Johnson and Rogers BMC Medical Ethics 2014, 15:63 http://www.biomedcentral.com/1472-6939/15/63 DEBATE Open Access Joint issues – conflicts of interest, the ASR hip and suggestions for managing surgical conflicts of interest Jane Johnson1* and Wendy Rogers2 Abstract Background: Financial and nonfinancial conflicts of interest in medicine and surgery are troubling because they have the capacity to skew decision making in ways that might be detrimental to patient care and well-being. The recent case of the Articular Surface Replacement (ASR) hip provides a vivid illustration of the harmful effects of conflicts of interest in surgery. Discussion: We identify financial and nonfinancial conflicts of interest experienced by surgeons, hospitals and regulators in the ASR case. These conflicts may have impacted surgical advice, decision-making and evidence gathering with respect to the ASR prosthesis, and contributed to the significant harms experienced by patients in whom the hip was implanted. Drawing on this case we explore shortcomings in the standard responses to conflicts of interest – disclosure and recusal. We argue disclosure is necessary but by no means sufficient to address conflicts of interest. Using the concept of recusal we develop remedies including second opinions and third party consent which may be effective in mitigating conflicts, but their implementation introduces new challenges. Summary: Deployment of the ASR hip is a case of surgical innovation gone wrong. As we show, there were multiple conflicts of interest involved in the introduction of the ASR hip into practice and subsequent attempts to gloss over the mounting body of evidence about its lack of safety and effectiveness. Conflicts of interest in surgery are often not well managed. We suggest strategies in this paper which can minimise the conflicts of interest associated with surgical innovation. Keywords: ASR hip, Conflicts of interest, Disclosure, Recusal, Surgical innovation Background The paper begins by outlining the conflicts of interest Surgical innovation raises ethical concerns to do with that were involved, before briefly describing salient features increased risk of harms to patients, inadequate in- of the ASR case and identifying the financial and nonfi- formed consent, conflicts of interest and potentially in- nancial conflicts that arose with respect to this prosthesis. appropriate health care spending. The recent case of Finally, we consider remedies to help prevent or mitigate the Articular Surface Replacement (ASR) hip provides some of the harmful effects that conflicts of interest have an excellent illustration of the ways these ethical concerns the potential to generate in surgery. are not idle philosophical speculation, but manifest and Conflicts of interest in surgery, and in healthcare play out in practice. In this paper we focus solely on con- generally, are of concern because they have the capacity flicts of interest regarding surgical innovation. We identify to skew decision making in ways that might possibly, but a number of financial and other conflicts implicated in the not necessarily, impact patient care adversely. Broadly case and examine how their effects might be prevented or speaking, these conflicts can arise in professional contexts at least mitigated in the future. when a secondary interest has the potential to distract from and/or affect a primary one [1,2]. Primary interests * Correspondence: [email protected] are those directly related to fulfilling a particular role and 1Department of Philosophy, Macquarie University, Sydney, NSW 2109, Australia in the case of surgeons, these include acting in the Full list of author information is available at the end of the article best interests of patients, promoting patient welfare, © 2014 Johnson and Rogers; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Johnson and Rogers BMC Medical Ethics 2014, 15:63 Page 2 of 9 http://www.biomedcentral.com/1472-6939/15/63 performing surgery only in areas they are competent to As well as impacting on the decision making of surgeons, do so and so forth. Conversely, secondary interests are conflicts of interest can also influence patient decision not directly related to the role in question, and might making, and the way healthcare funding is disbursed. include receiving a payment for designing a device or The recent case of the Articular Surface Replacement promoting a particular product. Such secondary inter- (ASR) hip provides a vivid illustration of the effects of ests may be entirely legitimate; however they remain conflicts of interest. conflicts and have the potential to distract from primary DePuy Orthopedics (a subsidiary of Johnson and interests or inappropriately bias the professional in their Johnson) launched the ASR hip in the late 1990s. The primary capacity. hip used metal-on-metal technology with components With respect to