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by Michael Davis and Andrew Stark (Editors)
Oxford University Press, 2001
Review by Denise M. Dudzinski, Ph.D. on Dec 3rd 2002

Conflict of Interest in the Professions

            As the title attests, Conflict of Interest in the Professions is composed of seventeen thematic articles considering conflicts of interests in a variety of professions including journalism, accounting, engineering, law, academics, government, anthropology, health care, and economics.  Authors present a diversity of perspectives, which offers a clue to understanding the contextual nature of conflicts of interests.  As author and editor Andrew Stark points out, conflicts of interest manifest differently for different professions depending on whom the profession serves (individuals, the public, or both) and the nature of the professional’s role  (as judge, advocate, service provider, and/or diagnostician). (344)

So what is a conflict of interest? In a chapter entitled “Conflict of Interest & Physical Therapy”, authors Martin & Gabard offer a cogent definition.  They write simply, “conflicts of interest are situations in which individuals have interests that significantly threaten their role responsibilities, or would do so for a typical person having their role.” (316) Likewise, Davis describes the standard view of conflict of interest as a situation in which a person P is in a relationship requiring P to exercise some judgment on another’s behalf and P has an interest “tending to interfere with the proper exercise of that judgment”. (8)  With regard to professional conflicts of interest, both definitions suggest that the person in question is licensed to make a judgment by virtue of the individual’s professional status and that the individual is then accountable to others within and outside his/her profession for that judgment.  Several authors also emphasize the importance of avoiding even the appearance of conflict of interest.  In “Law’s Blindfold”, David Luban writes that the credibility of a judge’s ruling is threatened by the appearance of impropriety since “justice must not only be done but be seen to be done” lest the impartiality of the judge be questioned. (26)

There are several articles I recommend to readers interested in health care.  In “Ethical Conflict in Correctional Health Services” Kenneth Kipnis studies several ethical conflicts arising when health care providers strive to respect the well-being and autonomy of patients within a penal system where autonomy is restricted by design, and the safety and health of the population is paramount.  Martin and Gabard’s “Conflict of Interest and Physical Therapy” is the clearest and most thorough analysis of conflict of interest in health care. The authors discuss the difference between systemic and episodic conflicts, conflicts arising in receiving gifts, and conflicts arising when patients make sexual advances toward their physical therapists (a problem apparently more prevalent than the inverse).  The authors’ analysis is clear and their advice practical and balanced.  Least impressive is an article entitled “Conflict of Interest in Medical Practice”.  Author Stephen Latham chronicles the pecuniary conflicts of interests arising for physicians in both managed care and fee-for-payment reimbursement schemes.  The article is instructive but does not adequately consider non-pecuniary conflicts of interests in medical practice such as the dual role of clinician researcher.  Many health care providers may find Latham’s analysis myopic since non-pecuniary conflicts are often more difficult to manage.

Several other articles might interest health care practitioners or educators, especially David Luban’s “Law’s Blindfold”, a beautifully written article investigating the importance of avoiding or managing conflicts that undermine the credibility of a professional’s judgment, including the appearance of bias or impropriety, financial and familial conflicts, ideological conflicts, and conflicts that arise in negotiating dual obligations to individuals and to the broader society.  In my estimation, this article addresses the heart of the matter – namely that conflicts of interest are stickiest when one makes subjective judgments based on one’s professional expertise. In so doing, experts have an obligation to prioritize the fiduciary responsibilities constitutive of that professional relationship (for example, the faith a client/patient/defendant has in the professional’s expert opinion).  In addition to Luban’s article, Merrilee Salmon’s “Conflict of Interest in Anthropology” explores the anthropologist’s duty to the populations s/he studies, which is not unlike the duty a health care professional has to the broader society.

One controversial article highlights the importance of professional context in assessing conflicts of interest.  In “Resisting Reasonableness”, English professor Jane Gallop argues that sexual relationships between professors and their graduate students should not be prohibited. She writes that “(t)he conflict is not between pedagogy and love but between two aspects of the pedagogical relation, evaluation and advocacy.” (189)  She argues that the professor’s academic relationship with her students produces formidable conflicts of interest, suggesting more by appeal than argument that the professor advocates for her students for two reasons. First, she truly cares about her students and second, good students reflect well on their professors.  Both interests can conflict with the professor’s duty to “objectively” evaluate the student’s work.  Apparently, the fact that conflict of interest is endemic to pedagogy means that we need not worry about conflicts arising in romantic relationships between professors and students – a curious conclusion but one offered with passion and accompanied by commentaries from two of Gallop’s students. I appreciated this article not for its insights on conflicts of interest, but for its unorthodox assertions and a literary style that highlights the ethical importance of considering the rich personal and professional dimensions of professor-student relationships.

The book’s greatest strength is its variety.  It contains seventeen chapters including an introduction and an epilogue written by each of the editors.    The introduction and conclusion frame the book well, defining conflict of interest and outlining similarities among and disparities between the authors’ arguments.  Authors agree that some conflicts of interest are inevitable and offer advice for handling foreseeable conflicts and avoiding those that are harmful. For well researched, precise definitions and descriptions of conflicts of interest see chapters by Davis, Luebke, Cohen, Martin & Gabard). For chapters containing cases, thought experiments, or vignettes useful in teaching, see chapters by Luban, Luebke, Kipnis, Cohen, Orts, Gallop.

The authors (all university professors), thorough notes and bibliographies, and an index make this book a fine reference or course text.  In the context of teaching and research, the strengths and weaknesses of an author’s arguments can be explored; implicit and explicit claims about conflict of interest can be examined, and the contextual features of professional conflicts can be studied.  While not all articles will be of interest to all readers, the book appeals to a wide audience and most professionals will find something of interest (and something worthy of critique) in the collection of essays.

 

© 2002 Denise M. Dudzinski

 

Denise M. Dudzinski, PhD, Assistant Professor, Medical Ethics, University of Washington School of Medicine