Comment (Barry Blackwell)

The picture your essay portrays accurately and elegantly is not so much an ethical "conflict of interest" as a conflict between a homogeneous (specific) approach to drug discovery and clinical treatment versus a heterogeneous (DSM) one. I think it is a mistake to view this as a difference between "education" and "marketing" for the following reasons:

1. You omit all mention of safety and concentrate on efficacy. But the Hippocratic ideal of "First do no harm" surely applies equally to both industry and education and was the foundation of the Kefauver Amendments that set FDA policy. Risk is increased to the extent that largehomogeneous populations are used to "prove" efficacy and should be of interest to both educators and industry especially since the etiology of a side effect may have nothing to do with the mechanism of therapeutic efficacy.

2. Your thesis demands a narrow definition of who is an educator. As clinical psychopharmacology evolved it moved from asylums, the VA and private practice to academic medical centers - the heart of medical education after the Flexner revolution. And this is where the DSM and double blind methodology flourished precisely because they had a false aura of scientific integrity, serving as an antidote to psychoanalytic ideology. Educators are as much, perhaps more, to blame as is industry for developing and endorsing the tools that led to a heterogeneous approach. The subsequent fact that industry bribed education and its professional associations (APA, ACNP) to support the approach long after its falsehood became clear to a few wise individuals (like yourself) makes any distinction between "education" and "industry" dubious at best.

3. There is an extent to which making the distinction as you do dilutes the moral implications. So educators are not responsible for what industry does (even as they endorse it) while industry is only trying to make an honest profit (even as it stifles research findings, raises false hopes and kills people).Meanwhile they both foster the heterogeneous approach to clinical efficacy.
In short I am far less concerned with what I believe to be a weak "straw man" definition of "conflict of interest" than I am about the mutual harm both "educators" and "industry" have wrought by endorsing the heterogeneous approach to efficacy while downplaying side effects.

Barry Blackwell

January 30, 2014