GENERAL ORTHOPAEDICS
Ethical standards for orthopaedic surgeons
M. Benson, N. Boehler, M. Szendroi, L. Zagra, J. Puget† From Nuffield Orthopaedic Centre, Oxford, United Kingdom
M. Benson, MB, FRCS, Emeritus Orthopaedic Surgeon, Chairman EFORT Ethics Committee Nuffield Orthopaedic Centre, Windmill Road, Oxford, OX3 7HE, UK. N. Boehler, MD, University Professor, Head of Orthopaedic Department Allgemeines Krankenhaus Linz, Abt. Orthopädie , Krankenhausstrasse 9, 4020 Linz, Austria. M. Szendroi, MD; PhD; Dsc, Professor Semmelweiss University, , Department of Orthopaedics, Budapest, H-1113, Hungary. L. Zagra, MD, Orthopaedic Surgeon IRCCS Orthopaedic Institute, Galeazzi, Milan, Italy. J. Puget†, MD, Professor Hôpital Rangueil, 1, Ave du Pr. Jean Poulhès, TSA 50032, 31059, Toulouse, Cedex 9, France. Correspondence should be sent to Mr M. Benson; e-mail: [email protected]. uk q ©2014 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.96B8. 34206 $2.00 Bone Joint J 2014;96-B:1130–2. Received 2 April 2014; Accepted 2 April 2014
1130
This paper offers a summary of the ethical guide for the European orthopaedic community; the full report will be published in the EFORT Journal. Cite this article: Bone Joint J 2014;96-B:1130–2.
In 2013, the European Federation of Orthopaedic and Trauma Societies (EFORT), decided that the perceived differences in ethical standards in orthopaedic practice across Europe should be reviewed. A committee was formed under the initial chairmanship of Professor J. Puget, to produce an ethical guide for the European orthopaedic community; the results of which were agreed by the Executive of EFORT and will be published in the EFORT Journal. They are summarised in this editorial. In its simplest terms, ethics is the science of human duty. There is a clear link between ethics and the law, but the former tends to concentrate on values and the latter on rights. Concerns for our patients’ welfare and the behaviour of those who treat them date back 4000 years to the Code of Hammurabi, and it is 25 centuries since Hippocrates is reputed to have exhorted us “to abstain from doing harm”. In 2005, an editorial in the The Journal of Bone & Joint Surgery British Volume (JBJS [Br]) noted that our patients and governments grant us privileges, but expect us to be guided by ethical principles.1 We set the standards for entry, assessment, training and certification and seek to ensure that these standards are maintained throughout a professional lifetime. In return, we are expected to treat our patients with skill, care and consideration. All practising surgeons should combine honesty and integrity with altruism. We need to maintain physical and mental health in order to practise efficiently and should strive to balance work, family and recreational pursuits appropriately. Professionally, we must work within the limits of our competence. We should consult and listen to colleagues’ advice when in doubt. We must keep up-to-date by attending relevant meetings and reading current research. We should regularly review our own practice by audit and keep accurate, complete
and legible records. We should offer effective treatment based on the best available evidence. When a cure is not possible, we must do all we can to alleviate pain and distress. We should avoid influence by bribery, status, and religious or ethnical considerations. In times of financial restraint, we know the problems caused when cost savings are achieved at the expense of patient care. Halligan noted: “The medical profession’s technical and scientific brilliance has not been matched by its leadership or compassion”.2 When we have doubts about the facilities available or the competence of a colleague we should be prepared, if simple discussion fails to resolve the issue, to pursue the matter to resolution. Our patients and their relatives should understand our commitment to maintaining confidentiality. They need to choose between treatments we offer, and we are responsible for explaining the options honestly, simply and clearly. The advice should be based both on the best-available evidence, and our own experience. The options offered should consider any limitations imposed by the resources available to us. Whenever possible, a simple procedure should be preferred to a complex one. When things go wrong, we must manage problems with compassion and understanding; patients need our support and must never feel abandoned. We should explain fully and promptly what has happened, the likely effects and how we intend to remedy matters. If a patient complains about our care, we must respond promptly, fully and honestly, and be prepared to apologise when appropriate. Every surgeon should recognise the limitations of his experience, skill and expertise, and be prepared to refer to a more experienced colleague when necessary. We must not promise excellent clinical results when the outcome is unpredictable. It is the duty of a more experienced doctor THE BONE & JOINT JOURNAL
ETHICAL STANDARDS FOR ORTHOPAEDIC SURGEONS
