To the Editor:

Butterworth and Rathmell1correctly point out that not all groups are appropriately constituted or have “proper standing” to produce credible “consensus statements, guidelines, and parameters.” They state that “it seems obvious that small groups funded either directly or indirectly by pharmaceutical companies (even when the money has been “laundered” through a medical education company) lack standing....”

I have participated in committees of the American Society of Anesthesiologists (ASA) and other “appropriate medical societies” that have produced practice parameters and standards, as well as groups of highly qualified experts funded in the manner decried by Butterworth and Rathmell. It is possible for an expert panel, through a medical education company, to build a sufficient barrier from the funding agency to conduct their process without influence of a pharmaceutical company that may have provided an unrestricted educational grant.2“Appropriate” medical societies do not have a monopoly on exceptional knowledge, opinion, or judgment.

The implication, by the use of the term “money… laundering,” that an expert group convened by a medical education company is conducting an illicit or intentionally deceptive activity3is inappropriate and misguided. I assume that Butterworth and Rathmell are concerned about conflict of interest. Although that is an appropriate and important concern, we should recognize that, in one way or another, we all have such conflicts. Some may be directly financial; others may be more subtle, but nevertheless, of at least equal importance and impact.

The ASA, with the guidance of James F. Arens, M.D., has done a remarkable job and provided an extraordinary service in producing a number of such documents. The formal process of the ASA for expert-authored guidelines and parameters requires approval by the Society's House of Delegates.

However, the origins of this approval process were not necessarily altruistic and without fiscal motivation.4Interestingly, the ASA does not publish information regarding the conflicts of interest that may exist for their experts, consultants, and reviewers. Similarly, we do not know of the conflicts of the members of the House of Delegates who must approve each document—and notably, the House rejected one such document.5 

Such conflicts may not be trivial. For example, take the practice guidelines for pulmonary artery catheterization6,7and perioperative transesophageal echocardiography.8,9Do we know whether any of those involved (or members of their families) in the construction or approval of the guideline had a financial interest in any firm manufacturing or selling the catheters, probes, or devices required for their use? Do we know how many of these individuals billed separately for the procedures?

The ASA and some component societies have apparently voiced a negative opinion of proposals limiting the ability of physicians to bill separately for such services.10I do not mean to imply any dishonesty or impropriety of those involved; nor am I addressing the issue of billing per se , but rather I am noting the potential for the appearance of a conflict of interest.

Note, in contrast, the full disclosure of the authors of a recent recommendation regarding otitis media produced by an international group of experts whose meeting expenses were funded by an unrestricted educational grant from a pharmaceutical firm through a medical education company.2 

Aside from the issue of direct financial conflicts, other conflicts are possible. Does not a certain increased standing and respect among one's colleagues accrue from having participated in expert panels? May such participation not lead to other activities—such as lectures, visiting professorships, and so forth—all of which may add to one's status at an academic institution and assist with promotion possibilities along with the associated increase in standing and salary?

It is an unreasonable requirement to convene a panel of the best experts none of whom have conflicts of interest, as they likely will have been consulted by others because of their expertise. However, those expected to read and abide by conclusions and recommendations contained in the documents have the right to know of real and apparent conflicts.

I suggest that the ASA provide the readership with complete funding and disclosure information for expert-authored practice parameters, standards, guidelines, and recommendations, and that readers not automatically dismiss documents provided by appropriate experts when produced using a thorough and appropriate process.

University of California, San Francisco, San Francisco, California.


Butterworth JFI, Rathmell JP: Standard care, standards for care, or standard of care? Anesthesiology 2010; 112:277–8
Vergison A, Dagan R, Arguedas A, Bonhoeffer J, Cohen R, Dhooge I, Hoberman A, Liese J, Marchisio P, Palmu AA, Ray GT, Sanders EA, Simoes EA, Uhari M, van Eldere J, Pelton SI: Otitis media and its consequences: Beyond the earache. Lancet Infect Dis 2010; 10:195–203
The Random House Dictionary of The English Language, Unabridged. Second edition. Edited by Flexner SB. New York, NY, Random House, Inc., 1987:pp 1088Flexner SB
New York, NY
Random House, Inc
Arens JF: A practice parameters overview. Anesthesiology 1993; 78:229–30
Arens J: On behalf of the American Society of Anesthesiologists Committee on Practice Parameters. Anesthesiology 2003; 99:775–6
Practice guidelines for pulmonary artery catheterization: An updated report by the American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization. Anesthesiology 2003; 99:988–1014
Practice guidelines for pulmonary artery catheterization. A report by the American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization. Anesthesiology 1993; 78: 380–94
Practice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 2010; 112:1084–96
Practice guidelines for perioperative transesophageal echocardiography. A report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 1996; 84:986–1006
“Bundling” invasive lines: Anesthesiologists take on the payers, American Society of Anesthesiologists Newsletter, October 1999; vol 63, no 10