Principles of Medical Ethics

PREAMBLE:

Concerns for the patient’s welfare and the appropriate behaviour of the physician are a part of the heritage of medicine.
Guidelines for ethical behaviour must address the demands for contemporary orthopaedic practice.
The code of medical ethics and professionalism was developed primarily for the benefit of our patients and to serve as a guide to conduct in the physician-patient relationship.
The document is directed to concerns of specific interest to orthopaedic surgeons.
The code of medical ethics will provide standards of conduct that define the essentials of honourable behaviour for the orthopaedic surgeon.
While taking into account the legal requirements of medical practice, the code will call for and espouse a standard of behaviour that is higher than that required by law.
Orthopaedic surgeons-in-training and other health care professionals should by their deeds and actions comply with the code of medical ethics and professionalism.

THE PHYSICIAN-PATIENT RELATIONSHIP:
1. 1. The orthopaedic profession exists for the primary purpose of caring for the patient.
  2. The physician-patient relationship is the central focus of all ethical concerns.
2. 1. The physician-patient relationship has a contractual basis and is based on confidentiality, trust and honesty.
  2. Both the patient and the orthopaedic surgeon are free to enter or discontinue the relationship within any existing constraints of a contract with a third party.
  3. An orthopaedic surgeon has an obligation to render care only for those conditions that he or she is competent to treat.
  4. The orthopaedic surgeon shall not decline to accept patients solely on the basis of race, colour, gender, sexual orientation, religion or national origin or on any basis that would constitute illegal discrimination.
3. 1. The orthopaedic surgeon should render services to the best of his or her ability, but may choose whom he or she will serve.
  2. Having undertaken the care of a patient, the orthopaedic surgeon may not neglect that person.
  3. Unless discharged by the patient, the orthopaedic surgeon may discontinue service only after giving adequate notice to the patient so that the patient can secure alternative care.
  4. If the enrolment of a physician or patient is discontinued in a managed care plan, the physician will have an ethical responsibility to assist the patient in obtaining follow up care. In this instance the physician will be responsible to provide medically necessary care for the patient until appropriate referrals can be arranged.
4. 1. When obtaining informed consent for treatment, the orthopaedic surgeon is obligated to present to the patient or to the person responsible for the patient, in understandable terms, pertinent medical facts and recommendations consistent with good medical practice.
  2. Such information should include alternative modes of treatment, the objectives, risk and possible complications and consequences of no treatment.
PERSONAL CONDUCT
1. 1. The orthopaedic surgeon should maintain a reputation for truth and honesty.
  2. In all professional conduct, the orthopaedic surgeon is expected to provide competent and compassionate patient care, exercise appropriate respect for other health care professionals, and maintain the patient’s best interest as paramount.
2. 1. The orthopaedic surgeon should conduct himself or herself morally and ethically, so as to merit the confidence of patients entrusted to his or her care.
  2. The orthopaedic surgeon should render to each patient a full measure of service and devotion.
3. 1. The orthopaedic surgeon should obey all laws, uphold the dignity and honour of the profession, and accept the profession’s self-imposed discipline.
  2. Within legal and other constraints, if the orthopaedic surgeon has a reasonable basis for believing that a physician or other health care provider has been involved in any unethical or illegal activity, he or she should attempt to prevent the continuation of this activity by communicating with that person and/or identifying that person to a duly-constituted peer review authority of the appropriate regulatory agency.
  3. The orthopaedic surgeon should also cooperate with peer review and other authorities in their professional and legal efforts to prevent the continuation of unethical or illegal conduct.
4. 1. Because of the orthopaedic surgeon’s responsibility for the patient’s life and future welfare, substance abuse is a special threat that must be recognized and stopped.
  2. The orthopaedic surgeon must avoid substance abuse and, when necessary, seek rehabilitation.
  3. It is ethical for an orthopaedic surgeon to take actions to encourage colleagues who are chemically dependent to seek rehabilitation.
CONFLICTS OF INTEREST:
1. 1. The practice of medicine inherently presents potential conflicts of interest.
  2. When a conflict of interest arises, it must be resolved in the best interest of the patient.
  3. The orthopaedic surgeon should exercise all reasonable alternatives to ensure that the most appropriate care is provided to the patient.
  4. If the conflict of interest cannot be resolved, the orthopaedic surgeon should notify the patient of his or her intention to withdraw from the relationship.
2. 1. If the orthopaedic surgeon has a financial ownership or interest in a durable medical goods provider, imaging centre, surgery centre or other health care facility where the orthopaedic surgeon’s financial interest is not immediately obvious, the orthopaedic surgeon must disclose this interest to the patient.
  2. The orthopaedic surgeon has an obligation to know the applicable laws regarding ownership, compensation and control of these services and facilities.
3. 1. When an orthopaedic surgeon receives anything of significant value from industry, a potential conflict exists which should be disclosed to the patient.
  2. When an orthopaedic surgeon receives inventor royalties from industry, the orthopaedic surgeon should disclose this fact to the patient if such royalties relate to the patient’s treatment.
  3. It is unethical for an orthopaedic surgeon to receive compensation of any kind from industry for using a particular device or medication.
  4. Reimbursement for reasonable administrative costs in conducting or participating in a scientifically sound research clinical trial is acceptable.
4. 1. An orthopaedic surgeon reporting on clinical research or experience with a given procedure or device must disclose any financial interest in that procedure or device if the orthopaedic surgeon or any institution with which that orthopaedic surgeon is connected, has received anything of value from its inventor or manufacturer.
5. 1. Except when inconsistent with applicable law, orthopaedic surgeons have a right to dispense medication, assistive devices, orthopaedic appliances and similar related patient-care items, and to provide facilities and render services as long as their doing so provides a convenience or an accommodation to the patient without taking financial advantage of the patient.
  2. Ultimately, the patient must have the choice of accepting the dispensed medication or patient-care items or obtaining them outside the physician’s office.
MAINTENANCE OF COMPETENCE
1. 1. The orthopaedic surgeon continually should strive to maintain and improve medical knowledge and skill.
  2. The orthopaedic surgeon should make available to patients and colleagues the benefits of his or her professional attainments.
  3. Each orthopaedic surgeon should participate in continuing medical educational activities.
RELATIONSHIPS WITH ORTHOPAEDIC SURGEON, NURSES AND ALLIED HEALTH PERSONNEL
1. 1. Good relationship among physicians, nurses, and other health care professionals are essential for good patient care.
  2. The orthopaedic surgeon should promote the development of an expert health care team that will work together harmoniously to provide optimal patient care.
2. 1. The professional conduct of the orthopaedic surgeon will be scrutinized by local professional associations, hospitals, managed care organizations, peer review committees, and state medical and/or licensing boards.
  2. These groups deserve the participation and cooperation of orthopaedic surgeons.
3. 1. Orthopaedic surgeons are frequently called upon to provide expert medical testimony in courts of law.
  2. In providing testimony, the orthopaedic surgeon should ensure that the testimony provided is non-partisan, scientifically correct, and clinically accurate.
  3. The orthopaedic surgeon should not testify concerning matters about which the orthopaedic surgeon is not knowledgeable.
  4. It is unethical for an orthopaedic surgeon to accept compensation that is contingent upon the outcome of litigation.
RELATIONSHIP TO THE PUBLIC
1. 1. The orthopaedic surgeon should not publicize himself or herself through any medium or form of public communication in an untruthful, misleading or deceptive manner.
  2. Competition between and among surgeons and other health care practitioners is ethical and acceptable.
2. 1. Professional fees should be commensurate with the services provided.
  2. It is unethical for orthopaedic surgeons to bill individually for services that are properly considered a part of the “global service” package where defined, i.e. services that are necessary part or the surgical procedure.
  3. It is unethical for orthopaedic surgeons to submit billing codes that reflect higher levels of service or complexity than those that were actually required.
  4. It is unethical for orthopaedic surgeons to charge for services not provided.
3. 1. Physicians should be encouraged to devote some time and work to provide care for individuals who have no means of paying.
  2. The physician has an obligation to serve as the patient’s advocate to ensure that the patient’s welfare remains the paramount concern.
GENERAL PRINCIPLES OF CARE
1. 1. An orthopaedic surgeon should practice only within the scope of his or her personal education, training and experience.
  2. If an orthopaedic surgeon contracts to provide comprehensive musculoskeletal care, then he or she has to the obligation to ensure that appropriate care is provided in areas outside his or her personal experience.
2. 1. It is unethical to prescribe, provide or seek compensation for unnecessary services or not to provide services that are medically necessary.
  2. It is unethical to prescribe controlled substances when they are not medically indicated.
  3. It is also unethical to prescribe substances for the sole purpose of enhancing athletic performance.
3. 1. The orthopaedic surgeon should not perform a surgical operation under circumstances in which the responsibility for diagnosis or care of the patient is delegated to another who is not qualified to undertake it.
4. 1. When a patient submits a proper request for records, the patient is entitled to a copy of such records as they pertain to that patient individually.
  2. Charges should be commensurate with the services to reproduce the medical records.
  3. Certain correspondence from insurance carriers or attorneys may call for conclusions on the part of the orthopaedic surgeon as such. A reasonable fee for professional services is permissible.
RESEARCH AND ACADEMIC RESPONSIBILITIES
1. 1. All research and academic activities must be conducted under conditions of full compliance with ethical, institutional and government guidelines.
  2. Patients participating in research programmes must have given full informed consent and retain the right to withdraw from the research protocol at any time.
2. 1. Orthopaedic surgeons should not claim as their own intellectual property which is not theirs.
  2. Plagiarism or the use of others’ work without attribution is unethical.
3. 1. The principal investigator of a scientific research project or clinical research project is responsible for proposing, designing and reporting the research.
  2. The principal investigator may delegate portions of the work to other individuals, but this does not relieve2 the principal investigator of the responsibility for work conducted by other individuals.
  3. The principal investigator or senior author of a scientific report is responsible for ensuring that appropriate credit is given for contributions to the research described.
COMMUNITY RESPONSIBILITY
1. 1. The honoured ideals of the medical profession imply that the responsibility of the orthopaedic surgeon extends not only to the individual but also to society as a whole.
  2. Activities that have the purpose of improving the health and well being of the patient and/or the community in a cost-effective way deserve the interest, support and participation of the orthopaedic surgeon.

