Marc A. Rodwin's new book explores how Japan, France, and the United States sometimes succeed, but often fail, to address conflicts of interest in medicine. Since Rodwin's first book on the United States was published (Medicine, Money and Morals, 1993), more scholars have explored the collision of physicians' clinical and pecuniary interests. This expanding body of research has led to more awareness of conflicts of interest, and may have helped focus congressional attention on the need for new policies. Starting in 2014, the Physician Payment Sunshine Act will require pharmaceutical companies to publicly report payments made to physicians.

Much of this book focuses on financial conflicts of interest, where financial rewards rather than patient needs can influence treatment. Rodwin also addresses conflicts that arise from divided loyalties, such as instances of physicians treating patients who are participating in their research trials; these loyalties can also be influenced by financial incentives. Financial conflicts vary depending on physicians' ability to increase or substitute the services they provide, refer patients to facilities they own, choose self-employment over salaried employment (although salaried physicians can receive incentives that create conflicts of interest), and whether they receive payments on a fee-for-service basis. Organizations can provide financial incentives, either directly (via fees and consulting arrangements, for example) or indirectly (by sponsoring a medical society's conference).

Financial conflicts of interest are rife worldwide. A similar entrepreneurial itch afflicts physicians everywhere: Physicians in prestigious public hospitals in Japan apparently receive cash payments from patients (patients reportedly pay around a month of their salary), even though such payments are banned. Media cartoons in the book indicate that cynicism regarding the monetization of medicine transcends national borders, even if policymakers often look the other way.

This is an important contribution to our understanding of institutionalized conflicts of interest in medicine, and it contributes to our understanding of health-care politics and comparative health policy. In all three countries, physicians' associations have opposed and secured independence from regulation (though less so in France) by leveraging their professional status. They have successfully claimed that the profession, not government, is the best arbiter of conflicts of interest. In contrast to most comparative work on physician political power, which frequently focuses on organized medicine's role in fighting national health insurance, Rodwin's vantage point provides insights into the politics of private-sector medicine and the broader political economy of health care. We learn about long-standing disagreements over physicians' rights to refer patients to physician-owned facilities in the three countries.

Physicians' associations have employed Cassandra-like warnings of negative patient impacts when regulations are proposed. French physicians successfully fought early efforts by insurers to review the services they provided to individual patients on the grounds that it would compromise patient privacy. Privacy of medical records was protected, while scrutiny of physicians was conveniently removed. Opposition to salary-based compensation was justified on the grounds that it would create conflicts of interest for physicians and harm patients. Physician organizations argued against limits on pharmaceutical funding because attending (generously funded) meetings would benefit patients—physicians said they could learn about the “latest” and most advanced treatments.

Rodwin reels in considerable information about the current delivery systems, financing, and broader policy issues in each country. His account of Japanese health care is particularly welcome, given relatively fewer English-language books available. He also reviews current physician–government relations in France and gives a full account of recent changes in physician reimbursement policies there.

The book captures the relative lack of attention paid to conflicts of interest by policymakers compared to other policy goals; health policy reformers are more likely to give priority to cost containment or quality improvement, and overlook conflicts of interest. Therefore, new policies inadvertently create new conflicts of interest. For example, policies mandating continuing physician education (to improve the quality of care) opened the door for pharmaceutical companies to fund continuing medical education courses.

The pharmaceutical industry is not the only generator of conflicts of interest, even if drug companies are frequently discussed in the media. Rodwin is equally concerned with the insidious and seemingly innocuous everyday conflicts of interest in physician practices. The medical treatment we receive is molded by the national regulatory framework, or lack of it. When conflicts of interest are weakly regulated, physicians may recommend or provide unnecessary care, which raises the potential for medical errors or false-positive results. Physicians in Japan and the United States can refer patients to imaging centers and other physician-owned facilities, and arrange for physician-administered drugs. France is stricter, and these kinds of services are usually not reimbursed. However, Rodwin also acknowledges that patients can benefit from some of these arrangements: In-office testing provides real-time information and convenience. He argues, therefore, that conflict-of-interest policies must weigh the likelihood of conflict of interest occurring and its costs against benefits to the patient.

Physician organizations cannot adequately address or substitute government oversight of conflicts of interest. While professional organizations sometimes discourage unethical practices, historically their concern has been only a veneer, and weak “ethical” codes of conduct are perfunctory. Likewise, we can infer from the book that universal coverage is likely to be a necessary, but not sufficient, condition for eliminating conflicts of interest, Japan being a clear example. It may be preferable, on balance, since a lack of universal coverage seems to provide the conditions for an unregulated private health-care sector. This can also lead to contradictions later if government develops its own programs. Rodwin contrasts the robust U.S. anti-kickback laws that apply to Medicare (although they are relatively recent) with the lack of protection for privately insured patients. Universal coverage is not sufficient for eliminating conflicts of interest (e.g., Japan); the key intervention is limiting the independence of professional associations. In France, the historic regulation of guilds and associations constrained professional power, although France still falls short by keeping professional disciplinary proceedings secret and failing to regulate privately paid physician services.

Rodwin reviews various policy solutions, including converting for-profit to not-for-profit organizations, increased professional self-regulation, more market competition, salaried government physicians, higher malpractice liability penalties when physicians refer patients to their own facilities, and stronger disclosure laws. He raises important questions about the value of disclosing financial conflicts of interest. For example, when and how should information about financial incentives be provided to a patient? Should physicians provide disclosures to patients directly? Given that people exhibit cognitive dissonance in that most patients will not want to see their physician as compromising their treatment for financial incentives, can disclosure be effective? For the United States, Rodwin recommends more public employment of physicians, tighter controls on entrepreneurial behavior, and more regulation of financial ties with third parties. He advocates engaging professional medical judgment in the defining of clinical criteria, but under conditions of transparency and independence. Scholars of bureaucracy and politics might add that formal institutional responsibility, in the federal government, is also needed for regulating conflicts of interest, not only in the public sector but also in the private sector.

Among political scientists, Conflicts of Interest and the Future of Medicine is likely to be of most interest to those who study the politics of health care. The book does not seek to advance theories of policymaking or interest-group behavior. Political scientists might interpret Rodwin's findings through the lens of interest-group politics, or suggest that concentrated interests are more likely to triumph against patients, who naturally have fewer incentives to mobilize. Indeed, physicians' political successes do reflect their steadfast and stubborn protection of their turf. But these explanations do not completely account for the larger puzzle of why the medical profession has enjoyed a long-standing and persistent independence from government. Perhaps the answer is that legislators have significant trust in physicians and physician organizations. A high level of trust might lead legislators to discount potential conflict-of-interest issues, such that they do not gather momentum. And while there is generalized cynicism about the role of money in health care, policymakers, like patients, may not want to see physicians as influenced by financial incentives. However, legislators in the United States are taking small steps to address conflicts of interest, and attitudes might be shifting. This book provides thoughtful insights on past, current, and future conflicts of interest in medicine for scholars and policymakers alike.