THE MODERATION EFFECT OF NARCISSISM ON POWER
AND THE ENGAGEMENT IN A CONFLICT OF INTEREST.
March 28
th2017
Christina Bernadette Ruhl
(s2367815)
Eendrachtskade 10 c1, 9726 CW Groningen
c.ruhl@student.rug.nl
Supervisor: Dr. Jennifer Jordan
Second evaluator: Dr. Tim Vriend
ABSTRACT
The current rise of pharmaceutical sponsorships have brought increasing attention to conflicts of interest (COI) in medicine. One crucial question concerns what factors lead people to engage in COIs. Therefore, I examine two of these potential factors, including power and narcissism. I make two conflicting hypotheses about the role of power in COIs – one is that power increases (H1a) and the other is that power decreases (H1b) the likelihood that one will engage in a COI. If H1a is supported, I also hypothesize that this relationship will be strengthened when individuals score high on narcissism. If H1b is supported, I also hypothesize that this relationship will be weakened when individuals score high on
narcissism. The hypotheses were tested running a laboratory study on students (Study 1) and an online scenario study on medical students (Study 2). H1b which predicted a negative relationship between power and COIs was supported in Study 1, showing that higher power decreased the likelihood of accepting a COI. No other hypotheses were supported. Still, two correlations were found that showed that men were generally more narcissistic than women and that former education on COIs decreased the likelihood of accepting the COI in the medical sample. These findings highlight the importance of influential variables, especially in the context of a medical setting, and improve the understanding of the influence power
position has on accepting or declining a COI. Practically, the findings emphasize the positive effects of educating about COIs.
THE MODERATION EFFECT OF NARCISSISM ON POWER AND THE ENGAGEMENT IN A CONFLICT OF INTEREST
Imagine that you are a resident physician. Although you graduated from medical school only one year ago, you work in a hospital in which you have a lot of power and influence; your colleagues seriously consider your opinion. During a 10-minute meeting with a drug rep, you and she start a conversation about your research. The drug rep expresses great interest in what you do, as it is closely tied to many of the areas of research that the drug rep’s employer is also interested in. The drug rep suggests that the pharmaceutical company for which she works would be willing to subsidize your research for the coming 2 years. The company asks for nothing explicit in return and just says that they find your research very impressive and would like to financially help you develop your program of research. How likely would you be to accept the research funding from the pharmaceutical company?
This can be a tough decision, especially since accepting the funding seems to have no negative consequences for you. But still, you have a lot of power and influence, so how might the decision affect you and others? Does your personality influence your decision? Or would you be more or less likely to accept the funding if you had very little power and influence? These and others questions are of interest to ethical researchers who explore the topic of conflicts of interest (COI).
One field in which COIs are especially important is the medical field, which was also the focus of the scenario above. For example, according to the consumer interest website, ProPublica (2013), in 2011, twelve pharmaceutical companies, including giants like Pfizer, Merck, GlaxoSmithKline, AstraZeneca, and Johnson and Johnson, reported making payments to doctors related to their associations with the companies. In addition, Engelberg, Parsons, and Tefft (2014) found that payments to doctors were associated with an increased
drugs has been examined, and the results suggest that pharmaceutical sponsorship reduces the likelihood of reporting unfavorable results and increases the chances of reporting that the drug is better compared to a placebo (Friedberg, Saffran, Stinson, Nelson, & Bennett, 1999; Perlis et al., 2014). To understand these effects, more research on COIs in the medical field is needed. Specifically, a crucial question is which factors lead doctors (as well as other people) to be more or less likely to engage in a COI? One factor that is important to examine is how the characteristics of the individual facing the conflict affects his or her likelihood of
accepting the conflict. While factors such as emotional intelligence (Deshpande & Joseph, 2008), empathy, and moral identity (Detert, Treviño, & Sweitzer, 2008) have been examined in previous research, one essential factor that has not been examined is how the power position of the decision maker affects his or her likelihood of accepting or rejecting the COI. There are convincing reasons to suggest that power indeed affects this relationship – although the directionality of the relationship is not entirely clear. In addition to investigating the connection between power and a COI, I also examine the moderating influence of the personality variable, narcissism, in this relationship. My proposed model is depicted below (Figure 1) and the hypotheses will be elaborated on in the next section.
Figure 1. Summary of the hypotheses.
In this section, I elaborate upon the relevant theoretical background of power, COI, and narcissism. I also discuss how these relationships are specifically relevant to the medical context.
Power
Research background. Definitions of power can vary but the general idea is usually the same: power is the capability of one individual to influence another individual. This capacity is acquired by the control of valuable resources or an ability to reward and punish (Anderson & Galinsky, 2006; Galinsky, Magee, Gruenfeld, Whitson, & Liljenquist, 2008; Keltner, Gruenfeld, & Anderson, 2003). The power obtained through controlling resources can be explained by power-dependence relations (Emerson, 1962). Specifically, the
importance of a resource and the degree to which it is obtainable somewhere else determine the power of the resource holder. So if a resource is important and not obtainable somewhere else the resource holder will have high power, compared to when the resource is unimportant or can be gotten from someone else. Therefore, individuals who are able to control important resources can use this power to influence others (Kipnis, 1972).
