy’s The Antidepressant Era and Marcia Angell’s The Truth About the Drug Companies: How They Deceive Us and What to Do About It.
In the concluding chapter of her book, Dr. Angell, former editor of the New England Journal of Medicine, alerts readers to one essential step all patients and families can take to mitigate the risk that a doctor’s outside financial ties will bias treatment recommendations. Her advice is straightforward: Ask. At the first appointment, ask doctors if they have any financial ties whatsoever to drug companies, device companies, treatment centers, or any other healthcare organizations. If they reply in the affirmative, request a written statement detailing the amounts earned annually in supplemental income from each and every outside healthcare entity.
Potential Conflict of Interest of Merritt Mental Health
Merritt Mental Health has no financial ties whatsoever to drug or device companies, treatment centers, diagnostic centers, or any other healthcare concerns. Dr. Merritt is not a paid speaker, lecturer, researcher, or writer for any company. Neither he nor anyone else at Merritt Mental Health receives or awards any “referral fees” whatsoever.
Clients, however, should be aware of one area of potential conflict of interest. Treatment centers occasionally invite Dr. Merritt to visit and tour facilities and meet clinical staff at the expense of the treatment center. No money or gifts are exchanged or rewarded, but the treatment centers sometimes pay for airfare, hotel, and/or meals during these one- or two-day visits.
Should clients of Merritt Mental Health who are requesting recommendations to treatment centers know about this potential conflict of interest? Yes. Although Dr. Merritt earns no income from these professional visits—and in fact loses time and income from his consulting by making them—impressions are made, relationships form, and potential “reciprocity” biases may develop. If someone gives you a gift, you may feel inclined by genetic hardwiring and social conditioning to give one back in return. In this case, the return gift might be a referral.
While Merritt Mental Health encourages clients to be on guard against all forms of potential conflict of interest, we believe that the reciprocity biases stemming from these professional visits are small. The visits are not paid vacations. They are full-day tours accompanied by lectures and introductions to clinical staff. There are no kickbacks or favors asked in return. There is no financial gain whatsoever—not a dollar, dime or nickel—that accrues to Dr. Merritt or MMH.
Dr. Merritt visits treatment centers for two overriding purposes: 1) to learn from other clinicians and 2) to improve the quality of his consultations to patients and families through face-to-face encounters and observations. Upon request, we will provide you with a list of treatment centers that have funded professional visits by Dr. Merritt, in whole or in part.
The Omaha Steak Story—A Message to Treatment Centers
One fine February morning Merritt Mental Health received a curious delivery, a large Styrofoam cooler labeled “Omaha Steaks.” Its contents were two pork chops, two filet mignon, two top sirloin steaks, two Omaha steak burgers, four stuffed baked potatoes, and a chocolate cake. An enclosed note, sent by a treatment center, wished Merritt Mental Health “A Happy New Year.”
The next day a father contacted us seeking advice on various treatment centers for his 18-year-old daughter, including the center that had sent us the steaks. The father wanted to know our opinion about that treatment center. Did we think it was the right choice for her?
Our request to treatment center directors and outreach staff is that you send no gifts whatsoever to Merritt Mental Health. We will refer to you out of respect for the quality of your services and your integrity. If anything, gifts will have a counterproductive effect. We prefer not to receive them.
Thank you for your understanding.
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Eli Merritt, M.D.
Eli Merritt, M.D. is a psychiatrist and mental health expert who consults with patients and families with the goal of maximizing the health and well-being of all. He is a former Clinical Faculty member in the Stanford Department of Psychiatry and Behavioral Science and past president of the San Francisco Psychiatric Society. He interned in medicine at the Lahey Clinic and trained in psychiatry at Stanford and medical ethics at Yale. He has written on diverse topics in medicine and psychiatry, including diagnosis, insomnia and depression, addiction, suicide prevention, informed consent, and privacy issues in mental illness.
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