MEDICAL PROFESSIONALISM TODAY : A PHYSICIAN CHARTER

PREAMBLE:

Physicians today are experiencing frustrations as changes in the health care delivery system in virtually all industrialized countries, threaten the very nature and values of medical professionalism.

Recently voices from many countries have begun calling for a reviewed sense of professionalism, one that is activist in reforming health care systems. Responding to this challenge a “charter” was developed to encompass a set of principles to which all medical professionals can and should aspire. The charter supports physicians’ efforts to ensure that health care systems and the physicians working in them remain committed both to patient welfare and the basic tenets to be applicable to different cultures and political systems.

Professionalism is the basis of medicine’s contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health. The principles and responsibilities of medical professionalism must be clearly understood by both the profession and society. Essential to this contract is public trust in physicians, which depend on the integrity of both individual physicians and the whole profession.

At present, the medical profession is confronted by an explosion of technology, changing market forces, problems in health care delivery, bioterrorism and globalization. As a result, physicians find it increasingly difficult to meet their responsibilities to patients and society. In these circumstances, reaffirming the fundamental and universal principles and values of medical professionalism which remain ideals to be pursued by all physicians, becomes all the more important.

The medical profession everywhere is embedded in diverse cultures and national traditions, but its members share the role of healer. The medical profession must contend with complicated legal and market forces. Moreover, there are wide variations in medical delivery and practice through which any general principles may be expressed in both complex and subtle ways.

Despite these differences, common themes emerge and form the basis of the charter in the form of three fundamental principles and as a set of definitive professional responsibilities.

FUNDAMENTAL PRINCIPLES

PRINCIPLE OF PRIMACY OF PATIENT WELFAREThis principle dates from ancient times it is based on a dedication to serving the interests of the patient. Altruism contributes to the trust that is central to the patient-physician relationship. Market forces, societal pressures and administrative exigencies must not compromise this principle.
PRINCIPLES OF PATIENT AUTONOMYThis principle has more recent history. Only in the latter part of the last century have people begun to view the physician as an advisor, often one of many, to an autonomous patient. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patient’s decisions must be paramount, as long as those decision are in keeping with ethical practice and do not lead to demands for inappropriate care.
PRINCIPLE OF SOCIAL JUSTICEThe medical profession must promote justice in the health care system, including a fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion or any other societal category.