Nowadays, research on power is growing because of the vital importance of the topic. Especially in the workplace, higher power means more security and financial rewards
(Anderson & Brion, 2014). Previous research has shown that power influences different behaviors, such as taking action (Galinsky, Gruenfeld, & Magee, 2003), displaying anger (Tiedens, 2000), generosity (Chen, Lee-Chai, & Bargh, 2001), and risk-taking (Anderson & Galinsky, 2006). But research has also shown that it influences certain mindsets, for example, self-serving attributions (Kipnis, 1972), perspective taking (Galinsky, Magee, Inesi, &
Gruenfeld, 2006; Keltner et al., 2003), decision-making (Magee & Langner, 2008), moral awareness (DeCelles, DeRue, Margolis, & Ceranic, 2012), and stereotyping (Fiske, 1993).
Medical context. Power in medicine was often discussed using the concepts of
authority over others, while professional autonomy is the legitimate control a doctor has over the patient in terms of the medical profession. This conceptualization of power is certainly relevant to the issue of a COI in medicine, as it suggests that patients are willing to accept whatever recommendations their doctors suggest. However, this is more of an internal-external operationalization of power - that is, a view of the power differential between the doctor (internal) and the patient (external). Still, even within medical professionals, there are variations in the power that individuals possess (i.e., internal variations in power). Thus, in the current investigation, I am examining power within medical professionals – which is
consistent with the control and autonomy definition of power described above (Anderson & Galinsky, 2006; Emerson, 1962; Galinsky et al., 2008; Keltner et al., 2003).
Conflict of Interest (COI)
Research background. A COI is a situation in which one’s professional judgment is a risk of being biased due to interest (Thompson, 1993). Not all clashes between self-interest and the self-interests of the one to whom a professional is providing advice qualify as a COI. According to Carson (1994), the conflicting interests must in one way or another prevent the professional from following the normal duties related to his/her work or compromise his or her judgment. In addition, the mere motivation to stay objective is not enough to prevent a COI from occurring (Kunda, 1990). A COI can happen in any profession; however, for the purpose of my thesis, I will focus on the medical domain.
Institutions often try to counteract a COI with mandating disclosure (Sah &
Loewenstein, 2014). Here, individuals who might be influenced by a COI openly state that they may face a conflict.
Medical context. According to MacKenzie and Cronstein (2006, p. 198), COIs have become the “forefront of the discourse pertaining to professional ethics in medicine”.
This immensely increased the potential risks for a COI. Alexander, Humensky, Guerrero, Park, and Loewenstein (2010) reported that 56% of their physician sample admitted that they could be influenced by potential financial gain (i.e., COI) when making treatment decisions for their patients. Physicians engage in a COI for different reasons. MacKenzie and Cronstein (2006) mention a few potential influences, including the desire for recognition and promotion, the quest for knowledge, or the patient’s well-being. In any case, the increased public
awareness of medical COIs is affecting the trust in doctor-patient relationships. This skepticism can be evidenced in the development of governmental websites (e.g. the Open Payment Database), in which patients can check if their doctor receives any known payment from a pharmaceutical firm.
In the 1980s, the first formal steps were taken to address medical COIs (Rodwin, 1993), and in 1991 the American Medical Association declared that physicians have to engage in self-referral when there is a chance of a COI (Clarke et al., 1992). Self-referral means that a physician has to report him-/herself when he/she receives any financial compensation for the referral of patients to certain products, tests, or treatments. This disclosure of a COI has become more and more apparent, even though, according to
Thompson (1993), disclosure only reveals a problem but not a solution to it. For example, in medical research publications, the authors sometimes write an extra paragraph stating
specifically which author has a financial connection with a pharmaceutical company. However, research shows that disclosing a COI may lead professionals to give even more biased advice because they feel licensed to do so (Cain, Loewenstein, & Moore, 2005; Sah, Loewenstein, & Cain, 2013). But Sah and Lowenstein (2014) show that this effect only appears when the COI is unavoidable. When the COI is avoidable and certain policies are designed to increase disclosure, disclosure motivates advisors to try and avoid a COI because they do not want to be viewed as biased.
Given the research on power and our understanding of COIs, there are two competing ways to think about the relationship between these two variables.
On the one hand, Galinsky and colleagues (2006) show that power is associated with more difficulties to take others’ perspectives. In addition, Keltner and colleagues’ (2003) approach and inhibition model of power shows that high power is related to focusing attention on rewards instead of threats, experiencing more positive emotions instead of negative
emotions, using more automatic cognition instead of systematic/controlled cognition, and engaging in disinhibited, state/trait driven behavior instead of inhibited, situationally
constrained behavior. Therefore, their research shows that high-power individuals tend to act in ways that disregard conventions, morals, and the effects on others. Furthermore, Fiske (1993) has shown that powerful individuals are more likely to stereotype because they pay less attention to the powerless. This indicates that they are not likely to take the perspective of the powerless into account when making decisions as they are not paying much attention to them. In the context of a COI this highlights the focus of the powerful to make self-serving decisions and thereby makes them more likely to engage in a COI. Lastly, research by Galinsky, Magee, Gruenfeld, Whitson, and Liljenquist (2008) shows that power is not
their actions (Anderson & Galinsky, 2006). Therefore, it is plausible that power is positively correlated with accepting a COI.
