Panacea or veneer, transparency remains essential

“Transparency is almost a panacea” is a mantra in which we once had faith (doi:10.1136/bmj.329.7472.0-g).1 What’s clear (and I guess we always knew this) is that nothing is a panacea. A criticism of transparency now is that a façade of public soul baring can give authors freedom to say and write comments that are unfairly skewed in favour of the very competing interests they are declaring (doi:10.1136/bmj.n1583).2

Transparency may offer a veneer of respectability to biased arguments, plans, and strategies that go unscrutinised, which isn’t the intention. Transparency may create trust where it isn’t deserved. That’s a reason The BMJ no longer lets authors with competing interests write clinical editorials or education articles. This policy means that many good authors miss out, but it’s a point of principle that has served us and readers well since 2015.2 Apart from routinely asking authors and reviewers to declare their competing interests on all articles, we also ask the same of contributors to our journalism.

Margaret McCartney describes a study into how England’s commissioning groups managed competing interests and how they focused on transparency rather than managing conflicts (doi:10.1136/bmj.p1646).3 One conclusion of the study, as we have reached with our clinical articles, was that transparency is a way to identify people who are too conflicted to be involved in decision making. Transparency, therefore, may not be a panacea, but it remains important if we are to deal adequately with competing interests.

An investigation by The BMJ finds that since 2015 UK medical royal colleges have received more than £9m (€10.5m; $11.6m) in marketing payments from drug and device manufacturers (doi:10.1136/bmj.p1658).4 The amount is an underestimate, because the data compiled by Disclosure UK, an online database run by the industry regulator the Association of the British Pharmaceutical Industry (ABPI), don’t include all transactions.

One reaction might be to say that these payments add up to only a small sum, around 1% or less of income, according to several royal medical colleges we approached; that they don’t influence policy; and that the colleges are subject to honourable rules of engagement. Another reaction might equally be to ask what that money was used for, why it isn’t transparently declared, and how any potential competing interests were handled.

Industry targets its marketing spending only where it hopes to generate revenue or advantage. That much hasn’t changed since the ABPI code of practice encouraged industry to shift its focus from individual prescribers to healthcare organisations, professional colleges and societies, and patient groups (doi:10.7861/clinmedicine.8-2-128).5

Industry’s response—and every chief executive I’ve spoken to has told me this—is that its purpose is to make people healthier and improve wellbeing. The profits help research and development, to innovate and to create better products. That may be so, but I can’t think of an example of a drug company that used its marketing spend to promote a competitor’s product, a non-pharmaceutical intervention, or no intervention at all, where these are known to be better for patients.

The evidence is clear on how clinicians’ prescribing habits are influenced by industry marketing (doi:10.1136/bmj.l6015).6 It’s why the College of Psychiatrists of Ireland stopped taking sponsorship from drug companies in 2012. Why then don’t other medical colleges and societies follow the lead of the Irish college and build trust, especially if the sums involved are such a small proportion of their income? Why are we still waiting for a mechanism for transparent declaration of funding received by medical colleges and societies? What is there to hide?

BMJ’s income includes advertising and subscription revenues from drug and device manufacturers. Editorial staff don’t know which company is buying advertising or when and where the advertising will be placed. BMJ sales staff do not know what articles The BMJ is publishing. This is a strict firewall. Advertising drugs and devices to clinical practitioners is legal and governed by extensive regulations. Without the revenue that comes from advertising The BMJ might be less able to hold governments to account, to challenge industry, and fight for a better world based on the best evidence. (doi:10.1136/bmj-2023-075149).7 A small proportion of BMJ’s group revenue is from industry supported educational events. BMJ has full editorial control over these events, including the content and choice of speakers. Perhaps we should stop taking industry funding for these events?

The hope that transparency would be a panacea may have faded, if it was ever a genuine one, but transparency is still essential. Medical colleges and societies have no good excuse to be shirking a leadership responsibility to be open about their industry funding (doi:10.1136/bmj.n1360).8 Without that transparency, competing interests become hard to detect and deal with.