I appreciate the opportunity to serve the AANS as president this year. This
position is a high honor, and I hope I can perform with some semblance of the
distinction and wisdom of those who have preceded me in this office. Each year
has its own challenges, though many are recurring problems. With the advice
of many proven and future leaders within this organization as well as every
member’s support, I am confident that AANS members and our profession will
be well-served in the coming year.
Of all the advantages that neurosurgeons may enjoy, in value none exceeds public trust. Holding the public trust is the privilege of a proven profession. Neurosurgery holds dear its tradition of empathy and excellence, built by our predecessors over decades of dedication. Their examples we emulate and their achievements we strive to surpass.
Public trust is grounded in professionalism. Medical professionalism is based on three qualities, according to scholar and Pulitzer Prize-winning author Paul Starr. First, knowledge and competence are validated by a community of peers, which self-regulates through systemic required training and collegial discipline. Second, the knowledge has a rational scientific basis, and a highly technical, specialized application. And third, judgment and advice are rendered on an altruistic service basis, rather than a profit motive, with behavior constrained by a formal professional code of ethics. It is the third quality that distinguishes the medical profession from other occupations.
Every professional society bears the responsibility for defining the ethical standards of conduct for its members, ensuring not just their education and technical competence, but the correct and ethical use of their knowledge and influence. Public trust individually and collectively depends on the assurance that members will act in the interest of their individual patients and the public welfare — and not primarily in their own self-interest.
Professional conduct is not always above reproach. A controversial issue at present involves physician-industry relationships and conflicts of interest. The sheer size of health-related industries (pharmaceutical and medical device manufacturers, hospitals and other care-rendering institutions) and the drive for profitability tempts physicians with lucrative financial opportunities that expand in amount and number each year.
Twenty-six years ago, as the trend toward commercial for-profit medical ventures accelerated, Starr wrote:
The contradiction between professionalism and the rule of the market is long-standing and unavoidable. Medicine and other professions have historically distinguished themselves from business and trade by claiming to be above the market and pure commercialism. In justifying the public’s trust, professionals have set higher standards of conduct for themselves than the minimal rules governing the marketplace and maintained that they can be judged under those standards only by each other, not laymen.
More recently some physicians have slipped the restraints of professional single-mindedness and found expanding opportunities for financial rewards from industry. High-profile inquiries into physician-industry relationships have followed, eroding the public’s trust in doctors. In 2007, news of agreements between five orthopedic device manufacturers and the U.S. Department of Justice that levied $311 million in fines were one result of the DOJ’s investigations into payments to orthopedists. These investigations have spurred legislation that would require medical device and pharmaceutical industries to publish on publicly accessible Web sites all payments to doctors over $25. The investigations also have tarnished the image of physicians and at the same time have threatened to surrender to government the right and responsibility to define and oversee professional behavior, at least in respect to physician-industry relations.
The erosion of trust is lethal to professional success. It’s time to wake up, stop the hemorrhage of trust, and reassert our professional heritage.
We must begin by explicitly defining professional behavior. We cannot expect our members to judge industry offers ethically if we have not defined the basis for judgment. We cannot claim professional authority to oversee our members’ actions if we are unwilling to set standards against which they can be measured.
For this reason, in April 2008 the AANS Board of Directors adopted the Guidelines on Neurosurgeon-Industry Conflict of Interest document. This document is the result of months of proposals and revisions to build a consensus among neurosurgical leaders, including all of the AANS/CNS sections and the Executive Committee of the Congress of Neurological Surgeons. The AANS and CNS have adopted identical guidelines.
The guidelines are directive but voluntary in that the AANS has no investigative enforcement structure. However, the guidelines are formulations of ethical professional behavior, as is the AANS Code of Ethics; in fact, they are derived from principles already contained in the Code of Ethics. Members agree by virtue of their AANS membership to abide by the Code of Ethics, and the same is true of the new Conflict of Interest guidelines. Perceived violations will be handled by member complaint through the Professional Conduct Committee.
With these guidelines we intend to build public trust in neurosurgeons. This is the third document — the others are the AANS Corporate Relations guidelines and the recently revised Conflict of Interest guidelines for the Journal of Neurosurgery — developed to promote professional behavior in relationships between neurosurgeons and industry representatives. All are working documents that will be revised or expanded as deemed necessary.
From a strengthened base of ethical leadership, we can again lay claim to our proper social and political role: setting standards for medical and surgical care in healthcare policy.
James R. Bean, MD, is the 2008-2009 AANS president. He is president and managing director of Neurosurgical Associates PSC in Lexington, Ky. The author reported no conflicts for disclosure.
Click here to read the recent interview with Dr. Bean.
For Further Information
Guidelines on Neurosurgeon-Industry Conflict of Interest, www.aans.org/about/membership/Neurosurgeon-Industry_Conflicts-of-Interest5-08.pdf