Hypothesis 1a (H1a): Power is positively related to accepting a COI.
On the other hand, there is research demonstrating that the powerful often feel more responsibility for their positions and those whom they lead (Beatty, 1999; Hermann, Preston, Korany, & Shaw, 2001). Overbeck and Park (2001; 2006) showed that high powerholders in organizations felt a greater sense of responsibility than low powerholders. They argue that power fosters a desire to excel in given tasks and thereby gives a sense of responsibility in order to perform well. This indicates that power increases feelings of responsibility which can influence the engagement or disengagement in a COI. Specifically, Kalshoven, Den Hartog, and de Hoogh (2013) found that responsibility feelings in leaders can lead to ethical
leadership which is “the demonstration of normatively appropriate conduct” (Brown, Treviño, & Harrison, 2005, p. 120) and, therefore, to the disengagement in a COI.
Concerning the medical context, doctors are unquestionably mindful of their
responsibilities to their patients (e.g., they take an oath to uphold this responsibility) and their goals of keeping them healthy and safe. Patients want doctors that they can trust and doctors are legally obliged to keep their patients’ health confidential (i.e., medical confidentiality; Irvine, 1999). Engaging in a COI can put the well-being of patients at risk. Especially, when it concerns new pharmaceutical products that are not yet well tested longitudinally. Therefore, the goals of a doctor should be to keep their patients safe and healthy, and thereby benefitting others (i.e., patients). The research mentioned earlier indicates that high power individuals’ can ignore extrinsic distractions, like a COI, in goal achievement when the goal is to serve others (Kalshoven, Den Hartog, & de Hoogh, 2013). Therefore it is plausible that power is negatively correlated with accepting a COI, especially for medical practitioners.
Hypothesis 1b (H1b): Power is negatively related to accepting a COI.
Research background. Early research on narcissism focused on narcissism as a personality disorder. The DSM-V defines the narcissistic personality disorder (NPD) as impairment in personality functioning, including impairments of the self-functioning either in identity (e.g. exaggerated self-appraisal, excessive reference to others for self-esteem
regulation) or self-direction (e.g. goal setting according to the desire to gain approval from others, high standards to see oneself as exceptional), and the presence of pathological personality traits that include grandiosity (i.e. feelings of entitlement, self-centeredness) and attention seeking (American Psychiatric Association, 2012). A second direction evolved more recently. Here the attention is directed toward “normal” people who display some of the NPD characteristics but not enough to be diagnosed with NPD. This is the “non-clinical” form of narcissism on which the focus of my thesis lies.
Narcissism is increasingly more common in a normal sample (Twenge, Konrath, Foster, Campbell, & Bushman, 2008). Twenge et al. (2008) found that college students from 2006 were 30 percent more narcissistic compared to students from 1979. This corresponds well with previous studies suggesting that narcissism increases with generations because of the growing societal focus on individualism and away from collectivism (Fukuyama, 1999; Seligman, 1990; Twenge, 2006). Also, Foster, Campbell, and Twenge (2003) found a significant negative correlation between narcissism and age, presenting that younger people tend to be more narcissistic than older people.
extraversion (Bradlee & Emmons, 1992), social boldness (Emmons, 1984), high self-esteem (Campbell, 1999), and less social anxiety (Watson & Biderman, 1993). Thus, it appears that narcissism is a double-edged sword.
In the context of power and COIs the conceptualization of Brunell, Gentry, Campbell, Hoffman, Kuhnert, and Demarree (2008) is helpful. They conceptualize narcissism as
containing three basic characteristics: (1) positive and inflated self-view; (2) pervasive pattern of self-regulation that maintains the positive self-view, often at the expense of others; and (3) interpersonal relationships that lack warmth and intimacy. These characteristics would lead a narcissistic individual with high power to focus on a reward (i.e., accepting a COI), as he/she is mainly focused with his/her own interests independent of the interests of others.
Furthermore, Kajonius, Persson, and Jonason (2015) showed that individuals who have high power and score high on narcissism are less helpful to other individuals. This also indicates, that narcissistic individuals are more likely to accept a COI because they focus on their own benefits.
Medical context. The medical field is characterized by situations with great uncertainty and high stakes. Therefore, individuals working in these conditions need self-confidence and self-confidence in their decision-making. This is important as their decision can mean the life or death of a patient. When doctors make the wrong decision this can threaten their ego and question their confidence. Researchers have shown that this questioning can lead to an unstable self-esteem which can show itself in maladaptive behaviors that are aimed at bolstering or safeguarding the self-image (Bushman & Baumeister, 1998; Kernis, 2003). Specifically, Rhodewalt, Madrian, and Cheney (1998) have shown that an instability of self-esteem is correlated with narcissism. Therefore, because doctors are exposed to situations in which they have to make decisions that are characterized by great uncertainty and high stakes (life or death) they might be more likely to show narcissistic behaviors and be more
that physicians that score high on narcissism respond to self-esteem threatening situations with greater confidence in their decisions. Similar research has shown that narcissists are self-absorbed (Post, 1993) and have a tendency toward extreme self-confidence (Glad, 2002). They are contemptuous to others and their decisions are dominated by self-interest (Meissner, 1979).
