tag:theconversation.com,2011:/au/topics/conflicts-of-interest-2647/articlesConflicts of interest – The Conversation2023-07-24T05:47:56Ztag:theconversation.com,2011:article/2096872023-07-24T05:47:56Z2023-07-24T05:47:56ZIt’s not just tax. How PwC, KPMG and other consultants risk influencing public health too<figure><img src="https://images.theconversation.com/files/538467/original/file-20230720-17-1g1ldx.jpg?ixlib=rb-1.1.0&rect=5%2C5%2C992%2C660&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/people-working-office-building-london-511423942">Shutterstock</a></span></figcaption></figure><p>Concerns about the <a href="https://publicintegrity.org.au/research_papers/big-four-contracts-increase-1276">use</a> of private consultancy firms advising government – such as PwC, KPMG, Deloitte and EY – has led to a <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Finance_and_Public_Administration/Consultingservices">Senate inquiry</a>.</p>
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<p>Until now, much <a href="https://www.theguardian.com/business/2023/may/12/disgraceful-breach-of-trust-how-pwc-one-of-the-worlds-biggest-accountancy-firms-became-mired-in-a-tax-scandal">media interest</a> has centred on PwC’s advisory role to the Australian Tax Office while also advising private clients on tax matters.</p>
<p>But <a href="https://kpmg.com/au/en/home/industries/health.html">such companies</a> <a href="https://www.theguardian.com/business/2023/jul/20/pwc-tax-scandal-project-synergy-scrapped-government-trial-innowell">also advise</a> government <a href="https://www.croakey.org/concerns-raised-about-kpmg-conducting-national-health-and-climate-strategy-consultation/">on health issues</a>. And there’s <a href="https://www.croakey.org/role-of-consultancy-firms-in-health-policy-under-growing-scrutiny/">growing concern</a> about the potential for conflicts of interest and undue influence on health policy.</p>
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Read more:
<a href="https://theconversation.com/my-3-point-plan-to-untangle-the-public-service-from-consultants-such-as-pwc-210050">My 3-point plan to untangle the public service from consultants such as PwC</a>
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<h2>How do these firms consult on health?</h2>
<p>Private consultants offer a <a href="https://www.pwc.com.au/health.html">range of health services</a> and <a href="https://www.ey.com/en_au/health">advice</a> to government. These <a href="https://kpmg.com/au/en/home/industries/health.html">include</a> contracts about electronic health systems, policy, taxation, program design and evaluation, improving hospital performance, and health sector restructuring. Firms also <a href="https://www2.deloitte.com/au/en/pages/human-capital/solutions/health.html">develop</a> major public and private health-care initiatives.</p>
<p>There might be an argument for engaging external consultants when that expertise does not already exist in the public service. However, when consultants are engaged more widely, we have potential problems.</p>
<p>For example, we’ve raised concerns about <a href="https://www.croakey.org/concerns-raised-about-kpmg-conducting-national-health-and-climate-strategy-consultation/">KPMG’s involvement</a> in the <a href="https://www.health.gov.au/our-work/national-health-and-climate-strategy">National Health and Climate Strategy</a>, which aims to prepare the health system for the impacts of climate change. The firm also advises the <a href="https://www.croakey.org/role-of-consultancy-firms-in-health-policy-under-growing-scrutiny/">fossil fuel industry</a>.</p>
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<p>Senator Barbara Pocock, Greens spokesperson for finance and the public service, <a href="https://www.croakey.org/role-of-consultancy-firms-in-health-policy-under-growing-scrutiny/">shares our concerns</a>:</p>
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<p>KPMG’s work on the National Health and Climate Strategy is the latest worrying example. This is core public service work that should be conducted by a robust public sector where there is no risk of a conflict of interest between a consultant with a fossil fuel client list and the public interest.</p>
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<p>Pocock <a href="https://www.theguardian.com/australia-news/2023/jun/27/kpmg-australia-launches-internal-review-after-potential-conflict-of-interest-concerns-raised">is also concerned</a> about KPMG auditing aged care facilities for government at the same time as charging others for advice on audits and accreditation. The firm says it has launched an internal inquiry.</p>
<p>The use of consultants to government has been noted at the state level too. New South Wales is running its own <a href="https://www.parliament.nsw.gov.au/committees/inquiries/Pages/inquiry-details.aspx?pk=2963">public inquiry</a>, <a href="https://www.medicalrepublic.com.au/infestation-of-pwc-consultants-on-public-boards/94014">including</a> looking into how consultants are used <a href="https://www.theaustralian.com.au/business/nsw-parliament-consultancy-inquiry-questions-pwc-acting-chiefs-role-on-health-body/news-story/90133dc872748571d480c20ef7b18ec0">in health</a>.</p>
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Read more:
<a href="https://theconversation.com/blacklisting-pwc-wont-stop-outsourcing-here-are-3-reasons-it-has-become-embedded-in-the-australian-public-service-206772">Blacklisting PwC won't stop outsourcing: here are 3 reasons it has become embedded in the Australian public service</a>
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<h2>What are the concerns?</h2>
<p><strong>1. No scrutiny</strong></p>
<p>Contracts between consultancies and government, and advice that arises, are not easily publicly available. So we cannot say if we’re getting good advice. There’s <a href="https://theconversation.com/my-3-point-plan-to-untangle-the-public-service-from-consultants-such-as-pwc-210050">the risk</a> consultants give answers government wants to hear, instead of the “<a href="https://theconversation.com/after-robodebt-heres-how-australia-can-have-a-truly-frank-and-fearless-public-service-again-209488">frank and fearless</a>” advice from public servants. </p>
<p>Then there’s the issue of whether that advice, or contracted service, provides value for money.</p>
<p>University College London economist <a href="https://www.ucl.ac.uk/bartlett/public-purpose/people/mariana-mazzucato">Mariana Mazzucato</a> refers to the extensive use of commercial consultants to government in her book <a href="https://marianamazzucato.com/books/the-big-con">Big Con</a>. She says neither theory nor evidence show private sector consultancy is more <a href="https://theconversation.com/after-robodebt-heres-how-australia-can-have-a-truly-frank-and-fearless-public-service-again-209488">efficient and cost effective</a> than what the public sector can provide.</p>
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Read more:
<a href="https://theconversation.com/who-needs-pwc-when-consultancy-work-could-be-done-more-efficiently-in-house-207330">Who needs PwC when consultancy work could be done more efficiently in-house?</a>
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<p><strong>2. Conflicts of interests</strong></p>
<p>There’s the risk of conflicts of interest, as we’ve highlighted above. This arises, for instance, when firms have both government clients, and private sector ones, and information is shared.</p>
<p>There are also conflicts of interest in the <a href="https://theconversation.com/the-revolving-door-why-politicians-become-lobbyists-and-lobbyists-become-politicians-64237">revolving doors</a> phenomenon. This is the term used for staff movements between consultancy firms, government departments, revenue authorities or corporate regulators.</p>
<p>This has been well-documented for the <a href="https://theconversation.com/we-worked-out-how-many-tobacco-lobbyists-end-up-in-government-and-vice-versa-its-a-lot-205382">tobacco industry</a>, among others. </p>
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<p><strong>3. Impact on health policy</strong></p>
<p>Consultants have <a href="https://www.tandfonline.com/doi/full/10.1080/09692290.2022.2161112">extensive influence</a> over health policy due to recurring government contracts. Such influence includes supporting a neoliberal policy agenda. This promotes small government, and puts profits above the public’s wellbeing and public interest. This risks influencing health outcomes.</p>
<p>For instance, our <a href="https://www.adelaide.edu.au/stretton/ua/media/568/sa-heaps-unfair-state-final-report.pdf">own research</a> in South Australia points to policymakers outsourcing government functions to private firms being a factor in increasing health inequities. </p>
<p>Changes to the public sector since the 1980s have resulted from the adoption of “managerialism” or the growing reliance on professional managers and business models. This leads to a decline in evidence-based health policies and helpful collaboration between different sectors, and a shift away from addressing health inequities.</p>
<p>One example is the <a href="https://grattan.edu.au/news/what-do-we-get-for-the-millions-spend-on-covid-consultancies/">millions of dollars paid</a> to private consultancies during the COVID pandemic. This did not prevent numerous failures in the rollout. Delays increased the risk of critical health impacts including outbreaks and community lockdowns. The secrecy around these contracts is unacceptable.</p>
<p><strong>4. Impact on the public service and governance</strong></p>
<p>A <a href="https://www.finance.gov.au/sites/default/files/2023-05/Audit%20of%20Employment%20-%20Report_1.pdf">government audit</a> showed outsourcing to consultants in 2021–2022 was equal to the cost of paying 954 full-time public sector staff. This, and other forms of outsourcing, forms a so-called “shadow public service”.</p>
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<a href="https://images.theconversation.com/files/538468/original/file-20230720-25-cbbw6u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two women and man looking at computer screen in office, one woman pointing to screen" src="https://images.theconversation.com/files/538468/original/file-20230720-25-cbbw6u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/538468/original/file-20230720-25-cbbw6u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/538468/original/file-20230720-25-cbbw6u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/538468/original/file-20230720-25-cbbw6u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/538468/original/file-20230720-25-cbbw6u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/538468/original/file-20230720-25-cbbw6u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/538468/original/file-20230720-25-cbbw6u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">When governments rely on private firms, knowledge and expertise are lost from the public service.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mature-older-ceo-businesswoman-mentor-glasses-2025930416">Shutterstock</a></span>
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<p>When governments rely on private firms, knowledge and expertise are lost from the public service. This makes it hard for governments to plan ahead to reduce long-term health policy problems. Consultants shaped by the neoliberal environment tend to <a href="https://www.adelaide.edu.au/stretton/ua/media/568/sa-heaps-unfair-state-final-report.pdf">offer solutions</a> that are likely to stress more privatisation and use of consultants, as <a href="https://www.toronto.ca/ext/digital_comm/inquiry/inquiry_site/cd/gg/add_pdf/77/Procurement/Electronic_Documents/Miscellaneous/privateinterest.pdf">Canadian research has shown</a>. </p>
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Read more:
<a href="https://theconversation.com/after-robodebt-heres-how-australia-can-have-a-truly-frank-and-fearless-public-service-again-209488">After robodebt, here's how Australia can have a truly 'frank and fearless' public service again</a>
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<h2>How can we fix this?</h2>
<p>These firms hold power due to their expert knowledge and insufficient regulation. So we need strong commitment by the major political parties to:</p>
<ul>
<li><p><strong>reinvest in the public sector</strong> to foster the skills for planning long-term health policies in the public interest </p></li>
<li><p><strong>ensure full transparency over contractual arrangements</strong> and remove “commercial in confidence” legal clauses when consultants are used</p></li>
<li><p><strong>manage conflicts of interests transparently</strong>, especially when private firms advise both industry sectors and governments</p></li>
<li><p><strong>ban political donations</strong> <a href="https://www.consultancy.com.au/news/4891/how-much-pwc-kpmg-ey-and-deloitte-donate-to-political-parties">from firms</a> with extensive government contracts to avoid <a href="https://www.adelaide.edu.au/stretton/ua/media/568/sa-heaps-unfair-state-final-report.pdf">undermining</a> principles of accountability.</p></li>
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Read more:
<a href="https://theconversation.com/pwc-scandal-shows-consultants-like-church-officials-are-best-kept-out-of-state-affairs-205560">PwC scandal shows consultants, like church officials, are best kept out of state affairs</a>
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<h2>In a nutshell</h2>
<p>While commercial firms can make a positive contribution to society, they can potentially <a href="https://www.thelancet.com/series/commercial-determinants-health">increase</a> ill health, inequity, and harm to the planet via the advice or services they provide.</p>
<p>For as long as consulting firms act as a “shadow public service” in Australia, health and equity will continue to be undermined. This must change.</p><img src="https://counter.theconversation.com/content/209687/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Fran Baum receives funding from the National Health and Medical Research Council and the Australian Research Council
I am the immediate past co-chair of the People's Health Network's Global Steering Council and current member of their Advisory Council
I am a member of the Board of the Cancer Council SA and Australia 21 </span></em></p><p class="fine-print"><em><span>Julia Anaf does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There’s growing concern about the potential for conflicts of interest and undue influence on public health policy.Julia Anaf, Postdoctoral research fellow, Stretton Health Equity, Stretton Institute, University of AdelaideFran Baum, Professor of Health Equity, The Stretton Institute, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1268892019-11-13T13:09:44Z2019-11-13T13:09:44ZHouse impeachment inquiry may help restore the political and social norms that Trump flouts<figure><img src="https://images.theconversation.com/files/301390/original/file-20191112-178506-16qwgqt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Trump has broken a lot of norms.</span> <span class="attribution"><span class="source">AP Photo/Seth Wenig</span></span></figcaption></figure><p>President Donald Trump regularly uses blatant violations of long-established social and political norms to <a href="https://www.the-american-interest.com/2018/01/14/trump-the-authentic/">signal his “authenticity”</a> to supporters. </p>
<p>Asking <a href="https://www.wsj.com/articles/trump-urges-ukraine-china-to-investigate-the-bidens-11570114755">foreign countries</a> to investigate and deliver dirt on his political opponents, which prompted an impeachment inquiry in the U.S. House of Representatives, is the most recent example in a long string of norm-shattering behaviors. Other examples of flouting the standards of his presidential office include <a href="https://www.theatlantic.com/politics/archive/2017/08/trump-defends-white-nationalist-protesters-some-very-fine-people-on-both-sides/537012/">defending white nationalists</a>, <a href="https://www.nbcnews.com/politics/2016-election/hes-not-war-hero-donald-trump-mocks-john-mccains-service-n394391">attacking prisoners of war</a>, <a href="https://www.washingtonpost.com/opinions/2019/02/15/trumps-emergency-is-his-latest-assault-norms-american-democracy/">abusing the use of emergency powers</a>, <a href="https://www.cnn.com/2018/02/27/politics/judge-curiel-trump-border-wall/index.html">personally criticizing federal judges</a> and <a href="https://www.dallasnews.com/news/politics/2018/01/14/shattered-norms-in-just-one-year-has-donald-trump-changed-the-presidency-forever/">much more</a>. </p>
<p>Norms are perceptions or beliefs about what we understand the rules for acceptable behavior to be. They are powerful predictors of behavior. By openly broadcasting his anomalous actions and views, Trump is shifting public attitudes about what is deemed appropriate – not only in politics, but also <a href="https://hechingerreport.org/early-evidence-of-a-trump-effect-on-bullying-in-schools/">in society</a>.</p>
<p>However, based on my research on <a href="https://www.sunitasah.com/publications">institutional corruption, ethical decision-making and the power of professional norms</a>, I know norms can be shifted – even reversed – by activities like the House’s impeachment inquiry. </p>
<h2>The power of norms</h2>
<p>Norms are crucial in understanding how people succumb to unethical influences. We often decide what to do in a situation by first looking at what others are doing. </p>
<p>For example, if a <a href="https://financialservices.royalcommission.gov.au/publications/Documents/research-paper-conflicts-interest-disclosure.pdf">financial adviser</a> starts working in an institution in which her managers and leaders condone unethical practices that put profits over clients, she will understand the norm in that environment to be “self-interest first.” It then becomes perfectly appropriate, and even desirable, for that adviser to succumb to conflicts of interest and neglect or even defraud clients in the pursuit of profits. </p>
<p>Such behavior was evident in financial crises in the <a href="https://www.govinfo.gov/content/pkg/GPO-FCIC/pdf/GPO-FCIC.pdf">U.S.</a> and more recently in Australia, which <a href="https://financialservices.royalcommission.gov.au/publications/Documents/research-paper-conflicts-interest-disclosure.pdf">I examined</a> for the Royal Commission into Misconduct in the Financial Services Industry. </p>
<p>And institutional norms, once set, can be incredibly persistent.</p>
<p>My recent research shows that requiring advisers to <a href="https://doi.org/10.1016/j.obhdp.2019.07.005">disclose conflicts of interest</a> – the ways they would profit from their advice – doesn’t work if the company’s norms put self-interest first. In fact, disclosure in these instances can actually make things worse by leading to more biased advice. </p>
<p>However, if the institutional norm was to put “clients first,” disclosure improved the quality of advice. </p>
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<img alt="" src="https://images.theconversation.com/files/301611/original/file-20191113-77342-15pcfjt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/301611/original/file-20191113-77342-15pcfjt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/301611/original/file-20191113-77342-15pcfjt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/301611/original/file-20191113-77342-15pcfjt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/301611/original/file-20191113-77342-15pcfjt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/301611/original/file-20191113-77342-15pcfjt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/301611/original/file-20191113-77342-15pcfjt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Diplomats testify during the first public impeachment hearing on Nov. 13.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Trump-Impeachment/1f4c85f1e0a44b259e78ae09859b1143/31/0">Jim Lo Scalzo/Pool Photo</a></span>
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<h2>How norms shift</h2>
<p>Fortunately, Americans draw on many sources of information to perceive norms, not just the president’s deeds and tweets. </p>
<p>The behavior of other people, mass media and laws all factor into how we think about norms – good or bad – and can influence norm shifts. </p>
<p>For example, when the U.S. Supreme Court ruled in favor of same-sex marriage in 2015, <a href="https://pdfs.semanticscholar.org/3875/09456581f4f69c7d1a448a04da35ac2c0210.pdf">a survey of norms and attitudes</a> revealed that Americans perceived stronger and increasing public support for gay marriage after the ruling. This shift in perceived norms occurred in spite of the fact that personal attitudes toward gay marriage did not immediately change.</p>
<p>These shifts matter because norms can actually change our minds over time. A more <a href="https://www.pnas.org/content/116/18/8846">recent 2019 study</a> found that the Supreme Court ruling on gay marriage ultimately changed attitudes as well as norms, resulting in a reduced anti-gay bias in many parts of the country.</p>
<h2>Re-establishing ethical norms</h2>
<p>Although people select which news sources and peers to pay attention to, it is hard to ignore the behavior of the president. That’s why pursuing Trump’s impeachment, regardless of whether it is successful or not, is necessary to give a clear, authoritative legal signal of what is unacceptable behavior. </p>
<p>Of course, re-establishing the norms that have been broken over the past few years will take more than the actions of the political party that opposes the president. The voices of Republicans are also important. But so far, their <a href="https://www.nytimes.com/2019/09/30/opinion/republicans-trump-impeachment.html">general silence</a> has only strengthened Trump’s ability to break down norms. </p>
<p>Research on <a href="https://www.simplypsychology.org/milgram.html">obedience</a> and <a href="https://www.simplypsychology.org/asch-conformity.html">conformity</a> show that all it takes is one dissenting voice to speak out against authority to inspire others to do the same. </p>
<p>If more <a href="https://www.npr.org/2019/11/03/775897740/whistleblower-offers-to-field-written-questions-about-call-trump-says-was-perfec">whistleblowers</a>, <a href="https://www.axios.com/john-kasich-donald-trump-impeachment-396c6ca9-9ce4-4e7f-9e0b-bd14c9eab250.html">Republicans</a> and members of the administration speak up, the ethical, social and political norms that Trump has broken may start to regain their vitality.</p>