to support junior colleagues as a priority, and not to leave them unsupervised in managing cases with which they have little experience. Our patients should understand that we work in teams to achieve the best results. We must avoid unjustified criticism of a colleague in front of other colleagues, trainees or patients. We should support those who are the subject of unjust claims or blame. However, if concern is brought to our attention about a colleague’s performance, we are obliged to act. This may involve the inappropriate management of patients, inadequate standards of surgery or follow-up, health matters, unethical conduct and financial irregularity. When the concern is minor, it is wise to discuss matters with the surgeon before proceeding further. If, however, there are concerns for the safety of patients, the issue must be promptly brought to the attention of the medical director and hospital management. Informed consent is a mandatory part of clinical practice, especially when an operation is involved. Such consent has medico-legal implications, but also demands our ethical concern: it is not just a bureaucratic procedure where an operation is listed and a signature requested. Our responsibility is to ensure that the patient has enough information to make an appropriate judgement. The risks, alternatives, advantages and disadvantages of the proposed treatment must be discussed. The consent form should be witnessed by a surgeon who is fully conversant with the procedure and adequate time should be allowed for an explanation and questions. Potential conflicts of interest such as research, industry grants, financial or other rewards for the doctor or institution should be discussed. The decision to treat must not be based on financial reasons. In both privately and publicly funded systems, the decisions about the form of treatment that is offered should be based on need and not on finance. We should not advise expensive treatments or devices with no proven benefit to patients. Fees, when payable for private practice, should reflect the time, complexity, skill and experience of the surgeon. Patients should be aware that they will not be abandoned if they run out of money as a result of unforeseen complications. Doctors must not seek gifts or other personal advantage. As orthopaedic teachers and trainers, we must ensure that future surgeons develop the requisite knowledge and ethical standards needed to look after patients with skill and care. We must stress that patients’ interests come first. Our students, trainees and colleagues learn in part by the example that we set. We share medical knowledge and surgical techniques but must also ensure our trainees understand the importance of compassion, understanding and appropriate explanation in treating patients. Research is essential for progress. It should increase the understanding and management of disease and improve the outcome of treatment. Where possible, laboratory experiments are preferred to animal or human ones. The European Union directive of 1986 regarding the protection of animals in experimentation was updated in 20103 but there VOL. 96-B, No. 8, AUGUST 2014
1131
remains considerable variation in the manner member countries choose to exercise the directive. Anyone who conducts patient-related research should understand the ethical, institutional and government guidelines that guide behaviour. The Helsinki accord of 1975 promoted the concept of human rights, including the belief in individual freedom of thought, conscience and religion. Patients must be fully informed about the objectives, risks and potential benefits of the study. The patients should be informed if the investigator and his team stand to benefit individually or institutionally. Poor results should not be excluded for any reason. We all have a responsibility to report ethical misconduct in scientific research including plagiarism, deception, falsification and/or fabrication of data. Our relationships with industry and drug companies should be open and transparent. It is inevitable that conflicts of interest may arise when the ambition of the individual is in conflict with ethical obligation. Conflicts may also arise when personal, financial, medical and political goals interfere with our links both to the companies and to our patients’ best interests. Manufacturing and drug companies are aware of the pitfalls associated with inappropriate links with surgeons; for example, the Eucomed Code of Ethical Business Practice4 defines how the necessary close links should be forged. We must ensure that contracts remain honest, fair and open and prevent any action, which might not be in the best interests of our patients. Our dealings must always be seen to be ‘reasonable’. The financial support from industry for research, teaching programmes and conferences should follow wellplanned and documented agreements to which local, national and, where indicated, international medical committees, have agreed. Many surgeons are disconcerted by advertisements which promote the skills of one particular surgeon, institute or technique, but there are surprisingly few official restrictions. The American Medical Association’s ethical code on advertising and publicity notes simply that we should not deceive the public: a doctor “may publicize him or herself through any commercial publicity or other form of public communication.”5 Advertising is now inevitable: many believe that surgeons and institutions need to publicise their skills and expertise and claim that this is in the public interest as patients recognise that, if they are to make their own decisions about treatment, they need the ability to choose between the options available. In many countries, advertising is already widespread. It remains a matter of concern, however, that patients may be misled by persuasive selfpromotion. Those who do advertise should always be responsible and honest and refrain from claiming precedence over other individuals and organisations. We should remember that publicity can both benefit and harm careers. As orthopaedic surgeons, we should continue to treat our patients with honesty, compassion, skill and care in order to preserve the long tradition of respect and established trust our patients and colleagues place in us.