When faced with a COI, these characteristics could lead individuals scoring high on narcissism to concentrate on themselves and engage in the COI in order to obtain the reward. Especially in situations involving power, these tendencies might get more extreme. For example, Glad (2002) showed that individuals with psychological characteristics that can be related to narcissism may engage more in self-focused behaviors when they have a high level of power. Therefore, I propose that if power shows a positive relationship with accepting a COI (i.e., H1a), narcissism would moderate this relationship, increasing the strength of the relationship.
Hypothesis 2a (H2a): The potential positive relationship between power and accepting a COI is stronger when narcissism is high rather than low.
Hypothesis 2b (H2b): The potential negative relationship between power and accepting a COI is weaker when narcissism is high rather than low.
To test these hypotheses, I ran one laboratory study (Study 1) and one scenario study (Study 2).
STUDY 1
I used Study 1 to test the relationship between power, COI, and narcissism in a general sample that has no medical background. The experiment was done in a laboratory with
students from the Faculty of Economics and Business at the Rijksuniversiteit Groningen in the Netherlands.
Methods
Participants. This experiment was conducted with 218 participants (131 male, 87 female), 158 were White/Caucasian, 25 were Asian, and the rest had different ethnic
backgrounds. The participants were between 17 and 33 years old (M = 21.08, SD = 2.78) and received either research points for their university courses or 8 Euros as a compensation for taking part in this study.
Data exclusions. Two attention checks were included in the survey, anyone who failed both was excluded from the final analyses. Also participants who had a suspicious response pattern (e.g. by always clicking on the same bubble) were excluded. In addition, this study was part of a larger study including experimental conditions that were not related to the current hypotheses. Therefore, participants who were in conditions unrelated to this project were not taken into account in the analysis. After implementing these adjustments the analysis was done with a sample of 136 participants.
they were asked what they thought this study was about and to indicate their demographics. Before leaving they were debriefed about the actual content of this study and asked not to disclose any information about this study to their peers.
Measures
Independent variable: power. The power perspectives of the participants were
manipulated by making their evaluation of the other student´s essay count differently into the grading. Participants in the high-power condition were told that their evaluation accounts for 85% of the final mark. Participants in the low-power condition were told that the lecturer will decide on the final mark of the student but that he or she will consider the participants
evaluation and eventually integrate it into the mark. Therefore, participants in the high power condition had more power because they had a high influence on the mark for the essay. This made them powerful because they were able to control a valuable resource (i.e., mark). Participants in the low-power condition had less power because they had not much influence on the mark for the essay. This made them powerless because they were not able to control a valuable resource (i.e., mark).
Moderator: narcissism. To measure narcissism, I used the NPI 15 by Schütz, Marcus,
and Sellin (2004). It is a shortened version of the NPI by Raskin and Terry (1988). The scale is a forced-choice response scale and asks participants to choose the statement that is closer to their own feelings and beliefs. Examples of statement choices are “I have a natural talent for influencing people.” versus “I am not good at influencing people.” or “I want to amount to something in the eyes of the world.” versus “I just want to be reasonably happy.”, where the first statements indicate narcissism (for the full scale see Appendix B).
Dependent variable: COI. The COI was induced by the “other student” who asked
the participant agreed to receive the relatives’ data by saying “Yes” it was counted as
accepting the COI. If the participant refused the relatives data by saying “No” it was counted as rejecting the COI.
Data analysis. To analyze the data I used the SPSS Computer Software for Statistics. Results were taken as significant if they had a p-value lower as or equal to 0.05. A logistic regression was performed to test the hypotheses. To estimate scale reliability, I used Cronbach´s alpha.
Results
To test for the relationship between power and engagement in a COI (H1a and H1b) and the moderation effect of narcissism (H2a and H2b) I ran a logistic regression. In order to run the analysis I contrast-coded the power conditions. Specifically, I coded the high-power condition as 1 and the low-power condition as -1. Furthermore, I standardized the narcissism scores.
Preliminary analysis. Before testing the hypotheses, I calculated Cronbach´s alpha for the Narcissism scale, and the means, standard deviations, and correlations for all other variables (see Table 1). In addition to the focal independent variables, I included gender and age as control variables. Gender was coded as 1 indicating female and 2 indicating male. I was not able to find correlations between power, COI, and age. Still, I found that gender was positively correlated with narcissism (r = .18, p < .05), indicating that males were more likely to score high on narcissism.
To test the hypotheses1, I, first, checked if power is related to the acceptance of a COI, this relates to H1a (i.e. power is positively related to accepting a COI) and H1b (i.e. power is negatively related to accepting a COI). The main effect of power on accepting a COI was statistically significant (B = -.46, SE = .21 p = .03), indicating that power is negatively related to accepting a COI (H1b).