PROFESSIONAL RESPONSIBILITIES

COMMITMENT TO PROFESSIONAL COMPETENCEPhysicians must be committed to lifelong learning and be responsible for maintaining the medical knowledge and clinical and team skills necessary for the provision of quality care.The profession as a whole must strive to see that all of its members are competent and must ensure that appropriate mechanisms are available for physicians to accomplish his goal.
COMMITMENT TO HONESTY WITH PATIENTSPhysicians must ensure that patients are completely and honestly informed before the patient has consented to treatment and after treatment has occurred. This expectation does not mean that patients should be involved in every minute decision about medical care; rather they must be empowered to decide the course of the therapy.Physicians should also acknowledge that in health care, medical errors that injure patients do sometime occur. Whenever patients are injured as a consequence of medical care, the patient should be informed promptly because failure to do so seriously compromises patient and societal trust. Reporting and analyzing medical mistakes provides the basis for appropriate prevention and improvement strategies and for appropriate compensation to injured parties.
COMMITMENT TO PATIENT CONFIDENTIALITYEarning the trust and confidence of patients requires that appropriate confidentiality safeguards be applied to disclosure of patient information. This commitment extends to discussions with persons acting on behalf of the patient when obtaining the patient’s own consent is not feasible.Fulfilling the commitment to confidentiality is more pressing now than ever before, given the widespread use of electronic information systems for compiling patients’ data and increasing availability of genetic information.Physicians recognize however that their commitment to patient confidentiality must occasionally yield to overriding considerations in the public interest (example: when patients endanger others).
COMMITMENTS TO MAINTAINING APPROPRIATE RELATIONS WITH PATIENTSGiven the inherent vulnerability and dependency of patients, certain relationships between physicians and patients must be avoided. In particular, physicians should never exploit patients for any sexual advantage, personal financial gain or other private purpose.
COMMITMENT TO IMPROVING QUALITY OF CAREPhysicians must be dedicated to continuous improvement in the quality of health care. This commitment entails not only maintaining clinical competence but also working collaboratively with other professionals to reduce medical error, increasing patient safety, minimize overuse of health care resources and optimize the outcomes of care.Physicians must actively participate in the development of better measures of quality of care and the application of quality measures to assess routinely the performance of all individuals, institutions and systems responsible for health care delivery. Physicians, both individually and through their professional associations, must take responsibility for assisting in the creation and implementation of mechanism designed to encourage continuous improvement in the quality of care.
COMMITMENT TO IMPROVING ACCESS TO CAREMedical professionalism demands that the objective of all health care systems be the availability of a uniform and adequate standard care.Physicians must individually and collectively strive to reduce barriers to equitable health care. Within each system, physicians should work to eliminate barriers to access based on education, laws, finances, geography and social discrimination.A commitment to equity entails the promotion of public health and preventative medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession.
COMMITMENT TO A JUST DISTRIBUTION OF FINITE RESOURCESWhile meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals and payer to develop guidelines for cost-effective care.The physician’s professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes ones patients to avoidable harm and expenses but also diminishes the resources available to others.
COMMITMENT TO SCIENTIFIC KNOWLEDGEMuch of medicine’s contract with society is based on the integrity and appropriate use of scientific knowledge and technology. Physicians have a duty to uphold scientific standards, to promote research, and to create new knowledge and ensures its appropriate use.The profession is responsible for the integrity of this knowledge, which is based on scientific knowledge and physician experience.
COMMITMENT TO MAINTAINING TRUST BY MANAGING CONFLICTS OF INTERESTMedical professionals and their organizations have many opportunities to compromise their professional responsibilities by pursuing private gain or personal advantage.Such compromises are especially threatening in the pursuit of personal or organizational interactions with for-profit industries, including medical equipment manufacturers, insurance companies and pharmaceutical firms.Physicians have the obligation to recognize, disclose to the general public, and deal with conflicts of interest that arise in the course of their professional duties and activities.Relationships between industry and opinion leaders should be disclosed, especially when the latter determine the criteria for conducting and reporting clinical trials, writing editorials or therapeutic guidelines, or serving as editors of scientific journals.
COMMITMENT TO PROFESSIONAL RESPONSIBILITIESAs members of a profession, physicians are expected to work collaboratively to maximize patient care, be respectful of one another, and participate in the processes of self-regulation, including remediation and discipline of members who have failed to meet professional standards.The profession should also define and organize the educational and standard-setting process for current and future members. Physicians have both individual and collective obligations to participate in these processes. These obligations include engaging in internal assessment and accepting external scrutiny of all aspects of their professional performance.

OPINION ON ETHICS AND PROFESSIONALISM

ADVERTISING BY ORTHOPAEDICF SURGEONS

ISSUES RAISED:

What parameters exist to guide orthopaedic surgeons regarding advertising?

Applicable provision of the principles of medical ethics and professionalism.

The orthopaedic surgeon should not publicize himself or herself through any medium or form of public communication in an untruthful, misleading or deceptive manner.

Applicable provisions of the code of medical ethics and professionalism

1. 1. When obtaining informed consent for treatment, the orthopaedic surgeon is obliged to present to the patient or the person responsible for the patient, in understandable terms, pertinent medical facts and recommendations consistent with good medical practice.
  2. Such information should include alternative modes of treatment, the objectives, risks and possible complications and consequences of no treatment.
1. 1. The orthopaedic surgeon should maintain a reputation for truth and honesty.
  2. In all professional conduct, the orthopaedic surgeon is expected to provide competent and compassionate patient care, exercise appropriate respect for other health care professionals, and maintain the patients’ best interests as paramount.
1. 1. The orthopaedic surgeon should not publicize himself or herself through any medium or form of public communication in an untruthful, misleading or deceptive manner.

LEGAL ANALYSIS:

State laws prohibit medical associations like the SAOA from impeding physicians who use truthful advertising. The reason for this prohibition is to preserve and promote a free and open market by enabling physicians to disseminate information about their services to patients. It is believed that truthful advertising may assist patients in making better informed judgements and choices.
Although truthful advertising has substantial legal protections, physician advertising that is not truthful is not protected. In fact, physician advertising that is false, deceptive or misleading is illegal.
Patients who have been injured by false or misleading physician advertising may be able to sue the physician involved for damages under consumer protection statutes or common law fraud claims.

