The discussion of conflicts of interest (CI) as a part of morality began about 50 years ago and has since been found in ethics committees, government codes of conduct, court decisions, and corporate policy (1). Naturally, CIs are also addressed in the healthcare system, and standardized measures are implemented to avoid them, particularly in this context. One example is the extensive and standardized declarations of conflicts of interest that authors submit in many scientific journals. Since this measure likely captures only a small portion of the actual CIs in the healthcare system, but CIs are a significant topic for health services research—especially as reviewers, editors, and publishers of scientific products are also exposed to the risks of a conflict of interest—this topic is addressed here.
Which actors have conflicts of interest?
Interactions are of paramount importance in the healthcare sector because they occur more frequently than commonly assumed. They can be defined as "a state of mismatch between the goals of two or more actors in a system" (2). This mismatch of goals will not be identical in any form of interaction, be it confidential communication, the generation or dissemination of knowledge, or the sale of a good or service. In all cases, it can be assumed that interactions exist between the actors to a greater or lesser degree. This is not only about the carefully examined potential economic relationships between academic authors and industry. Sectoral separation induces interactions between actors in outpatient and inpatient care. For understandable reasons, healthcare providers attempt to market their own methods using scientific arguments. Thus, one of the most important medical journals highlights the "non-inferiority of a new antidiabetic drug compared to placebo" (3). Clinicians generally do not have the time to carefully analyze news of this kind. The desired marketing effect is achieved even with this accurate but worthless statement. It follows that everyone has interfering factors (ICs): including reviewers, editors, and publishers of scientific products. The ICS simply vary in intensity. Therefore, the first conclusion that can be drawn is that ICS cannot be avoided, but only weighed against each other (4). We need new strategies to deal with ICS appropriately.
How should conflicts of interest be handled?
Furthermore, existing interpersonal communication (IM) practices are highly unethical because they usually affect several of the five major ethical principles simultaneously: respect for the autonomy of all those entrusted to care, not just patients; the obligation to do good; justice; the obligation to do no harm; and integrity (5). Published examples show that insufficient attention to conflicts—here using the example of domestic violence—can be associated with significant societal risks (6). Everyone remembers, to a greater or lesser extent, the Grexit, the FIFA scandal (7), the already predictable banking scandal (8, 9), the diesel scandal, and the IM-tainted design of the PREFERE disaster (10).
Agreed, that's old news; but not without learning the lessons from this naive credulity and its consequences. There are methods to transform political prevention rhetoric into scientifically sound projects (7). The British Medical Journal, together with the Centre for Evidence-based Medicine, launched the "Manifesto 2.0" campaign against interfering with (IC) practices, featuring a list of 20 errors (11).
It is the British who show us how to deal with intercultural communication: there is no magic formula, only civic courage and transparency. These will not be visible if scientists do not speak out and the editors and publishers of scientific products shy away from publishing critical statements and "out-of-the-box" comments (OOTBCs).
It is regrettable when leading international journals, in order to protect their own internal standards, preferentially accept publications that conform to mainstream concepts but hinder innovation. It should be embarrassing for us when our scientific errors are first discussed in the public media before we scientists critically examine the screening programs for breast, colon, and prostate cancer.
We could be 20 years further along and avoid a significant amount of over- and under-provision if we dared to discuss our own ICT and accepted that innovative solutions are much easier to implement when they are discussed before ICT has established itself as an economic sector.
If we assume that there are more opponents than proponents of intercultural communication (IC), because the majority of citizens can assess the consequences of its ever-expanding reach, then it is up to the reviewers and editors of journals and books in the academic field to shape their appearance accordingly. High-quality contributions that are critical of the system, fair, goal-oriented, and feasible are perceived as a positive signal by potential authors. The editors and publishers are interested in the acceptance of their journal among the readership. The journal's success corresponds to the central and natural interest of the editorial staff and the publisher.
From the reviewers' perspective, the journal's financial stability plays a rather minor role, because reviewers generally provide their services on a voluntary basis, thus eliminating any possibility of remuneration as a conflict of interest. However, if the reviewers' names are not disclosed, academic competition remains a potential conflict of interest if the author and reviewer are experts in the same field. These conflicts of interest are avoidable.
In summary, the second key point is this: everyone benefits when interpersonal conflicts (ICs) are identified very early, immediately after their creation. Reviewers, editorial board members, and publishers of scientific products should be aware of their undoubtedly existing IICs. It is certainly not possible to identify all of the authors' IICs through the requested declarations, which were already called for in 1998 (12) and reaffirmed 10 years later (13). The IICs of editorial boards and publishers can be recognized by the appearance of the scientific product.
The two decision criteria
Reviewers and editors should distinguish between technical and content-related reasons when rejecting a manuscript. A rejection based on technical reasons can be identified when the submitted work only inadequately meets the expectations set by the standards of statistics, clinical epidemiology, and Good Clinical Practice (GCP). It should be possible to compile a list of the most common technical errors and provide this to the reviewers for review. Since some scientific journals apparently use very young colleagues as reviewers, one increasingly receives reviews that vehemently demand the correction of irrelevant details but apparently fail to recognize, or are unable to recognize, the significance of results-relevant statements. For the authors and the journal, reviews of this kind are more detrimental than beneficial and should be avoided. The processing of qualified lists for specific study types by younger reviewers (14) will result in a largely objective assessment. The subsequent appraisal should, in any case, be reserved for experienced colleagues (14).
A rejection based on content will depend on the expectations of the reviewer and/or the editors/publisher. An editor who approves of an article will publish it, and vice versa. The works accepted for publication shape the journal's character.
A semi-quantitative assessment of intercultural relationships could be helpful for decision-makers: This can be achieved by comparing an author's statements with the role that author plays in society. Furthermore, undisclosed social connections can be identified through intelligent system-
Recognizing themes: Semantic analysis of social networks is extremely helpful in this regard. It has been shown that by combining the networks „knows“ (friend of a friend) and „co-author“ (15), information can be obtained that is valuable as an indication of potential inter-corporate intelligence.
Thus, the third statement underscores the importance of reviewers, editors, and publishers as "gatekeepers" of science communication. There are indeed various ways to uncover the unavoidable intermediaries, which are not always reported by the authors, using newer methods.
The three data-supported statements suggest that the focus of the Institute of Medicine's most recent statement on conflicts of interest (16) and its update (17) remains on direct financial conflicts of interest. Consideration of broader conflicts of interest that affect the content of scientific publications is becoming increasingly important. Readers will need to critically examine the question of balanced versus biased reporting in the future.
Summary
Three statements are described that indicate that authors' internal conflicts of interest (ICs) are only partially captured by existing declarations. Supplementary methods for capturing ICs include comparing authors' societal roles with statements in submitted manuscripts and analyzing social networks. In addition to authors' ICs, reviewers also face ICs when they compete scientifically with the authors of submitted manuscripts. These conflicts can be avoided internally through appropriate editorial policies. Editorial boards and publishers also experience conflicts of interest, which are made transparent through the appearance of published journals and books. Successful scientific publications will give readers the impression that a scientifically balanced presentation of current topics is being pursued. Furthermore, international recommendations for avoiding ICs need to be updated.