Second, I also checked if narcissism moderates this negative relationship between power and the acceptance or decline of a COI. This relates to H2b (i.e. the potential negative relationship between power and accepting a COI is weaker when narcissism is high rather than low; it was not logical to test H2a, as I found a negative effect of power on accepting the COI [H1b]). The two-way interaction between power and narcissism for accepting the COI was not statistically significant (B = -.04, SE = .06, p = .50), indicating that narcissism does not moderate the negative relationship between power and accepting a COI.
Discussion
This study showed that power was significantly related to declining a COI. Therefore, H1b can be supported - suggesting that power can lead people to act ethically. Unfortunately, no support for H2b was found, as narcissism did not significantly moderate the negative relationship between power and accepting a COI.
One interesting side finding in this study was that gender and narcissism were correlated. Even though narcissism is originally assumed to describe both female and male individuals likewise (Philipson, 1985), an increasing number of studies has shown that males are more narcissistic than women (e.g., Bushman & Baumeister, 1999; Foster, Campbell, & Twenge, 2003). This study adds to these studies by also showing a gender effect on
narcissism.
1 To ensure that the implicit or explicit condition did not influence the results, a linear regression with a
To conclude, by showing that power has a negative relationship with COIs, this study is able to contribute to the literature focusing on the positive social effects that power can have on individuals (e.g., Beatty, 1999; Overbeck & Park, 2001; Kalshoven et al., 2013).
STUDY 2
Study 2 was used to test the relationship between power, COI, and narcissism in a more applied sample, namely with medical school students. As shown in the theoretical review, the variables used in this research have a special stance for medical practitioners (e.g., COIs very important as of pharmaceutical share), therefore individuals in this field might be different (e.g., more narcissistic) and react differently (e.g., more COI decline) than a general sample. In addition, medical students might receive more specialized education on COIs because of the importance of the topic in this field. This might make them more sensitive toward a COI and lead to different results. To see if this is the case and what differences exist between a general and a medical sample, Study 2 was conducted. This online survey used two scenarios that were developed in collaboration with personnel from the medical faculty
(UMCG) of the Rijksuniversiteit Groningen in the Netherlands. The study was then implemented via Qualtrics and distributed to medical students in the US.
Methods
Participants and design. I conducted this scenario study with 525 medical students (445 female, 77 male, 3 other) from the US. The participants were between 18 and 51 years old (M = 22.68, SD = 4.44) and were given $13.50 (12.58 Euro) for their time. Recruitment was done through a Qualtrics panel.
education, while the rest were in the medical (MD) phase of their education. Specifically, 129 were in their first year of study, 134 in their second, 144 in their third, 105 in their fourth, and 13 in another year. Around half of the participants (53.5%) had received formal education on COIs in medicine before and 58.7% perceived received an informal education on COIs in medicine before.
Participants were randomly assigned to one of four cells in a 2 (power: high/low) x 2 (scenario: research/symposium) between-subjects design. As in Study 1, I also measured individual differences in trait narcissism (Schütz, et al., 2004).
Procedure. The survey was available through the online platform, Qualtrics. The link to this survey was shared through a Qualtrics panel with the medical students who were eligible to participate. I told the participants that this survey was about decision-making. After indicating their current level of study, I instructed participants that they will have to imagine a certain scenario and react as if they were in this situation. Next participants read the scenario, in which the power role and scenario manipulation was embedded. I included two different scenarios so that diverse and realistic clinical contexts could be anticipated. Afterwards, I asked the participants to indicate on a 7-point Likert scale how likely they were to engage in the COI. Next, I measured individual differences in trait narcissism (Schütz, et al., 2004). Then, I included a manipulation check, followed by suspicion probe. Lastly, participants indicated their demographics.
Measures.
Independent variable: power. I manipulated participants´ power roles by asking them
to imagine themselves in one of two scenarios (one of the scenarios was also used in the introduction of this thesis). In both scenarios participants were resident doctors (a
colleagues did not consider their opinion very much when making decisions. The explanation of the different scenarios is directly related to the definition of power. Specifically, power is the capability of one individual to influence another individual. In both conditions the participant has either a lot or hardly any influence on the colleagues, and thereby is powerful or powerless.
Independent variable: scenario. I created the scenarios with the help from the medical
school personnel at the University of Groningen, so that they reflected realistic COI situations in medicine. We created two scenarios, which participants were randomly assigned to. In Scenario 1, the participants had a meeting with a drug rep who was very interested in the participant´s research and offered that the pharmaceutical company subsidizes the research for the coming two years. In Scenario 2, participants were told to imagine that they wanted to organize a very expensive symposium for top scholars and clinicians. But the institution of the participant was only able to finance a small percentage of the costs, so a well-known
pharmaceutical company offered to subsidize the remainder of the costs.
Dependent variable: COI. I measured participants’ engagement in a COI by asking
them on a 7-point Likert scale ranging from very unlikely (1) to very likely (7) how likely they are to accept the offer of the pharmaceutical company.
Moderator: narcissism. As in Study 1, I used the NPI-15 by Schütz and colleagues
(2004) to measure narcissism.