ETHICAL ANALYSIS:

Orthopaedic surgeon, like all physicians, has an ethical obligation to present themselves and the services they provide to patients in a clear and accurate manner.
A successful physician-patient relationship is based on trust. The patient trusts that the physician has the appropriate training and skills, will listen to the patient’s complaints and symptoms, and will advise the patient accurately and objectively about the alternative courses of treatment. It is essential in this relationship that the patient has confidence that the physician is honest and is not manipulating the information presented for any purpose. Because the patient is often in a relatively uninformed position, patients usually assume that the physician is telling them all they need to know and that what they are told is accurate.Consequently, patients are especially at risk for untruthful, misleading or deceptive advertising. For this reason false and deceptive advertising by physicians destroys the trust relationship between the physician and patient which is essential to quality medical care. A physician’s misrepresentation may harm patients by making them less likely to seek out treatments they need or vulnerable to accepting treatments that are not essential.
Four general rules to determine whether physician advertisements are truthful and not false, deceptive or misleading have been developed. They are:

Advertisements should be accurate and not contain explicit false claims or misrepresentations of material fact. Generally, a false claim or misrepresentation of fact would be material if it would be likely to affect the behaviour or actions of an ordinary and prudent person regarding a physician or physician service.
Advertisement should not contain material implied false claims or implied misrepresentation of material fact. An advertisement that does not contain direct false claims or misrepresentations should not by implication create false or unjustified expectations about the physician or physician services being publicized. An implied false claim or misrepresentations would be material if it would be likely to affect the behaviour of an ordinary and prudent person towards a physician or physician service.
There should be no omissions of material fact from advertisements. In advertisements, disclosures of information are necessary where omission would make the advertisement as a whole misleading to an ordinary and prudent person or an average member of the audience to whom it is directed.
Physicians should be able to substantiate material claims and personal representations made in the advertisementThe ultimate question of whether an advertisement is truthful can be determined by addressing whether all four of these rules of truthful advertising have been followed in the development and dissemination of the advertisement.

SPECIFIC ISSUES:

ENDORSEMENTS AND PICTURESEndorsements and pictures are sometimes used to represent the benefits of specific orthopaedic services, such as degree of relief, recovery, or other benefits that may be attained if the services are used.The primary concern raised by endorsement and pictures, is whether they communicate benefits of orthopaedic services that are representative of the benefits ordinary attained by the average patient. If they communicate a degree of relief or recovery that is exceptional or otherwise not representative of the average patient, they may mislead patients into having unjustified medical expectations about the orthopaedic services advertised.
CLAIMS : “PAINLESS”:The degree of comfort, ease, or pain involved in the provision of an orthopaedic service is difficult to measure by objective standards. How these factors are experienced by an individual is subjective and varies from patient to patient.Therefore, claims or representations about the degree of comfort, or lack of pain involved in an orthopaedic service may be difficult to substantiate and may be misleading if not used with care.Statements that an orthopaedic procedure does not cause pain or is painless raise concerns if the services advertised are invasive. It is highly unlikely that an invasive orthopaedic procedure will not cause some degree of pain.
CLAIMS : “SAFE OR EFFECTIVE”:General representations about the safety or effectiveness of specific orthopaedic services should not be misleading. Such representations may cause a layperson to lack appreciation for the nature of any risks or adverse effects associated with the orthopaedic procedure, even if the likelihood that adverse effects may occur is low. More specific representation also causes concerns. For example, a statement that an orthopaedic surgeon has cured or successfully treated a large number of cases involving a particular serious ailment is deceptive if it implies a certainty or result and creates unjustified and misleading expectations in prospective patients. Representations about safety and effectiveness of orthopaedic services should be substantiated with sound scientific support, such as peer reviewed publications in medical literature of other authoritive sources of scientific information.Simply using a phrase such as “safe” is likely to deceive prospective clients by implying and absolute standard, when in fact the “safety” of an orthopaedic procedure is necessarily a qualified concept. The failure to qualify the claim is particularly objectionable since a variety of phrases could easily be employed to communicate the safety/risk relationship (eg. “Relatively safe”, “safe for the most patients”. or, “Among the safer type of orthopaedic surgery.”)
CLAIMS : “CURE”:Use of the term “cure” with reference to a problem is often deceptive. To “cure” a condition means to alter the circumstances so that the condition no longer exists and will not recur.In order not to be misleading, the term “cure” should almost always be further explained and qualified to give the patient an accurate understanding of his/her prospects for improvement.
CLAIMS : PHYSICIAN QUALIFICATIONSOrthopaedic surgeon qualifications include education, training, and other indicators of status and achievement within the profession. The lay public does not have a good understanding about what various qualifications represent.Most patients will assume that physician qualifications in an advertisement indicate training, knowledge, expertise and competence with respect to the services being advertised. That assumption is likely because patients will conclude that the qualifications are listed in an advertisement to substantiate the orthopaedic surgeon’s ability to perform the service being advertised.It is possible for patients to be misled if the qualifications listed imply a level of education or training which the orthopaedic surgeon did not receive; if they imply a degree of scrutiny of the orthopaedic surgeon’s knowledge, training and competence that did not occur; if they imply a qualification which the orthopaedic surgeon does not have; if the qualifications are inaccurately listed; or if the qualifications do not indicate education, training, knowledge, or competence with respect to the services being advertised.
CLAIMS : “WORLD FAMOUS”, “TOP SURGEON”, “PIONEER”:Only a small fraction of all orthopaedic surgeons can justifiably claim to be “world famous.” These may include some orthopaedic surgeons who are editors of major journals, who have authored widely used texts, or who have made major, original contributions to medical techniques. However, it is the very elusiveness of measures of “fame” which make invoking them in trying to lure patients misleading. Merely travelling widely, presenting addresses at professional meetings or treating patients from abroad does not mean that an orthopaedic surgeon is “word-famous.” To so indicate is to use the inherent impression of the concept fame to mislead patients. There can be little question that such claims are employed in order to give patients the impression that the orthopaedic surgeon meets some objective, high level of competence, skill or recognition – which probably does not exist with respect to the advertiser.The same is true of advertising oneself as a “top orthopaedic surgeon.” Saying that one has “pioneered advances in orthopaedic surgery” is also deceptive. Such a phrase connotes a major break through, not a minor alteration or refinement of conventional procedures. Simply being one of many “investigators” for a type of orthopaedic prosthesis, using one piece of equipment, or using a slightly refined surgical procedure does not justify use of the term “pioneer”. Since all orthopaedic surgery requires some degree of innovation, an orthopaedic surgeon cannot meaningfully claim to be an originator or developer of a technique or product simply because he or she has modified what existed before in some minor way.
CLAIMS : FEES AND COSTSOrthopaedic surgeons may advertise truthful information about fees and costs.However, statements about fee information can be misleading if they do not fairly inform the public about the costs likely to be incurred when patronizing the advertised physician. For example, the description of any service for which a fee or a range of fees is advertised must not be deceptive or misleading, and the statement should also indicate whether there may be additional fees for related services that are commonly required when the advertised service is obtained.

