Ethics in orthopaedic surgery.

©2005 British Editorial Society of Bone and Joint Surgery doi:10.1302/0301-620X.87B11. 16936 $2.00 J Bone Joint Surg [Br] 2005;87-B:1449-51. Medicine, law and religion are the three traditional learned professions. With professionalism should come both privilege and responsibility. As surgeons we study to achieve specialised knowledge and supplement this with training and experience. Our patients and our Governments grant us certain privileges, but expect us to be guided by ethical principles. We set the standards for entry, assessment, training and certification into our specialty and seek to ensure these standards are maintained throughout a professional lifetime. Our patients allow us the right, after careful explanation, to perform operations upon them which cannot be free of potential complications. Our responsibilities commit us to develop and maintain our skills, to further medical knowledge and to train the next generation of surgeons. We are expected to show altruism and to remember that care for our patients should take preference over personal gain, whether this be financial, social or professional. It is inevitable that conflicts of interest arise when the aspiration of the individual is in conflict with obligation. Such conflicts may stem from methods of payment, our links with the pharmaceutical and manufacturing industries, our ambitions in both medical and political spheres and our impulse to perform unnecessarily an operation which we do well. Relman 1 in 1984 noted in The New England Journal of Medicine that authors must disclose their financial connections with industry. In 1990 he updated that Journal’s policy 2 which prohibited editors and authors of review articles from having any financial connection with a company that could benefit from a drug or device discussed in the article. Most scientific publishers have followed this example. The Executive of the Pharmaceutical Research and Manufacturers of America (PhRMA) adopted a new code 3 in 2002 to govern the relationship of the pharmaceutical industry with physicians. This stated “that all interactions should be focussed on informing healthcare professionals about products, providing scientific and educational information, and supporting research and education”. 3 The code advises: “Nothing should be offered or provided in a manner or on conditions that would interfere with the independence of a healthcare professional’s prescribing practices”. 3 It adds that nominal consulting or advisory arrangements do not justify compensating healthcare professionals for their time or their travel, lodging or other out-of pocket expenses”. The code allows that “modest” meals, but not entertainment or recreational activities, may accompany informational presentations by companies. Financial support of scientific and educational conferences should go to the conference organisation and not to an attendee directly. Recompense for expenses should be payable only to the Faculty. It is entirely reasonable for companies to sponsor scholarships and fellowships, but the selection process should be in the hands of the academic or training institution. Fundamental to the code is the understanding that no reward should be offered to an individual in return for a commitment to the prescribing of a particular product. Many countries with major pharmaceutical sectors have similar national codes. Medicines Australia 4 has clarified company relationships with the medical profession. The Association of the British Pharmaceutical Industry 5 has a clinical trial agreement for sponsored research in National Health Service Trusts. For countries without national codes, two international guidelines may apply: the World Health Organisation’s Criteria for medicinal drug promotion 6 and the Code of pharmaceutical marketing practice from the International Federation of Pharmaceutical Manufacturers Associations. 7