Data analysis. To analyze the data and test the hypotheses I used a linear regression to regress acceptance of the COI on power, scenario, narcissism, and their 2- and 3-way
interactions. Results
Preliminary analysis. Before testing the hypotheses, I calculated Cronbach´s alpha for the narcissism scale, and the means, standard deviations, and correlations for all other variables (see Table 3). In addition to the focal independent variables, I included gender, age, and level of study as control variables. Gender was coded as 1 indicating female and 2 indicating male. I was not able to find correlations between power, scenarios, acceptance of the COI, narcissism, and age. Still, gender was positively correlated with narcissism (r = .08,
p < .05), such that males were more likely to score high on narcissism, and level of study was
negatively correlated with acceptance of the COI (r = -.13, p < .01), such that the higher the level of study the less likely participants were to accept the COI.
Hypotheses testing. One participant did not provide all data on the variables of interest, therefore I performed the linear regression analysis with 524 participants instead of 525. All b´s, standard errors, t-values, 𝑅2´s, and F´s for the analysis can be found in Table 4.
H1a stated that power was positively related to accepting a COI and H1b stated that power was negatively related to accepting a COI. Unexpectedly, neither H1a nor H1b were supported, as there was no main effect between power and acceptance of a COI (b = -.07, SE = .06, t(521) = -1.24, p = .21). H2a and H2b stated that the potential positive (H2a) or
negative (H2b) relationship between power and accepting a COI was stronger (H2a) or weaker (H2b) when narcissism was high rather than low. Unfortunately, narcissism did not moderate the main effect of power on acceptance of the COI (b = -.04, SE = .06, t(521) = -.66, p = .51) as proposed by these Hypotheses. Furthermore, I did not find any significant two- or three-way interactions, as can be seen in Table 4. Therefore, none of the hypotheses can be supported.
Discussion
COIs. Still, as in Study 1 gender and narcissism were significantly correlated, which
constitutes the studies showing that males are more narcissistic than women (e.g., Bushman & Baumeister, 1999).
Another interesting side finding in this study was that the level of study was negatively correlated with COI. This means that the higher medical students are in their education the less likely they are to accept the COI. This is good news for medical scholars, as it indicates that education on COIs in medicine is helpful. Therefore, teaching medical
students about COIs and their effects seems to be a useful tool and can influence the student’s decision-making in situations containing a COI.
To conclude, even though no significant results were found that indicate a relationship between power and COIs, some interesting side findings emerged that can contribute to practice by showing the influence of education on declining a COI.
GENERAL DISCUSSION
With the increasing importance of power and the rise of pharmaceutical sponsorship it is important to recognize how power affects the engagement in a COI. In the current study, my goal was to increase the understanding of how power influences the engagement in a COI, and if narcissism has a moderating impact on the potential relationship between power and COIs. In addition, I tried to put a specific focus on these variables in the healthcare context. Specifically, I examined with one general and one medical sample whether power is a positive or negative predictor of accepting a COI and if narcissism facilitates the potential positive relationship between power and accepting a COI. I only found a negative main effect (support for H1b) in Study 1.
2010), I was not able to find this effect in either of the two studies. In contrast, having more power was related to declining a COI - but only in Study 1. This finding dovetails with the findings from former research that demonstrated increasing responsibility feelings (Hermann, et al, 2001) and ignorance of extrinsic distractions, like COIs, in goal achievement (Guinote, 2007) for high power individuals. The findings of Study 1 thus demonstrated that having high power did not lead to self-serving decision-making (i.e., accepting the COI) – rather, it led to ethical decision-making (i.e., declining the COI). Still, no such effect was found in Study 2.
One explanation for the inconsistency of results could be the public interest in COIs in medicine. Big pharmaceutical sponsoring scandals, like the one with Merck and their pain killer, Vioxx in 2004, have made it into the media and hospitals. Therefore, universities, have started to offer education on COIs so that these scandals do not repeat themselves. As
mentioned before, in Study 2 around half of the participants have received formal education on COIs in medicine. In addition, nearly 60% received an informal education on COIs in medicine. None such education questions were asked in Study 1, but it can be assumed that they had less education on COIs as they were from differing fields were COIs might not yet be as apparent and attended to as in the medical field.. Therefore, the participants of Study 2 might have had more knowledge about COIs than the participants of Study 1. This could have influenced their choice to accept or reject the COI.
Another explanation for the findings could be that not actual power but felt power predicts COI engagement. Both studies were conducted giving participants actual power, but maybe that does not have as much influence as felt power. A person can have power but does feel powerless or a person cannot have power but feel powerful. Researchers have shown that by priming individuals with power their reaction can change. For example, Van Loo and Rydell (2012) found that perceived power moderated stereotype threat-based math test
influences in quite different contexts and therefore it also likely that it had an influence in this research. Feeling powerful was not measured in either of the studies, but maybe this is a possible direction for future research.