The orthopaedic surgeons relationship with industry

ISSUES RAISED:

under what, if any circumstances are it appropriate for orthopaedic surgeons to accept gifts or other financial support from industry, including pharmaceutical, biomaterial or device manufacturers?

Applicable provisions of the principles of medical ethics and professionalism

Physician- patient relationship
- The orthopaedic profession exists for the primary purpose of caring for the patient.
- The physician-patient relationship is the central focus of all ethical concerns.
- The orthopaedic surgeon should be dedicated to providing competent medical service with compassion and respect.

Applicable provisions of the code of medical ethics and professionalism:

1. 1. The orthopaedic profession exists for the primary purpose of caring for the patient.
1. 1. When an orthopaedic surgeon receives anything of significant value from industry, a potential conflict exists which should be disclosed to the patient.
  2. When an orthopaedic surgeon received inventor royalties from industry, the orthopaedic surgeon should disclose this fact to the patient if such royalties relate to the patient’s treatment.
  3. It is unethical for an orthopaedic surgeon to receive compensation of any kind from industry for using a particular device or medication.
  4. Reimbursement for reasonable administrative costs in conducting or participating in a scientifically sound research clinical trial is acceptable.
1. 1. The orthopaedic surgeon continually should strive to maintain and improve medical knowledge and skill.
  2. The orthopaedic surgeon should make available to patients and colleagues the benefits of his or her professional attainments.
  3. Each orthopaedic surgeon should participate in continuing medical educational activities.

DISCUSSION

Orthopaedic surgeons have long recognized the importance or continuing medical education in maintaining their professional skills.

Both orthopaedists-in-training and practicing orthopaedic surgeons attend and participate in numerous continuing medical educational programmes and seminars.

Industry, including pharmaceutical, biomaterial and device manufactures, has generously supported many of these beneficial programmes.

For several years, there has been concern about industry making gifts to physicians. Some of these gifts that reflect customary marketing practices of industry may not be consistent with basic principles of medical ethics. The line is sometimes burred between industry’s providing funds for an actual continuing medical educational experience and providing funds to promote the use or purchase of a particular pharmaceutical, biomaterial or a piece of orthopaedic equipment.

Generally the SAOA believes that it is acceptable for industry to provide financial and other support to orthopaedic surgeons if such support has significant educational value and has the purpose of improving patient care. All the dealings between orthopaedic surgeons and industry should benefit the patient and be able to withstand public scrutiny.

GUIDELINES

To avoid acceptance of inappropriate gifts or other financial support, the SAOA recommends that orthopaedic surgeons observe the following guidelines.

Benefit to patientsThe patient’s best interest is paramount. Therefore it is of utmost importance that any gift or other financial support accepted by an orthopaedic surgeon should primarily entail a benefit to his or her patient.A gift of any kind from industry should in no say influence the orthopaedic surgeon in determining the most appropriate treatment for his or her patient.It is only by strict adherence to this principle that the orthopaedic surgeon may maintain the patient’s trust.
Gifts with condition attachedOrthopaedic surgeon should not accept gifts with conditions attached.No gifts (including goods, meals, accommodations, meeting registration, travel etc to attend educational meetings or learning new skills under the tutelage of an expert) should be accepted with the implicit requirement that the orthopaedic surgeon use the products or services provided by that particular industry.
Social functionsAlthough the SAOA is generally opposed to social events sponsored by industry, social functions supported by industry in combination with significant continuing medical education events are acceptable.However, social functions supported by industry (e.g. dinners, tickets to sporting events or theatre, golf outings etc.) where there is no educational element, should not be offered to nor accepted by orthopaedic surgeons.
Cash GiftsCash gifts from industry to orthopaedic surgeons must not be offered nor accepted.
Continuing medical education events
1. SubsidiesSubsidies by industry to underwrite the costs of educational events where CPD credit is provided can contribute to the improvement of patient care and are acceptable. A corporate subsidy received by the conference’s sponsor is appropriate and acceptable so long as such support is publicly acknowledged and the location, curriculum, faculty and educational methods of the conference or meeting are determined solely by the organization sponsoring the educational course, not industry.Industry reimbursement, whether direct or indirect, for an orthopaedic surgeon to attend an educational event is not appropriate.
2. Faculty expenses and honoraria for CPD activitiesIt is appropriate for faculty at educational events where CPD credits are provided to accept reasonable honoraria and to accept reimbursement for reasonable travel, lodging and meal expenses from the conference’s sponsor.
Other educational eventsEducational; events sponsored by industry may be of educational value and improve patient care. Orthopaedic surgeons are responsible for ensuring that decisions to accept subsidies from industry are in the best interest of their patients. The SAOA believes that a potential conflict or interest exists when an orthopaedic surgeon receives such subsidies.Special circumstances may arise in which orthopaedic surgeons may be required, to learn new techniques demonstrated by an expert in the field or to review new implants or other devices on-site. On-site education provides the added benefit of educating a larger number of attendees per session and offers important insights into the function of ancillary staff and institutional protocols. In these circumstances, reimbursement for expenses may be appropriate.Reimbursement should be limited to expenses that are strictly necessary and able to withstand public scrutiny. In no case should honoraria or reimbursement for time off to attend the course be offered or accepted. In addition, attending the course and learning the technique must not require or imply that the orthopaedic surgeon must subsequently use that technique.
Scholarships for orthopaedic surgeons-in-trainingScholarships or other specific funds from industry to permit orthopaedic surgeons-in-training to attend continuing medical education conferences are appropriate as long as the selection of students, registrars or fellows who will receive the funds is made by the orthopedist-in-training’s programme director.
Consultant expenses and honorariaIt is appropriate for consultants to industry who provide genuine services as faculty in educational events to receive reasonable compensation and to accept reimbursement for reasonable travel, lodging and meal expenses.Token consulting or advisory arrangements such as passive attendance at a meeting or being named to an advisory board for simply discussing a device without making any real contribution to product development or analysis, cannot be used to justify compensating orthopaedic surgeons for their time, travel, lodging or other out-of packet expenses.
Other consulting arrangementsA symbiotic relationship exists between orthopaedic surgeons and industry. Orthopaedic surgeons are best qualified to provide innovative ideas and feedback, conduct research trails, serve on scientific advisory boards, and to serve as faculty to teach the use of new technology. Orthopaedic surgeons, in an effort to improve patient care, rely on industry to bring their creative ideas to fruition. A collaborative relationship between orthopaedic surgeons and industry is necessary to improve patient care but must be carefully scrutinized to avoid pitfalls or improper inducements, whether real or perceived.It is appropriate for consultants to industry that provides genuine services to receive reasonable compensation for their services. Such arrangements should be established in advance and in writing to include evidence of the following:
1. Documentation of actual need for the service
2. Proof that the service was provided
3. Evidence that physician reimbursement for consulting services should be equal to fair market value.
Examples of inappropriate relationships between orthopaedic surgeons and industry include but are not limited to:
1. Receiving a consultant fee for simply attending a meeting
2. Receiving remuneration for using a particular implant
3. Receiving consultant fees or other financial inducement for switching form one manufacturer’s product to another.
Proper collaborative relationship s between orthopaedic surgeons and industry are essential for advancement and improvement in patient care. Such relationships allow industry to fulfill their goals to improve patient care and increase patient access to new products and are also beneficial to orthopaedic surgeons and their patients. Orthopaedic surgeons must continually strive to improve patient care through the development of new advances and methodology.

