Margaret Norman, MD
Harry Emson, MD

These guidelines were reviewed and approved by the CAP Executive, September 25, 1996
Published in the January-February issue of the CAP Newsletter


All of us recognize that we will be found in a conflict of interest at some time and we feel that the most important key element of this document is that such conflict should be declared openly.

PREAMBLE

It is recognized that conflict of interest may occur from time to time.  There is a responsibility to recognize and acknowledge this conflict of interest and deal with it appropriately.

The relationship between a laboratory physician and a patient is a variant of the general doctor/patient relationship, the principles of which are always applicable.  It is a fiduciary relationship; that is, it is always intrinsically unequal and the physician bears a disproportionate duty towards the patient.  This includes the duty not to exploit the relationship for inappropriate personal gain of any sort.

There are two main types of conflict of interest:

  1. Conflict between a physician's personal interests, including but not limited to financial interests, and the interests of the patient.
  2. Conflict in that the physician has a duty to two or more patients, and/or a patient(s) and a third party.

A physician making clinical decisions and choices has the duty to decide/choose solely  in the interests of the patient, and on the basis of good medical practice.  This must be without reference to his/her own interests including income.  A physician may not be an entrepreneur in the sense of maximizing service to a patient for reasons other than clinical benefit.  Laboratory physicians should be paid only for services which they have actually performed, or for which they are responsible as supervisor.

PRINCIPLES

   1. A physician is in a position of conflict of interest when he/she refers tests to a laboratory or company

    1.1 owned by a medically related corporation whose stock is publicly traded in which the physician owns shares, and/or which employs the physician

    1.2 which is a private medical facility of which the physician owns all or part

    1.3 in which the physician is involved in a joint venture or group, and/or owns stock, or is involved in equipment leases, rental of space, and/or discounting of services.

Such conflict of interest must always be declared openly, and if appropriate in writing.

   2. A laboratory physician should not accept gifts, reward or honoraria in money or "in kind" from prospective or actual vendors of any supplies or equipment.  A site visit to inspect a vendor's equipment should be paid for by the prospective purchaser or purchaser's institution.

When a piece of equipment has been purchased, it is legitimate for a physician and/or his/her staff  (such as technologists) to attend a course(s) on the operation of the equipment  paid for by the vending company.

   3. Tariff committees
      A physician sitting as a member of a tariff committee should declare in confidence the amount and manner of  any remuneration they receive for services falling under the tariffs considered.  Tariffs should be set on the basis of the actual cost of the test, including the degree of automation and the difference between automated and non-automated tests, and the costs of labour, supplies, and other laboratory costs (e.g. equipment service, maintenance and proportionate share of administrative costs).
   4. A laboratory physician should hire, fire and promote staff solely on the basis of  professional merit, subject to the provisions of any collective agreement.  There should be no favouritism or nepotism in determining employment.
   5. A laboratory physician, who is also a teacher, must remember that this is a fiduciary relationship.  The imbalance of power between teacher and student must not be used for personal benefit of any kind. The teacher must not compromise his/her responsibility to instruct and evaluate students in a fair and effective manner.
   6. In deciding priority in examining specimens, the only criterion to be used is the clinical benefit to the patient(s).  Priority of examination may not be decided by source of specimen or manner of payment.
   7. A laboratory physician must report knowledge or suspicion of professional malpractice or negligence of which he/she becomes aware in the course of their practice, without prejudice, fear or favour and in good faith to the appropriate professional authority.
   8. A laboratory physician involved in an  accreditation process will do so without prejudice and in good faith, in a fair and constructive manner.
   9. As a general principle, a physician must not refer a test to a laboratory which he/she owns or operates.  This principle may be modified, any such modification to be stated openly, publicly and in writing; for example

    9.1 for a family physician operating an "office" laboratory doing a small and approved range of tests

    9.2 when the physician owns or operates the only laboratory reasonably capable of performing the test.

  10. In submission of manuscripts for publication, abstracts for professional meetings, applications for research funding, educational material as part of a course,  a physician  must declare a conflict of interest if any  processes, products or services are discussed in which the physician has another interest. Such information must include financial interests or other relationship with  manufacturer or supplier, products or provider of services; any other relationship  e.g. grant from a commercial supporter, support of research or any benefit gained as employee, consultant, major stock holder, member of speakers bureau or in any other way.

REFERENCES:
 

  1. Rodwin MA AMedicine, Money and Morals@, pub Oxford Univ. Press
  2. UBC Conflict of Interest Document
  3. Conflict of Interest document sent out with call for abstracts for the annual scientific meeting of the American Association of Neuropathologists