<p>[ <em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/126889/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sunita Sah is a Visiting Scholar at the Russell Sage Foundation. The Academy of Management is a funding partner of The Conversation US.</span></em></p>Norms are perceptions or beliefs about what we understand the rules for acceptable behavior to be. Trump’s impeachment could help restore some of them.Sunita Sah, Associate Professor of Management and Organizations, Cornell UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1114122019-02-21T00:12:24Z2019-02-21T00:12:24ZHow Big Pharma donations may influence public drug coverage<figure><img src="https://images.theconversation.com/files/260007/original/file-20190220-148539-hkqy2x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A new review of 372 patient group submissions to the Canadian Agency for Drugs or Technology in Health -- about whether new medicines should be covered by public plans -- reveals a total of 1896 conflicts of interest.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>The Canadian Agency for Drugs and Technology in Health (CADTH) is a not-for-profit organization that provides health-care decision-makers with evidence and recommendations for optimal use of health technologies. </p>
<p>It has two arms that evaluate drugs and make recommendations to public drug plans about whether they should pay for the drugs for particular uses — one for cancer and one that looks at all other drugs. Both allow patient advocacy groups to make submissions about whether a drug should be funded, and in those submissions they must declare any donations from drug companies. </p>
<p>My study, <a href="https://doi.org/10.1371/journal.pone.0212399">just published in <em>PLoS One</em></a>, examines whether such drug company donations influence patient group views.</p>
<h2>Many conflicts of interest</h2>
<p>I looked at 372 patient group submissions to CADTH filed between 2012 and 2018. Across most (just under 90 per cent) of the submissions, patient groups declared a total of 1,896 conflicts of interest. More than 85 per cent of the time those conflicts were with the company that made the drug under consideration. </p>
<p>In 13 per cent of submissions, groups declared conflicts with other drug companies. Just eight per cent of the time there were no conflicts with any drug company. </p>
<p>Occasionally, groups said what percentage of their budget came from the donations that they received. In a few cases, it was a substantial portion of their budget — up to 36 per cent — and in other cases it was just one to two per cent. Two patient groups didn’t see the value in providing any information about how much money that they received, saying: “We do not see the purpose of asking how much money has been contributed by any entity.”</p>
<h2>Support for public drug plans to pay</h2>
<p>Whether they had a conflict of interest with the company making the drug, a conflict with another company or no conflict at all, patient groups were overwhelmingly in favour of having public drug plans pay for the drug. Ninety per cent of the time they had a positive opinion about funding, nine per cent of the time a neutral view and just one per cent of the time, they had a negative view.</p>
<p>The arm of CADTH that assesses cancer drugs also allows groups to comment on preliminary decisions. If the organization recommended funding the drug in question then, not surprisingly, 94 per cent of the time groups agreed with that decision. If it rejected funding then almost 90 per cent of the time groups disagreed with that recommendation.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/259857/original/file-20190219-43273-1nf7k1g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/259857/original/file-20190219-43273-1nf7k1g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/259857/original/file-20190219-43273-1nf7k1g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/259857/original/file-20190219-43273-1nf7k1g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/259857/original/file-20190219-43273-1nf7k1g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/259857/original/file-20190219-43273-1nf7k1g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/259857/original/file-20190219-43273-1nf7k1g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">More research is needed – to understand whether money from drug companies influences how patient groups act.</span>
<span class="attribution"><span class="source">(Unsplash/rawpixel)</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>My study does not prove that funding from pharmaceutical companies directs the views that patient groups have about whether drugs should receive public funding. </p>
<p>However, industry funding does put patient groups in a conflict-of-interest situation, where their primary interest is in the welfare of the patients that they represent and a secondary interest is in the financial health of the companies that provide them with funding and that are marketing the drugs under consideration. </p>
<h2>Extensive lobbying in Québec</h2>
<p>The possibility that the position that patient groups adopt may be influenced by their funding is raised by Medicines Australia, the lobby arm of the pharmaceutical industry in Australia, in a <a href="https://doi.org/10.1136/bmj.331.7529.1359-b">guide published for its members</a>. The guide says that companies sponsoring non-profit groups might find that such sponsorship increases their chances of getting their drugs publicly funded under Australia’s Pharmaceutical Benefits Scheme.</p>
<p>After the National Institute for Excellence in Health and Social Services of Québec recommended that the Ministry of Health not fund four cancer drugs due to cost-effectiveness concerns, the Coalition Priorité Cancer (CPC), a Québec-based patient advocacy group, denounced the decision and lobbied extensively to reverse it. It was successful for three of the four drugs. </p>
<p>A <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3999544/">subsequent investigation</a> of the group concluded that its commitment to patient members was questionable. This conclusion was based on a number of observations, including the absence of a clear position or warning against the use of bevacizumab for breast cancer, although there was <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3266439/">no evidence that it worked</a>, and the CPC’s focus on the issue of reimbursement of expensive, low-efficiency drugs.</p>
<p>In the United States, the <a href="https://www.citizen.org/sites/default/files/patients-groups-and-big-pharma-money-report.pdf">Centers for Medicare and Medicaid Services proposed a project</a> aimed at lowering spending on the most costly treatments offered under Medicare Part B, the federal insurance plan that covers outpatient drug costs. </p>
<p>The proposed reform was to study the effect of modifying reimbursement methods so as to decrease physicians’ incentives to administer the most expensive medications. In addition to drug companies and doctors’ groups, 147 patient groups signed letters opposing the project, 110 of which received funding from the pharmaceutical industry.</p>
<h2>A cause-and-effect relationship?</h2>
<p>Patient groups serve a valuable function, speaking on behalf of their membership to government agencies, health-care professionals and health-care institutions like hospitals, and they are often the voice of patients in the media. </p>
<p>However, we need to do further research to understand whether the money that drug companies give them influences how they act. </p>
<p>If there is a cause-and-effect relationship at play, then patient groups need to consider whether they’re serving their membership by accepting industry funding, governments need to think about working with patient groups to develop new sources of unbiased support and CADTH needs to consider the weight that it gives to patient group input.</p><img src="https://counter.theconversation.com/content/111412/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>In 2015-2018, Joel Lexchin was a paid consultant on three projects: one looking at indication-based prescribing (United States Agency for Healthcare Research and Quality), a second to develop principles for conservative diagnosis (Gordon and Betty Moore Foundation) and a third deciding what drugs should be provided free of charge by general practitioners (Government of Canada, Ontario Supporting Patient Oriented Research Support Unit and the St Michael’s Hospital Foundation). He also received payment for being on a panel that discussed a pharmacare plan for Canada (Canadian Institute, a for-profit organization), a panel at the American Diabetes Association, for a talk at the Toronto Reference Library and for writing a brief for a law firm. He is currently a member of research groups that are receiving money from the Canadian Institutes of Health Research and the Australian National Health and Medical Research Council. He is member of the Foundation Board of Health Action International and the Board of Canadian Doctors for Medicare.</span></em></p>A new study reveals how many patient groups lobby for new drugs to be funded by public plans in Canada – all while receiving funding from the companies manufacturing the drugs in question.Joel Lexchin, Professor Emeritus of Health Policy and Management, York University, Emergency Physician at University Health Network, Associate Professor of Family and Community Medicine, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1082552018-12-06T09:55:20Z2018-12-06T09:55:20ZInfant formula companies are behind the guidelines on milk allergy, and their sales are soaring<figure><img src="https://images.theconversation.com/files/249170/original/file-20181206-186052-1inle1h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Infant formula manufacturers have been funding the development of guidelines for the diagnosis and treatment of cows' milk allergy in infants.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>There has been a six-fold increase in sales of infant formula prescribed for babies with cows’ milk protein allergy in the United Kingdom from 2006 to 2016. This is despite no evidence of a concurrent increase in the prevalence of infants with the allergy. </p>
<p>An investigation published today in the <a href="https://www.bmj.com/content/363/bmj.k5056">BMJ</a> found infant formula manufacturers have been funding the development of guidelines for the diagnosis and treatment of cows’ milk allergy as well as providing research and consultancy funds to those who wrote them.</p>
<p>Rates of cow’s milk allergy appear to have been <a href="https://www.ncbi.nlm.nih.gov/pubmed/25864712">relatively stable</a> – estimated at between 1-2% over the last decade. </p>
<p>Research has found the perception of an allergic response to cow’s milk protein in children is <a href="https://www-ncbi-nlm-nih-gov.ezproxy.uws.edu.au/pmc/articles/PMC3716921/">ten times greater</a> than what actual diagnosis would indicate. This means guidelines on allergy for doctors are really important.</p>
<p>In some cases, doctors who spoke to the BMJ said the guidelines were so vague that</p>
<blockquote>
<p>virtually every single infant could potentially be diagnosed using these symptoms. </p>
</blockquote>
<p>A diagnosis can only be made only by excluding cow’s milk protein from the maternal diet, observing symptoms, and then reintroducing it. But the BMJ paper notes that <a href="https://www.ncbi.nlm.nih.gov/pubmed/30306546?dopt=Abstract">evidence for advising</a> such exclusions to treat non-specific symptoms in breastfed infants is weak.</p>
<p>The paper also found much of the education for health professionals and parents about cows’ milk allergy was provided by organisations also funded by the infant formula industry.</p>
<p>Previous <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001500">research has found</a> that changes in diagnostic and treatment guidelines can have enormous effects on the revenue of pharmaceutical and nutritional products. Conflicts of interest due to industry funding have been <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000352">found to affect</a> doctors’ prescribing behaviour, research results and the quality of patient care.</p>
<p>Parents are also vulnerable to marketing. They crave a happy, quiet, calm baby who sleeps, eats and poos in a predictable pattern. </p>
<p>But babies wake often. They can have difficulty adjusting to life outside the womb and their stomachs are getting used to digesting food. They vomit. They cry for reasons that are hard to understand. </p>
<p>Marketing takes this normal infant behaviour and turns it into a problem that can be solved by buying a product.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-advertisers-use-pictures-to-sell-pharmaceuticals-and-shouldnt-53968">Why advertisers use pictures to sell pharmaceuticals – and shouldn't</a>
</strong>
</em>
</p>
<hr>
<p>When businesses are allowed to shape the guidelines health professionals use to diagnose and treat, this can lead to guidelines that find normal infant behaviour is treatable – with a product. </p>
<p>Unfortunately there may similar pressures on doctors in Australia.</p>
<p>A variety of infant formula products available in Australia claim to be antidotes to normal challenges new parents face such as crying, vomiting and constipation. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/249161/original/file-20181206-186070-10nz4x9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/249161/original/file-20181206-186070-10nz4x9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/249161/original/file-20181206-186070-10nz4x9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/249161/original/file-20181206-186070-10nz4x9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/249161/original/file-20181206-186070-10nz4x9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/249161/original/file-20181206-186070-10nz4x9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/249161/original/file-20181206-186070-10nz4x9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/249161/original/file-20181206-186070-10nz4x9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">An advertisement in Australian Doctor.</span>
<span class="attribution"><span class="source">.</span>, <span class="license">Author provided</span></span>
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</figure>
<p>The above advertisement is from the publication <a href="https://www.australiandoctor.com.au/">Australian Doctor</a> (which is available through subscription to medical professionals and includes drug advertising). It is a powerful piece of persuasion. It invokes every parent’s desire for a good night’s sleep and a contented, healthy baby to drive purchasing behaviour. Notice the presence of the mother in this picture. Although we can’t see her, we presume she is also sleeping somewhere. </p>
<p>When parents are desperate for help, doctors want to provide it. Colic is a variation of normal infant behaviour. It has no known medical cause or cure and this can make doctors feel powerless. However, this advertisement offers them a way to help. It gives doctors a solution – they just need to suggest the infant formula. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/my-baby-is-crying-is-it-colic-how-can-i-help-62952">My baby is crying. Is it colic? How can I help?</a>
</strong>
</em>
</p>
<hr>
<p>Parents are told to seek assistance from health professionals when they are concerned about their baby. However, if health professional guidelines and education is contaminated with marketing and influenced in other ways by infant formula manufacturers, the support they provide will be of poor quality. </p>
<p>Health professionals need independent, non-commercial information on infant feeding and parents should be protected from predatory marketing through effective enforcement of regulations.</p><img src="https://counter.theconversation.com/content/108255/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Karleen Gribble is affiliated with the Infant and Young Child Feeding in Emergencies Core Group, the World Breastfeeding Trends Initiative, and the Australian Breastfeeding Association. </span></em></p><p class="fine-print"><em><span>Nina J Berry's research is supported by funding from Australian Government Department of Health; the Australia Indonesia Centre and the University of Sydney. Dr Berry is a member of the International Union for Health Promotion and Education; the Public Health Association of Australia; the Asian Studies Association of Australia; the World Public Health Nutrition Association; Collaboration on Social Science in Immunisation; the Sydney Global Child Health Research Network; the Sydney South East Asia Centre; the Sydney Lifespan Research Network; and volunteers as a trainer, assessor, and counsellor for the National Breastfeeding Helpline.</span></em></p>New research shows a six-fold increase in sales of infant formula prescribed for babies with cows’ milk protein allergy in the UK, despite no evidence of an increase in the incidence of the allergy.Karleen Gribble, Adjunct Associate Professor, School of Nursing and Midwifery, Western Sydney UniversityNina Jane Chad, Post-doctoral Research Associate, Sydney School of Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/983752018-06-15T22:05:07Z2018-06-15T22:05:07ZWhy New York state is suing the Trumps: 5 questions answered<figure><img src="https://images.theconversation.com/files/223389/original/file-20180615-85822-1szfehr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Eric, Don Jr., Ivanka and Donald Trump</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Trump-Foundation-Investigation/78ce9f5bfdbc46fbb2de2851a7c33cc0/1/0">AP Photo/Evan Vucci</a></span></figcaption></figure><p><em>Editor’s note: New York state Attorney General Barbara D. Underwood is <a href="https://ag.ny.gov/press-release/attorney-general-underwood-announces-lawsuit-against-donald-j-trump-foundation-and-its">suing Donald Trump’s foundation</a> and its board of directors over an alleged “pattern of persistent illegal conduct.” <a href="https://scholar.google.com/citations?user=sQq-KYcAAAAJ&hl=en&oi=ao">Megan Tompkins-Stange</a>, a University of Michigan public policy professor, explains what the repercussions might be for the Trump family.</em></p>
<h2>1. Who is being accused of doing what, exactly?</h2>
<p>Trump and his three eldest children – Donald Jr., Eric and Ivanka – all sit on the Donald J. Trump foundation’s board, which <a href="https://ag.ny.gov/sites/default/files/court_stamped_petition.pdf">Underwood’s lawsuit</a> says exists “in name only.”</p>
<p>New York state’s attorney general is accusing the four Trumps of violating not just norms but laws. It says their foundation made payments that were “unlawful because they benefited Mr. Trump or businesses he controls.”</p>
<p>These are allegations of “<a href="https://theconversation.com/what-trump-foundations-self-dealing-disclosure-means-for-a-conflicted-president-elect-70075">self-dealing</a>” – that is, leveraging charitable assets for personal benefit. The foundation, which <a href="https://www.politico.com/story/2016/11/trump-foundation-irs-charitable-funds-self-dealing-231743">admitted to engaging in this illegal practice</a> in 2016 without providing many details, is also accused of illegally coordinating with Trump’s presidential campaign and manipulating the foundation’s giving to bolster the president’s political ambitions.</p>
<p>Underwood described the Trump foundation’s grants and expenditures as “little more than a checkbook for payments from Mr. Trump or his businesses to nonprofits, regardless of their purpose or legality,” in a statement summing up the allegations.</p>
<p>“This is not how private foundations should function and my office intends to hold the Foundation and its directors accountable for its misuse of charitable assets,” she stated.</p>
<p>Among other things, the New York state lawsuit specifically alleges that foundation money was misused to <a href="http://time.com/5312380/donald-trump-foundation-sued-new-york-attorney-general/">settle legal claims against the Trump family’s business</a> and <a href="http://www.mcclatchydc.com/news/politics-government/election/article105849807.html">curry favor with key political constituents</a>. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1007271867298836482"}"></div></p>
<h2>2. What is the big deal about self-dealing?</h2>
<p>All nonprofits, including the Donald J. Trump Foundation, pay no taxes on income, earnings or assets. This exemption is made in exchange for their mission to serve the public good. </p>
<p>One reason why charitable self-dealing is a big deal has to do with tax law.</p>
<p>In this case, it would essentially mean that taxpayers were subsidizing the wealthy Trump family, rather than simply allowing them to take advantage of <a href="https://www.thebalancesmb.com/what-qualifies-a-nonprofit-for-tax-exemption-2501886">tax breaks to benefit the public</a>.</p>
<p>When foundations originated in the early 1900s, some benefactors abused their philanthropic operations. The Rockefeller and Sage foundations, for example, originally served as <a href="http://www.jstor.org/stable/j.ctt5vktdq.7">tax havens for their founders’ fortunes</a> in addition to charitable purposes.</p>
<p>Since <a href="http://www.capdale.com/the-1969-private-foundation-law-historical-perspective-on-its-origins-and-underpinnings">Congress cracked down on this practice in 1969</a>, as part of a sweeping tax reform effort that outlawed using foundation assets for personal gain, <a href="http://hepg.org/hep-home/books/policy-patrons">the vast majority of foundations have scrupulously followed</a> these rules. </p>
<p>By contrast, the Trump family, according to in-depth reporting by The Washington Post’s <a href="http://www.pulitzer.org/winners/david-fahrenthold">David Fahrenthold</a> and other journalists, has brazenly and repeatedly broken charitable laws, even going so far as to use foundation money to <a href="https://www.washingtonpost.com/politics/a-clue-to-the-whereabouts-of-the-6-foot-tall-portrait-of-donald-trump/2016/09/14/ae65db82-7a8f-11e6-ac8e-cf8e0dd91dc7_story.html">buy a portrait of Donald Trump that was displayed at one of Trump’s private clubs</a>.</p>
<p>Separately, when foundations give money away to bolster someone’s political fortune, it can break campaign finance laws. Foundations need not disclose their donors, unlike political campaigns. </p>
<h2>3. Are there any similar precedents?</h2>
<p>This lawsuit is more than a big deal for the Trump family. It marks the first time since 1969 that any private foundation has been formally censured for self-dealing.</p>
