Declining public trust in government and expert advice is a public health priority, given its impact on vaccination uptake, adherence to guidelines and social cohesion. In the context of the COVID-19 Vaccine Task Force, conflicts of interest that can threaten public trust are handled primarily through disclosures. However, this places the onus on the public to discern the relevance, severity and impact of these conflicts and does little to address whose interests guide decision making. Alternatively, expert advisory committees should adopt more trustworthy strategies, including promoting independence from commercial and political interests.

Introduction

Lexchin (2022a) carefully documents the ways that the Canadian COVID-19 Vaccine Task Force considered members' conflicts of interest, whether and how they were reported and what actions were taken to mitigate the risk that personal or third-party commercial interests might compromise the integrity of the decision-making process. The Task Force initially took the need for public transparency for granted, assuming that oversight by a governmental secretary was sufficient and that as experts, leaders and volunteers, members were entitled to public trust (Lexchin et al. 2020). What emerges from Lexchin's (2022a) analysis is that transparency alone will be insufficient to ensure public trust in their recommendations and subsequent policy action. Instead, expert advisory committees should shift their focus to ways they can be trustworthy, including strategies to promote independence from commercial and political interests and accountability to the public they were tasked to serve.

A Crisis of Trust

As we near the two-year mark in the global COVID-19 pandemic, public trust in scientists, the government and its institutions is under threat. With critical implications for compliance with public health measures, vaccine uptake and social cohesion (Algan et al. 2021), waning public trust in government, healthcare and scientific institutions can be characterized as a "crisis of trust" (Goldenberg 2021). While social media and its targeted misinformation campaigns present a significant public health challenge, Goldenberg (2021) argues for greater scrutiny and intervention in relation to other root causes of public mistrust – namely, systemic medical racism and the commercialization of health research, including the high prevalence of conflicts of interest among clinicians and researchers. Currently, however, expert groups, health regulators and public health leadership continue to locate the trust deficit within the public – often attributing it to a lack of information or misunderstanding – instead of critically examining whether their actions and decision making is, in fact, trustworthy (Goldenberg 2021).

The dominance of disclosure as the means to address commercial influence within healthcare and scientific research follows a similar logic. Many Organisation for Economic Co-operation and Development countries (though not Canada) have introduced "sunshine" legislation requiring pharmaceutical and medical device companies to publicly report all payments to health professionals with the hope that public transparency might serve as a deterrent to inappropriate relationships – while allowing productive and beneficial activities to continue – and a form of caveat emptor for members of the public (Fabbri et al. 2018; Grundy et al. 2018). Scientific journals, clinical guideline development groups and expert committees advising health product regulators now routinely require that members disclose conflicts of interest arising from financial relationships with commercial entities interested in the outcome of research or decision making (Grundy et al. 2020a). Disclosure requirements are largely premised on the assumption that public trust is dependent upon "how transparently an author's relationships and activities … are handled" and that, ultimately, transparency is necessary to enable a reader's "own judgments regarding whether an author's relationships and activities are pertinent to a paper's content" (ICMJE 2021). While promoting skepticism (which may indeed be warranted), placing the onus on members of the public to judge the credibility and integrity of evidence or scientific advice does little to build public trust.

Disclosure Is More Than an Exercise in Risk Management

Transparency is necessary but insufficient for maintaining public trust. Disclosures are frequently missing, incomplete, inconsistent and inaccessible (Grundy et al. 2020b). In other cases, authors flood statements with long lists of financial relationships (one statement disclosed payments from 42 different entities, including 23 drug and medical device companies), biographical information or ambiguous descriptors – for example, including 130 different ways of stating there were no conflicts of interest (Grundy et al. 2020b). Consequently, public conversation about the problem of conflicts of interest within health and scientific institutions is fixated on the adequacy of disclosure processes instead of ways to ensure the integrity and independence of evidence-led processes.

When disclosure processes are implemented to merely inform the public about the existence of conflicts of interests, it may have unintended consequences such as increasing pressure to comply with biased advice (Loewenstein et al. 2012) or normalizing the extent of industry relationships. For example, as Lexchin (2022a) documents following public scrutiny and the resignation of one member, the Task Force adopted a disclosure process, clearly defining the types of interests requiring disclosure (National Research Council of Canada 2020b). However, though Task Force members clearly and comprehensively disclosed all relationships between themselves or their institutions and vaccine manufacturers, without understanding the context, relevance and nature of the risk, the disclosures could instead be read as a colourful description of the myriad and diverse commercial relationships within the scientific enterprise (National Research Council of Canada 2021). A highly comprehensive approach to disclosure may also have a flattening effect, suggesting that everyone is equally "biased" and obscuring the relationships that pose a serious risk to the integrity or independence of the Task Force's process (Grundy 2021).

From Transparency to Accountability

The true value of public disclosure is in its ability to enable accountability. Public transparency around the existence and management of conflicts of interest enables the public to compare a committee's actions around conflicts of interest to their intentions, assess congruence and hold committees accountable. Goldenberg (2021) argues that the public needs to have confidence in the knowledge, competence and moral integrity of individual experts and also maintain confidence that their advice and activities will further public interest and not alternate agendas that are unjust or oppressive. Trust is built and maintained when the public can be confident that an expert group will do what they say they will do, and that these actions are consistent with the public's best interests.