surgeons, the bias caused by conflicts made from cobalt, chromium and titanium. There were of interest can influence decision making in one of two two versions of the ASR prosthesis– one offered total ways. First, decisions might be affected quite deliberately hip replacementa and the other the resurfacing of nat- with a surgeon intentionally choosing a particular device ural hips.b ASR hips involved a smaller surgical incision because of a financial relationship with the manufac- than competitors [7] and the metal-on-metal technology turer, such as being a consultant for them. Such purpose- promised reduced risk of fracture and dislocation, good ful actions are unprofessional, unethical, and potentially positional sensitivity, and greater longevity [8]. Compared fraudulent. Second, a surgeon might be influenced uncon- to total hip replacement, the resurfacing option offered sciously; for instance, being unaware that their reason for quicker recovery rates and the potential for greater and a preferring a particular device derives from a favourable lasting mobility; these features opened up the possibility relationship with a manufacturer. There is evidence that younger and more active individuals (who require that unconscious bias is potentially more widespread a robust and long-lasting hip replacement) could be and harmful than conscious bias (which may be considered candidates for the ASR prosthesis. a form of bribery). This is because the decision-maker Both types of ASR hip were approved for use in the is unaware of it, and the bias can arise from apparently European Union and Australia, while in the United States innocuous interactions and gifts, which are known to only the total hip replacement was approved, though US trigger feelings of reciprocity in the beneficiary [3]. surgeons could use the resurfacing option ‘off label’ [9]. There is also evidence that surgeons are more tolerant Over time ASR hips have been implicated in a range of conflicts of interest than, for instance, medical physi- of localised and systemic health problems including pain, cians [4]. This is arguably the result of changes in the rela- inflammation,infection,tiredness,nausea,visualim- tionships between surgeons and device manufacturers pairments, problems with mobility, tinnitus, heart palpi- over time such that industry representatives are frequently tations and depression [10]. Perhaps the most unequivocal now part of the theatre team, regarded as colleagues and measure of the failure of both versions of the ASR hip is friends [4]. Contemporary innovations tend to be driven their high revision rate (i.e. the need to re-operate). These by industry rather than surgeons, with the former seeking problems seem to have arisen primarily as a result of the out prominent surgeons to be involved in what can some- design of the ASR hip which can lead to metal grinding times amount to expensive ‘me too’ devices with unclear on metal. This in turn contributes to disintegration of or unnecessary indications [5]. the prosthesis, leakage of cobalt and chromium ions and The nature and extent of financial relationships be- subsequent toxicity. tween industry and surgeons are hard to track. However, In 2010 DePuy, after a protracted campaign denying work by Hockenberry et al. reveals payments from five that there were problems with the prostheses, issued a device manufacturers to orthopaedic surgeons disclosed worldwide recall of the ASR hip. as part of the settlement of a US Department of Justice In the following section we identify a range of conflicts law suit. The payments were for consulting, royalties and of interest that arose in the case of the ASR hip and suggest research support. In 2007, the mean payment received by ways in which such conflicts and their impact might be pre- orthopaedic surgeons from the five manufactures was vented, or at least mitigated, in the future. $190,331. In 2010, it was $233,108 (based on data available from three firms only). Some payments were in excess of Discussion $1,000,000 [6]. Financial conflicts of interest and the ASR hip Financial conflicts of interest receive the most attention, The ASR case involved financial conflicts of interest on where the secondary interest competing with the primary the part of surgeons, hospitals and regulators and these one derives from some type of monetary incentive or played out in ways that arguably contributed to patient reward. As we discuss below, however, nonfinancial harm. conflicts also arise in surgery and may be more challenging Surgeons involved in the design of the ASR hip pros- to identify and remedy. theses received significant royalties, which, if properly Johnson and Rogers BMC Medical Ethics 2014, 15:63 Page 3 of 9 http://www.biomedcentral.com/1472-6939/15/63 managed, could be consistent with ethical and profes- the Australian results by suggesting they did not properly sional norms.