doi:10.1111/imj.14233 ETHICS IN MEDICINE Conflicts of interest: new thinking, new processes Paul A. Komesaroff , 1,2 Ian Kerridge 2 and Wendy Lipworth 2 1 Alfred Hospital, Monash University, Melbourne, Victoria, and 2 Sydney Health Ethics, University of Sydney, Sydney, New South Wales, Australia Key words conflicts of interest, interest, ethics, non- pecuniary interest, guidelines. Correspondence Paul A. Komesaroff, Alfred Hospital, Monash University, Commercial Road, Prahran, Vic. 3181, Australia. Email: paul.komesaroff@monash.edu Received 20 December 2018; accepted 21 January 2019. Abstract Although the concept of ‘conflict of interest’ (COI) arises in many contexts in healthcare, it is often poorly understood, and commonly accepted, definitions are often circular, self-contradictory and unable to provide procedural guidance. To overcome such confusion and imprecision, we offer a reformulation of COI that carefully defines interests, clarifies their scope and articulates a simple, non-punitive approach to manag- ing them. We define an ‘interest’ as ‘a commitment, goal, obligation or duty related to a particular social role or practice’. We show how in a particular setting multiple inter- ests can be at play, which can be either financial or non-financial, with the latter often being the most potent drivers of behaviour. We define a ‘conflict of interest’ as the con- dition that arises when two coexisting interests directly conflict with each other: that is, when they are likely to compel contrary and incompatible outcomes. COI therefore reflect objective states of affairs rather than internal mental states; they do not imply moral error; and they are identified through public rather than private processes involving ethical dialogues among relevant stakeholders. Once a COI has been identi- fied, responses must be determined based on the seriousness of the conflict and the conditions that generated it. Such responses may be minimal or they may require a for- mal disengagement from one of the conflicting interests. The framework described, reflects the rich diversity of interests in modern societies, is universally applicable and provides simple, readily applicable guidelines for the identification and management of conflicts arising between them. INTRODUCTION The concept of ‘conflict of interest’ (COI) arises in many contexts in the work of physicians, including in clinical practice, research, administrative tasks, educational activities, the conduct of meetings and the receipt of gifts and hospitality. Despite its importance and visibility, however, the concept is often loosely applied and poorly understood. This is not surprising, given that commonly accepted definitions of COI are often circular or self-contradictory or, at best, fail to provide procedural guidance. The defi- nition that is most commonly referred to is that of the US National Academy of Medicine (formerly the Insti- tute of Medicine), which defines a COI as ‘a set of cir- cumstances that creates a risk that professional judgement or actions regarding a primary interest will be unduly influenced by a secondary interest’. 1 This definition both fails to define what an ‘interest’ is (and is therefore circular) and makes the unsupported assump- tion that there will always be a clear hierarchy of ‘pri- mary’ and ‘secondary’ interests in biomedical research, policymaking and practice. The Australian National Health & Medical Research Council’s National Statement on Ethical Conduct in Human Research defines a COI as occurring where ‘a person’s individual interests or responsibilities have the potential to influence the carrying out of his or her institutional role or professional obligations…’. 2 Again, we see that ‘interests’ are not defined and that flawed assumptions are made about the nature of biomedicine—in this case that ‘influences’ on roles and obligations necessarily entail conflicts—which is not necessarily the case. In addition, ‘interests’ appear to be conflated with ‘respon- sibilities’, despite the fact that these are two different things. Other definitions of COI focus exclusively on the com- patibility of one’s personal interests with those of an organisation with which he or she is associated. The Funding: None. Conflict of interest: None. Internal Medicine Journal 49 (2019) 574–577 © 2019 Royal Australasian College of Physicians 574