A more theoretical explanation can also be offered with a paper by Rus, Knippenberg, and Wisse (2010). They found in their study that the behavior of leaders (i.e., self-serving vs. group-serving) is not necessarily determined by the power of an individual but by the extent to which internal beliefs influence these behaviors. This fits with the idea of Chen, Lee-Chain, and Bargh (2001), who showed that mental relationship orientation can influence social-responsibility or self-serving behavior in high power situations. Specifically, high power individuals that associated power with a communal relationship orientation responded in social-responsible ways, whereas high power individuals that associated power with an exchange relationship orientation responded in self-serving ways. Therefore, accepting or declining the COI can also be attributed to the situation and the mental beliefs the students had about the situations. In Study 1 the COI happened in an educational context were fairness in grading is seen as a norm. The mental belief of fairness in an educational setting can
influence the decision of the participant to decline the COI. In Study 2, the COI happened in a less clear context, even though accepting COIs in medicine is generally seen as wrong,
accepting or declining the COI was not unfair in either of the scenarios. This could have influenced the decision-making and explain why I was not able to find any significant result for accepting or declining the COI in Study 2.
narcissistic characteristics engage more in self-focused behaviors especially in high-power situations (Glad, 2002), was not supported.
In sum, only one finding did dovetail with prior studies indicating that power is negatively related to accepting a COI. The remainder of the findings was not able to confirm prior studies on the influence of power and acceptance of a COI, and the influence of
narcissism on the relationship between power and acceptance of a COI. In addition, I was not able to find support for any of the hypotheses in the healthcare context (i.e., Study 2). Still, this study was able to extend the research on this matter. The mixed results between the two samples indicate that medical students have a different connection and viewpoint to a COI than students from other professions. Therefore, they might not easily accept or decline them, independent of power position. In addition, the finding that narcissism did not moderate the relationship between power and accepting a COI, even though former studies indicated a possible connection, shows that the influence may be more sophisticated.
Limitations and Future Directions
To better understand the findings of the present studies and give directions for future research, I will elaborate on the limitations. A first limitation is the forced-choice format of the narcissism scale. Participants denoted that they had problems deciding on one of the two options because neither of them fit. This can influence the narcissism score by making
individuals either more or less narcissistic than they really are. An alternative narcissism scale that does not rely on forced-choice or a situational-judgment scale that focuses on specific situations could yield better results.
A second limitation is the use of quite different designs in both studies. Study 1 was an experimental study and the COI was assessed by grading another student, while Study 2 was a scenario study were the COI was assessed by accepting or declining a funding. These are quite different dependent variables in different contexts and are therefore not really
then compare the samples. This could yield more conforming results between studies. A related limitation, is the difference in length and compensation. Study 1 was part of larger study that took participants 60 minutes to complete; Study 2 was not part of a larger study and took only 15 minutes. In addition, participants in Study 1 earned 8 Euros for participation or research points for university courses, participants in Study 2 earned 12.58 Euros for
participation. Therefore, participants may have been differently motivated and concentrated. If participants are not paying enough attention this can falsify their results. Therefore, future research could take this into account when setting up the research.
In connection to the relationship between power and acceptance of a COI, future research could tap into other moderator variables besides narcissism to understand why only Study 1 was able to yield some significant results. Possible moderators could be the situation and internal beliefs as proposed by Rus and colleagues (2010). In addition, more research on narcissism in healthcare and its specific connection and influence on power and COI can also be a direction for future research. Specifically, narcissism could be an antecedent of power as shown by studies on leadership in organizations (e.g., Brunell, Gentry, Campbell, Hoffman, Kuhnert, & DeMarree, 2008). These studies argue that narcissism is about acquiring and maintaining power with little concern for the well-being of others. Thereby, narcissists are more likely to obtain high power positions but also have the potential to bring a host of problems to their organization because of their narcissistic characteristics. This idea is especially interesting in healthcare because the well-being of others (i.e., patients) is one of the main concerns for the individuals working there.
Managerial Implications
The present findings also have some managerial implications. Managers are in high power positions and often make decisions which influence the outcomes of their employees and the firm. Power in this kind of contexts was often depicted as something bad. For
evaluations negatively. Specifically, as the power of evaluators increased, performance ratings of others got increasingly negative. In addition, research by Lammers, Stapel, and Galinsky (2010) demonstrated that power increases hypocrisy. In contrast, this research shows that power can influence individuals in a positive way. Managers are increasingly facing COIs, for example in the context of stockholdings (Byrd, Parrino, & Pritsch, 2015). Therefore, correct reactions to these are of high importance for firm performance. I was able to show that power decreased the engagement in a COI in a general sample. This finding implies that high power managers could be more likely to make an ethical correct decision in comparison to low power individuals, even though COIs only recently started to gain attention in this context. Organizations can use this knowledge and try to enhance ethical behavior (i.e., lower the acceptance of a COI) by educating managers about COIs. Knowing how to detect a COI and how to react to one can help in responding ethically correct.
Education and disclosure was already implemented in the medical sector years ago and has been shown to be helpful (Kojima, 2016). Also, in this research, the medical students in Study 2 received more education on COIs which influenced their choice in rejecting or accepting the COI and might have led to the non-significant findings. Therefore, a similar strategy than the one used in the medical field can be used for the business sector to enhance ethical behavior. Specifically, organizations can offer workshops on COIs that focus on the specific context they have in companies (e.g., stockholdings). In addition, universities can offer courses for business students to educate them about COIs even long before they rise to managerial positions. This can increase their awareness early on and help them in detect COIs and react to them in the future.
