“Reason should be the slave of passion.”     David Hume

It is inherent in our nature to believe that views we passionately hold on given issues are correct. However, much too often, eventually we find them wanting. This realization did not keep David Hume, the empiricist/pragmatist par excellence, and one of the most influential figures in the past five-hundred years, to conclude “Reason should be the slave of passion.” (Ref. 1).  The topic of this commentary is an example where I found myself wondering if my long-held conviction of the harm brought about by an inappropriate relationship between orthopaedics and Industry, now spread throughout most of the industrialized world, needed to be questioned and radically modified.

The United States’ Justice Department investigation of serious trespasses and unethical conduct in the relationship, already in its fifth year, does not seem to have had a meaningful impact (Ref. 2). All we hear is that most of the identified culprits had “resolved” the conflicts by claiming that the receipt of moneys from Industry was justified because they represented grants devoted to legitimate educational ventures. It is very likely that this argument was valid in some instances since many educators/researchers are honest and reputable members of the orthopaedic community. On the other hand it is naïve, at best, to believe such an excuse applies to all the accused individuals, particularly in light of the fact that many of the identified parties are not in any way involved in educational or research endeavors.

I have previously reported on episodes where I was either offered by high-industry representatives large amounts of money for the use of implants by the faculty of the department I shared at the time, or even larger funds for accepting to have a total hip prosthesis named after me even though I had nothing to do with its development. After refusing the dishonest “deals’, the response I got was, “But we do this all the time.” In the early 1970s I was invited by Industry to lecture in the capital cities of five Latin American countries. I declined on the grounds that I considered unprofessional the acceptance of the attractive offer. My reply was followed by a letter from the firm’s headquarters saying that they would not have any trouble finding someone to fill my place. I responded by saying that I was aware of the availability of others for such deeds and resentful of the fact his company seemed to consider orthopaedics a bordello, where the choice of a prostitute is simple and uncomplicated. (Ref. 3).

It is most demeaning to our profession that some of our representative organizations as well as directors of residency programs and other people occupying high positions in the hierarchy continue to perpetuate the situation. I suspect it would be very difficult to find at this time many heads of orthopaedic societies and directors of orthopaedic residency programs in America whose dependency in Industry is not significant.

A number of subterfuges are used to justify all kind of questionable activities. Sometimes funds are provided to academic programs to pay the salary of new Fellows and faculty members. Endowed chairs are accepted without hesitation in some places; in other instances the real funding source is camouflaged under the name of some “generous donor,” when the true funding source is Industry.

Would not be anything wrong with Industry’s “generosity” if it were not by the fact that Industry expects a great deal of say in the selection of topics for discussion and the choice of faculty. In addition, it economically compensates for the moneys given away by escalating the costs of their products (Ref. 4). Industry continues to win the battle. The subordination of the orthopaedic profession to Industry’s profit-driven wishes seems complete (Ref. 5).

However, throughout the land, there is a growing number of people in our discipline who are increasingly unhappy with the breakdown of the moral sphere and professionalism in our ranks, and the control of education by Industry. The increasingly large number of orthopaedists in private practice and many in the academic world are not getting sufficient support from their representative organizations, which have chosen to remain silent and comfortably continue to enjoy the status quo.

This crisis may soon become of a serious nature. We most respond with a loud and unequivocal chorus opposing the current practices. If we continue to simply limit our efforts to increasing our financial well-being and to dwell on self-serving pocketbook issues the future our heirs will inherit from us will be an unhappy one.

References:

1)  Hume, David. A treatise of human nature. Oxford, 1888

2) United States Justice Department. Christopher J. Christie. Press Release September 27, 2007

3)  Sarmiento A. Bare Bones. Prometheus, 2005.

4) Sarmiento A.  Medicine Challenged. Publish America,2009.

5)  Sarmiento A. Rise and Decline. JBJS (A) 91:2740-2,  2009.

Dr. Sarmiento is the former Professor and Chairman of Orthopaedics at the Universities of Miami and Southern California, and past-president of the American Academy of Orthopaedic Surgeons.  He is a contributor to Implant Identification on OrthopaedicList.com.