Orthopaedic surgeons should never lose sight of their primary ethical responsibility to provide competent, compassionate patient care, maintaining professionalism and objectivity at all times.

OPINION ON ETHICS AND PROFESSIONALISM

CONTINUING MEDICAL EDUCATION

ISSUES RAISED:

What are the standards of continuing medical education to which orthopaedic surgeons should subscribe?

Applicable provision of the principles of medical ethics and professionalism.

The orthopaedic surgeon continually must strive to maintain and improve medical knowledge.
The orthopaedic surgeon should make relevant information available to patients, colleagues and the public.

APPLICABLE PROVISION OF THE CODE OF MEDICAL ETHICS AND PROFESIONALISM

1. 1. The orthopaedic surgeon should continually strive to maintain and improve medical knowledge and skill.
  2. The orthopaedic surgeon should make available to patients and colleagues the benefits of his or her professional attainments.
  3. Each orthopaedic surgeon should participate in continuing medical educational activities.

BACKGROUND:

Every orthopaedic surgeon has an ethical and professional obligation to stay abreast of the developing knowledge in the musculoskeletal sciences. The contract that exists between surgeon and patient, and between the profession and society, requires the acceptance of this obligation. The rate of growth of scientific knowledge and clinical experience in our specialty place an extraordinary responsibility on each orthopaedic surgeon to maintain his or her knowledge base.

The South African Orthopaedic Association believes that a lifelong commitment to continuing medical education is essential for orthopaedic surgeons. This commitment is essential if orthopaedic surgeons as professionals are to fulfill their commitments to provide high quality health care.

The choice of educational methods or experience is the responsibility of individual orthopaedic surgeons. The SAOA places no specific requirements on its members in terms of areas or types of instruction, minimum number of hours of education during a particular time period, or preferred providers of education programmes.

RECOMMENDATIONS:

The SAOA believes that each orthopaedic surgeon must develop hi s or her own approach to knowledge maintenance in an organized and explicit manner to assure that it addresses content in all areas in which care is provided.

To do this requires:

A self generated practice audit to determine the types of conditions, procedures, complications etc, which comprise one’s practice experience, and to assess the results of treatment provided.
A periodic self-assessment evaluation which addresses the knowledge and content areas relevant to the individual practice.
The development of a personal education plan, to include study in identified areas of deficiency, and the subsequent scheduling of educational activities to fulfill the goals developed in the education plan.

As an association devoted to the education of orthopaedic surgeons and others the SAOA makes available current authoritive and evaluative educational materials to enhance orthopaedic knowledge and to facilitate the provision of improved patient care.

The SAOA’s commitment to education is enduring and substantive. Every orthopedist should make a similar commitment to excellence.

OPINION ON ETHICS AND PROFESSIONALISM

ETHICS IN HEALTH RESEARCH IN ORTHOPAEDIC SURGERY

ISSUE RAISED:

What are the general ethical issues involved in the conduct of health research in orthopaedic surgery.

APPLICABLE PROVISIONS OF THE PRINCIPLES OF MEDICAL ETHICS AND PROFESSIONALISM

INTEGRITY
- The orthopaedic surgeon should maintain a reputation for truth and honesty with patients and colleagues.
- The orthopaedic surgeon should strive to expose through the appropriate review process those physicians who are deficient in character or competence or who engage in fraud and deception.
MEDICAL KNOWLEGDE
- The orthopaedic surgeon continually must strive to maintain and improve medical knowledge.
- The orthopaedic surgeon should make relevant information available to patients, colleagues and the public.