Conclusion
With the present findings I am able to contribute to the literature by highlighting the mixed effects of power on COIs. There is not yet a full understanding of how power
(Hermann, et al., 2001), while others argue that it has negative effects by decreasing the attention paid to others (Galinsky, et al., 2006). By showing that power had, indeed, a negative effect, as significantly more high power compared to low power individuals did not accept the COI in one of the samples, this research was able to add to the unravelling of this relationship. In addition, the finding that there was no significant relationship between power and COIs in the other sample shows that the relationship might be more complex in the healthcare sector.
To conclude, in this investigation, I showed that power is related to rejecting a COI in one of my samples. I was not able to find any support for an influence of narcissism on the relationship between power and a COI, which does not fit with former studies suggesting that there is some kind of connection. My findings add to the literature by highlighting the
importance of possible influential variables, especially in the healthcare sector, by improving the understanding of power on engagement in a COI, and by emphasizing the positive
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Table 1
Cronbach´s Alpha (α), Means (M), Standard Deviations (SD), and Bivariate Correlations of the Variables of Study 1
Variables α M SD 1 2 3 4 1. Power -0.03 1.00 2. COI -0.01 1.00 -.01 3. Narcissism .78 7.09 3.52 -.13 -.03 4. Age 21.02 2.89 .005 .08 -.05 5. Gender 1.63 0.48 -.05 -.04 .18* -.01
Notes. N = 136; Gender: 1 = female, 2 = male; Power: -1 = low power, 1 = high power; *p <
Table 2
Regression Results for Predicting Acceptance of COI - Study 1
Notes. N = 136; Power: -1 = low power, 1 = high power; *p < .05; **p < .01.
Table 3
Cronbach´s Alpha (α), Means (M), Standard Deviations (SD), and Bivariate Correlations of the Variables of Study 2
Variables α M SD 1 2 3 4 5 6 1. Power -0.01 1.00 2. COI 4.78 1.46 -.05 3. Scenario 0.34 0.33 .04 .00 4. Narcissism .72 21.16 3.23 .03 -.04 .01 5. Gender 1.16 0.38 -.07 .04 .02 .08* 6. Age 22.66 4.45 .00 -.01 .04 .02 .06 7. Level of study 1.13 0.33 -.07 -.13** -.04 .00 .01 .07
Notes. N = 525; Gender: 1 = female, 2 = male; Power: -1 = low power, 1 = high power; Scenario: -1 = Scenario 2, 1 = Scenario 1; *p < .05; **p <
Table 4
Regression Results for Predicting Acceptance of COI - Study 2
Notes. N = 524; Power: -1 = low power, 1 = high power; Scenario: -1 = Scenario 2, 1 = Scenario 1; **p < .01, P = power, S = Scenario, N =
Narcissism (which was mean centered before entering it into the model)
Model 1 Model 2 Model 3
Appendix A
The printed chat instructions participants received during the laboratory study.
Chat instructions
Please, wait till the other student initiates the conversation. The other students is instructed to not video call you, but only chatting with you.
Before leaving the chat, please be sure that the other student has done communicating with you.
When the chat is over, please, leave the cubicle and let the experimenter now.
Standardized Interview
The aim of this conversation is for you to gather information on the three areas (numbered “1 – 3”) below. You should ask the student these three questions directly, preferably in the format and order stated below, since structured interviews result in better and fairer outcomes than non-structured interviews.
1. How useful were the lectures in helping you successfully complete the essay? 2. What do you think are the strengths of your essay?
3. What do you think you could have done better in this essay?
This document is just for you to be reminded about what questions you need to ask during the standardized interview. The researcher will not collect this sheet, and neither the student nor the lecturer will get your notes.
You have 5 minutes for the interview.
You may use the blank space below to make notes.
Appendix B
The NPI 15 scale by Schütz, Marcus, and Sellin (2004) used to measure Narcissism. Please read each pair of statements and then choose the one that is closer to your own feelings and beliefs. Indicate your answer by circling the letter "A" or "B" to the left of each item. Please do not skip any items.
1. A: I have a natural talent for influencing people.
B: I am not good at influencing people.
2. A: When people compliment me I sometimes get embarrassed.
B: I know that I am good because everybody keeps telling me so.
3. A: I prefer to blend in with the crowd.
B: I like to be the center of attention.
4. A: I am no better or no worse than most people.
B: I think I am a special person.
5. A: I am not sure if I would make a good leader.
B: I see myself as a good leader.
6. A: I like having authority over people.
B: I don't mind following orders.
7. A: I find it easy to manipulate people.
B: I don't like it when I find myself manipulating people.
B: I want to amount to something in the eyes of the world.
9. A: I have a strong will to power.
B: Power for its own sake doesn't interest me.
10. A: I really like to be the center of attention.
B: It makes me uncomfortable to be the center of attention.
11. A: Being an authority doesn't mean that much to me.
B: People always seem to recognize my authority.
12. A: I would prefer to be a leader.
B: It makes little difference to me whether I am a leader or not.
13. A: I am going to be a great person.
B: I hope I am going to be successful.
14. A: I am a born leader.
B: Leadership is a quality that takes a long time to develop.
15. A: I am much like everybody else.