<p>That may be because self-dealing does not appear to be a widespread practice in private foundations. All 501(c)(3) private foundations, including the one bearing Trump’s name, make grants. Often controlled by members of a single family, these foundations are relatively unaccountable to the public. Their sole formal responsibility to the public is to comply with IRS regulations.</p>
<p>As scholars Brian Mittendorf and Philip Hackney <a href="https://theconversation.com/what-trump-foundations-self-dealing-disclosure-means-for-a-conflicted-president-elect-70075">have previously explained</a>, only <a href="https://www.irs.gov/uac/soi-tax-stats-domestic-private-foundation-and-charitable-trust-statistics">0.25 percent</a> of private foundation tax returns in a recent 10-year period suggested any evidence of this kind of wrongdoing.</p>
<p>In contrast, self-dealing by public charities, nonprofits that run programs and offer services, is more common. For example, the Wounded Warrior Project – a public charity – was accused in 2016 of lavishing millions of dollars of donations <a href="https://www.news4jax.com/news/investigations/scathing-senate-report-released-following-wounded-warrior-project-investigation">on its own leaders</a>. This resulted in a Senate investigation and <a href="https://www.news4jax.com/news/investigations/wounded-warrior-ceo-optimistic-group-can-recover-from-scandal">sharp declines in donations</a> but no prosecution or formal punishment. </p>
<h2>4. How have the Trumps responded?</h2>
<p>Without addressing any of the specifics of this allegedly illegal behavior, President Trump has dismissed the lawsuit as a “<a href="https://twitter.com/realDonaldTrump/status/1007278825661784064">ridiculous case</a>” and accused Underwood’s office of “<a href="https://www.yahoo.com/news/trump-foundation-hits-back-political-motivations-new-york-attorney-generals-lawsuit-204141170.html">playing politics</a>.”</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1007300993162334210"}"></div></p>
<p>But the evidence against the family does look strong, in my opinion, partly because some of the Donald J. Trump Foundation’s alleged illegal transactions were relayed in writing. </p>
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<h2>5. What are the potential consequences?</h2>
<p>If they are found guilty, the Trumps could potentially be forced to <a href="https://ag.ny.gov/press-release/attorney-general-underwood-announces-lawsuit-against-donald-j-trump-foundation-and-its">pay a US$2.8 million fine</a> because Underwood’s office said that the foundation funneled at least that amount to Trump’s presidential campaign. They may also have to dissolve the foundation – something that the Trump family has already said <a href="https://www.vanityfair.com/news/2017/11/trump-family-foundation-investigation">it plans to do</a>. </p>
<p>That figure also, as it happens, equals the amount of money President Trump gave the foundation bearing his name <a href="https://www.cnn.com/2016/09/12/politics/donald-trump-foundation-charity/index.html">between 2001 and 2008</a>. Since then, all donations going into the organization have come from other sources, including World Wrestling Entertainment and NBCUniversal.</p>
<p>President Trump may be prohibited from serving on the board of any nonprofit for 10 years. His children, who are involved in other charitable pursuits that have in some cases raised <a href="https://www.usatoday.com/story/news/politics/onpolitics/2017/06/06/report-trump-used-kids-cancer-charity-funds-business/102565070/">additional legal concerns</a>, could be similarly barred for one year. </p>
<p>Because Underwood’s office has relayed its findings to the Federal Election Commission and the Internal Revenue Service, additional probes could result in additional penalties for the president and his family.</p>
<p>Notably, should the Trumps be found to have violated campaign finance and tax laws while abusing their foundation’s tax-exempt status, I believe that Congress might have <a href="http://history.house.gov/Institution/Origins-Development/Impeachment/">concrete justifications to pursue impeachment proceedings</a>.</p><img src="https://counter.theconversation.com/content/98375/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Megan Tompkins-Stange does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Donald J. Trump Foundation allegedly violated charitable norms and laws.Megan Tompkins-Stange, Assistant Professor of Public Policy, Gerald R. Ford School of Public Policy, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/689212017-01-20T11:01:32Z2017-01-20T11:01:32ZSultan Donald Trump?<p>Family is important to Donald Trump. The president-elect has appointed <a href="https://www.washingtonpost.com/news/post-politics/wp/2017/01/09/tumps-son-in-law-jared-kushner-expected-to-join-white-house-as-a-senior-adviser/?utm_term=.1e5a5de2104b">his son-in-law Jared Kushner</a> as a senior White House adviser. For the duration of the presidency, the real estate mogul has <a href="http://www.bbc.com/news/business-38587628">handed over </a>the reins of his company to two of his sons Donald and Eric (and the CFO Allen Weisselberg). His children have played important roles in <a href="http://elections.ap.org/content/trump-childrens-roles-blur-line-between-transition-company?">the election campaign</a>; in <a href="http://www.abc.net.au/news/2016-11-12/donald-trump-loyalists-children-to-steer-white-house-transition/8019982">transition reviews</a> of new appointments; and have even participated in meetings with foreign visitors.</p>
<p>By <a href="http://www.nytimes.com/2016/07/22/us/politics/donald-ivanka-trump-family.html?_r=0">many accounts</a>, the next generation of Trumps and in-laws are impressive. </p>
<p>Friends of mine at the General Services Administration, which manages government property, report that Ivanka Trump was universally regarded as thoroughly professional in all her interactions with GSA staff in the lease negotiations for the Old Post Office on Pennsylvania Avenue. But this new Trump hotel, in which <a href="https://www.washingtonpost.com/news/digger/wp/2016/12/07/conservative-groups-foreign-leaders-flock-to-trumps-d-c-hotel/?utm_term=.7d98e14e052b">foreign leaders have been choosing to stay</a>, thereby profiting Trump enterprises, is a half-mile from the White House and epitomizes the conflicts of interest raised by Trump’s presidency. </p>
<p>A clause in the lease that Ivanka Trump negotiated, for example, includes a standard <a href="https://www.gsa.gov/portal/content/154314">provision</a> in government contracts to prevent or limit conflicts of interests: </p>
<blockquote>
<p>“No…elected official of the Government of the United States..shall be admitted to any share or part of this Lease, or to any benefit that may arise therefrom…”</p>
</blockquote>
<p>So far, however, any conflict of interest problems have been <a href="http://time.com/4631551/donald-trump-press-conference-russia-ethics-transcript/">brushed aside </a>by Donald Trump.</p>
<p>So what might happen in a presidential democracy where the leader or those working for the leader are motivated by absolute personal or family loyalty and ignore legal requirements and procedural traditions?</p>
<p>As a comparative political scientist who studies different types of governments, I’m particularly interested in whether Trump’s way of governing will fit into what we call “sultanism” where the rule of law, procedures and institutions are eroded by personal loyalties. Such a system, history shows, has eroded institutions and – in a democracy – could lead toward authoritarianism. </p>
<p>Let me explain.</p>
<h2>What sultanism means</h2>
<p>It was over a century ago that the famous political sociologist Max Weber developed the concept of sultanism, which, he wrote, <a href="https://www.amazon.com/Economy-Society-Set-Max-Weber/dp/0520280024">“operates primarily on the basis of discretion.”</a></p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/153328/original/image-20170118-26555-l5ezbt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/153328/original/image-20170118-26555-l5ezbt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=728&fit=crop&dpr=1 600w, https://images.theconversation.com/files/153328/original/image-20170118-26555-l5ezbt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=728&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/153328/original/image-20170118-26555-l5ezbt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=728&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/153328/original/image-20170118-26555-l5ezbt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=915&fit=crop&dpr=1 754w, https://images.theconversation.com/files/153328/original/image-20170118-26555-l5ezbt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=915&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/153328/original/image-20170118-26555-l5ezbt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=915&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">35th sultan of the Ottoman Empire and 114th caliph of Islam, Mehmed V.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Sultan_Mehmed_V_of_the_Ottoman_Empire_cropped.jpg">Library of Congress</a></span>
</figcaption>
</figure>
<p>“Sultans,” or kings, of the Ottoman empire were absolute rulers, their power made legitimate by theology. They used arbitrary and despotic powers. Their lifestyles were <a href="https://books.google.com/books?id=cTnMY_D63FMC&printsec=frontcover&dq=Ottoman+Empire+decline&hl=en&sa=X&ved=0ahUKEwjqtYXQ54DRAhWDRCYKHZxtB44Q6AEIHDAA#v=onepage&q=Ottoman%20Empire%20decline&f=false">lavish and decadent.</a> And over time they lost their power. While rival European empires such as the Hapsburgs’ Austro-Hungary and Weber’s native Germany <a href="https://books.google.com/books?id=jGboBAAAQBAJ&pg=PT233&dq=Hapsburg+Kaiser+Wilhelm+Bureaucracy&hl=en&sa=X&ved=0ahUKEwig04Pc6IDRAhUESSYKHdM3D1kQ6AEIUzAI#v=onepage&q=Hapsburg%20Kaiser%20Wilhelm%20Bureaucracy&f=false">were rising</a> in the 19th century as they developed impressive civil and military bureaucracies and procedures, the Ottoman Empire was declining. </p>
<p>The late Juan J. Linz and Alfred Stepan of Columbia University <a href="https://jhupbooks.press.jhu.edu/content/problems-democratic-transition-and-consolidation">argued</a> that sultanism is both a regime type (like democracy and authoritarianism) and an adjective describing a style of personal rule that is possible under all regime types, including democracy. They wrote:</p>
<blockquote>
<p>“The essence of sultanism is unrestrained personal rulership…unconstrained by ideology, rational-legal norms, or any balance of power.” </p>
</blockquote>
<p>Sultanism, in other words, is most common under authoritarian and autocratic rule, but it can also be present in democracies, where leaders personalize decision-making instead of following established institutional or legal processes.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/153324/original/image-20170118-26582-2ax3mn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/153324/original/image-20170118-26582-2ax3mn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=801&fit=crop&dpr=1 600w, https://images.theconversation.com/files/153324/original/image-20170118-26582-2ax3mn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=801&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/153324/original/image-20170118-26582-2ax3mn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=801&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/153324/original/image-20170118-26582-2ax3mn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1007&fit=crop&dpr=1 754w, https://images.theconversation.com/files/153324/original/image-20170118-26582-2ax3mn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1007&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/153324/original/image-20170118-26582-2ax3mn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1007&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">‘Papa Doc’ Duvalier of Haiti in 1968.</span>
</figcaption>
</figure>
<p>Some might assume it irrelevant to compare any U.S. leader to <a href="https://books.google.com/books?id=rPNSnRYzIdgC&printsec=frontcover&dq=sultanistic+regimes+juan+Linz&hl=en&sa=X&ved=0ahUKEwiT7tC_74DRAhVCwiYKHRanCr8Q6AEIJTAA#v=onepage&q=sultanistic%20regimes%20juan%20Linz&f=false">classic sultanistic rulers</a> such as the <a href="https://books.google.com/books?id=0ezGBQAAQBAJ&pg=PT202&dq=Francois+Jean+Claude+Duvalier&hl=en&sa=X&ved=0ahUKEwjagv3Z7oDRAhWM24MKHSaBD9EQ6AEINzAF#v=onepage&q=Francois%20Jean%20Claude%20Duvalier&f=false">Duvaliers</a> of Haiti, Ferdinand Marcos of the Philippines or Joseph Stalin of the Soviet Union. These regimes were nondemocratic and dominated by a single personality with family members intensely involved. </p>
<p>However, like the U.S., South Korea is a democracy and its president, Park Geun-hye, <a href="https://www.washingtonpost.com/news/monkey-cage/wp/2016/12/12/south-koreas-president-was-just-impeached-this-is-what-it-means-and-what-comes-next/?utm_term=.0c810fad4782">was impeached Dec. 9</a> for corrupt activities, many connected to a close family adviser. The adviser, allegedly a <a href="http://www.dictionary.com/browse/shaman">shaman</a>, is herself the daughter of another Rasputin-type religious figure <a href="https://www.ft.com/content/840b203a-b177-11e6-a37c-f4a01f1b0fa1">who had also secretly advised</a> the president’s father during his 18 years in office. </p>
<p>Another example can be found in Nicaragua. President Daniel Ortega – who packed his Supreme Court to allow him a third consecutive term – has as his vice president his wife, Rosario Murillo, one of the few leaders he trusts, <a href="http://www.nytimes.com/2016/10/31/world/americas/nicaragua-daniel-ortega-rosario-murillo-house-of-cards.html">having alienated much of his party.</a> </p>
<h2>American precedents</h2>
<p>It is also the case that the U.S. has had sultanistic tendencies of its own in the past. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/153325/original/image-20170118-26582-1f1rmpb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/153325/original/image-20170118-26582-1f1rmpb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=475&fit=crop&dpr=1 600w, https://images.theconversation.com/files/153325/original/image-20170118-26582-1f1rmpb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=475&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/153325/original/image-20170118-26582-1f1rmpb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=475&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/153325/original/image-20170118-26582-1f1rmpb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=597&fit=crop&dpr=1 754w, https://images.theconversation.com/files/153325/original/image-20170118-26582-1f1rmpb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=597&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/153325/original/image-20170118-26582-1f1rmpb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=597&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">President John F. Kennedy and Attorney General Robert F. Kennedy with FBI Director Edgar J. Hoover.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/pingnews/274988824">National Archives</a></span>
</figcaption>
</figure>
<p>President John F Kennedy’s closest adviser and his attorney general was his younger brother Robert, indispensable during the perilous time of the Cuba Missile Crisis. And JFK, while in office and sometimes with his brother Robert involved, took enormous risks in having flings with women with dubious political connections – from a <a href="http://articles.latimes.com/1999/sep/26/news/mn-14342">socialite with links to the mob</a> to a <a href="http://www.nytimes.com/books/97/11/30/reviews/971130.30powerst.html">possible East German spy</a>. This is not mere indiscretion.</p>
<p>The reaction of Congress to all this was to pass, in 1967, the <a href="https://www.law.cornell.edu/uscode/text/5/3110">Anti-Nepotism Statute</a> – nicknamed the <a href="http://time.com/4574971/donald-trump-transition-jared-kushner-legal-anti-nepotism-law/">“Bobby Kennedy Law”</a> – to make sure close relatives no longer assume official positions. <a href="https://concurringopinions.com/archives/2012/06/nepotism-and-the-cabinet.html">Some suggest</a>, however, that the law does not exclude unofficial advisers.</p>
<p>Another example of sultanistic practices include Hillary Clinton, who was her president-husband’s lead and unpaid adviser on health care reform. </p>
<p>And then, in George W. Bush’s Cabinet, the two most powerful foreign policy advisers – Defense Secretary Donald Rumsfeld and Vice President Dick Cheney – were both alumni of George H. W. Bush’s administration. After the terrorist attacks of 9/11, Rumsfeld and Cheney, with Bush’s approval, established <a href="http://www.nytimes.com/2006/02/05/books/review/spies-and-spymasters.html">arbitrary policy</a> that permitted <a href="https://www.amazon.com/Official-Senate-Report-Torture-Interrogation/dp/1634506022/ref=pd_sbs_14_t_1?_encoding=UTF8&psc=1&refRID=X8SN4WTC04VSQQA6MC6J">torture</a>, warrantless surveillance and targeted assassinations. </p>
<p>These Bush-era “law-free” zones in national security matters, which some have called <a href="http://illinoislawreview.org/wp-content/ilr-content/articles/2013/2/Alexander.pdf">dictatorial</a>, were based on the legal concept of the “unitary executive.” The idea is that the judicial and legislative branches cannot check or regulate the president on “executive” matters, especially those involving national security.</p>
<p><a href="https://books.google.com/books/about/The_Imperial_Presidency.html?id=zbLO9aNL6ncC">The unitary executive</a> in turn facilitated sultanism by asserting that the president monopolizes all executive power, however exercised. As <a href="http://loc.gov/law/help/usconlaw/pdf/senate%20judiciary%20sept_16_%202008.pdf">some noted constitutional scholars</a> have said, this theory basically places the president above the law. </p>
<h2>What makes Trump different</h2>
<p>Modern American presidents have risen through the institutions of U.S. democracy – state political parties, Capitol Hill, the military. They have been vetted and embedded in institutional rules, attitudes and relationships. Someone coming in “from the cold,” in contrast, brings his family and close associates and makes decisions outside of those formal and informal institutions. </p>
<p>Having masterminded his unexpected victory based on an unconventional campaign, Trump has already shown a tendency to trust his instincts on major decisions of governance, creating impulsive, unpredictable decisions. His past record as CEO and his outsider status make Trump self-reliant and assured that most of the world is misguided and only he and his few trusted advisers, including his family, have the answers. </p>
<p>When questioned, for example, on <a href="https://www.donaldjtrump.com/press-releases/donald-j.-trump-statement-on-preventing-muslim-immigration">his pledge</a> to ban Muslims from entering the country “until our country’s representatives can figure out what is going on,” Trump said: </p>
<blockquote>
<p>“What I’m doing is no different than FDR. If you look at what he was doing, it was far worse … and he’s one of the most highly respected presidents — they name highways after him.”</p>
</blockquote>
<p>Here Trump was evoking the <a href="https://en.wikipedia.org/wiki/Korematsu_v._United_States">1944 Korematsu decision</a>, which upheld almost unlimited executive powers over immigration to permit the detention of Japanese-Americans without any evidence (and none existed) of subversion. This decision is considered by many <a href="http://blog.constitutioncenter.org/2015/12/trumps-muslim-comments-start-a-debate-with-constitutional-scholars/">constitutional scholars</a> as the most ignominious in Supreme Court history, a “tragic mistake that we should not repeat.” Even the late Justice <a href="https://www.washingtonpost.com/news/volokh-conspiracy/wp/2014/02/08/justice-scalia-on-kelo-and-korematsu/?utm_term=.dce59aacb4ae">Antonin Scalia disavowed it</a>. </p>
<p>The U.S. presidency has always been prone to sultantistic tendencies, but under a Trump presidency what were once isolated incidents could become a way of governing. When the closest advisers, both institutional (in <a href="https://www.washingtonpost.com/news/post-politics/wp/2017/01/09/tumps-son-in-law-jared-kushner-expected-to-join-white-house-as-a-senior-adviser/?utm_term=.1e5a5de2104b">the case of son-in-law Jared Kushner</a>) and informal (in the case of his three children), are dominated by family members, the decision-making process will not only be influenced by private family interests but also tend to ignore legal procedures. </p>
<p>Instead of <a href="https://hbr.org/2009/04/leadership-lessons-from-abraham-lincoln">a “team of rivals” </a>under the rule of law, the Trump presidency may be akin to medieval monarchy, with decisions made by court politics, not legal procedures.</p><img src="https://counter.theconversation.com/content/68921/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Henry F. (Chip) Carey does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A political scientist looks at the similarities between the new American president and the sultans of the Ottoman Empire. What might the parallels portend for US politics?Henry F. (Chip) Carey, Associate Professor, Political Science , Georgia State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/714012017-01-18T11:03:48Z2017-01-18T11:03:48ZTrump snubs ethical norms because we’ve forgotten why they matter<p>Let’s be honest. Conflicts of interest are boring.</p>
<p>The president-elect knows this. In fact, he’s banking on it.</p>
<p>Instead of addressing his conflicts in a meaningful way at his press conference last week, Trump <a href="https://www.nytimes.com/2017/01/11/us/politics/trump-press-conference-transcript.html">pointed to a stack of folders</a> behind him. He then turned the press conference over to a lawyer, who talked about Trump’s plans for long enough for viewers to lose interest. It sounded official and complicated, even though it’s an embellished version of his <a href="http://news.sky.com/story/donald-trump-to-leave-business-empire-to-avoid-conflict-of-interest-10677844">November announcement</a> to turn the business over to his children.</p>
