Breastfeeding and conflicts of interest

Conflict of interest sign written in a notepad.

Financial conflicts of interest loom large in our evaluation of research and they should. But financial conflicts of interest are not limited to the impact of big corporations.

It is easy to understand how formula companies might represent a major conflict of interest in research about the benefits of breastfeeding; no one has any trouble recognizing that researchers who receive financial payments from formula companies might be tempted, possibly only subconsciously, to tilt research findings in favor of their financial sponsors. That’s why it is so important to for researchers to disclose any industry association. It doesn’t mean that the research is wrong or biased, but it helps readers evaluate the legitimacy of the claims within scientific papers.

Lactation professionals are no different from surgeons when it comes to conflicts of interest in promoting their skill set.

But money is money whether it comes from a large formula corporation or from elsewhere. Arguably, those whose entire income depends on promoting breastfeeding are even more vulnerable to financial conflicts of interest in breastfeeding research than those who receive payments or sponsorships from formula companies.

If payments from formula companies disappeared, the researchers who received them could still conduct research and would still receive salaries from their institutions. But if your entire job depended on finding benefits to breastfeeding — for example if you were employed by the breastfeeding industry — you’d have a very powerful financial conflict of interest to exaggerate the benefits of breastfeeding, as powerful as that stimulated by any formula company payments.

Such conflicts of interest occur all the time in medicine. For example, many types of cancer can be treated by surgery or radiation or chemotherapy or some combination of two or all three. We recognize that surgeons have a vested interest in promoting surgery, radiation oncologists in promoting radiation oncology and medical oncologists in promoting chemotherapy. That’s why many physicians, myself included, routinely recommend second and even third opinions before embarking on cancer treatment. It is only by learning the perspective of different professionals that patients can gain the best understanding of their treatment options.

Lactation professionals are no different from surgeons when it comes to conflicts of interest in promoting their skill set. Their recommendations about the benefits of breastfeeding, therefore, should be treated no differently than a surgeons’ recommendations about the benefits of surgery. It doesn’t mean they are venal and it doesn’t mean that they are wrong. It just means that their financial conflict of interest should never be forgotten.

Financial conflicts of interest are not the only conflicts of interest that can affect research results and professional recommendations.

That’s the point that Richard Saver seeks to make in Is It Really All About The Money? Reconsidering Non-Financial Interests In Medical Research:

Concern about financial ties crowds out consideration of other influences that may bias research conduct. But why? This article argues that we under-prioritize non-financial interests at our peril…

Making Sense of Non-Financial Competing Interests, written by the editors of PLoS Medicine offers examples:

Imagine you’re a peer reviewer who’s received a request to referee a paper. The paper reports the results of a study using cell lines derived from an aborted fetus as a diagnostic tool in identifying certain viral infections. You are also a member of a religious organization morally opposed to fetal cell research. In your review, you raise questions about the study’s validity and methodology that might undermine the paper’s chance of publication.

Imagine you’re an editor and you receive a paper from the scientist who supervised your postdoctoral fellowship. It’s been a couple of years since you left his lab, but he has supported your career and you have warm feelings toward him; plus you still join your former lab mates occasionally at their monthly pub night. You select sympathetic reviewers and you fight hard for the paper at the editorial meeting.

Such conflicts of interest may be even more important than financial conflicts of interest:

Non-financial competing interests (sometimes called “private interests”) can be personal, political, academic, ideological, or religious. Like financial interests, they can influence professional judgment… Indeed, because professional affinities and rivalries, nepotism, scientific or technological competition, religious beliefs, and political or ideological views are often the fuels for our passions and for our careers, private competing interests are perhaps even more potent than financial ones.

It’s not hard to imagine the private interests of breastfeeding researchers. Most have staked their entire research careers on the belief that breastfeeding is the “best” way to feed babies because it has substantial medical benefits. They have a vested psychological interest in promoting breastfeeding and even when their findings don’t support the foundational belief that breastfeeding is best, they are generally spun to ignore that reality or are dismissed with the claim that the failure to find benefits reflects a cultural “lack of support” for breastfeeding. Moreover, there are reports that suggest that over the past decades it has been nearly impossible to get acceptance for publication of papers that dispute the benefits of breastfeeding.

How can we address these non-financial conflicts of interest? With disclosure, policy and research.

Disclosure:

It’s necessary to establish a standard by which authors, reviewers, and editors are required to disclose whether they have non-financial interests that (1) might influence their reporting or review of the paper and/or (2) would negatively or positively be influenced by the publication of the paper… For example, authors should declare if they serve on the editorial board of the journal to which they are submitting or if they have acted as an expert witness in relevant legal proceedings. Reviewers should be expected to declare if they have held grants, co-authored papers, or worked in the same institution with the authors of the study they are reviewing.

Moreover, journal editors should be explicit in acknowledging their biases. If breastfeeding journals won’t accept papers that question the benefits of breastfeeding or papers that reveal risks of breastfeeding, they should publicly state that fact.

