this is exactly what he told me. At the same time, it was not his usual manner with me, so I was puzzled by his unrelenting approach. In fact, he was a fantastic, dedicated doctor who treated me well and worked very hard to make me better. It was also not the first time I refused a treatment. Over many years of interacting with medical professionals, I had decided to have some treatments and not others. But none of my doctors, including the head of the burn department, had ever tried to guilt me into having a treatment.
In an attempt to solve this mystery, I went to his deputy, a younger doctor with whom I had a friendly rapport. I asked him to explain why the department head had put me under such pressure.
“Ah, yes, yes,” the deputy said. “He’s already performed this procedure on two patients, and he needs just one more in order to publish a scientific paper in one of the leading medical journals.”
This additional information certainly helped me better understand the conflict of interest I was up against. Here was a really good physician, someone I had known for many years and who had consistently treated me with compassion and great care. Yet, despite the fact that he cared a great deal about me in general, in this instance he was unable to see past his conflict of interest. It goes to show just how hard it is to overcome conflicts of interests once they fundamentally color our view of the world.
After years of experience publishing in academic journals myself, I now have a greater understanding of this physician’s conflict of interest (more about this later). Of course, I’ve never tried to coerce anyone into tattooing his face—but there’s still time for that.
The Hidden Cost of Favors
One other common cause of conflicts of interest is our inherent inclination to return favors. We humans are deeply social creatures, so when someone lends us a hand in some way or presents us with a gift, we tend to feel indebted. That feeling can in turn color our view, making us more inclined to try to help that person in the future.
One of the most interesting studies on the impact of favors was carried out by Ann Harvey, Ulrich Kirk, George Denfield, and Read Montague (at the time all were at the Baylor College of Medicine). In this study, Ann and her colleagues looked into whether a favor could influence aesthetic preferences.
When participants arrived at the neuroscience lab at Baylor, they were told that they would be evaluating art from two galleries, one called “Third Moon” and another called “Lone Wolfe.” The participants were informed that the galleries had generously provided their payment for participating in this experiment. Some were told that their individual payment was sponsored by Third Moon, while the others were told that their individual payment was sponsored by Lone Wolfe.
Armed with this information, the participants moved to the main part of the experiment. One by one, they were asked to remain as motionless as possible in a functional magnetic resonance imagining (fMRI) scanner, a large machine with a cylinder-shaped hole in the middle. Once they were situated inside the massive magnet, they viewed a series of sixty paintings, one at a time. All the paintings were by Western artists dating from the thirteenth through the twentieth century and ranged from representational to abstract art. But the sixty paintings were not all that they saw. Near the top-left corner of each painting was the handsome logo of the gallery where that particular picture could be purchased—which meant that some pictures were presented as if they came from the gallery that sponsored the participant, and some pictures were presented as if they came from the non- sponsoring gallery.
Once the scanning portion of the experiment was over, each participant was asked to take another look at each of the painting-logo combinations, but this time they were asked to rate each of the pictures on a scale that ranged from “dislike” to “like.”
With the rating information in hand, Ann and her colleagues could compare which paintings the participants liked more, the ones from Third Moon or the ones from Lone Wolfe. As you might suspect, when the researchers examined the ratings they found that participants gave more favorable ratings to the paintings that came from their sponsoring gallery.
You might think that this preference for the sponsoring gallery was due to a kind of politeness—or maybe just lip service, the way we compliment friends who invite us for dinner even when the food is mediocre. This is where the fMRI part of the study came in handy. Suggesting that the effects of reciprocity run deep, the brain scans showed the same effect; the presence of the sponsor’s logo increased the activity in the parts of the participants’ brains that are related to pleasure (particularly the ventromedial prefrontal cortex, a part of the brain that is responsible for higher-order thinking, including associations and meaning). This suggested that the favor from the sponsoring gallery had a deep effect on how people responded to the art. And get this: when participants were asked if they thought that the sponsor’s logo had any effect on their art preferences, the universal answer was “No way, absolutely not.”
What’s more, different participants were given varying amounts of money for their time in the experiments. Some received $30 from their sponsoring gallery, others received $100. At the highest level, participants were paid $300. It turned out that the favoritism toward the sponsoring gallery increased as the amount of earnings grew. The magnitude of brain activation in the pleasure centers of the brain was lowest when the payment was $30, higher when the payment was $100, and highest when the payment was $300.
These results suggest that once someone (or some organization) does us a favor, we become partial to anything related to the giving party—and that the magnitude of this bias increases as the magnitude of the initial favor (in this case the amount of payment) increases. It’s particularly interesting that financial favors could have an influence on one’s preferences for art, especially considering that the favor (paying for their participation in the study) had nothing at all to do with the art, which had been created independently of the galleries. It is also interesting to note that participants knew the gallery would pay their compensation regardless of their ratings of the paintings and yet the payment (and its magnitude) established a sense of reciprocity that guided their preferences.
Fun with Pharma
Some people and companies understand this human propensity for reciprocity very well and consequently spend a lot of time and money trying to engender a feeling of obligation in others. To my mind, the profession that most embodies this type of operation, that is, the one that depends most on creating conflicts of interests, is—of course—that of governmental lobbyists, who spend a small fraction of their time informing politicians about facts as reported by their employers and the rest of their time trying to implant a feeling of obligation and reciprocity in politicians who they hope will repay them by voting with their interest in mind.
But lobbyists are not alone in their relentless pursuit of conflicts of interest, and some other professions could arguably give them a run for their well-apportioned money. For example, let’s consider the way representatives for drug companies (pharma reps) run their business. A pharma rep’s job is to visit doctors and convince them to purchase medical equipment and drugs to treat everything from A(sthma) to Z(ollinger-Ellison syndrome). First they may give a doctor a free pen with their logo, or perhaps a notepad, a mug, or maybe some free drug samples. Those small gifts can subtly influence physicians to prescribe a drug more often—all because they feel the need to give back.1
But small gifts and free drug samples are just a few of the many psychological tricks that pharma reps use as they set out to woo physicians. “They think of everything,” my friend and colleague (let’s call him MD) told me. He
