Andrew Stark sees intractable polarization in the conflicts of interest debates in biomedicine and wants to move them forward by clarifying one of the underlying causes. The key to his argument is a distinction between internal versus external conflicts of interest. Stark's thesis is immensely useful, even if some of his empirical assumptions are somewhat questionable. But to focus on these details would be to miss the meat of Stark's argument. Rather, I want to burrow deeper into the internal/external distinction. The two goals of this commentary will therefore be to, first, briefly clarify the distinction between internal and external conflicts, and two, draw out in broad strokes its key implications.

In what follows, the reader can assume that the main set of conflicts of interest that I am referring to are those that arise for academic physicians, in the realm of creation and dissemination of clinical knowledge. In my view, the academic physician clearly sits on the moral fulcrum of this debate.

INTERNAL AND EXTERNAL CONFLICTS OF INTEREST

Although the distinction between internal and external conflicts of interest has intuitive appeal, Stark's discussion of it can sometimes be confusing. An uncharitable reader might argue that the “blurring” of the internal/external distinction that Stark sees in medical conflicts of interest may actually be due to an instability in his description (rather than in the relatively unique features of the medical profession). Because this is the central idea of his essay, it deserves some attention.