Applicable provisions of the code of medical ethics and professionalism

1. 1. When an orthopaedic surgeon receives anything of significant value from industry, a potential conflict of interest exists which should be disclosed to the patient.
  2. When an orthopaedic surgeon receives inventor royalties from industry, the orthopaedic surgeon should disclose this fact to the patient if such royalties relate to the patient’s treatment.
  3. It is unethical for an orthopaedic surgeon to receive compensation of any kind from industry for using a practical device or medication.
  4. Reimbursement for reasonable administrative costs in conducting or participating in a scientifically sound research clinical trial is acceptable.
1. 1. An orthopaedic surgeon reporting on clinical research or experience with a given procedure or device must disclose any financial interest in that procedure or device if the orthopaedic surgeon or any institution with which that orthopaedic surgeon is connected, has received anything of value from its inventor or manufacturer.
1. 1. The orthopaedic surgeon continually should strive to maintain and improve medical knowledge and skill.
  2. The orthopaedic surgeon should make available to patients and colleagues the benefits of his or her professional attainments.
1. 1. All research and academic activities must be conducted under conditions of full compliance with ethical, institutional and government guidelines.
  2. Patients participating in research programmes must have given full informed consent and retain the right to withdraw from research protocol at any time.
2. 1. Orthopaedic surgeons should not claim as their own intellectual property which is not theirs.
  2. Plagiarism or the use of others’ work without attribution is unethical.
3. 1. The principle investigator or a scientific research project or clinical research project is responsible for proposing, designing and reporting the research.
  2. The principal investigator may delegate portions of the work to other individuals, but this does not relieve the principal investigator of the responsibility for work conducted by other individuals.
  3. The principal investigator or senior author of a scientific report is responsible for ensuring that appropriate credit is given for contributions to the research described.

DEFINITIONS:

Orthopaedic surgeons conduct research in a number of areas. “Health Research” is considered to be the universe of research dealing with health care-related matters. Health care research encompasses various types of research, including clinical research, outcome studies research, psychological research and demographic and economic studies. Clinical research is defined as a part of a systematic programme competently designed, under accepted standards of scientific research, to produce data that are scientifically valid and significant.

In this opinion, unless otherwise noted, the broad term “Health Research” will be used.

ETHICAL CONSIDERATIONS:

According to the SAOA’s opinion on ethics and professionalism regarding continuing medical education, upon completion of orthopaedic residences, orthopaedic surgeons assume an ethical and professional obligation to stay abreast of developing knowledge in the musculoskeletal sciences. Many orthopaedic surgeons have chosen to go beyond this basic obligation to assist in the advancement of musculoskeletal knowledge and its dissemination.

Orthopaedic surgeons who conduct health research have special ethical responsibilities. They must accept responsibility for ethical conduct in their own scientific work and should help support high standards of ethical conduct in the scientific community. Failing to do so may impede or delay progress in learning about musculoskeletal sciences and will damage the credibility of all health researchers, thereby harming not only the research community, but also the greater orthopaedic community and the patients whose care depends on the results of research.

The SAOA believes that the tenets described below constitute reasonable guidelines to assist health researchers in orthopaedics. These guidelines include the following:

The purpose of health researchHealth research should be designed and conducted to develop new or confirmatory knowledge that promotes health, prevents diseases and injuries and improves diagnosis and treatment of diseases and injuries. If the research involves human subjects, it is appropriate only when potential risks to the patient are reasonable in relation to the potential benefits to the patient or the future patients and the importance of the knowledge which reasonably might be gained.Examples of unethical conduct:
- Designing and conducting research with the primary purpose of discerning methods of causing injury, illness or suffering.
- Designing or conducting research that is repetitious or redundant with the primary intent of advancing individuals or specific groups financially or professionally.
- Designing or conducting research that is not intended to produce new or confirmatory information that is valid or significant; and
- Purposefully stating, reporting or misinterpreting data to arrive at a pre-determined theory or opinion.
Support or sponsorship of researchSupport by industry for biomedical research has risen sharply in recent years.For many years health researchers perceived that commercial support of research was inappropriate because of the potentially biased results which may occur. This position has softened significantly since many major medical developments have resulted from research funded by private sources. Furthermore, industry support of health research particularly biotechnology research, has become substantial in recent years.There are three parties, with distinct interests, concerned with the corporate funding of health research: (1) the individual researcher; (2) the research institution: (3) the corporation funding the research. The interrelationships among these groups may vary substantially.In the first type of relationship, the funding corporation develops a request for proposal or presents a research protocol to the researcher and fund the researcher for carrying out the protocol. This essentially creates a fee-for-service arrangement. Assuming that basic rules for scientific propriety are followed, this constitutes an appropriate remunerative relationship. In this relationship, it may be undesirable for the researcher to deal or negotiate with the corporation funding the research. Consequently research institutions or other parties may create a structure whereby funded research arrangements can be negotiated in a manner that is satisfactory to all parties.A second type of relationship involves the researcher submitting an unsolicited research proposal directly to the funding corporation. The researcher would benefit by obtaining funds for needed equipment and supplies and the funding corporation would benefit by the possibility of expanding its market potential for a given product. This arrangement may also be viewed as ethically appropriate and mutually beneficial, assuming the proper conduct of science ensues and full disclosure is maintained.A third type of relationship involves truly cooperative projects. Often, these types of relationships are enacted in the setting of clinical trials. Numerous advantages exist for the researcher, the research institution, and the funding corporation for the development of cooperative programmes between medicine and industry. Full disclosure is essential to the success of this type of venture.
Ethical problems may arise when the researcher or the research institution have a direct financial interest in the research programme. For example, researchers may hold stock or stock options in the funding corporation that manufacturers the product or they may have other profit-sharing arrangements with the company. These financial interests may compromise (or give the impression of compromising) the objectivity of the researchers and cause them to downplay or suppress negative data while exaggerating favourable data. Such economic incentives may also introduce subtle biases into the way research is conducted, analysed or reported.

The SAOA believes that guidelines for circumstances in which researchers face economic conflicts of interest may be determined in reference to two ethical principles:
- A researcher may ethically share the economic rewards of his or her efforts. If a drug, device or other product becomes financially remunerative, the researcher may receive profits that reasonably resulted from his or her contribution. The code of medical ethics and professionalism explicitly permits an orthopaedic surgeon to receive royalties. However, the researcher ethically may not reap profits that are not justified by the value of his or her actual efforts.
- Potential sources of bias in research should be eliminated, particularly where there is a direct relationship between a researcher’s personal interest and potential outcomes of the research.
Several conclusions result by applying these two ethical principles. Once the researcher becomes involved in a research project for the funding corporation or knows that he or she might become involved in the research, he or she should not buy or sell the funding corporation’s stock until the involvement ends and the results of the research are publicly disseminated. As long as the researcher is involved in research on the funding corporation’s product, he or she has the potential to derive profits that stem from inside information, rather than from individual effort.

Researchers may serve as consultants or may be retained to lecture on behalf of the funding corporation. However, the researchers’ remuneration ethically must be commensurate with his or her actual efforts on behalf of the funding corporation.

