The Donald Rumsfeld classification of conflicts of interest

I naively thought that financial conflicts of interest were either known or unknown depending on whether or not a presenter at a conference or author of an article disclosed his or her financial links with pharmaceutical or medical device companies that might influence interpretation of data or its presentation.

However, even when financial links with industry are disclosed, the amounts of money involved are not revealed. So what we really know is that we do not know the magnitude of the conflict of interest. To paraphrase Donald Rumsfeld, those conflicts of interest are known unknowns.

Because nobody with financial conflicts of interest discloses their full extent, there are no known knowns.

Conflicts of interest can also fall into Rumsfeld’s third category – unknown, unknowns. That obviously applies when presenters conceal their conflicts, but there are other and perhaps more insidious types of unknown unknowns.

For 35 years I researched the role of persistent foramen ovale (PFO) in aetiology of diseases including decompression sickness in divers, stroke and migraine. Initially there was limited interest in this and I was invited to speak only at small meetings. Then, about 18 years ago, I started to receive invitations to speak about my research at large cardiology and neurology conferences in Europe and North America. On some occasions there were more than five thousand doctors in the audiences.

Much later, a vice president for marketing of a corporation that made medical devices for closing PFOs told me that his corporation had regularly paid large sums to the organiser of conferences on condition that I was invited to lecture on titles provided by the corporation. My talks were not in industry-sponsored satellite symposia, but were part of the main programme of the meetings and no link to industry or sponsorship was disclosed.

The executives of the corporation knew from hearing me speak at parochial meetings that what I said was likely to favour increased PFO closure, which would financially benefit the corporation. So they paid large sums to get my talks on their chosen topic  into large meetings and the conference organisers accepted the inducements.

My talks may have carried more weight with the audiences because they were not in industry-sponsored satellite meetings and because my slides said that I had no conflicts of interest – I did not know of any.

In reality, my presentations were highly conflicted, but the audience was unaware, because the conference organisers and the corporation kept their financial arrangement secret, even from me. My invitation to speak about PFOs at major conferences decreased considerably when my message changed and was less in keeping with the corporation’s aims.

Donald Rumsfeld might have described those presentations funded by secret industry sponsorship as having an unknown unknown conflict of interest.

It is impossible to know how often this type of message manipulation by industry based on secret payments to conference organisers including medical societies occurs, but I suspect it may be common. My reason for thinking it may be common is that at some of the same meetings other speakers were asked to give lecture with titles that meant that they were effectively advertising a specific medical device.

We should have full disclosure of financial arrangements of sponsored presentations and sponsored speakers at conferences.

One response to “The Donald Rumsfeld classification of conflicts of interest

  1. […] Wilmshurst explains in a new blog post on his own example how a clinical researcher, invited to speak at a fancy conference, can end up […]


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