<p><a href="http://www.economist.com/news/united-states/21714346-plan-put-trump-organisation-arms-length-doesnt-go-far-enough-donald-trumps">Many</a> <a href="http://www.pbs.org/newshour/bb/trumps-plan-company-enough-avoid-conflicts-interest/">condemned</a> Trump’s <a href="https://www.nytimes.com/2017/01/11/us/politics/trump-press-conference-transcript.html">plan</a> to handle his <a href="https://www.buzzfeed.com/johntemplon/help-us-map-trumpworld?utm_term=.kiwYWg91dL#.puqYaR6zLJ">myriad conflicts</a> of interest as president as wholly inadequate, including the director of the U.S. Office of Government Ethics. </p>
<p>But most likely, Trump will get away with it – for now – and continue to ignore the warnings of government ethics officials, tasked with preventing things from going terribly wrong. </p>
<p>For decades, they’ve been so successful at preventing a major government ethics scandal, Trump’s conflicts of interest now seem academic and even soporific to the average voter. Unfortunately for Trump, his unwillingness to listen makes a disaster much more likely. On the upside, a scandal would at least remind Americans why ethics-based precautions matter.</p>
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<h2>Owning is knowing</h2>
<p>Trump’s <a href="https://www.nytimes.com/2017/01/11/us/politics/trump-press-conference-transcript.html">plan</a> consists of handing management of the family business to his sons, Don and Eric, and a current Trump executive. Trump pledges not to discuss business with his sons. </p>
<p>Trump will not be divesting his golf clubs, commercial properties, resorts, hotels or royalty rights. The plan also provides for no “new” foreign deals, though new domestic deals will be permitted subject to a “vetting process.” Existing foreign and domestic deals will presumably continue.</p>
<p>Walter Shaub, who directs the Office of Government Ethics, <a href="http://money.cnn.com/2017/01/11/news/office-government-ethics-trump-conflicts/">condemned</a> Trump’s plan as “meaningless.” Turning over management of the business to others – especially his own children – is not a “blind trust” because Trump “knows what he owns.” Trump’s own attorney used this fact as an argument that nothing could be done about the conflict. </p>
<p>Shaub disagreed. If Trump divests his assets and places them in a blind trust – meant to prevent an elected official from making decisions that would benefit his or her own business interests – he won’t know what he owns. The independent trustee would make decision about selling assets and which assets to buy in their place. Under the government’s <a href="https://oge.gov/Web/oge.nsf/Resources/Model+Qualified+Blind+and+Diversified+Trust+Documents">standard blind trust agreement</a>, the trustee wouldn’t tell the president which assets are in the trust. </p>
<h2>Much ado about nothing?</h2>
<p>Nevertheless, Republican Representative Jason Chaffetz <a href="http://www.deseretnews.com/article/865671101/Chaffetz-criticized-for-going-after-federal-ethics-official-who-spoke-out-against-Trump.html">called Shaub</a> “highly unethical” for publicly criticizing Trump’s plan. </p>
<p>It’s certainly unusual, but, as with all things Trump, we’re in uncharted waters.</p>
<p>For some Trump supporters, all of this ethics criticism feels alarmist and exaggerated. One explained to me that these conflicts of interests are all hypothetical and abstract. Nothing terrible has happened yet. He argued that Trump’s potentially problematic behavior thus far – like his business-related inquiries of the <a href="http://talkingpointsmemo.com/edblog/cashing-in-bigly-in-argentina">Argentinian president</a> or complaints to Brexit leaders about wind farms <a href="http://www.nytimes.com/2016/11/21/business/with-a-meeting-trump-renewed-a-british-wind-farm-fight.html">near his golf course</a> – is small potatoes compared to other national priorities.</p>
<p>This reaction is understandable. It’s hard to imagine a giant presidential ethics scandal because there hasn’t been one <a href="https://www.senate.gov/artandhistory/history/common/investigations/Watergate.htm">since the Nixon administration</a>. Why worry?</p>
<p>Anyone in the business of prevention understands this challenge. In “<a href="https://books.google.com/books/about/The_Black_Swan.html?id=YdOYmYA2TJYC">The Black Swan</a>,” Wharton scholar Nicholas Nassim Taleb described the most “mistreated heroes” as those “we do not know were heroes, who saved our lives, who helped us [by] avoid[ing] disasters.” </p>
<p>Taleb presents the thought experiment of a hypothetical legislator who passed a law requiring that cockpit doors be locked as of Sept. 10, 2001. Yes, the legislator would have succeeded in preventing a terrorist attack. But he would also erase the proof that his legislation was valuable. </p>
<p>In the business of prevention, the benefits are hypothetical and the costs are real. The diseases prevented by vaccines have become so rare that they have reached the status of a <a href="https://theconversation.com/stories-of-vaccine-related-harms-are-influential-even-when-people-dont-believe-them-58314">hypothetical threat</a>. Some parents now decline vaccines based on ephemeral fears because the benefits have become even more ephemeral. </p>
<p>William Ruckelshaus, a Republican and the first Environmental Protection Agency administrator, <a href="http://www.opb.org/news/article/seattles-first-epa-chief/">summed up the problem</a> nicely:</p>
<blockquote>
<p>“During the late ‘60s, the early ‘70s … [y]ou could see the air pollution on your way to work in the morning. When I first moved to Washington, the air was brown, mostly associated with automobile emissions. We had rivers that caught on fire like the (Cuyahoga) going through Cleveland, Ohio. …today it doesn’t galvanize as much public demand that something be done as was true back in the 1960s. EPA is a victim of its own success. A lot of the changes in the air and the water have been a result of a pretty vigorous agency going after polluters.”</p>
</blockquote>
<h2>Make ethics great again</h2>
<p>Conflicts of ethics rules serve as preventative measures, as Shaub <a href="http://www.deseretnews.com/article/865671101/Chaffetz-criticized-for-going-after-federal-ethics-official-who-spoke-out-against-Trump.html">pointed out</a>. </p>
<p>Blind trusts make conflicts of interest impossible because government officials both no longer have control of the assets and don’t know what they are. It is impossible to be influenced by ownership of an unknown asset. </p>
<p>All of the presidents since the Watergate scandal have acted as though the <a href="https://www.law.cornell.edu/uscode/html/uscode05a/usc_sup_05_5_10_sq3.html">Ethics in Government Act of 1978</a> applied to them, even though technically it doesn’t. </p>
<p>In a sense, the entire Executive Branch has been vaccinated against conflicts of interest for the last 40 years. That is until now, with an incoming president who stated repeatedly during his press conference that conflict of interest rules don’t apply. So maybe we’re due for a scandal?</p>
<p>Sometimes, retrenchment can be helpful to the cause of prevention. In 2015, a measles outbreak at Disneyland led to an <a href="http://www.seattletimes.com/seattle-news/health/amid-outbreaks-measles-shots-surge-27-percent-in-state/">increase in vaccination rates</a>. Trump’s unprecedented conflicts of interest could do the same for Washington, spurring a renewed push to bind the president to higher ethical standards.</p>
<p>At it stands, Trump’s failure to address his conflicts means that he remains exposed to the possibility of a full-blown conflicts-of-interest scandal. All it would take is for President Trump to have another conversation with British politicians about those <a href="http://www.nytimes.com/2016/11/21/business/with-a-meeting-trump-renewed-a-british-wind-farm-fight.html">pesky wind farms</a> near his golf course in Scotland, this time from the Oval Office.</p>
<p>Yes, it would be a blow to the office of the presidency. But on the upside, it would – to borrow the president-elect’s favored phrase – make ethics great again.</p><img src="https://counter.theconversation.com/content/71401/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elizabeth C. Tippett made a contribution to the Hillary Clinton election campaign.</span></em></p>We haven’t had a major government ethics scandal since Watergate, which means Americans have forgotten how bad it can be. That’s why Trump may end up accidentally reminding us.Elizabeth C. Tippett, Assistant Professor, School of Law, University of OregonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/700752016-12-15T04:09:52Z2016-12-15T04:09:52ZWhat Trump Foundation’s ‘self-dealing’ disclosure means for a conflicted president-elect<p>Earlier this month, we learned that the Donald J. Trump Foundation <a href="https://www.washingtonpost.com/politics/trump-foundation-apparently-admits-to-violating-ban-on-self-dealing-new-filing-to-irs-shows/2016/11/22/893f6508-b0a9-11e6-8616-52b15787add0_story.html?utm_term=.703a16e5017a">admitted to acts of self-dealing</a> in its most recent IRS filing. </p>
<p>But what is self-dealing and, more significantly, what does it mean for the president-elect as he deals with <a href="https://theconversation.com/why-president-elect-trump-doesnt-think-he-has-a-conflict-of-interest-problem-70006">his many conflict of interest issues</a> when he runs the country? </p>
<p>The potential of these conflicts to become problems surfaced recently as the president-elect began discussions with foreign leaders. As illustrated by his conversations with <a href="http://www.nytimes.com/2016/11/19/us/politics/ivanka-trump-shinzo-abe.html">Japan’s prime minister</a>, <a href="http://timesofindia.indiatimes.com/us-elections-2016/Donald-Trump-meets-Indian-partners-hails-PM-Modis-work/articleshow/55469451.cms">Indian business partners</a> and <a href="http://www.huffingtonpost.com/entry/president-elect-trump-argentinian-president_us_58332bb1e4b030997bc087da">Argentina’s prime minister</a>, his <a href="http://www.theatlantic.com/politics/archive/2016/11/trump-conflict-of-interest/508583/">vast global business holdings</a> suggest his decision-making could be influenced by his financial interests.</p>
<p>As researchers who have examined the filings and activities of foundations for years, we see this high-profile case as an opportunity to explain self-dealing, its consequences, how it can be avoided and what it may mean for the incoming administration.</p>
<h2>What is self-dealing?</h2>
<p>Though the <a href="https://www.washingtonpost.com/people/david-a-fahrenthold/?utm_term=.d3bd02e91b2e">intrepid reporting</a> of David Fahrenthold of the Washington Post brought questions of self-dealing at the Trump Foundation forward months ago, this is the first admission by the foundation itself. </p>
<p>These issues provide a backdrop to the broader discussion of conflicts of interest the president-elect faces, an issue he had planned to address but <a href="https://www.bloomberg.com/politics/articles/2016-12-12/trump-said-to-postpone-announcement-on-future-of-his-businesses">has since postponed</a>. This is particularly true if <a href="http://www.nytimes.com/2016/12/07/us/politics/trump-organization-ivanka-trump.html?hp&action=click&pgtype=Homepage&clickSource=story-heading&module=first-column-region&region=top-news&WT.nav=top-news&_r=1">early reporting</a> that he intends to keep financial interests in his various businesses materializes. </p>
<p>Self-dealing refers to a <a href="https://www.irs.gov/charities-non-profits/private-foundations/acts-of-self-dealing-by-private-foundation">class of transactions</a> between a private foundation and a person who exercises control over it because of official authority or because of large contributions. Such individuals are referred to in the statute as “disqualified persons.” </p>
<p>There are precise definitions for the different types of transactions (e.g., sales, loans, use of facilities, transfer of assets, etc.) that fall under this classification. But the gist of the rule is that an activity conducted by the private foundation that could benefit a person who has substantial influence over the foundation’s decisions is generally viewed as prohibited self-dealing.</p>
<p>In the Trump Foundation case, the potential self-dealing transactions are many: from <a href="https://www.washingtonpost.com/politics/trump-used-258000-from-his-charity-to-settle-legal-problems/2016/09/20/adc88f9c-7d11-11e6-ac8e-cf8e0dd91dc7_story.html?utm_term=.0a0537045086">buying a painting at a charity auction</a> that was displayed at Trump-owned properties and <a href="https://www.washingtonpost.com/politics/trump-used-258000-from-his-charity-to-settle-legal-problems/2016/09/20/adc88f9c-7d11-11e6-ac8e-cf8e0dd91dc7_story.html?utm_term=.0a0537045086">using a foundation grant as a means to settle a lawsuit</a> to <a href="https://surlysubgroup.com/2016/10/03/trumps-abuse-of-trump-foundation-criminal-tax-implications/">using foundation funds in promotion</a> of “Celebrity Apprentice.” </p>
<p>Because the foundation has not made the details public, we cannot say for sure which, if any, of these is the source of the admission, but they all have a similar flavor: the foundation spends funds in a way that can benefit Trump himself.</p>
<h2>Why is the rule in place?</h2>
<p>Congress grants charitable organizations both exemption from income tax and the ability to accept tax deductible contributions. In exchange for this subsidy, Congress views these organizations as holding money for public charitable purposes and insists funds are used accordingly.</p>
<p>Private foundations are in a particularly delicate position in this regard because they are typically established and controlled by one wealthy family. In a <a href="http://www.finance.senate.gov/imo/media/doc/SPrt101.pdf">report from the U.S. Treasury Department in 1965</a>, its legal counsel indicated concern that a small group of founders of private foundations were using charities as their private piggy banks. They might make their private foundation lease or buy property from themselves for too much money. In response to these concerns, Congress included a <a href="https://www.law.cornell.edu/uscode/text/26/4941">tax on all self-dealing</a> in the 1969 Tax Act to reduce the potential for abuse.</p>
<p>The Trump Foundation’s recent admission that it engaged in self-dealing is uncommon in the private foundation world. Over the most recent 10-year period for which IRS data is available (2004-2013), <a href="https://www.irs.gov/uac/soi-tax-stats-domestic-private-foundation-and-charitable-trust-statistics">fewer than 0.25 percent of returns</a> filed by private foundations entailed recognized acts of self-dealing. </p>
<p>This is consistent with the findings of the Treasury Department in its 1965 report, which focused on a small number of violations and has led <a href="https://www.independentsector.org/panel">Congress to continue</a> to find ways to <a href="https://www.law.cornell.edu/uscode/text/26/4958">rein in abuses</a> in the broader charitable sector. </p>
<h2>What are the consequences?</h2>
<p>The legislation prohibiting self-dealing did not criminalize this activity. Thus, the fact that the Trump Foundation admitted self-dealing is not an admission that it engaged in an illegal act.</p>
<p>However, there are two primary consequences that result from a self-dealing transaction. First, the disqualified person who engaged in a self-dealing transaction must pay a tax equal to 10 percent of the greater of the amount paid or the fair market value of the transaction. For instance, if a disqualified person sold a building to a private foundation in a self-dealing transaction for $100,000, the disqualified person would owe an excise tax of $10,000 (assuming the fair market value is also $100,000). </p>
<p>Secondly, the charity must seek to correct the transaction, meaning it must reverse what took place. The disqualified person must return the money or thing he or she received. If the disqualified person does not correct the transactions after the IRS assesses the self-dealing excise tax, other more significant taxes can apply.</p>
<p>Self-dealing rules were written to address situations that are ethically difficult. When a private foundation and its founder engage in a transaction, it can be hard to tell whether the foundation got the bad end of the stick or not. </p>
<p>The Trump Foundation, however, seems to have engaged in some transactions where there may be more clear benefits to the disqualified person, for example, when the foundation acquired paintings of its founder. Such instances could also violate a charity law called inurement, which prohibits a charitable organization from providing its earnings to its founders or those who control it. If the IRS were to determine that the Trump Foundation violated the inurement prohibition, the IRS could revoke its tax exemption.</p>
<p>Finally, and least likely, there <a href="https://surlysubgroup.com/2016/10/03/trumps-abuse-of-trump-foundation-criminal-tax-implications/">could be criminal consequences</a> for Trump or others if they were found to have willingly and knowingly filed false returns. It is highly unlikely that the IRS would bring such a case. Typically, the IRS only brings such cases when it finds a pattern of egregious conduct. </p>
<h2>How do organizations prevent self-dealing?</h2>
<p>While the penalties associated with self-dealing are real, the bigger picture is that self-dealing is a symptom of a governance failure. </p>
<p>Self-dealing arises when a governance system fails to adequately separate the interests of influential individuals from the mission of the institution they serve. Such failings permeate the institution well beyond the isolated acts of self-dealing to the point of threatening the organization’s credibility.</p>
<p>The principles of effective governance that shield against self-dealing and build public trust for foundations are arguably universal in that they form the hallmark of effective governance for a variety of institutions. In particular, foundations that instill public trust:</p>
<ol>
<li><p>Develop a culture that makes clear distinctions between the institution and the individuals who run it. This can be achieved by putting rules in place that no single individual has excessive authority for decision-making or receives outsized pay;</p></li>
<li><p>Remove potential conflicts of interest, both real and perceived. Foundations can ensure this by establishing a policy that activities are not approved unless it is first concluded that they will not benefit insiders or could even be perceived as such; and</p></li>
<li><p>Establish and respect layers of independent review. This is assured in foundations by segregating duties so that decisions must be reviewed and/or approved by those without connections, familial or otherwise, to those who are most influential.</p></li>
</ol>
<h2>Preparing to lead a much larger organization</h2>
<p>The principles of private foundation governance surely could help prevent self-dealing at the Trump Foundation moving forward; however, they may also represent much more than that. </p>
<p>Given Trump’s substantial conflicts of interest <a href="http://www.theatlantic.com/politics/archive/2016/11/trump-conflict-of-interest/508583/">created by his international business holdings</a>, self-dealing at the Trump Foundation should serve as a warning bell for the president-elect – and the rest of us – as he prepares to take the reigns of a much larger taxpayer-subsidized institution. </p>
<p>Self-dealing at a relatively small foundation should be an affront to taxpayers, albeit one with limited repercussions. Self-dealing when you’re the president with an obligation to put the public trust ahead of your own personal and business interests could be calamitous.</p><img src="https://counter.theconversation.com/content/70075/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Philip Hackney is a registered Democrat</span></em></p><p class="fine-print"><em><span>Brian Mittendorf is a registered Democrat.</span></em></p>Given Trump’s substantial conflicts of interest, the foundation’s admission of self-dealing should sound a warning to both the president-elect and voters as he takes the oath of office.Philip Hackney, James E. & Betty M. Phillips Associate Professor of Law, Louisiana State University Brian Mittendorf, Fisher College of Business Distinguished Professor of Accounting, The Ohio State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/700062016-12-07T02:10:21Z2016-12-07T02:10:21ZWhy President-elect Trump doesn’t think he has a conflict of interest problem<p>President-elect Trump will face an array of conflicts of interest when he takes office. These conflicts are not minor or isolated. They are legion. And, to use his own favored language, they will be “huge.”</p>
<p>His real estate holdings abroad <a href="http://www.nytimes.com/2016/11/26/us/politics/donald-trump-international-business.html?_r=0">make him vulnerable</a> to offers of favorable treatment (or financial threats) by governments overseas. He stands to <a href="http://www.npr.org/2016/12/05/503611249/trumps-businesses-and-potential-conflicts-sorting-it-out">personally benefit (or suffer)</a> from decisions made by government departments like the Internal Revenue Service, the Department of Labor and the Environmental Protection Agency.</p>
<p>Several conflicts have already surfaced. The president-elect apparently <a href="http://www.nytimes.com/2016/11/21/business/with-a-meeting-trump-renewed-a-british-wind-farm-fight.html">complained to British politicians</a> about wind farms near his golf course and <a href="http://talkingpointsmemo.com/edblog/cashing-in-bigly-in-argentina">asked the Argentinian president</a> about permitting issues for a planned office building. Trump’s hotel in Washington, D.C. is <a href="https://www.theatlantic.com/politics/archive/2016/11/trump-dc-hotel-lease/509126/">leased</a> by the federal government. The Secret Service might even <a href="http://nypost.com/2016/11/24/trump-tower-security-may-take-over-2-floors-and-cost-millions/">rent space</a> in Trump Tower for security purposes.</p>
<p>That would be an overwhelming number of conflicts even for someone without Trump’s <a href="http://www.bloomberg.com/politics/articles/2016-11-18/trump-university-settles-fraud-claims-for-25-million">questionable track record</a>. </p>
<p>But unlike many <a href="http://www.wsj.com/articles/the-trump-family-political-business-1479426984">outside observers</a>, <a href="https://www.theguardian.com/us-news/2016/nov/30/donald-trump-conflicts-of-interest-business-ethics-president">ethicists</a> and the <a href="https://twitter.com/OfficeGovEthics/">government department responsible for ethics</a>, Trump doesn’t seem to grasp the enormity of the problem. In that regard, Trump may not be alone. Social science research suggests that we all tend to be blind to our own ethical failings.</p>