1132
M. BENSON, N. BOEHLER, M. SZENDROI, L. ZAGRA, J. PUGET†
It is with the greatest sadness that the authors recall that the contributions made to this ethical study by our first chairman, Professor J. Puget, were abruptly halted by his untimely death. We honour his enthusiasm, good humour and deeply held ethical beliefs. The world of orthopaedics is made poorer by his departure. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
3. No authors listed. European Directive 2010/63/EU revising Directive 86/609/EEC on the protection of animals used for scientific purposes http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2010:276:0033:0079:en:PDF (date last accessed 9 May 2014).
References
5. No authors listed. American Medical Association Council on Ethical and Judicial Affairs, Code of Medical Ethics: Advertising and Publicity. http://www.ama-assn.org/ ama/pub/physician-resources/medical-ethics/code-medical-ethics/ opinion502.page? (date last accessed 9 May 2014).
1. Benson MK, Bourne R, Hanley E Jr, et al. Ethics in orthopaedic surgery. J Bone Joint Surg [Br] 2005;87-B:1449–1451. 2. Halligan A. The Francis report: what you permit, you promote. J R Soc Med 2013;106:116–117.
4. No authors listed. Eucomed Code of Ethical Business Practice http:// www.eucomed.org/key-themes/ethics (2008) (date last accessed 9 May 2014).
THE BONE & JOINT JOURNAL
Ethical standards for orthopaedic surgeons
M. Benson, N. Boehler, M. Szendroi, L. Zagra, J. Puget† From Nuffield Orthopaedic Centre, Oxford, United Kingdom
M. Benson, MB, FRCS, Emeritus Orthopaedic Surgeon, Chairman EFORT Ethics Committee Nuffield Orthopaedic Centre, Windmill Road, Oxford, OX3 7HE, UK. N. Boehler, MD, University Professor, Head of Orthopaedic Department Allgemeines Krankenhaus Linz, Abt. Orthopädie , Krankenhausstrasse 9, 4020 Linz, Austria. M. Szendroi, MD; PhD; Dsc, Professor Semmelweiss University, , Department of Orthopaedics, Budapest, H-1113, Hungary. L. Zagra, MD, Orthopaedic Surgeon IRCCS Orthopaedic Institute, Galeazzi, Milan, Italy. J. Puget†, MD, Professor Hôpital Rangueil, 1, Ave du Pr. Jean Poulhès, TSA 50032, 31059, Toulouse, Cedex 9, France. Correspondence should be sent to Mr M. Benson; e-mail: [email protected]. uk q ©2014 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.96B8. 34206 $2.00 Bone Joint J 2014;96-B:1130–2. Received 2 April 2014; Accepted 2 April 2014
1130
This paper offers a summary of the ethical guide for the European orthopaedic community; the full report will be published in the EFORT Journal. Cite this article: Bone Joint J 2014;96-B:1130–2.