This congruence between what an institution says it will do, what the public relies on it to do and what it actually does is the notion of institutional integrity (Marks 2019). Lexchin (2022a) points out that while the Task Force made conflict of interest disclosures and corresponding management actions public, the meeting minutes were not published, which would have been helpful to understand why the disclosed interest was relevant, what was at stake within the deliberations and the positions taken or to trace the line of decision making. Rather than using this information to detect "bias," enhanced transparency (such as documenting meeting minutes) around the committee's purpose, the role of evidence within the decision-making framework, efforts to ensure independence and the underlying values guiding recommendations could bolster the trustworthiness of the process. Though the scientific community emphasizes objectivity in decision making (Goldenberg 2015; Intemann and de Melo-Martín 2016), risk of "bias" is not the only consideration in the context of evidence-led advisory processes. For example, expert advice related to vaccine research, development and manufacture should also include considerations of equity, stewardship of public resources, environmental impact, human rights and independence.

Enhanced transparency and management of conflicts of interest of individual members is, thus, just one facet of ensuring the integrity of the Task Force and public trust in its activities. The federal government publicly set out the Task Force's mandate, which included identifying and prioritizing activities related to vaccine research, development, manufacturing and supply chain coordination (National Research Council of Canada 2020a). While committing to an evidence-led approach with critical implications for public health, this advisory process required consideration of numerous additional non-scientific elements including logistical, economic, commercial, social, political and cultural factors. Recognizing the need for multiple perspectives and different forms of expertise, the government made a conscious decision to include people who may have current or past ties with companies engaged in vaccine research and/or manufacturing (National Research Council of Canada 2020a). What requires greater emphasis is the primary obligation or purpose that unites these diverse perspectives, which is necessary to enable evaluation, in the first instance, of whether secondary interests indeed create a conflict of interest. Scientific institutions are focused on identifying and disclosing secondary interests that might compromise the primary obligation or interest of an expert entrusted to make decisions on behalf of patients or the public. However, the primary obligation or interest at stake is typically much more implicit and vaguely referenced as the "public interest" (Grundy et al. 2020a), or in this case "to protect the health and safety of Canadians during the pandemic" (National Research Council of Canada 2020a).

An explicit, clear and measurable primary interest is necessary to determine the relevance or severity of disclosed interests (WHO 2014). For example, in the Handbook for Guideline Development, the World Health Organization (WHO) clearly identifies the publics to which guideline developers are accountable and their guiding primary interest, which is generally to "serve WHO's Member States by producing recommendations that improve the health and well-being of populations, globally or in specific areas or countries" (WHO 2014: 57). Specific guideline-development committees can then operationalize this obligation for a specific context, community and set of population health outcomes against which all decision making can be scrutinized.

In some cases, the interests or relationships of individual experts might pose too high a risk of compromising the committee's primary obligation. Expert committees should clearly identify what interests or relationships are considered high risk and prioritize the selection of members who are free from such conflicts of interest. To ensure that evidence-led processes are independent from political and commercial interests but still have access to the necessary expertise (located in industry, for example) may require the development of creative strategies such that independent committees have access to, but do not necessarily include, such expertise.

Conclusion

To address the growing crisis of mistrust, expert health and scientific committees must clearly identify the communities they serve, the values they will prioritize and the explicit role that evidence will play within their decision-making framework, recognizing that evidence-led processes are inherently value-laden (Goldenberg 2015; Intemann and de Melo-Martín 2016). For an expert committee, such as the Task Force, with a mandate that has critical implications for public trust but also the prospect of incredible commercial gain (or loss), independence as a quality of decision making and evidence-led processes is a requisite for accountability and public trust. Moving beyond disclosure, expert committees must consider additional strategies including diversifying our notion of who can be an "expert" as well as clear, consistent selection criteria for experts, including those who are free or willing to divest from conflicting commitments deemed high risk.

Declaration

The author is a member of the conflict of interest panel for the Cochrane Collaboration and the four-person independent panel tasked with evaluating the implementation of the conflict of interest policy for the Australian National COVID-19 Clinical Evidence Taskforce.

Commentaire – De la transparence à l'imputabilité: trouver des moyens de rendre les conseils d'experts dignes de confiance

Résumé

La baisse de confiance du public dans le gouvernement et les conseils d'experts est une question d'ordre prioritaire pour la santé publique compte tenu de son impact sur la vaccination, sur le respect des directives et sur la cohésion sociale. Dans le cadre du groupe de travail sur les vaccins contre la COVID-19, les conflits d'intérêts susceptibles de menacer la confiance du public sont principalement traités par la divulgation. Cependant, cela oblige le public à discerner la pertinence, la gravité et l'impact de ces conflits et il y a peu de précisions sur les intérêts qui guident la prise de décision. Par ailleurs, les comités consultatifs d'experts devraient adopter des stratégies plus fiables, notamment la promotion de l'indépendance vis-à-vis des intérêts commerciaux et politiques.

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