Entering the exhibit hall at an annual meeting of the American Association of Neurological Surgeons (AANS) is like wandering into an industrial jungle. The number of corporate exhibitors exceeds 200, with displays ranging from single product booths to elaborate displays of surgical instruments and implantable devices. Product representatives, who often during the day outnumber neurosurgeon customers, are armed with information and enthusiasm enough to convert even passing interest to potentially voluminous product sales. This is the medical device industry in full dress parade. This is also a microcosm of the sometimes conflicted interdependency of neurosurgeons and the companies whose products are integral to their daily craft.
 James R. Bean, MD |
A stroll down the aisles offers the expert eye a quick review of a dazzling array of the newest tools of the trade. The tour is reminiscent of a childhood walk down the aisles of a toy store; one is overwhelmed by the sheer volume of products and attracted by each new object capturing the wandering eye. In succession pass a host of products, from stereotactic frames to spinal stimulators.
Neurosurgery’s dependency on these products is a fact of life. They are the reason lumbar and cervical disc surgeries can be outpatient events, tumors can be volumetrically resected, aneurysms can be occluded with only a groin puncture for access, and basal ganglia stimulation can be translated into control of Parkinsonian tremor. They have expanded the reach and delicacy of neurosurgical techniques, lessened risk, shortened recovery, lengthened survival, and reduced pain. They are the physical extension of the neurosurgeon’s knowledge and experience, and the practical application of basic and applied scientific research, converting neurosurgeons’ ideas and hopes to visible and palpable reality.
But these products create a tension, a perpetual conflict between the product vendor and the physician user whose motives and ethical responsibilities differ radically.
The vendor’s primary motive is profit, to sell as many products at the best price the product can command and that the market will bear. The product may be of sterling quality and confer outstanding benefit to the recipient, the price may be well within a competitive range, and the service may be flawless, but in the end, the motive of the medical product vendor marketplace is profit, acquired through the agency of the user neurosurgeon.
The neurosurgeon’s motive, if true to the profession, is patient welfare, not personal gain or vendor profit. A fundamental principle of professionalism, quoting Paul Starr in “The Social Transformation of American Medicine,” is “a service rather than profit orientation, enshrined in its code of ethics.” Acting as an advocate for a patient’s best interest in recommending treatment and conducting surgery, the physician bears a fiduciary relationship to the patient in the interaction, a relationship to which profit is only peripheral and incidental.
These two motives must interact, but must not be confused. To the patient receiving the benefit of the product, the vendor’s motive is irrelevant. But the physician’s motive and consequent action is critically important.
Trust is the fundamental quality necessary for a successful relationship between a patient and a physician. In respect to a surgeon, this means not only trusting in the surgeon’s knowledge and skills, but also trusting his or her judgment and motives: the judgment to select the most effective treatment and tools to accomplish it; the motives to act with care and compassion only in the interest of the patient, not for personal gain. Trust cannot exist where unethical inducements cloud a physician’s judgments or distort a surgeon’s motives.
Products do not sell themselves, and good products require expensive and time-consuming research and development, which must be recouped in sales. Product marketing requires education and persuasion. Most of that information dissemination is legitimate: advertising, product brochures, meeting displays, even training courses. But some of it is not, when claims exceed proof, or persuasion crosses into unethical inducement.
In this issue of the AANS Bulletin, the relationship between neurosurgery and the medical device industry is explored in some depth. The reciprocal dependency of each on the other to achieve their respective goals is examined, with the public and each patient benefiting when the relationship works well. But an underlying theme also is the need for constant vigilance by individual neurosurgeons in their personal relationships and by the specialty as a whole to guard against the ethical errors that destroy public trust and patient confidence. By guarding our ethical limits, we expand our professional and technical horizons.
James R. Bean, MD, is editor of the Bulletin and the AANS treasurer. He is in private practice in Lexington, Ky.