<h2>‘I don’t care about my company’</h2>
<p>Trump’s previous plan for addressing conflicts of interest was to hand the business over to his children, even though <a href="http://www.nytimes.com/2016/11/23/us/politics/trump-new-york-times-interview-transcript.html">he believed he could still</a>, in theory, run it as president.</p>
<p>In recent tweets, Trump promised to provide more information on Dec. 15 on a plan to “take [him] completely out of business operations.” This could represent a departure from the old plan or simply the implementation of the original one. </p>
<blockquote><p>Hence, legal documents are being crafted which take me completely out of business operations. The Presidency is a far more important task!</p>— Donald J. Trump (@realDonaldTrump) <a href="https://twitter.com/realDonaldTrump/status/803931490514075648">November 30, 2016</a></blockquote>
<p>The “hand it over to kids” plan has <a href="http://www.democracy21.org/uncategorized/statement-by-norm-eisen-and-richard-painter-on-trump/">been criticized</a> as insufficient, partly because he will likely remain in contact with them and partly because he would remain <a href="http://www.theatlantic.com/business/archive/2016/11/whats-to-stop-president-trump-from-putting-his-portfolio-first/507500/">knowledgeable about the assets he owns</a>. As long as he knows about specific assets, his decisions may be influenced by his financial motives with respect to those assets.</p>
<p>President-elect Trump seems to discount the seriousness of these conflicts, suggesting they are cleansed by the sincerity of his commitment to the American public. He <a href="http://www.nytimes.com/2016/11/23/us/politics/trump-new-york-times-interview-transcript.html">told The New York Times</a>:</p>
<blockquote>
<p>“I don’t care about my company. It doesn’t matter. My kids run it. They’ll say I have a conflict because we just opened a beautiful hotel on Pennsylvania Avenue, so every time somebody stays at that hotel, if they stay because I’m president, I guess you could say it’s a conflict of interest… The only thing that matters to me is running our country.”</p>
</blockquote>
<p>Given the magnitude of Trump’s conflicts, and his underwhelming plan to address them, it seems hard to believe that Trump was sincere when he said he didn’t care about his business. But it is possible. The president-elect – just like the rest of us – may overestimate his own ethicality.</p>
<h2>We’re all biased about ourselves</h2>
<p>As business ethics professors Max Bazerman and Ann Tenbrunsel explain in their 2011 book, <a href="http://press.princeton.edu/titles/9390.html">“Blind Spots”</a>:</p>
<blockquote>
<p>“Prior to being faced with an ethical dilemma, people predict that they will make an ethical choice. When actually faced with an ethical dilemma, they make an unethical choice.”</p>
</blockquote>
<p>Despite these unethical choices, people still tend to tend to think of themselves as ethical, the professors argue. In others words, we overestimate our ethical tendencies.</p>
<p>They cite <a href="https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwjC2ZDpgt7QAhUGMGMKHQ4gBnYQFggcMAA&url=http%3A%2F%2Ffaculty.chicagobooth.edu%2Fnicholas.epley%2FEpleyandDunning2001.pdf&usg=AFQjCNGl2PFvNOXflPFKGaMSZe43vQpuqw">a study</a> in which participants were asked whether they would later buy a daffodil to support the American Cancer Society. Eighty-three percent said yes, but only about 43 percent actually did so.</p>
<p>In a related study, participants also overestimated the likelihood that they would cooperate in a “prisoner’s dilemma” scenario, where partners are rewarded for “cheating” rather than cooperating. They did, however, accurately predict the frequency with which others would cheat. In other words, we’re actually pretty good at predicting the unethical behaviors of others. We just can’t see it in ourselves.</p>
<h2>‘Moral hypocrisy’</h2>
<p>It is possible that Trump is indifferent to notions of undivided loyalty. But his condemnation of the <a href="http://www.nytimes.com/interactive/2016/10/22/us/elections/clinton-trump-foundation-comparison-criticism.html?_r=0">Clinton Foundation</a> as a conduit for potential improper influence and Clinton’s paid speeches to Goldman Sachs suggests he understands the threat that conflicts pose. More likely, he considers himself immune to influence.</p>
<p>He would not be the first to overlook the conflicts at his doorstep. As Bazerman and Tenbrunsel point out, Justice Antonin Scalia <a href="http://www.pbs.org/newshour/updates/law-jan-june04-scalia_03-18-04/">famously refused</a> to recuse himself from a case that involved Dick Cheney, his friend and hunting partner. No jurist, however careful, can expect to be impartial when a personal friend is a party in the case. </p>
<p>“Moral hypocrisy” is actually a term of art in social science, referring to our tendency “<a href="https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwiel9LXh97QAhVIVWMKHenpAm0QFggdMAA&url=https%3A%2F%2Fvaldesolo.squarespace.com%2Fs%2Fmoral-hypocrisy.pdf&usg=AFQjCNHb-eBxsEH0vf8dY3OoIzAVGA0oTA&bvm=bv.1397825">to hold a belief while acting in discord with it</a>.” In <a href="https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwiel9LXh97QAhVIVWMKHenpAm0QFggdMAA&url=https%3A%2F%2Fvaldesolo.squarespace.com%2Fs%2Fmoral-hypocrisy.pdf&usg=AFQjCNHb-eBxsEH0vf8dY3OoIzAVGA0oTA&bvm=bv.1397825">one study</a>, participants were given the choice between assigning a long, boring task to another participant or risk being assigned the boring task randomly by a computer. Those who assigned the boring task to someone else rated their decision as more “fair” than a neutral observer watching the experiment. </p>
<p>In <a href="https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwiF5L7Dht7QAhUOwWMKHTt1DNUQFggcMAA&url=http%3A%2F%2Fwww.hbs.edu%2Ffaculty%2FPublication%2520Files%2F09-078.pdf&usg=AFQjCNHtcr66Qr4hztGZYNZDT2IbLRukQA">another study</a>, participants tended to downplay the moral significance of cheating on a test after reading a hypothetical scenario in which they were the cheaters.</p>
<p>Our failure to recognize our own conflicts is fueled by a related concept known as “<a href="https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwiTjZfFk97QAhVP1mMKHap8D2YQFggcMAA&url=http%3A%2F%2Fwww.psych.utoronto.ca%2F%7Epeterson%2Fpsy430s2001%2FKunda%2520Z%2520Motivated%2520Reasoning%2520Psych%2520Bu">motivated reasoning</a>” – our tendency to interpret facts in ways that favor the outcome we prefer. When faced with a conflict of interest that could be quite costly to address, we’re motivated to persuade ourselves that the conflict of interest isn’t so bad. </p>
<p>Trump seems to think he can will away the conflicts through sheer mental acrobatics, even as he cannot help but push his business interests in talks with foreign dignitaries. </p>
<h2>Conflicts can’t be willed away</h2>
<p>Conflicts of interest aren’t about moral restraint. They are pernicious. They can operate beyond our conscious awareness. As the Supreme Court has <a href="https://supreme.justia.com/cases/federal/us/364/520/case.html">observed</a>, “an impairment of impartial judgment can occur in even the most well-meaning men when their personal economic interests are affected by the business they transact on behalf of the Government.” </p>
<p>By way of illustration, suppose that Batman or Ironman were elected president, while maintaining ownership of their business empire. Even with unquestionably good motives, could either be trusted to exclusively serve the American people? Unlikely. Not because of who they are, but the position it would put them in.</p>
<p>When it comes to conflicts of interest, Trump’s biggest weakness is not the breadth of his holdings but his overconfidence. Taking conflicts seriously requires us to admit we are human and subject to human frailty. </p>
<p>The United States <a href="https://twitter.com/OfficeGovEthics/">Office of Government Ethics</a> and the <a href="http://www.wsj.com/articles/the-trump-family-political-business-1479426984">Wall Street Journal</a> advise Trump to divest his assets. The Economist advocates a “<a href="http://www.economist.com/news/leaders/21710815-arms-length-arrangement-both-principled-and-practical-how-donald-trump-should-handle">ring-fence</a>” model that would put his assets at arm’s length. </p>
<p>These options would undoubtedly be expensive, but they wouldn’t be <a href="https://www.bloomberg.com/view/articles/2016-12-01/trump-s-business-is-not-too-big-to-sell">impossible</a>. If there were ever a time for the president-elect to defer to expert opinion, this would be it.</p><img src="https://counter.theconversation.com/content/70006/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elizabeth C. Tippett donated to the Hillary Clinton campaign.</span></em></p>The president-elect doesn’t think his extensive business and other conflicts will be a problem when he’s president. Research suggests it’s because of a behavioral bias that affects us all.Elizabeth C. Tippett, Assistant Professor, School of Law, University of OregonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/689992016-11-18T12:02:10Z2016-11-18T12:02:10ZWhat is a ‘blind trust’ and will it remove Donald Trump’s conflicts of interest?<figure><img src="https://images.theconversation.com/files/146548/original/image-20161118-19365-dmz2ek.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Donald Trump's sons are at the ready.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-386610478/stock-photo-las-vegas-nv-february-23-2016-donald-trump-is-flanked-by-sons-eric-right-and-donald-jr-left-during-mr-trumps-victory-speech-after-nevada-caucus-las-vegas-nv-at-treasure-islan.html?src=hSNzfW5w-BB0GQ6X4Ym9nw-1-47">Joseph Sohm / Shutterstock.com</a></span></figcaption></figure><p>The US president-elect, Donald Trump, has made his name as a businessman. His empire extends <a href="http://europe.newsweek.com/donald-trump-blind-trust-foreign-business-deals-500398?rm=eu">well beyond American shores</a>, as far afield as Azerbaijan, Turkey, the UAE and Indonesia. The potential this brings for possible conflicts of interest to both Trump and his administration, both home and abroad – whether it’s legislating tax breaks for business or negotiating trade deals – are incredibly wide ranging.</p>
<p>To overcome the problem, Trump has said he will use a “blind trust”. Of course, nobody can unknow what they already know about their company’s dealings. But, in a bid to show non-corruption, blind trusts involve severing ties with your business dealings, putting them all under somebody else’s control and having “no knowledge” of what is happening in the business. </p>
<p>This is not a legal requirement for presidents, but it is a longstanding convention. Reagan and Bush used this kind of arrangement – both appointing independent parties to administer of their business affairs. The Clintons also created one when they entered the White House in 1993. They then dissolved it in 2007, converting all their stocks to cash <a href="http://www.washingtonpost.com/wp-dyn/content/article/2007/06/14/AR2007061400474.html">to avoid financial conflicts when Hillary ran for president</a>.</p>
<p>The difference with Trump is that he has said his blind trust will be run by his son, Donald Trump junior. It will certainly be efficient, in terms of keeping Trump business stationery pretty much the same. But is it sufficient to prevent conflicts of interest? </p>
<h2>Full disclosure</h2>
<p>Conflicts of interest are a regular risk in business. With many people holding multiple jobs and positions – whether it is on boards or in voluntary work – managing this is a standard task for the executives and the HR function of an organisation. Even <a href="https://www.admin.ox.ac.uk/researchsupport/integrity/conflict/policy/illustrativeexamples/">within higher education</a>, considering this potential for conflict of interest is commonplace when staff of a university serve on other bodies such as research council committees or grant review panels. Similarly, researchers must disclose any “significant financial interest” or other relationship with the manufacturers of any commercial products or providers of commercial services discussed in the manuscript – and any financial supporters of the research.</p>
<p>Full disclosure tends to be the first port of call when it comes to circumventing conflicts of interest. In the UK parliament, disclosure rules are a key part of the <a href="http://www.publications.parliament.uk/pa/cm201516/cmcode/1076/107602.htm#a1">code of conduct for MPs</a>. The general principles are this code are described as selflessness, integrity, objectivity, accountability, openness, honesty and leadership. Whether the disclosure register has achieved this trust among the UK public in their politicians is debatable, however. </p>
<p>Interestingly, the first principle “selflessness” states that holders of public office must make decisions “solely in terms of public interest … and avoid any financial or other material benefits for themselves, their family, or their friends”. This again puts the spotlight on Trump’s decision to have a family member run his business and appoint <a href="http://www.wsj.com/articles/donald-trumps-son-in-law-could-get-key-white-house-role-1479343696">friends or relatives to his administration</a>.</p>
<h2>Complex business</h2>
<p>The Trump empire is diverse and – surprisingly despite a highly personal presidential campaign – it is still not entirely understood by most people. Of the 515 companies that Trump has a part in running, only just over half (268) bear his last name, according to a <a href="https://www.documentcloud.org/documents/2175187-trump.html">filing with the Federal Election Commission</a>.</p>
<p>This is compounded by the complexity of the Trump business model which has been involved in selling many products, but in recent years has sold its brand to companies across the world in exchange for franchise or royalty benefits. <a href="https://www.theguardian.com/world/2015/dec/11/donald-trump-towers-istanbul-condemns-anti-muslim-stance">Trump Towers Istanbul</a>, for example, is not owned by Donald Trump, but his company has sold the franchise to property developer Aydin Dogan.</p>
<p>With business arrangements across the world, even if Donald senior has nothing to do with his business going forward, distancing the business’s interests from foreign policy might be difficult for the administration and its international counterparts. Particularly if it has a significant Trump investment in its country.</p>
<p>The same applies domestically. Trump’s mandate to “Make America Great Again” must apply to the country across the board. Business plays a big part in this, especially with infrastructure and regulation high on Trump’s agenda. So his administration must be careful to show they are making decisions based on the whole country, not the president’s business interests. </p>
<p>It’s not just Trump who must manage his conflicts of interest. An estimated 6,000 government and high-profile appointments, including supreme court judges, are up for grabs. For these roles, a complex set of <a href="https://www.oge.gov/web/oge.nsf/Financial%20Conflicts%20of%20Interest/34F1CF2FAF392D7D85257E96006364EB?opendocument">conflict of interest rules exist</a> to prevent executive branch officials from profiting from their responsibilities – or even appearing to profit. Managing this will be a major HR challenge. </p>
<p>For the public to have faith in Trump’s blind trust, it will require clarity and robustness from the new administration to distance itself from any decisions that benefit the business interests of the Trump empire and its partners across the world.</p>
<p>On a practical level, any discussions at the Trump dinner table will either be very muted or will need a team of lawyers present. National Security will significantly constrain what the president can bring home from his day at the Oval Office. And a requirement of the blind trust will completely shut down any talk surrounding the business that Donald senior spent 45 years growing.</p><img src="https://counter.theconversation.com/content/68999/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Horan does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Trump must demonstrate that his presidential decision making will not be influenced by his business interests across the US and the globe.Mark Horan, Senior Lecturer Human Resource Management, University of HuddersfieldLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/651112016-09-09T02:15:50Z2016-09-09T02:15:50ZDastyari dilemma – the attraction of strangers bearing gifts<p>How would you like a free donut? A free Slurpee? A free dinner or holiday? How about someone paying your bills? These offers are tempting, but there can be a price to pay – as Canberra discovered this week.</p>
<p>On Wednesday, Labor senator Sam Dastyari <a href="https://theconversation.com/dastyari-forced-off-frontbench-65048">quit the frontbench</a> after he failed to adequately explain why his personal debt of A$1,670 was paid by Top Education Institute, a company with a strong link to the Chinese government. Further, Yuhu Group, also linked to the government in China, reportedly paid Dastyari’s <a href="http://www.abc.net.au/news/2016-09-05/sam-dastyari-chinese-donations-furore-explained/7816588">A$40,000</a> legal bill.</p>
<p>During the election campaign, Dastyari <a href="http://www.abc.net.au/news/2016-09-06/sam-dastyari-and-the-south-china-sea-quote-causing-trouble/7818588">made comments</a> about the South China Sea issue that were different to Labor policy. He said:</p>
<blockquote>
<p>The South China Sea is China’s own affair, Australia should remain neutral and respect China on this matter.</p>
</blockquote>
<p>Dastyari’s problems bring to mind an ancient saying: “Beware of strangers bearing gifts”. The original quote by the Roman poet, Virgil, is politically incorrect these days – “<a href="https:/en.wikipedia.org/wiki/Timeo_Danaos_et_dona_ferentes">Timeo Danaos et dona ferentes</a>”, or paraphrased as “Beware of Greeks bearing gifts” – but it refers to the story of the Trojan horse. A gift of a giant wooden horse hid Greek warriors who at night opened the city gates and defeated Troy. This is a clear warning about accepting gifts.</p>
<h2>Concerns about gift giving</h2>
<p>Giving and receiving gifts is generally a good thing. We love to exchange presents at Christmas, or receive gifts for a birthday. </p>
<p>In some cultures, gift-giving is an important social custom or ritual related to events, occasions and personal or business dealings. This is particularly important for the <a href="http://www.emeraldinsight.com/doi/pdfplus/10.1108/07363760710756002">Chinese</a>, for whom giving gifts is an expression of honour and respect, and shows the relationship is valued. </p>
<p>But line between gifts and corruption <a href="http://download.springer.com/static/pdf/399/art%253A10.1023%252FA%253A1005960026519.pdf?originUrl=http%3A%2F%2Flink.springer.com%2Farticle%2F10.1023%2FA%3A1005960026519&token2=exp=1473323771%7Eacl=%2Fstatic%2Fpdf%2F399%2Fart%25253A10.1023%25252FA%25253A1005960026519.pdf%3ForiginUrl%3Dhttp%253A%252F%252Flink.springer.com%252Farticle%252F10.1023%252FA%253A1005960026519*%7Ehmac=de676ad1f01a5cad9afbb8be017b40a6e2a2cea8a4dd5712e166b257d2764ce7">can easily blur</a>. </p>
<p>Some Australian organisations have established policies on accepting and giving of gifts, to scrutinise the timing, cost and intention. The New South Wales Department of Trade and Investment states:</p>
<blockquote>
<p>Staff must not give or accept gifts and benefits that will compromise, or appear to compromise, their integrity and objectivity in performing their duties or cause, or appear to cause a <a href="http://www.industry.nsw.gov.au/policies/items/gifts-and-benefits-policy">conflict of interest</a>.</p>
</blockquote>
<p>Other government institutions and departments <a href="http://www.canberratimes.com.au/national/public-service/what-do-government-agencies-ask-public-servants-to-do-with-gifts-20151005-gk1vfe.html">have rules</a> about not asking for gifts, not accepting money, not accepting gifts that could influence or be perceived to influence decisions or actions, and disclosing any gifts.</p>
<h2>Freebies</h2>
<p>Government is not the only environment where concerns are raised about freebies. The fast food industry has been criticised for giving samples of their product for consumers to try, which promotes unhealthy food and therefore, obesity. 7-Eleven has a Free Slurpee Day on November 7, and Krispy Kreme celebrates National Donut Day (June 3) with free original glazed donuts.</p>
<p>Celebrities are not immune to gifts. This year’s Academy Awards nominations <a href="https://mumbrella.com.au/and-the-oscars-winner-is-branding-349674">gift bag</a> of clothes, jewellery, food, travel and pampering was reportedly worth $US232,000. The celebrities would probably never put their name behind any of these gifts, but having them in the gift bag can give them the publicity to associate the company’s brand with the stars.</p>
<p>More concerning is the pharmaceutical industry. Drug companies are unable to advertise directly to the consumer, so they promote their pharmaceuticals directly to doctors. </p>
<p>Gifts given to GPs – including pens, notepads, lunches, dinners and “education” events in exotic locations – not only promote awareness and goodwill to the drug companies, they <a href="https://theconversation.com/drug-companies-are-buying-doctors-for-as-little-as-a-16-meal-61364">encourage doctors to prescribe</a> more of the company’s products. </p>
<h2>A business perspective</h2>
<p>So why do businesses give gifts?</p>
<p>There can be a variety of reasons. Generally, the aim is to generate support for the organisation’s overall objectives. This could mean promoting the products, brand name, or brand image; to increase awareness and goodwill towards an organisation; and, eventually, achieving the objectives of awareness, sales, profits, or even donations.</p>
<p>If a person gives you a gift for free, you will have a positive opinion about that person. If a company gives you a gift for free (for example, a donut), the company’s marketers hope you will have a positive opinion about the organisation. Maybe because of this incentive, you will consider buying their product or influencing others to buy in the future.</p>
<p>The more expensive the gift, the more positive the organisation will expect the opinion to be, particularly if the gift is given to a person with a degree of power or influence. This expected positive opinion can also lead to an expected positive action towards the gift-giver as a reward, even having some influence over the receiver’s future actions: “I scratch your back; you scratch mine”.</p>