In 2013, the European Federation of Orthopaedic and Trauma Societies (EFORT), decided that the perceived differences in ethical standards in orthopaedic practice across Europe should be reviewed. A committee was formed under the initial chairmanship of Professor J. Puget, to produce an ethical guide for the European orthopaedic community; the results of which were agreed by the Executive of EFORT and will be published in the EFORT Journal. They are summarised in this editorial. In its simplest terms, ethics is the science of human duty. There is a clear link between ethics and the law, but the former tends to concentrate on values and the latter on rights. Concerns for our patients’ welfare and the behaviour of those who treat them date back 4000 years to the Code of Hammurabi, and it is 25 centuries since Hippocrates is reputed to have exhorted us “to abstain from doing harm”. In 2005, an editorial in the The Journal of Bone & Joint Surgery British Volume (JBJS [Br]) noted that our patients and governments grant us privileges, but expect us to be guided by ethical principles.1 We set the standards for entry, assessment, training and certification and seek to ensure that these standards are maintained throughout a professional lifetime. In return, we are expected to treat our patients with skill, care and consideration. All practising surgeons should combine honesty and integrity with altruism. We need to maintain physical and mental health in order to practise efficiently and should strive to balance work, family and recreational pursuits appropriately. Professionally, we must work within the limits of our competence. We should consult and listen to colleagues’ advice when in doubt. We must keep up-to-date by attending relevant meetings and reading current research. We should regularly review our own practice by audit and keep accurate, complete
and legible records. We should offer effective treatment based on the best available evidence. When a cure is not possible, we must do all we can to alleviate pain and distress. We should avoid influence by bribery, status, and religious or ethnical considerations. In times of financial restraint, we know the problems caused when cost savings are achieved at the expense of patient care. Halligan noted: “The medical profession’s technical and scientific brilliance has not been matched by its leadership or compassion”.2 When we have doubts about the facilities available or the competence of a colleague we should be prepared, if simple discussion fails to resolve the issue, to pursue the matter to resolution. Our patients and their relatives should understand our commitment to maintaining confidentiality. They need to choose between treatments we offer, and we are responsible for explaining the options honestly, simply and clearly. The advice should be based both on the best-available evidence, and our own experience. The options offered should consider any limitations imposed by the resources available to us. Whenever possible, a simple procedure should be preferred to a complex one. When things go wrong, we must manage problems with compassion and understanding; patients need our support and must never feel abandoned. We should explain fully and promptly what has happened, the likely effects and how we intend to remedy matters. If a patient complains about our care, we must respond promptly, fully and honestly, and be prepared to apologise when appropriate. Every surgeon should recognise the limitations of his experience, skill and expertise, and be prepared to refer to a more experienced colleague when necessary. We must not promise excellent clinical results when the outcome is unpredictable. It is the duty of a more experienced doctor THE BONE & JOINT JOURNAL
ETHICAL STANDARDS FOR ORTHOPAEDIC SURGEONS
to support junior colleagues as a priority, and not to leave them unsupervised in managing cases with which they have little experience. Our patients should understand that we work in teams to achieve the best results. We must avoid unjustified criticism of a colleague in front of other colleagues, trainees or patients. We should support those who are the subject of unjust claims or blame. However, if concern is brought to our attention about a colleague’s performance, we are obliged to act. This may involve the inappropriate management of patients, inadequate standards of surgery or follow-up, health matters, unethical conduct and financial irregularity. When the concern is minor, it is wise to discuss matters with the surgeon before proceeding further. If, however, there are concerns for the safety of patients, the issue must be promptly brought to the attention of the medical director and hospital management. Informed consent is a mandatory part of clinical practice, especially when an operation is involved. Such consent has medico-legal implications, but also demands our ethical concern: it is not just a bureaucratic procedure where an operation is listed and a signature requested. Our responsibility is to ensure that the patient has enough information to make an appropriate judgement. The risks, alternatives, advantages and disadvantages of the proposed treatment must be discussed. The consent form should be witnessed by a surgeon who is fully conversant with the procedure and adequate time should be allowed for an explanation and questions. Potential conflicts of interest such as research, industry grants, financial or other rewards for the doctor or institution should be discussed. The decision to treat must not be based on financial reasons. In both privately and publicly funded systems, the decisions about the form of treatment that is offered should be based on need and not on finance. We should not