Policy:

Journals … they can develop clear and explicit policies that outline definitions of non-financial conflicts of interests and expectations for author, reviewer, and editorial behavior… Our policy states that no decision on papers submitted to PLoS journals will be made until the competing interests—financial, personal, and professional—of all authors are declared, and that we will publish all relevant positive and negative statements of competing interests. Reviewers are required to declare any interests that might interfere with their objective assessment of a manuscript, and these are considered by the editors in determining the suitability of the reviewer.

Research:

…The development and implementation of explicit policies on non-financial competing interests will clearly benefit from being based upon strong evidence of the extent, nature, and impact of private interests.

…Any assumption that non-financial competing interests are less common or influential than financial incentives is probably misguided.

The key point about non-financial conflicts of interest in breastfeeding research is this: Unless and until researchers, editors and reviewers acknowledge (to themselves and especially to the public) that their income, careers and even self-esteem may depend on confirming their personal belief that breastfeeding has major benefits, all research by breastfeeding professionals will be suspect.

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  • fiftyfifty1

    Yes, money is only the tip of the iceberg. Most doctors and researchers graduate near the top of their class. If money had been their main motivator, they could have gotten jobs in finance or business. Sure, doctors and academics can still be influenced by money, but I bet the non-money factors are even more influential. Factors like being respected, getting published, getting name recognition, getting tapped for leadership, being told you are helping people, being told you are saving people. Also getting out of the grind of seeing patient after patient, day after day, as a rank and file doctor.

    • mabelcruet

      If you wanted to be rich as a doctor in the UK, you go into dermatology or aesthetic surgery. Or go down the Andrew Wakefield route-falsify your research so it supports the single vaccine schedule system that you’ve got patents for, get struck off, make millions scaremongering and starring in dodgy films (about vaccines, not that other sort of dodgy film), start dating a supermodel.

      Can I have Robert Downey instead of the supermodel, please? Ta.

      • AnnaPDE

        RDJ doesn’t seem all that stupid, so maybe the scheme won’t work. Tim Carrey might be on the cards though?

  • mabelcruet

    Given that some lactivists have no compunction about lying or exaggerating about the benefits of breast feeding, I’m sure they’d have no ethical or moral worry lying about their vested interests, financial or otherwise. They’ll say that the end (exclusive breast feeding) justifies the means (lying, patronizing, bullying, gaslighting, and guilt-tripping of vulnerable and anxious mums)

  • rational thinker

    Lactivists seem to be one sided when it comes to this issue. If anything is said about formula even just saying that it is a healthy alternative to breastfeeding you are automatically accused of being a formula shill.

    Then when breastfeeding is pushed in the hospital by lactation consultants and you dare to speak out about being pressured sometimes to the point of mental breakdown they say “lactation workers are just trying to help you feed your baby how all mammals feed their babies, how dare you complain that you said no and they grabbed you anyway they are just doing their jobs”. A lot of people dont seem to realize that there is an industry that depends on women breastfeeding. Just because it comes out of your body does not mean it is free.

    • alongpursuit

      Being a mammal isn’t the only factor I had to consider when deciding how to feed my baby. That’s what I hate about the breast is best ideology – it completely ignores the context of infant feeding and the multiple factors that need to be managed.

      • Cartman36

        I think this happens within all age groups of child feeding. How many times have we heard people admonish parents (mostly mothers) for not providing home cooked, organic, nutritious meals for their children, or seen parents bragging online about the healthy bento boxes they prepare for their kids lunch and how it is “easy” if you just try, or call fast food or convenience / packaged foods poison. These things are said with no awareness of the multiple factors and challenges there are especially for poor mothers. I just finished the book Pressure Cooker: Why Home Cooking Won’t Solve Our Problems and What We Can Do About It. It interviewed a lot of poor mothers about food and was very eye opening to the very real challenges a lot of women face when it comes to preparing meals for their children.

        • rational thinker

          I would say most of the time getting Mcdonald’s for dinner after working all day was a lot cheaper than making a home cooked meal. Not to mention being worn out from working all day sometimes working ten days straight (with no overtime pay) it was a better option for my family. I did cook on my day off but that was only once a week. I find that most of the people who lecture others about what to feed your kids are usually stay at home mom”s that have time to to cook (and sit around judging others) and have a husband that brings in enough money to support the family.

          • Cartman36

            I like to use the phrase “born on 3rd base and think they hit a triple”. I see it in my fellow working moms too that don’t seem to have awareness of what life is like for moms that don’t have cushy middle class lives. parenting is hard enough when you are lucky like me to have lots of resources at your disposal. I can’t even imagine how hard it would be if I had to live with my 3 kids in a domestic violence shelter with no access to the family money, no job skills or professional resume, no health insurance, etc etc etc.

        • PeggySue

          Yes! Plus, if you have a fixed and limited amount of money to purchase food, you are likely to be sure that the children will eat what you purchase. You don’t have the luxury of cooking tons of fresh vegetables or experimenting with vegan cooking and then tossing the food if the children won’t eat it, and you who are moms know if they won’t eat it, they won’t eat it.