<p>If the intention for the gifts is to influence behaviour and decision-making, this creates a major ethical dilemma, which is why organisations develop policies and standards in the first place. This week is a good time for politicians to be reminded of the policies and standards their own departments work to, and for them to do the same.</p>
<p>As they say, there is no such thing as a free lunch – go ask a Trojan.</p><img src="https://counter.theconversation.com/content/65111/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Waller does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Offers off free food, holidays and gifts are tempting, but there can be a price to pay – as Canberra discovered this week.David Waller, Senior Lecturer, School of Marketing, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/602462016-06-01T02:54:45Z2016-06-01T02:54:45ZDon’t dismiss conflict-of-interest concerns in IVF, they have a basis<figure><img src="https://images.theconversation.com/files/124702/original/image-20160601-1925-11a230k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There appears to be a lack of transparency about the poor success rates of IVF. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>It’s estimated <a href="https://npesu.unsw.edu.au/surveillance/assisted-reproductive-technology-australia-new-zealand-2012">over 5 million children</a> have been born worldwide as a result of assisted reproductive technology treatments. Assisted reproductive technology, an umbrella term that includes in vitro fertilisation (IVF), is a highly profitable global industry, and fertility clinics are increasingly regarded as an attractive investment option. </p>
<p>In 2014, two major IVF clinics - Virtus and Monash IVF — floated on the stock exchange. Excited financial analysts <a href="http://www.quadrantpe.com.au/News/2013/afr-article-february-2013">observed at the time</a> that:</p>
<blockquote>
<p>people will pay almost anything to have a baby.</p>
</blockquote>
<p>Over the past 12 months, there have been numerous critical media analyses of the IVF industry in Australia, including Monday night’s ABC Four Corners program, <a href="http://www.abc.net.au/4corners/stories/2016/05/30/4469652.htm">The Baby Business</a>. The episode suggested IVF doctors are recommending treatments that are expensive, unsafe and likely to be futile. </p>
<p>The following morning the <a href="http://www.fertilitysociety.com.au/home/press-release-four-corners-report/">Fertility Society of Australia</a> rejected these assertions, saying: </p>
<blockquote>
<p>Four Corners presented no evidence to support these claims.</p>
</blockquote>
<p>One of the claims made in the program was that IVF doctors have a financial incentive to treat women with the more invasive practice of IVF. The program suggested this financial incentive conflicts with the doctor’s duty of care towards the patient. </p>
<p>Four Corners highlighted the conflicted nature of commercialised IVF, where some IVF doctors are more concerned about their own interests (making money for themselves or their clinics) than they are about their patients. </p>
<p>Not surprisingly, the Fertility Society of Australia strongly denied such conflicts of interest exist. It argued that the profession is both highly ethical and highly regulated.</p>
<h2>Why might doctors be conflicted?</h2>
<p>While it is certainly a big call to claim some IVF doctors may not be sufficiently committed to their patients, the possibility that practice is being shaped — at least in part — by conflict of interest cannot simply be dismissed. There are three key reasons individuals working in the IVF industry, and the industry more broadly, may be perceived to be conflicted.</p>
<p>First, every time a doctor advises patients to consider IVF treatment, he or she <a href="http://www.australiandoctor.com.au/news/news-review/baby-booming-the-business-of-ivf">profits financially</a> from the recommendation. While all Australian doctors receive fees for their services, many IVF doctors also own shares in assisted reproductive technology companies, so they receive passive income that reflects the amount of assisted reproductive technology the company sells. </p>
<p>It is also worth noting that, as employees of publicly listed companies, doctors at clinics such as <a href="http://ir.monashivfgroup.com.au/Investor-Centre/?page=Corporate-Governance">Monash IVF</a>, according to their code of conduct, must:</p>
<blockquote>
<p>recognise that (their) primary responsibility is to the Company and its shareholders as a whole.</p>
</blockquote>
<p>It is therefore not unreasonable for people to be concerned some clinicians may be motivated (perhaps unconsciously) by financial conflicts of interest to make decisions that may not be in the best interests of their patients.</p>
<p>Second, there appears to be a lack of transparency about IVF success rates. Success, as measured by a live birth, is very dependent on age and the reason for seeking assistance. </p>
<p>In the youngest age bracket in <a href="https://npesu.unsw.edu.au/surveillance/assisted-reproductive-technology-australia-new-zealand-2012">Australia and New Zealand</a> in 2013, the live birth per cycle rate was 27%. In the oldest it was between 1% and 5%, depending on whether a fresh or frozen egg was used. It is more likely that a cycle will result in failure than not, and some argue there is a lack of transparency about the likelihood of a live birth.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/124703/original/image-20160601-1925-iz43hf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/124703/original/image-20160601-1925-iz43hf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/124703/original/image-20160601-1925-iz43hf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/124703/original/image-20160601-1925-iz43hf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/124703/original/image-20160601-1925-iz43hf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/124703/original/image-20160601-1925-iz43hf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/124703/original/image-20160601-1925-iz43hf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/124703/original/image-20160601-1925-iz43hf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Even in the youngest age bracket, in Australia and New Zealand in 2013 the live birth per cycle rate was just 27%.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<p>A striking example of this was seen on Four Corners when Dr Gab Kovacs, ex-medical director of Monash IVF, <a href="http://www.abc.net.au/4corners/stories/2016/05/30/4469652.htm">claimed</a>:</p>
<blockquote>
<p>I know that if you hang in there you get pregnant, because one of my patients got pregnant after 37 cycles. And, ah, so I encourage people to stay on.</p>
</blockquote>
<p>While it is quite possible this woman made a fully informed decision to undergo this number of cycles, Dr Kovacs’ subsequent claim that he couldn’t say “no” and had no choice but to continue to offer the woman what she wanted inevitably makes one wonder what she knew about her real chances of success.</p>
<p>A third reason for concern about conflicts of interest, and one that might distinguish conflicts of interest in IVF from those in other medical settings, is the potential for exploitation of strong personal and social values associated with reproduction. </p>
<p>A strong discourse of hope runs through the IVF industry, and people seeking assisted reproductive technology are often very vulnerable. The profit motive of these companies has the potential to exploit these cultural norms and social pressures for ends that are not necessarily in the best interest of patients.</p>
<p>There are now two positions being taken: by those who consider some IVF practices are exploitative and unethical, and by those who consider that conflicts of interest are inherent in medical practice and are sufficiently well managed. </p>
<p>Rather than simply dismissing concerns about conflicts of interest, as the Fertility Society of Australia has just done, IVF specialists, ethicists and other stakeholders need to create a forum in which these concerns can be discussed openly and constructively.</p><img src="https://counter.theconversation.com/content/60246/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Brette Blakely receives funding from the NHMRC. </span></em></p><p class="fine-print"><em><span>Christopher Mayes receives funding from the National Health & Medical Research Council. </span></em></p><p class="fine-print"><em><span>Wendy Lipworth receives funding from the National Health & Medical Research Council. She is affiliated with DIA.</span></em></p><p class="fine-print"><em><span>Jane Williams does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Assisted reproductive technology is a highly profitable global industry, with fertility clinics increasingly being regarded as an attractive investment option.Jane Williams, Doctoral student at the Centre for Values, Ethics and the Law in Medicine (VELiM), University of SydneyBrette Blakely, Post-Doctoral Research Fellow, Macquarie UniversityChristopher Mayes, Post-Doctoral Fellow in Bioethics, University of SydneyWendy Lipworth, Senior Research Fellow, Bioethics, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/324312014-10-07T03:45:05Z2014-10-07T03:45:05ZWhat kind of research can we trust?<figure><img src="https://images.theconversation.com/files/60976/original/bpdqn58n-1412643107.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Conflicting recommendations about flu drugs has made it difficult for doctors to decide whether to prescribe them. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/stanrandom/3754123623">Andrew Wales/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Research involving pharmaceutical company input is notoriously compromised. While not all industry ties lead to biased research, and not all biases are a consequence of industry ties, <a href="http://www.ncbi.nlm.nih.gov/pubmed/23235689">many studies show</a> industry influence can make drugs look safer and more effective than they really are. So where can doctors and indeed the public turn to for reliable information?</p>
<p>One favoured option is research known as systematic reviews, which sift through evidence, evaluate their quality and synthesise conclusions and recommendations for clinical practice. Systematic reviews are considered to be the highest level of medical evidence because they summarise large volumes of evidence and follow strict processes to avoid biases. </p>
<p>Systematic reviews form the basis of evidence-based medicine, but there’s now growing doubt about whether these reviews are as untouched by industry influence as many of us expect them to be.</p>
<h2>A particular case</h2>
<p>Consider the case of a class of drugs known as neuraminidase inhibitors, which has been <a href="https://theconversation.com/the-tamiflu-saga-shows-why-all-research-data-should-be-public-13951">causing controversy</a> in the last few years. These drugs are said to minimise the impact of the flu; you’ll know them by their commercial names Tamiflu and Relenza. </p>
<p>Tens of millions of prescriptions for these drugs have been dispensed and governments worldwide have stockpiled them in preparation for a flu pandemic at the cost of billions of dollars. But there are conflicting views about both their safety and their efficacy – and they’re fuelled by conflicting systematic reviews. </p>
<p>One <a href="http://www.ncbi.nlm.nih.gov/pubmed/24815805">systematic review published this year</a>, for instance, encouraged early use of the drugs in any patient who looks appreciably unwell. <a href="http://www.bmj.com/content/348/bmj.g2545">Another cautioned</a> about their safety and questioned whether they should be used in practice at all.</p>
<p>In an article <a href="http://www.annals.org/article.aspx?doi=10.7326/M14-0933">published today in the Annals of Internal Medicine</a>, we tried to make sense of how such discrepancies arise despite the strict processes that underpin systematic reviews. </p>
<p>Given what we already know about industry influence on research, we suspected the differences might be associated with reviewers’ financial ties to companies that make the drugs. To test our hypothesis, we examined 26 systematic reviews published about neuraminidase inhibitors. </p>
<h2>Sleight of hand?</h2>
<p>We found reviewers with financial ties to drug companies were more likely to present evidence in favourable ways and recommend use of the drugs. In the reviews written by researchers with such ties, 88% of the conclusions were favourable. In the absence of financial links, just 17% were positive.</p>
<p>In other words, reviewers with financial ties to drug manufacturers overwhelmingly decided the drugs were safe and effective while those without ties were considerably more reserved about their value.</p>
<p>So how did the systematic reviews arrive at such different conclusions?</p>
<p>While we were unable to examine the differences statistically, one part of the review process stood out as the point where biases could be more easily introduced: generalising from results to recommendations.</p>
<p>For some systematic reviews, the recommendations made in the discussion sections didn’t match the evidence in the results. That suggests reviewers may have generalised in ways that aligned with predetermined views rather than what the evidence showed.</p>
<h2>What can be done?</h2>
<p>Ours is not the only study that has identified this type of problem. Last year, researchers identified the same association in <a href="http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001578">systematic reviews of sweetened beverages and weight gain</a>.</p>
<p>While this may make it tempting to ignore all evidence reported by researchers who receive industry funding, we don’t think that’s the answer. There’s much to be gained from collaborations with industry. What we need are <a href="http://www.futuremedicine.com/doi/pdf/10.2217/cer.14.31">better strategies for managing conflicts of interest</a>.</p>
<p>Being able to detect the kind of polarisation in the conclusions of systematic reviews we did is one step towards managing the effects of conflicts of interest. And one way to mitigate these effects may be to ask independent researchers to interpret results and formulate recommendations.</p>
<p>As with other drugs, conflicting recommendations about neuraminidase inhibitors has made it difficult for doctors to decide whether to prescribe them. The most authoritative reviews now show these drugs have small benefits and some risks. These reviews have led to <a href="http://www.theguardian.com/world/2014/apr/10/uk-wasted-560m-stockpiling-flu-drugs">suggestions</a> that <a href="http://www.smh.com.au/federal-politics/political-news/antiviral-drug-stockpile-a-waste-of-money-says-study-20140410-zqt3i.html">stockpiling them</a> may have <a href="http://www.theatlantic.com/magazine/archive/2009/12/the-truth-about-tamiflu/307801/">been unjustified</a>.</p>
<p>To be able to make informed decisions together, doctors and patients need research that’s trustworthy. If systematic reviews are to remain the pinnacle of evidence-based medicine, then the processes underpinning them need to be continually reassessed to ensure they meet the highest of standards.</p><img src="https://counter.theconversation.com/content/32431/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adam Dunn receives funding from the National Health & Medical Research Council.</span></em></p><p class="fine-print"><em><span>Florence Bourgeois receives funding from the National Institute of Health in the USA.</span></em></p>Research involving pharmaceutical company input is notoriously compromised. While not all industry ties lead to biased research, and not all biases are a consequence of industry ties, many studies show…Adam Dunn, Senior Research Fellow, UNSW SydneyFlorence Bourgeois, Assistant Professor of Pediatrics, Harvard UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/232322014-02-18T19:12:44Z2014-02-18T19:12:44ZBig Food lobbying: tip of the iceberg exposed<figure><img src="https://images.theconversation.com/files/41806/original/528rhrfd-1392711344.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Direct lobbying is one of several tactics food companies use to shape regulation and public perception in their favour.</span> <span class="attribution"><span class="source">Image from shutterstock.com</span></span></figcaption></figure><p>The influence of the food lobby has come into the public spotlight over the past week, with revelations that Assistant Health Minister Fiona Nash’s chief-of-staff, Alastair Furnival, has strong links to the food industry. Furnival <a href="http://www.abc.net.au/news/2014-02-14/staffer-at-centre-of-food-labelling-controversy-resigns/5261052">previously worked</a> as a lobbyist for several food companies and is the <a href="http://www.smh.com.au/federal-politics/political-news/chief-of-staff-for-minister-fiona-nash-forced-to-resign-20140214-32rli.html">co-owner of a firm</a> that has represented the food industry.</p>
<p>The controversy came as Nash <a href="http://www.smh.com.au/federal-politics/political-news/food-rating-fiona-nash-chief-of-staff-intervened-to-have-website-removed-20140211-32g3a.html">personally intervened</a> to have health department staff withdraw a website launching a new government-approved <a href="https://theconversation.com/industry-winning-the-fight-against-better-food-labelling-22472">health star rating</a> food labelling system for Australia. Nash has since been accused of breaching ministerial standards for failing to declare Furnival’s conflict. And Furnival <a href="http://www.smh.com.au/federal-politics/political-news/assistant-health-minister-fiona-nashs-chief-of-staff-alastair-furnival-resigns-20140214-32qol.html">resigned</a> from his chief-of-staff position on Friday.</p>
<p>This incident has exposed one of the many ways in which powerful food companies exert their influence over government policy. From a public health perspective, the major concern is that this is just the tip of the iceberg.</p>
<h2>Big Food tactics</h2>
<p>Big Food lobbying to avoid government regulations for improved food labelling is not new. </p>
<p>In Europe, the food industry reportedly spent a staggering <a href="http://www.corporateeurope.org/red-light-consumer-information">€1 billion</a> successfully lobbying the European parliament to reject a traffic-light food labelling scheme. The scheme, heavily favoured by public health advocates internationally, uses colours to indicate the relative healthiness of foods. The fear for the food industry is that by putting red labels on their products, sales would decline.</p>
<p>Big Food also <a href="http://www.economist.com/news/business/21588088-once-omnipotent-industry-fights-what-may-be-losing-battle-fizzing-rage">lobbied extensively</a> to oppose a proposed tax on soft drinks in Mexico. However, in that case, their lobbying could not prevent the <a href="http://www.theguardian.com/world/2014/jan/16/mexico-soda-tax-sugar-obesity-health">implementation of the tax</a>.</p>
<p>Direct lobbying is just one of <a href="http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001246">several tactics</a> that food companies use to shape the regulatory environment and public perception in their favour.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/41804/original/39ntbd93-1392705284.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/41804/original/39ntbd93-1392705284.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/41804/original/39ntbd93-1392705284.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/41804/original/39ntbd93-1392705284.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/41804/original/39ntbd93-1392705284.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/41804/original/39ntbd93-1392705284.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/41804/original/39ntbd93-1392705284.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Big Food lobbied hard against Mexico’s soda tax but ultimately lost.</span>
<span class="attribution"><a class="source" href="http://www.flickr.com/photos/scelera/2307196659/sizes/l/">Samantha Celera</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>In the media, food companies typically place the responsibility for obesity on individual choices, rather than <a href="http://www.ncbi.nlm.nih.gov/pubmed/23410611">environmental or corporate influences</a>. They also portray government actions to regulate food environments as interference in personal liberties and free choice.</p>
<p>Food companies frequently publicise their contributions to worthy causes, such as <a href="http://www.rmhc.org.au/">children’s charities</a>. This seeks to cast members of the food industry as respectable corporate citizens in the eyes of politicians and the public. However, some of these charities have been <a href="http://www.eatdrinkpolitics.com/2013/10/29/clowning-around-with-charity-how-mcdonalds-exploits-philanthropy-and-targets-children/">heavily criticised</a> as being predominantly marketing ploys that distract attention from harmful business practices.</p>
<p>The food industry also funds research that serves to <a href="http://www.foodpolitics.com/2013/11/more-on-food-company-sponsorship-of-nutrition-research-and-practice/">confuse the evidence</a> and keeps the public in doubt. They also set up <a href="http://www.huffingtonpost.com/michele-simon/best-public-relations-mon_b_3273159.html">front groups</a> to lobby on their behalf. And they promise self-regulation in efforts to avoid government regulation, despite the <a href="http://www.opc.org.au/downloads/OPC_Exposing_the_Charade_report_2012.pdf">demonstrated failure of self-regulation</a> for improving food environments.</p>
<p>These Big Food tactics <a href="http://www.ncbi.nlm.nih.gov/pubmed/19298423">closely mirror</a> those used by tobacco companies.</p>
<h2>Flow of unhealthy food</h2>
<p>The corporate sector has been very successful in shaping a regulatory environment that favours market liberalisation and free trade. </p>
<p>For food companies, this enables them to supply and heavily promote a high volume and enormous range of products, many of which are unhealthy. This increased supply of cheap, tasty, energy-dense food has been the <a href="http://www.ncbi.nlm.nih.gov/pubmed/21872749">main driver</a> of population weight gain over the last three decades. </p>
