Antony J. Porcino , BSc, PhD, HSI
Complementary Medicine Education and Outcomes Research Program, British Columbia Cancer Agency, Vancouver, BC, CanadaIdentifying and addressing forms of bias in research are critical to the integrity and value of research. Conflicts of interest are an important aspect of research that must be addressed equally to any other form of research bias. Conflicts of interest occur when the judgment of a party involved in the research, either a researcher or a treatment provider, may be compromised by more than one interest relative to the research. As therapeutic massage and bodywork (TMB) is a younger field of research, some forms or aspects of conflicts of interest may not be understood. This editorial explores the meaning of conflicts of interest, how to increase awareness of them, and facets of research specific to TMB that may create such conflicts. Full disclosure in grant applications and manuscripts is critical to ensure that grantors, reviewers, and users of research are better informed of potential conflicts of interest, can understand the steps taken to manage the conflicts, and ultimately can better assess the research integrity and value.
KEYWORDS: conflict of interest , editorial , author guidelines , writing
At the beginning of the year, the IJTMB published its new author guidelines. While detail has been added and the information reorganized in the guidelines to better assist writers, the core concepts remain the same. Most content is understood and well-addressed in therapeutic massage and bodywork (TMB) research and the submitted manuscripts. What I have learned from communication with authors, however, is that while the idea of conflict of interest seems straight-forward, actually understanding it is not. For this reason, the instructions regarding the declaration of conflicts of interest are more prominent in the new guidelines.
Many definitions of conflicts of interest can be found. The American Committee on Conflict of Interest in Medical Research, Education, and Practice of the Institute of Medicine of the National Academies defines conflicts of interest as:
“… a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest” (page 46)(1).
The Canadian National Sciences and Engineering Research Council definition—adopted by the Canadian Interagency Advisory Panel on Research Ethics—defines a conflict of interest as potentially existing when:
“… activities or situations place an individual or institution in a real, potential or perceived conflict between the duties or responsibilities related to research, and personal, institutional or other interests”(2).
There are key concepts in these definitions. “Activities”, “situations”, and “set of circumstances” go far beyond just the acceptance of money, funding for a project, or a job offer. Examples of activities and situations involving a TMB researcher or research therapy provider could include (1) the persons also being involved in a business concerning the development or teaching of the therapies or treatment programs; (2) the persons accepting or using a position within a business or organization to accept gifts or special rates on products or services, even if those gifts, products or services are not directly related to the research; or (3) the relationships amongst the researchers, research treatment providers, patients, and funders.
Of course, not all of the above situations constitute a conflict of interest. The question is whether they may constitute a “real, potential, or perceived conflict”— the foundation of the key phrases—thereby “creat[ing] a risk... of [undue influence] by a secondary interest”. Everyone needs to be able to take that step back and look at the situation as an outsider. Even if there is not an actual conflict of interest, is there the possibility that the situation could be perceived or construed as one existing? Could it seem that a researcher or TMB treatment provider may have un consciously biased the research process due to potential gains? (Conscious bias may be fraud, an extreme manifestation of a conflict of interest). These questions are common around the issue of funding in pharmaceutical research(3), but the conflicts of interest in TMB research may not be recognized because we are not as familiar with the potential conflict of interest scenarios. These can, for example, include the relationship to the research of the owner or teacher of a technique or therapy applied in the research, the possible benefit to the researcher or the therapy/ technique teachers/owners should one prove better than the other treatment(s) it is being compared to in a trial, or the possible desire of a project’s therapist(s) to have one therapy test better than another. Even the desire to see any type of beneficial treatment outcome that supports the growing body of massage research could potentially be a conflict of interest.
These issues are critical because they can jeopardize the integrity of the results—thereby potentially: resulting in a disvaluing or dismissal of research outcomes, jeopardizing the protection offered to the research participants, bringing suspicion on the research enterprise, and creating divided loyalties for one or more members of the research teams (2). Conflict of interest statements should therefore be part of participants’ consideration when consenting for participation in research(1), and available to reviewers of TMB research manuscripts.