advise expensive treatments or devices with no proven benefit to patients. Fees, when payable for private practice, should reflect the time, complexity, skill and experience of the surgeon. Patients should be aware that they will not be abandoned if they run out of money as a result of unforeseen complications. Doctors must not seek gifts or other personal advantage. As orthopaedic teachers and trainers, we must ensure that future surgeons develop the requisite knowledge and ethical standards needed to look after patients with skill and care. We must stress that patients’ interests come first. Our students, trainees and colleagues learn in part by the example that we set. We share medical knowledge and surgical techniques but must also ensure our trainees understand the importance of compassion, understanding and appropriate explanation in treating patients. Research is essential for progress. It should increase the understanding and management of disease and improve the outcome of treatment. Where possible, laboratory experiments are preferred to animal or human ones. The European Union directive of 1986 regarding the protection of animals in experimentation was updated in 20103 but there VOL. 96-B, No. 8, AUGUST 2014
1131
remains considerable variation in the manner member countries choose to exercise the directive. Anyone who conducts patient-related research should understand the ethical, institutional and government guidelines that guide behaviour. The Helsinki accord of 1975 promoted the concept of human rights, including the belief in individual freedom of thought, conscience and religion. Patients must be fully informed about the objectives, risks and potential benefits of the study. The patients should be informed if the investigator and his team stand to benefit individually or institutionally. Poor results should not be excluded for any reason. We all have a responsibility to report ethical misconduct in scientific research including plagiarism, deception, falsification and/or fabrication of data. Our relationships with industry and drug companies should be open and transparent. It is inevitable that conflicts of interest may arise when the ambition of the individual is in conflict with ethical obligation. Conflicts may also arise when personal, financial, medical and political goals interfere with our links both to the companies and to our patients’ best interests. Manufacturing and drug companies are aware of the pitfalls associated with inappropriate links with surgeons; for example, the Eucomed Code of Ethical Business Practice4 defines how the necessary close links should be forged. We must ensure that contracts remain honest, fair and open and prevent any action, which might not be in the best interests of our patients. Our dealings must always be seen to be ‘reasonable’. The financial support from industry for research, teaching programmes and conferences should follow wellplanned and documented agreements to which local, national and, where indicated, international medical committees, have agreed. Many surgeons are disconcerted by advertisements which promote the skills of one particular surgeon, institute or technique, but there are surprisingly few official restrictions. The American Medical Association’s ethical code on advertising and publicity notes simply that we should not deceive the public: a doctor “may publicize him or herself through any commercial publicity or other form of public communication.”5 Advertising is now inevitable: many believe that surgeons and institutions need to publicise their skills and expertise and claim that this is in the public interest as patients recognise that, if they are to make their own decisions about treatment, they need the ability to choose between the options available. In many countries, advertising is already widespread. It remains a matter of concern, however, that patients may be misled by persuasive selfpromotion. Those who do advertise should always be responsible and honest and refrain from claiming precedence over other individuals and organisations. We should remember that publicity can both benefit and harm careers. As orthopaedic surgeons, we should continue to treat our patients with honesty, compassion, skill and care in order to preserve the long tradition of respect and established trust our patients and colleagues place in us.
1132
M. BENSON, N. BOEHLER, M. SZENDROI, L. ZAGRA, J. PUGET†
It is with the greatest sadness that the authors recall that the contributions made to this ethical study by our first chairman, Professor J. Puget, were abruptly halted by his untimely death. We honour his enthusiasm, good humour and deeply held ethical beliefs. The world of orthopaedics is made poorer by his departure. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
3. No authors listed. European Directive 2010/63/EU revising Directive 86/609/EEC on the protection of animals used for scientific purposes http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2010:276:0033:0079:en:PDF (date last accessed 9 May 2014).
References
5. No authors listed. American Medical Association Council on Ethical and Judicial Affairs, Code of Medical Ethics: Advertising and Publicity. http://www.ama-assn.org/ ama/pub/physician-resources/medical-ethics/code-medical-ethics/ opinion502.page? (date last accessed 9 May 2014).
1. Benson MK, Bourne R, Hanley E Jr, et al. Ethics in orthopaedic surgery. J Bone Joint Surg [Br] 2005;87-B:1449–1451. 2. Halligan A. The Francis report: what you permit, you promote. J R Soc Med 2013;106:116–117.
4. No authors listed. Eucomed Code of Ethical Business Practice http:// www.eucomed.org/key-themes/ethics (2008) (date last accessed 9 May 2014).
THE BONE & JOINT JOURNAL