<p>Despite strong evidence that many very affordable and cost-effective government interventions – such as improvements to food labelling, restrictions on the marketing of unhealthy food and drinks to children, and taxes on unhealthy foods (such as soft drinks) – are likely to be <a href="http://www.ncbi.nlm.nih.gov/pubmed/21079620">highly effective</a> in improving population health outcomes, very few of these policies have been implemented globally. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/41797/original/zrwrvztc-1392702475.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/41797/original/zrwrvztc-1392702475.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=336&fit=crop&dpr=1 600w, https://images.theconversation.com/files/41797/original/zrwrvztc-1392702475.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=336&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/41797/original/zrwrvztc-1392702475.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=336&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/41797/original/zrwrvztc-1392702475.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=423&fit=crop&dpr=1 754w, https://images.theconversation.com/files/41797/original/zrwrvztc-1392702475.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=423&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/41797/original/zrwrvztc-1392702475.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=423&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The goal of food labelling is to help consumers make informed decisions.</span>
<span class="attribution"><a class="source" href="http://www.flickr.com/photos/franzj/4733041901/sizes/l/">Franzj/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>A <a href="http://www.iaso.org/site_media/uploads/bellagio_declaration.pdf">major reason</a> for this lack of action is that governments have faced strong pressure from food companies to maintain the status quo.</p>
<p>Corporate efforts to influence policy are a serious worry for public health. There’s a clear conflict of interest between big food companies seeking to profit from sales of their products (many of which are unhealthy) and public-interest efforts to improve population nutrition. </p>
<p>Indeed, the Director General of the World Health Organisation, Dr Margaret Chan, <a href="http://www.who.int/dg/speeches/2013/health_promotion_20130610/en/">recently referred</a> to the lobby forces of Big Food as one of the biggest challenge that countries face as they try to reduce obesity and diet-related diseases.</p>
<h2>Towards informed choices</h2>
<p>In the case of current efforts to improve food labelling in Australia, the
<a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/frontofpackcommittee">goal</a> of the new labelling scheme is to assist consumers to make informed dietary choices and, in so doing, help improve the health of the population. </p>
<p>The government has engaged heavily with public health experts, consumer groups and the food industry throughout the <a href="https://theconversation.com/industry-winning-the-fight-against-better-food-labelling-22472">policy development process</a>. And Australia’s food and health ministers have <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/ACA58089FC311682CA257BF0001CAB86/%24File/Final%20Forum%20Communique%2013%20December%202013.pdf">all agreed to support</a> the new labelling system.</p>
<p>However, it appears the food industry’s recent efforts to undermine the scheme are having some effect. </p>
<p>Hopefully, the enormous media attention that has accompanied the government’s decision to take down the new food labelling website will enourage the government to follow through on their previous commitments to support the scheme. </p>
<p>But more broadly, we need tighter rules around <a href="http://www.iaso.org/site_media/uploads/bellagio_declaration.pdf">government engagement</a> with the private sector, and <a href="http://onlinelibrary.wiley.com/doi/10.1111/obr.12074/abstract">closer monitoring</a> of the tactics used by Big Food to influence policy. This can generate evidence that can be used to hold food companies and governments to account for their roles in obesity prevention.</p>
<p><strong>Read more about the food labelling scandal:</strong></p>
<ul>
<li><a href="https://theconversation.com/should-the-food-industry-resign-from-the-health-department-too-23292">Should the food industry resign from the health department too?</a></li>
</ul><img src="https://counter.theconversation.com/content/23232/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gary Sacks receives funding from the Australian National Health and Medical Research Council (NHMRC).</span></em></p>The influence of the food lobby has come into the public spotlight over the past week, with revelations that Assistant Health Minister Fiona Nash’s chief-of-staff, Alastair Furnival, has strong links to…Gary Sacks, Senior Research Fellow, WHO Collaborating Centre for Obesity Prevention, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/232922014-02-18T03:33:37Z2014-02-18T03:33:37ZShould the food industry resign from the health department too?<figure><img src="https://images.theconversation.com/files/41767/original/bwd2mq6r-1392693149.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Assistant Minister for Health Fiona Nash's chief of staff has had to resign because of conflicts of interest.</span> <span class="attribution"><span class="source">Alan Porritt/AAP</span></span></figcaption></figure><p><a href="http://www.theguardian.com/world/2014/feb/14/fiona-nash-under-pressure-over-claims-she-misled-senate">Furore over links</a> between Assistant Minister for Health Fiona Nash’s office and industry continues today with <a href="http://www.smh.com.au/federal-politics/political-news/alcohol-lobby-link-to-dumping-health-body-20140217-32wft.html">revelations that her former chief of staff is connected to the alcohol</a>, as well as the food industry. </p>
<p><a href="http://www.smh.com.au/federal-politics/political-news/chief-of-staff-for-minister-fiona-nash-forced-to-resign-20140214-32rli.html">Alastair Furnival resigned last Friday</a> over his role in shutting down a website about the health star rating food labelling system and it’s now been revealed that he played a key role in cancelling the funding of the Alcohol and other Drugs Council of Australia. </p>
<p>Furnival is <a href="http://www.smh.com.au/federal-politics/political-news/chief-of-staff-for-minister-fiona-nash-forced-to-resign-20140214-32rli.html">co-owner of a lobbying firm</a> that has represented major food companies opposed to the new front-of-pack labelling system. According to Fairfax, he and his wife also co-own a company, which, in turn, owns another that lobbied for the alcohol industry in 2012. </p>
<p>Such <a href="http://www.nejm.org/doi/full/10.1056/NEJM199308193290812">conflicts of interest</a> place question marks over an individual’s capacity to judge a situation, perform a duty or make a decision in a fair and impartial manner. But what if a public institution, such as the Department of Health itself, has conflicted interests?</p>
<p>Furnival’s conflict of interest is worrying and should be thoroughly scrutinised. But the influence of the food and alcohol industries at the institutional-level precedes Furnival and will continue despite his resignation.</p>
<h2>A growing closeness</h2>
<p>The <a href="http://www.afgc.org.au/whoweare.html">Australian Food and Grocery Council</a> (AFGC) and the health department have developed close ties in recent years. Senior executives of the Council sat on the <a href="http://www.nhmrc.gov.au/your-health/nutrition/dietary-guidelines-working-committee">Dietary Guidelines Working Committee</a> and the <a>National Preventive Health Taskforce</a>.</p>
<p>It <a href="https://www.health.gov.au/internet/main/publishing.nsf/Content/phd-nutrition-childrens-survey">co-funded a major nutritional health research survey</a> with the health department in 2007, and is a prominent member of the <a href="http://www.foodhealthdialogue.gov.au/internet/foodandhealth/publishing.nsf">Food and Health Dialogue</a>.</p>
<p>At the 2009 AFGC annual dinner, Nicola Roxon, then-minister for health said these relationships weren’t cause for concern. <a href="http://web.archive.org/web/20100305011009/http://www.health.gov.au/internet/ministers/publishing.nsf/Content/sp-yr09-nr-nrsp281009.htm">Roxon</a> welcomed the industry’s partnership with health prevention strategies and research projects, adding that she “saw no reason for people to fear industry engagement – quite the opposite”. </p>
<p>Perhaps. But when the <a href="http://www.afgc.org.au/whatwedo.html">aim of the food and grocery council</a> is to “influence federal and state policies to ensure our members’ views are represented at the highest level”, legitimate questions arise about whether these partnerships conflict with the work of the health department. </p>
<p>Lawrence Lessig, professor of law and director of the <a href="http://www.ethics.harvard.edu/lab/about-us">Edmond J. Safra Center for Ethics</a> at Harvard University, warns that such partnerships can <a href="http://www.ethics.harvard.edu/lab/about-us">corrupt an institution</a> by creating:</p>
<blockquote>
<p>an economy of influence that illegitimately weakens the effectiveness of an institution especially by weakening the public trust of the institution. </p>
</blockquote>
<p>So does the health department’s relationship with the food and grocery council weaken its effectiveness and public trust of the institution? For many, the answer is yes.</p>
<h2>Keeping everyone happy?</h2>
<p>In 2011, the health department responded to the <a href="http://www.foodlabellingreview.gov.au/internet/foodlabelling/publishing.nsf/content/home">Blewett Review</a> of food labelling law and policy by rejecting the major recommendation of a traffic-light front-of-pack labelling system. <a href="http://www.smh.com.au/national/health/fat-chance-of-breaking-junk-food-grip-20111230-1pfgd.html">Journalists</a>, <a href="http://www.phaa.net.au/documents/111209%20Food%20Ministers%20too%20close%20to%20industry.pdf">public health researchers</a> and <a href="http://www.abc.net.au/lateline/content/2011/s3251022.htm">consumer groups</a> all believed the decision was due to the food and grocery council’s influence. </p>
<p>Catherine King, then-parliamentary secretary for health, defended the decision in an <a href="http://www.abc.net.au/radionational/programs/nationalinterest/stop2c-look2c-buy3a-traffic-lights-on-food/3710042#transcript">interview</a> with the ABC. King explained the traffic-light scheme would “be a fairly big change for industry” and decided that “we need to get public health and industry together to try and…look at another system”.</p>
<p>This led to the <a href="https://www.health.gov.au/internet/main/publishing.nsf/Content/frontofpackobjectives">Forum on Food Regulation</a>, a collaborative process involving the AFGC, public health researchers and health department officials. The Forum’s objective was to develop a front-of-pack food labelling system that “must strike a balance between seeking to ensure good public health outcomes and ensuring a strong and profitable food industry”.</p>
<p>But are these objectives compatible? If a profitable industry undermines public health, is a balance feasible? And does the attempt to reach a balance weaken the effectiveness of the health department, the institution that arbitrates this relationship?</p>
<p>A profitable food industry is certainly in the nation’s economic interest. But the idea that it should be a primary concern for the health department rubs against its more obvious objective of ensuring public health.</p>
<p>Individual conflicts of interest can cause <a href="http://en.wikipedia.org/wiki/Kids_for_cash_scandal">significant damage</a> – Furnival and those responsible for his appointment need to be fully investigated. But whether the increasing acceptance of <a href="http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2268079">public-private partnerships</a> is the best way to ensure public goods needs critical attention. These partnerships have the potential to undermine public trust and weaken the effectiveness of vital public institutions. </p>
<p>The public needs to be confident that public officials and public institutions are acting in their interest. Recent events at the individual and institutional level imply that such confidence is misplaced.</p>
<p><em>CORRECTION:</em> This article has been amended to reflect that the name of the health department recently changed from Department of Health and Ageing to Department of Health. The error was introduced during the editing process.</p><img src="https://counter.theconversation.com/content/23292/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The author would like to thank Associate Professor Jonathan H. Marks and Emeritus Professor Donald B. Thompson. This analysis partly draws on research undertaken as Postdoctoral Fellow on their collaborative project (<a href="http://rockethics.psu.edu/bioethics/food-ethics/research">http://rockethics.psu.edu/bioethics/food-ethics/research</a>) jointly funded by the Rock Ethics Institute at the Pennsylvania State University and the Edmond J. Safra Center for Ethics at Harvard University.</span></em></p>Furore over links between Assistant Minister for Health Fiona Nash’s office and industry continues today with revelations that her former chief of staff is connected to the alcohol, as well as the food…Christopher Mayes, Post-Doctoral Fellow in Bioethics, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/131032013-04-17T04:38:30Z2013-04-17T04:38:30ZSport concussion guidelines rife with conflicts of interest<figure><img src="https://images.theconversation.com/files/22457/original/hjt9hq3z-1366005091.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Collision sports such as AFL have adopted concussion management policies because it's an unavoidable feature of the games.</span> <span class="attribution"><span class="source">AAP Image/David Crosling</span></span></figcaption></figure><p>Athletes and officials in charge of collision sports (such as rugby league, AFL and American football) have an uneasy relationship with concussion; it’s an unavoidable feature of their games and there’s considerable debate about its short and long-term health effects. But the recent focus on concussion has also highlighted conflicts of interest in its management.</p>
<p>Because these codes cannot eliminate concussion, the <a href="http://www.nrl.com/About/ReferenceCentre/ManagementofConcussioninRugbyLeague/tabid/10798/Default.aspx">National Rugby League (NRL)</a>, the <a href="http://www.aflcommunityclub.com.au/fileadmin/user_upload/Manage_Your_Club/3._Club_Management_Program/9._Football_Operations/Trainers/Injury_Management/Management_of_Concussion/Concussion_Man_v7.pdf">Australian Football League (AFL)</a>, and the US <a href="http://www.nfl.com/">National Football League</a> (NFL) have all adopted concussion management policies that claim to protect the health and well-being of their players. </p>
<p>These policies involve using computerised neuropsychological (CNP) tests of memory and reaction time to assess the effects of concussion. In Australia and the United States, the most popular of these concussion tests are marketed by the companies <a href="http://www.impacttest.com/">ImPACT</a> and <a href="http://www.axonsports.com/index.cfm">CogState/Axon</a>. </p>
<p>Typically (but not always), an athlete is given a “baseline test” at the start of a sporting season and, if he sustains a head injury, his initial results are compared with a follow-up test to determine when he has sufficiently recovered to return to play. These tests are used by elite teams and their use is now being mandated every year by amateur and youth players across the globe. </p>
<p>The major corporate sponsor of the AFL, Toyota, has even agreed to provide CogState/Axon testing for a large number of <a href="http://www.axonsports.com/index.cfm?pid=91&pageTitle=Toyota-Good-For-Footy">youth clubs</a>.</p>
<h2>Concussion management policies</h2>
<p>The major justification for concussion management polices has been provided by a global “consensus statement” for managing concussion in sport. These guidelines were first drafted by an expert panel in <a href="http://www.ncbi.nlm.nih.gov/pubmed/11867482">2001</a>, updated at conferences in <a href="http://www.ncbi.nlm.nih.gov/pubmed/15793085085">2004</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/19433429">2008</a>, and most recently in <a href="http://www.ncbi.nlm.nih.gov/pubmed/23479479">2012</a>. </p>
<p>Over the last decade, neuropsychological concussion tests have been described by these guidelines as contributing significant clinical value to concussion evaluation, and even as a “cornerstone of concussion management”. </p>
<p>On the face of it, these policies seem designed to protect players from suffering the serious consequences of head injuries. But a closer examination of how they were developed reveals financial and professional conflicts of interest among experts who have recommended their use to manage concussion. </p>
<p>Some experts involved in their development have been members of panels at consensus conferences on the management of concussion. And companies that own and market these tests have been major funders of published research used to support using the tests. </p>
<p>Authors of the publications have included employees or part-owners of the companies and physicians who have received research support or been paid consultants to the companies. Some of these experts have also advised <a href="http://www.ncbi.nlm.nih.gov/pubmed/19130254">professional football leagues</a> on the management of concussion.</p>
<p>It can be difficult to assemble clinical expert panels free of conflicts of interest but when this is not possible, <a href="http://link.springer.com/article/10.1007%2Fs12152-013-9182-z#">transparency</a> about financial and non-financial conflicts of interest is essential. Until very recently, these international guidelines have not fully disclosed the conflicts of interest of all expert panellists.</p>
<h2>Awareness of conflicts of interest</h2>
<p>When discussing computerised neuropsychological testing, international guidelines on concussion in sport have also relied on evidence produced by the companies that own and market these tests (CogState and ImPACT). </p>
<p>In other areas of medicine, <a href="https://theconversation.com/insight-into-how-pharma-manipulates-research-evidence-a-case-study-4071">industry-funded research</a> has been shown to produce results that favour the sponsors’ product. Neutrally sponsored drug trials are much less likely to favour the drug than are trials funded by the pharmaceutical <a href="http://www.ncbi.nlm.nih.gov/pubmed/12775614">industry</a>.</p>
<p>Collectively, the consensus guidelines have also made little mention of research that has raised doubts about the reliability and utility of computerised neuropsychological tests. <a href="http://www.ncbi.nlm.nih.gov/pubmed/23373575">A recent study</a> had a group of concussed and non-concussed footballers complete the CogState and ImPACT tests. The researchers also recorded demographic information such as age, IQ and number of previous concussions. Neither CogState or ImPACT were significantly better at predicting the concussion status of the footballers compared to the demographic information alone.</p>
<p>Another <a href="http://www.ncbi.nlm.nih.gov/pubmed/16284633">review</a> argued that the tests didn’t meet the criteria to warrant routine clinical use. If independent assessment of these tests support the claims made by their designers, then no harm will have been done. But if these tests are not useful in evaluating and managing concussion, then athletes could be mistakenly “passed fit” to return to play and suffer further concussions that may contribute to longer lasting forms of cognitive impairment. </p>
<p>We believe that a high priority should be given to developing evidence-informed policies to manage concussions in sports and that this be done in ways that reduce the potential effects of conflicts of interest on the part of those who design and then evaluate such policies.</p><img src="https://counter.theconversation.com/content/13103/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bradley Partridge receives funding from NHMRC and ARC.</span></em></p><p class="fine-print"><em><span>Wayne Hall receives funding from NHMRC via an Australia Fellowship to research the ethical and social implications of addiction neuroscience research. He has also received funding from ARC for two research projects on topics that are unrelated to the subject of this article.</span></em></p>Athletes and officials in charge of collision sports (such as rugby league, AFL and American football) have an uneasy relationship with concussion; it’s an unavoidable feature of their games and there’s…Bradley Partridge, Postdoctoral Research Fellow in Public Health, The University of QueenslandWayne Hall, Professor & Deputy Director (Policy) UQ Centre for Clinical Research, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/50132012-03-29T17:18:33Z2012-03-29T17:18:33ZDon’t show me the money: the dangers of non-financial conflicts<figure><img src="https://images.theconversation.com/files/9080/original/d3sp65cw-1332911570.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Conflict of interest management depends on the existence of a critical culture that recognises the issues.</span> <span class="attribution"><span class="source">Waldo Jaquith</span></span></figcaption></figure><p><strong>TRANSPARENCY AND MEDICINE – A series examining issues from ethics to the evidence in evidence-based medicine, the influence of medical journals to the role of Big Pharma in our present and future health.</strong></p>
<p><strong>Here Paul Komesaroff and colleagues highlight a gap in our understand of conflicts of interest.</strong></p>
<p>The popular media frequently feature stories about surgeons profiting from installation of devices made by companies they hold shares in; professional bodies receiving sponsorship from industry; conference speakers whose travel has been paid for by the makers of products they’re commenting on; and GPs using software displaying drug company logos. </p>
<p>This concern about conflicts of interest (a situation that exists where two or more interests are contradictory and compel incompatible outcomes) is undoubtedly well founded, as a large volume of research shows that financial links between individuals and industry do, in fact, influence decision-making. </p>
<p>And now virtually every institution in the country has a process for addressing the issue and governments, peak bodies and professional bodies all, to a greater or lesser extent, require disclosure of financial interests in settings where a conflict of interest (CoI) may arise. </p>
