day-to-day pressures of decision making, which should help them assess more judiciously the potential risks posed by a particular financial interest to the institution’s core missions. This committee of the board of trustees could be supported by staff committees on institutional conflict of interest. Recommendation 8.2 calls for NIH to develop regulations requiring institutions covered by the 1995 PHS regulations to adopt institutional conflict of interest policies.

THE ROLE OF SUPPORTING ORGANIZATIONS

In carrying out medical research and education, providing patient care, and developing practice guidelines, physicians, researchers, and the institutions in which they work are part of complex intersecting systems. These systems can amplify or mitigate the pressures that individuals and institutions may experience to expose their primary professional obligations or social missions to undue influence from secondary interests, such as financial gain. Within these systems, a variety of organizations—public and private—can influence the policies and practices of institutions and support the norms of professional integrity. For example, accreditation and certification organizations set standards for medical schools, residency and fellowship programs, and individual physicians. State agencies license and relicense individual physicians, and specialty boards certify and recertify them. Journals publish medical research. The National Guideline Clearinghouse posts clinical practice guidelines. Public and private health insurers use a variety of financial and other incentives to influence the practices of institutions and individual clinicians. The U.S. Department of Justice and the Office of the Inspector General of the U.S. Department of Health and Human Services enforce laws limiting or prohibiting certain conflicts of interest, and NIH is responsible for overseeing compliance with PHS policies covering its grantees.

In addition to discussing incentives for policy adoption and implementation, the final chapter of the report discusses the roles of collaboration and consensus building in building conflict of interest policies that win acceptance and avoid needless burdens. Although the emphasis should be on preventing problems, policies should also be backed by enforcement and appropriate sanctions as well as assessment of their effectiveness.

Recommendation 9.1 proposes that groups such as accrediting organizations, public and private health insurers, and associations of medical journal editors develop incentives to make institutions more accountable for preventing, identifying, and managing conflicts of interest. The accompanying discussion gives examples of such incentives. The final recommendation, Recommendation 9.2, calls for more research to assess the positive and negative consequences of conflict of interest policies and provide a



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