How can conflicts of interest be managed? Start by thinking like the reviewers and users (grant providers, research ethics review boards, manuscript reviewers, health professionals, and the public) of the research: “If they knew about my connection with X, or desire to see Y succeed, would they be concerned that I/we would not be able to do Y without bias? If that is possible, then what should I do in the research process to ensure that bias has been prevented or addressed?” All quality research requires that the investigator take specific steps to minimize forms of bias in data collection and interpretation. In the same way, each potential conflict of interest can be addressed using methods appropriate to the research and the particular scenario. Minimizing conflicts of interest, or even the appearance of them, involves implementing additional research steps—for example, through quality assurance methods like protocol training or patient interviews—and declaring in the grant or manuscript the potential sources of bias and remedial steps taken, letting the reader decide whether the steps were appropriate and sufficient.
When it comes time to submit a manuscript, all issues involving conflicts of interest should be decisively addressed in the methods, and in the conflict of interest statement. The new IJTMB author guidelines are clear that the conflict of interest statement, as part of the manuscript, is sent to reviewers so that the reviewers have as complete a picture of the research context and potential influence as possible, and thus best provide appropriate critique of the manuscript. By the same token, IJTMB reviewers are also expected to declare to their Section Editor any potential conflicts of interest with regard to the manuscript, either their possible conflicts of interest, or those perceived in the manuscript.
I offer two personal examples. (1) For another journal, I was sent an abstract and asked to review its full manuscript. I was very interested in the research and the findings, but I reported to the requesting editor that it appeared to be by a colleague whose massage training/research program I was supporting, though I was not aware of this research project. The editor replied by thanking me for checking, and that it would be fine for me to continue with the review if I was interested. When I read the published article, I realized that it was not written by my colleague. (2) In this edition of the IJTMB , I am also lead author on a research manuscript. My conflict of interest statement includes acknowledgement that I am also Executive Editor of this Journal, and that the journal process reduces possible influence of my position on the review or publication process. I could have chosen a different journal to reduce any real or perceived conflicts of interest, but I chose the IJTMB because of the best fit with the readership, and to honor the funder of the research, which is also the primary funder of the IJTMB . Does this open acknowledgement make you think differently about the manuscript?
Conflicts of interest are complex, context-sensitive, and sometimes not apparent. Researchers, research participants, manuscript reviewers, and research users should all be more aware of how conflicts of interest can exist in TMB research. The IJTMB may consider a more formal approach to reporting conflicts of interest, such as using the International Committee of Medical Journal Editors’ formal Conflict-of-Interest Disclosure form (4). As an introduction to the topic with examples touching on some TMB-specific issues, I’ve briefly outlined a few scenarios here. If you would like further training in conflicts of interest, the free Canadian Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans tutorial and Conflict of Interest in Medical Research, Education, and Practice online book are good starting points.
With thanks to the IJTMB Editorial Board members for their reviews and suggestions.
The author declares there are no conflicts of interest.
1 Institute of Medicine (US) Committee on Conflict of Interest in Medical Research, Education, and Practice. Lo B, Field MJ, editors. Conflict of Interest in Medical Research, Education, and Practice. Washington (DC): National Academies Press (US); 2009. Available from: http://www.ncbi.nlm.nih.gov/books/NBK22942/ Published 2009. Accessed January 21, 2013.
2 Panel on Research Ethics, Tri-council policy statement 2 (TCPS-2). Chapter 7: Conflicts of Interest. Panel on Research Ethics website. http://www.pre.ethics.gc.ca/eng/policypolitique/initiatives/tcps2-eptc2/chapter7-chapitre7/ Date modified: August 8, 2012. Accessed January 20, 2013.
3 Institute of Medicine (US) Committee on Conflict of Interest in Medical Research, Education, and Practice. Conflicts of interest in biomedical research. In: Lo B, Field MJ, editors. Conflict of Interest in Medical Research, Education, and Practice. Washington (DC): National Academies Press (US); 2009. Available from: http://www.ncbi.nlm.nih.gov/books/NBK22940/ Published 2009. Accessed January 21, 2013.
4 International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals: Ethical considerations in the conduct and reporting of research: Conflicts of Interest. ICMJE website. http://www.icmje.org/ethical_4conflicts.html Published 2009. Accessed January 21, 2013.
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INTERNATIONAL JOURNAL OF THERAPEUTIC MASSAGE AND BODYWORK , VOLUME 6 , NUMBER 1 , March 2013