<p>But for all the attention the subject has attracted, the response has been curiously limited and partial. This reveals a major blind spot in the understanding of both interests and the conflicts they produce.</p>
<h2>The blind spot in CoI</h2>
<p>The discussion has focused almost exclusively on pecuniary, or financial, interests. But these may play a relatively minor role in medicine. Most doctors or researchers don’t do what they do primarily to increase their material wealth. If making money was their primary goal, they could choose more effective ways of doing so.</p>
<p>The motivations that underlie most decisions in medicine are not financial. Rather they range from an interest in patient care or research or public welfare, to a commitment to certain ideas, principles or values and the desire for personal advancement in career, reputation or status. </p>
<p>These factors are powerful drivers of decisions and actions and are no less capable of generating conflicts than the prospect of monetary rewards. Division of loyalties between the roles of clinician, researcher, administrator or public health practitioner may create serious concerns or anxieties; personal religious or political commitments may undermine the operation of an ethics or policy committee; and the quest for international recognition may overcome the natural caution or circumspection required of clinical judgement. </p>
<p>While it’s easy to highlight this gap in the understanding of conflicts of interest, how to deal with it is not quite as clear. Indeed, the reason why public debates have focused on financial interests and almost completely ignored non-monetary ones is that, by their very nature, the latter are more difficult to define and quantify. And, their impact is more difficult to prove.</p>
<h2>The nature of interests</h2>
<p>The problem is not simply that we’ve ignored non-pecuniary CoI but that our focus on financial interests has distorted our understanding of what interests are and what it means to say that they’re in conflict. </p>
<p>For starters, interests are not bad things, they refer simply to the ways in which we necessarily and habitually attach value to our relationships and practices. Every social role has associated with it a collection of moral imperatives into which one enters when one assumes that role. This applies regardless of whether you’re a doctor, teacher, researcher, administrator or public servant. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/9077/original/xthhcdgm-1332911251.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/9077/original/xthhcdgm-1332911251.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/9077/original/xthhcdgm-1332911251.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/9077/original/xthhcdgm-1332911251.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/9077/original/xthhcdgm-1332911251.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/9077/original/xthhcdgm-1332911251.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/9077/original/xthhcdgm-1332911251.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption"></span>
<span class="attribution"><span class="source">ShuttrKing|KT/Flickr</span></span>
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</figure>
<p>The chance of dualities, multiplicities and conflicts is increased by the great diversity of roles and responsibilities assumed by individuals in modern society. The existence of a CoI is neither unusual nor shameful and doesn’t reflect a psychological aberration. It’s a straightforward, unavoidable fact that we must accept and recognise. </p>
<p>This doesn’t mean that CoIs don’t produce problems. On the contrary, unregulated conflicts, both pecuniary and non-pecuniary, can confound and distort decision-making processes and generate inappropriate and harmful outcomes.</p>
<h2>Not for money</h2>
<p>Despite the difficulty in defining and evaluating non-financial interests, it’s possible to regulate them in a systematic way. The first, essential step is to recognise the issue and identify the key interests at stake within the setting. </p>
<p>There must also be a process of review or deliberation so relevant stakeholders can decide whether the existence of multiple interests has the capacity to corrupt a decision-making process. If it’s decided that this is the case, action may need to be taken to disengage the conflicting roles. The relevant community will also need to be assured that danger has been averted and the integrity of decisions preserved.</p>
<h2>Case studies</h2>
<p>The approach for managing these conflicts is the same as in most cases of financial conflicts of interest, but not all. Let’s consider some examples:</p>
<ul>
<li><p>A doctor working as both a clinician and a researcher encounters a conflict between the demands of science and clinical care. She recognises her conflicting interests, declares them and, with the help of an ethics committee, entrusts the job of recruiting research participants to an independent assistant;</p></li>
<li><p>An individual is approached to participate in a committee to write guidelines for the conduct of research involving embryonic stem cells. He recognizes that his strong religious beliefs would make it impossible for him to engage in the open dialogue required for the task, so after discussion with the chair he declines the invitation to join the committee;</p></li>
<li><p>A senior office holder in a professional organisation recognises that the fact that her husband’s role as a senior government official may compromise her independence of judgment. She declares her interests and recuses herself from discussions involving dealings with that government department; or</p></li>
<li><p>A surgeon involved in developing a new operation that may not only improve clinical practice but also enhance his personal reputation and standing recognises that he is vulnerable to errors owing to his duality of interests. To protect both himself and his patients, he engages in discussion with colleagues who agree to help guide him in cases where there might be uncertainty about the role of the new procedure. </p></li>
</ul>
<p>Of these examples, the last is the most difficult because it depends on a degree of introspection, even if objective criteria may still be recognisable to those around the surgeon. In such cases, we are forced to rely on two things – personal integrity and the vigilance of the community of practitioners in which the affected person works. </p>
<p>Both of these depend on the culture within which all parties operate, including the prevailing ethos of the hospital setting; the standards set by professional organisations; the ability of the educational process to develop the critical qualities of self-knowledge and humility; the level of community awareness; and the readiness of doctors to engage in open dialogues with their patients.</p>
<h2>Still an elephant</h2>
<p>Non-financial interests are the elephant in the room during discussions about conflicts of interest. Although they’ve received relatively little attention, it’s undeniable that they are as important as monetary interests in the decision-making process, and the risk posed by conflicts involving them is just as great. </p>
<p>With care, they can be recognised and managed, although the procedures involved may at times differ somewhat from those developed to deal with financial issues. Some conflicts of this kind fall into easily definable categories, such as specific roles, relationships or belief systems, while others may concern personal motivations and intentions. The management of these latter may depend on more complex processes. </p>
<p>The management of all conflicts – financial or not – ultimately depend on the existence of a critical culture that both recognises the importance of the issues and provides support and guidance for practitioners. </p>
<p><strong>This is the fifth part of Transparency and Medicine. You can read other instalments by clicking the links below:</strong> </p>
<p><strong>Part One: <a href="https://theconversation.com/power-and-duty-is-the-social-contract-in-medicine-still-relevant-3941">Power and duty: is the social contract in medicine still relevant?</a></strong></p>
<p><strong>Part Two: <a href="https://theconversation.com/big-debts-in-small-packages-the-dangers-of-pens-and-post-it-notes-4949">Big debts in small packages – the dangers of pens and post-it notes</a></strong></p>
<p><strong>Part Three: <a href="https://theconversation.com/show-and-tell-conflicts-of-interest-undeclared-for-clinical-guidelines-3890">Show and tell: conflicts of interest undeclared for clinical guidelines</a></strong></p>
<p><strong>Part Four: <a href="https://theconversation.com/eminence-or-evidence-the-ethics-of-using-untested-treatments-4046">Eminence or evidence? The ethics of using untested treatments</a></strong></p>
<p><strong>Part Six: <a href="https://theconversation.com/ghosts-in-the-machine-better-definition-of-author-may-stem-bias-4288">Ghosts in the machine: better definition of author may stem bias</a></strong></p>
<p><strong>Part Seven: <a href="https://theconversation.com/clearing-the-air-why-more-retractions-are-good-for-science-6008">Clearing the air: why more retractions are good for science</a></strong></p>
<p><strong>Part Eight: <a href="https://theconversation.com/pharmas-influence-over-published-clinical-evidence-5325">Pharma’s influence over published clinical evidence</a></strong></p>
<p><strong>Part Nine: <a href="https://theconversation.com/insight-into-how-pharma-manipulates-research-evidence-a-case-study-4071">Insight into how pharma manipulates research evidence: a case study</a></strong></p>
<p><strong>Part Ten: <a href="https://theconversation.com/why-data-from-published-trials-should-be-made-public-5599">Why data from published trials should be made public</a></strong></p>
<p><strong>Part Eleven: <a href="https://theconversation.com/open-disclosure-why-doctors-should-be-honest-about-errors-4070">Open disclosure: why doctors should be honest about errors</a></strong></p>
<p><strong>Part Twelve: <a href="https://theconversation.com/reaching-full-and-open-disclosure-for-universities-medical-schools-and-doctors-6004">Reaching full and open disclosure for universities, medical schools and doctors</a></strong></p>
<p><strong>Part Thirteen: <a href="https://theconversation.com/ethics-of-accepting-suppliers-gifts-in-the-business-v-medical-world-3968">Ethics of accepting suppliers’ gifts in the business v medical world</a></strong></p>
<p><strong>Part Fourteen: <a href="https://theconversation.com/conflicts-of-interest-in-guideline-development-the-nhmrc-responds-6395">Conflicts of interest in guideline development: the NHMRC responds</a></strong></p>
<p><strong>Part Fifteen: <a href="https://theconversation.com/consumer-input-in-medicines-australias-code-of-conduct-review-6370">Consumer input in Medicines Australia’s code of conduct review</a></strong></p><img src="https://counter.theconversation.com/content/5013/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Komesaroff receives funding from the ARC and NHMRC.</span></em></p><p class="fine-print"><em><span>Wendy Lipworth receives funding from the National Health & Medical Research Council.</span></em></p><p class="fine-print"><em><span>Ian Kerridge does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>TRANSPARENCY AND MEDICINE – A series examining issues from ethics to the evidence in evidence-based medicine, the influence of medical journals to the role of Big Pharma in our present and future health…Paul Komesaroff, Professor of Medicine, Monash UniversityIan Kerridge, Associate Professor in Bioethics & Director, Centre for Values and Ethics and the Law in Medicine, University of SydneyWendy Lipworth, Postdoctoral Research Fellow, Bioethics, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/38902012-03-27T19:11:48Z2012-03-27T19:11:48ZShow and tell: conflicts of interest undeclared for clinical guidelines<figure><img src="https://images.theconversation.com/files/8952/original/bzd27rsg-1332474677.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Perceptions of conflict can be just as damaging to community confidence as conflicts themselves.</span> <span class="attribution"><span class="source">401K/Flickr</span></span></figcaption></figure><p><strong>TRANSPARENCY AND MEDICINE – A series examining issues from ethics to the evidence in evidence-based medicine, the influence of medical journals to the role of Big Pharma in our present and future health.</strong></p>
<p><strong>Today Bebe Loff and colleagues discuss the lack of adequate management of conflicts of interest among experts generating clinical guidelines in Australia.</strong></p>
<p>Clinical guidelines are increasingly used to establish practice standards and are relied upon by governments when making decisions about allocating health-related funding. But the public has little basis for assuming that the recommendations of the range of medical groups around Australia that develop these guidelines are free of outside influence. </p>
<p>Last year, the National Heart Foundation (NHF) renounced a $330,000 deal it had with McDonalds that permitted the company to display the Foundation’s “Tick of Approval” on its menus. While the arrangement was always controversial, it was also unsurprising. </p>
<p>Corporate dollars (usually emanating from multinational pharmaceutical companies rather than global food chains) have long supported the work of professional medical associations such as the NHF and clinical researchers. They have also often topped up the wages of doctors. </p>
<p>Your general practitioner is probably writing with a pen provided by a drug business, and next year he or she may have their trip to a medical conference in Greece heavily subsidised by a different drug company. There’s nothing inherently sinister about such support, and often important medical breakthroughs are achieved because of it.</p>
<p>But there’s a problem in Australia surrounding the lack of disclosure of such money and how the perception of conflicting interests is managed. </p>
<h2>Clinical guidelines</h2>
<p>Late last year, we published <a href="https://www.mja.com.au/journal/2011/195/8/conflict-interest-guidelines-clinical-guidelines">an article</a> in the Medical Journal of Australia (MJA) looking at one particular example of how conflicts of interest are managed in one area of medicine – the development of clinical guidelines. </p>
<p>While many ordinary people may have never have heard of clinical guidelines, they are vital documents that assist doctors to quickly decide the appropriate care and treatment to give patients. So guidelines probably touch every one of us in some way, whether we are in the GP consulting room or on the operating table. </p>
<p>They’re also increasingly used by health authorities and government funders to ensure that care is standardised across the sector. And their importance will only grow in future as consistency will be used to both maintain quality of care and keep costs down. </p>
<h2>Lack of clarity</h2>
<p>Individuals who sit on the panels that draft guidelines, and the professional medical associations that sponsor their development, are reputable experts. But panel members and professional medical associations also receive support from pharmaceutical companies and other corporate entities. And because guidelines contain recommendations for commercially marketed drugs and medical devices, they are vulnerable to bias. </p>
<p>There’s no suggestion that guidelines are being deliberately biased through panel members or sponsoring institutions solely recommending a drug made by a company that offers them a speaker’s fee or research grant. </p>
<p>But influence can be subtle and insidious. </p>
<p>In the United States, for instance, the pharmaceutical company Eli Lilly sponsored a conference in 2003 that resulted in their very expensive drug for infections being <a href="http://www.nejm.org/doi/full/10.1056/NEJMp068197">placed on clinical guidelines</a> for intensive care patients. Further research showed the drug to be <a href="http://www.nejm.org/doi/full/10.1056/NEJMp068197">less effective than thought</a>, but the cost had already been accrued. </p>
<p>While a situation of this nature hasn’t arisen yet in Australia to our knowledge, it’s concerning that of all the guidelines we reviewed on the National Health and Medical Research Council’s (NHMRC) <a href="http://www.clinicalguidelines.gov.au/">Clinical Guidelines Portal</a>, only 15% had conflict of interest statements that listed the financial support offered to panel members. </p>
<p>Where guidelines did contain such statements, an even smaller percentage had details of the amounts given or explained the way potential conflict was managed by the panel or institution sponsoring the guideline in question. </p>
<h2>Engendering transparency</h2>
<p>To fix this, the nature of any support (financial or otherwise) from corporate interests to institutions and individuals, as well as the processes to manage conflicts needs to be disclosed on guidelines for which they are responsible. Some medical associations do make such disclosures, but they are exceptions rather than the norm. </p>
<p>While this issue has been debated in both the United States and the United Kingdom extensively, it’s seldom debated in Australia. </p>
<p>The United Kingdom has a central, public authority to develop all clinical guidelines. While this ensures that the institution is free of potential conflicts, processes are still required to manage conflicts of individuals sitting on drafting committees. </p>
<p>Professional medical associations do important work – they advocate for research into serious health problems; they educate both the community about staying well and doctors about the best treatment or procedures to use. And, in developing clinical guidelines, they undertake a vital service that governments haven’t seen fit to fund comprehensively. </p>
<p>But we must have confidence that the medications recommended in clinical guidelines, which taxpayers subsidise through the Pharmaceutical Benefits Scheme (PBS) to the tune of billions of dollars, are proposed for reasons of efficacy and not because of the intermingling of corporate money and medical research. </p>
<p>The perception of a conflict can be just as damaging to community confidence as the conflict itself. </p>
<p>When your doctor uses an expert guideline to help decide what treatment to give you, you should feel confident the guideline authors have disclosed conflicts of interest and that these have not affected the content of those guidelines. </p>
<p>That way, your doctor can be confident in the guideline’s advice, and you can be confident in your doctor’s advice.</p>
<p><strong>This is the third part of Transparency and Medicine. You can read other instalments by clicking the links below:</strong> </p>
<p><strong>Part One: <a href="https://theconversation.com/power-and-duty-is-the-social-contract-in-medicine-still-relevant-3941">Power and duty: is the social contract in medicine still relevant?</a></strong></p>
<p><strong>Part Two: <a href="https://theconversation.com/big-debts-in-small-packages-the-dangers-of-pens-and-post-it-notes-4949">Big debts in small packages – the dangers of pens and post-it notes</a></strong></p>
<p><strong>Part Four: <a href="https://theconversation.com/eminence-or-evidence-the-ethics-of-using-untested-treatments-4046">Eminence or evidence? The ethics of using untested treatments</a></strong></p>
<p><strong>Part Five: <a href="https://theconversation.com/dont-show-me-the-money-the-dangers-of-non-financial-conflicts-5013">Don’t show me the money: the dangers of non-financial conflicts</a></strong></p>
<p><strong>Part Six: <a href="https://theconversation.com/ghosts-in-the-machine-better-definition-of-author-may-stem-bias-4288">Ghosts in the machine: better definition of author may stem bias</a></strong></p>
<p><strong>Part Seven: <a href="https://theconversation.com/clearing-the-air-why-more-retractions-are-good-for-science-6008">Clearing the air: why more retractions are good for science</a></strong></p>
<p><strong>Part Eight: <a href="https://theconversation.com/pharmas-influence-over-published-clinical-evidence-5325">Pharma’s influence over published clinical evidence</a></strong></p>
<p><strong>Part Nine: <a href="https://theconversation.com/insight-into-how-pharma-manipulates-research-evidence-a-case-study-4071">Insight into how pharma manipulates research evidence: a case study</a></strong></p>
<p><strong>Part Ten: <a href="https://theconversation.com/why-data-from-published-trials-should-be-made-public-5599">Why data from published trials should be made public</a></strong></p>
<p><strong>Part Eleven: <a href="https://theconversation.com/open-disclosure-why-doctors-should-be-honest-about-errors-4070">Open disclosure: why doctors should be honest about errors</a></strong></p>
<p><strong>Part Twelve: <a href="https://theconversation.com/reaching-full-and-open-disclosure-for-universities-medical-schools-and-doctors-6004">Reaching full and open disclosure for universities, medical schools and doctors</a></strong></p>
<p><strong>Part Thirteen: <a href="https://theconversation.com/ethics-of-accepting-suppliers-gifts-in-the-business-v-medical-world-3968">Ethics of accepting suppliers’ gifts in the business v medical world</a></strong></p>
<p><strong>Part Fourteen: <a href="https://theconversation.com/conflicts-of-interest-in-guideline-development-the-nhmrc-responds-6395">Conflicts of interest in guideline development: the NHMRC responds</a></strong></p>
<p><strong>Part Fifteen: <a href="https://theconversation.com/consumer-input-in-medicines-australias-code-of-conduct-review-6370">Consumer input in Medicines Australia’s code of conduct review</a></strong></p><img src="https://counter.theconversation.com/content/3890/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dev Kevat does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations. </span></em></p><p class="fine-print"><em><span>Michael Williams does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
</span></em></p><p class="fine-print"><em><span>Bebe Loff does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>TRANSPARENCY AND MEDICINE – A series examining issues from ethics to the evidence in evidence-based medicine, the influence of medical journals to the role of Big Pharma in our present and future health…Bebe Loff, Associate Professor and Head of Human Rights & Bioethics, Monash UniversityDev Kevat, School of Public Health, Monash UniversityMichael Williams, Research Assistant, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.