Abstract
In this paper we argue that surgeons face a particular kind of within-role conflict of interests, related to innovation. Within-role conflicts occur when the conflicting interests are both legitimate goals of professional activity. Innovation is an integral part of surgical practice but can create within-role conflicts of interest when innovation compromises patient care in various ways, such as by extending indications for innovative procedures or by failures of informed consent. The standard remedies for conflicts of interest are transparency and recusal, which are unlikely to address this conflict, in part because of unconscious bias. Alternative systemic measures may be more effective, but these require changes in the culture of surgery and accurate identification of surgical innovation.
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Notes
If surgical techniques could be patented, then they too would invoke more traditional financial conflicts of interest. It is also possible that surgeons or hospitals advertising particular innovative procedures may attract patients on this basis, thereby creating potential financial conflicts of interest.
This dual role may lead to financial conflicts of interest—for example, through over-servicing—but this is not our concern here.
There are other areas of non-surgical health care practice where similar issues arise; for instance, interventional radiology or cardiology, psychology, or dentistry.
Of course, surgeons are not alone in taking up new procedures without good evidence. For instance, bone marrow transplantation was used to treat breast cancer for more than 10 years in spite of inadequate evidence regarding its effectiveness (Welch and Mogielnicki 2002).
For example, 40 years ago it became popular to perform an anastomosis between the common bile duct and duodenum at the time of removing the gall bladder on the basis that any gallstones remaining in the biliary tree could thereby easily enter the gastrointestinal tract. This procedure did not involve any external commercial interests such as device manufacturing companies. Surgeons were, however, keen to perform the operation to showcase this new technique. Unfortunately, the outcomes for patients were poor due to long-term complications from biliary tract infection.
We note that where innovation occurs in relation to unexpected anatomical anomalies or intra-operative events, it is not possible to halt the operation and awaken the patient to explain the new situation. In these cases, emergency innovation falls within the discretionary scope of clinical practice.
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Acknowledgements
We thank the audience at the annual conference of the Australasian Association of Bioethics and Health Law in July 2011 for helpful comments; we also thank members of the INCISIVE working group on conflicts of interest for feedback and comments.
Disclosure of Competing Interests
The authors have no financial or professional relationships that may pose a competing interest in relation to the content of this paper.
Funding
Research towards this paper was partly supported by an Australian Research Council (ARC) Linkage Grant (LP110200217), “On the Cutting Edge: Promoting Best Practice in Surgical Innovation.” The ARC had no control or influence over the decision to submit the final version of the manuscript for publication.
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A version of this paper was presented at the annual conference of the Australasian Association of Bioethics and Health Law in July 2011. Research toward this paper was partly supported by an Australian Research Council grant (LP110200217).
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Rogers, W.A., Johnson, J. Addressing Within-Role Conflicts of Interest in Surgery. Bioethical Inquiry 10, 219–225 (2013). https://doi.org/10.1007/s11673-013-9431-1
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DOI: https://doi.org/10.1007/s11673-013-9431-1