Conflict of interest (COI) is poorly defined and managed, leaving the level of harm and loss of trust that might ensue unknown. Importantly, COI lies at the intersection between professional duties and economic imperatives, providing an incentive not to manage it. Since the Institute of Medicine review of the issue in 2009, very little progress has been made in resolving definitional and judgment standards. Illustrative cases are widely available, depicting value discrepancies, apparently without distress to those involved. Progress at the global level is meager, even after clear evidence of harm from the commercial determinants of health. Because economic incentives are deeply embedded in healthcare, reforming the current landscape will involve significant pushback. Positive moves forward might include defining fair academic/commercial partnerships. But the most important takeaway is that focusing on individual COI is insufficient; attending to structural COI (conflicting values between sectors of institutions) is necessary.