Safeguards may be necessary to protect against the appearance of impropriety, even when ethically permissible relationships among the researcher, research institution and the funding corporation exist. Full disclosure presents the best mechanism to address doubts about propriety of a research arrangement. Researchers should disclose all ties to corporations whose products they are investigating for example, the researcher’s participation in educational activities supported by the corporation; participation in other research projects funded by the corporation; and consulting arrangements with corporation must be disclosed to the research institution, to the funding corporation, to audiences who hear the research results and to journals that publish the results of research.

Examples of unethical conduct:
- Knowingly negotiating for more funding than is appropriate to support the project and related institutional and departmental overhead costs.
- A researcher’s selling or purchasing stock in a company whose orthopaedic device is being tested by that orthopaedic surgeon-researcher.
- A researcher’s receiving financial incentives to alter data.
- A researcher’s receiving excessive remuneration by the funding corporation for evaluating that corporation’s products.
- A failure to disclose research or consulting arrangements with the funding corporation when reporting about research on devices manufactured by that corporation.
Use of research resourcesResources allocated by any agency, industry or organization for the performance of specific research should be used only for that purpose unless the granting agency gives specific permission for reallocation of the resources.Example of unethical conduct.
- Using resources provided by any organization for the direct financial benefit or personal use or the investigators.
Use of animals in researchThe SAOA believes that the appropriate and humane use of animals in research is justified to enhance the quality of life of both humans and animals. Animals should be used in research only when there are no suitable alternatives. Research projects should be designed to use the minimal number of animals possible in a manner that avoids abuse of animals and maintains appropriate standards of animal care. Researchers should conduct animal research only with the approval of the institution’s ethical committee and in compliance with applicable regulations and standards.Examples of unethical conduct:
- Using methods that cause animals unnecessary discomfort.
- Failing to maintain appropriate standards of animal care.
- Using excessive numbers of animals to perform experiments
- Using inappropriate animal models, and
- Using animals when other methods of conducting the research would be scientifically valid eg. computer simulations, tissue culture or mathematical models.
Use of human subjects in researchThe progress in medical care through research depends on informed partnership between patients and physicians in the development of new drugs and treatment methods It is recognized that certain advances in the knowledge of treatment of disease can only be learned by properly conducted clinical trials during which the result of varying treatments recommended by individual doctors are carefully compared.Human subjects should be used in health research only when there is no reasonable alternative. Human subjects should never be exposed to unnecessary risk, embarrassment or expense and should fully understand the purpose of the research and if their participation may benefit them (a therapeutic experiment) or is intended primarily to benefit future patients (a non-therapeutic experiment). The selection criteria of human subjects must be objective and reasonable.Human subjects should provide voluntary informed consent before being included in a prospective study and should be allowed to decline to continue participation in a research programme at anytime without compromising of their medical care. To ensure full informed consent, three elements must exist:
1. The orthopaedic surgeon must explain tot the patient in terms the patient can understand the proposed treatment, its likely effect on the patient, and purpose of the research. Orthopaedic surgeons must provide at least the degree of information that is required by applicable law, which will include at minimum information on the purpose of research, its potential side effects, alternatives and risks of the proposed treatment as well as the method, purpose, conditions of participation and the opportunity to withdraw from the research protocol without penalty.
2. The patient must understand for what they are providing consent. The orthopaedic surgeon must believe reasonably that the patient has understood the basic information and has engaged in rational decision-making in deciding to participate in the research: and
3. The patient must consent voluntary. The orthopaedic surgeon must believe that the patient’s consent is free from undue or overbearing influences, e.g. fear of loss of care or medical benefits if the patient declines to participate.
Human subjects participating in clinical research programmes should receive the care and treatment that is in their best interest and be assured that the potential benefit of the research outweighs the risks. Researchers should conduct human research only with the approval of the institution’s ethical committee on research and in compliance with all applicable regulations and standards.

Research on population designated as vulnerable (including children and pregnant women) must be scrutinized with special care. For research involving minors, assent (by the minor) may be required in addition to parental or guardian consent. In addition, any review of any patient information, including retrospective chart and X-ray review, for any purpose other than care of an individual patient or quality improvement, must be approved by the ethics committee.

Examples of unethical conduct:
- Failing to disclose risks
- Exposing participating patients to unnecessary risks
- Failing to obtain substituted consent of the patient’s legally authorized representative when the patient lacks the legal capacity to consent.
- Causing human subjects unnecessary embarrassment.
- Causing human subjects unnecessary expense.
- Manipulating human subjects cohorts with selected medical problems or results of treatment with the intent of proving the investigator’s bias or to promote a given treatment or medical device; and
- Directly or indirectly coercing human subjects to participate in the research protocol.
Responsibility of the research institutionThe ultimate responsibility for the ethical conduct of research resides within the institution in which the health research is conducted and/or with the primary investigator. Research institutions should assure that rigorous scientific standards are upheld by each of their facility, staff and students and should extend these standards to all reports, publications and databases produced by the institution. All medical schools and research institutions should implement guidelines for a review process for dealing with allegations of scientific misconduct, which include appropriate due process protections for these alleged to have committed scientific misconduct. In addition, the research institution must be capable of and committed to implementing effective procedures for examining allegations of scientific misconduct.Examples of unethical conduct:
- The research institution’s failing to maintain guidelines for dealing with allegations of scientific misconduct or fraud.
- The research institution’s failing to inform and educate staff and students of institutional guidelines for dealing with allegations of scientific misconduct or fraud; and
- The research institution’s failing to implement and enforce institutional guidelines for dealing with allegations of scientific misconduct or fraud.
Responsibilities of the principal investigator (PI)The principal investigator of a health research project is responsible for proposing, designing and reporting the research. In addition the PI may delegate portions of the work to other individuals, but this does not relieve the principal investigator of responsibility for work conducted by other individuals.Regulations and laws on a person’s privacy also affect the storage and dissemination of research information. Personally-identifiable information designed as protected health information (PHI) must be kept private. PHI includes any information which might identify an individual as well as any information in a medical record, including diagnosis, treatment, health status and test results. The principal investigator is responsible for following this rule. The PI must also determine the minimum of PHI necessary to perform the research; to obtain consent from all subjects for obtaining PHI for research and to document how PHI will be stored, who will have access to the PHI and how reports including PHI will be disseminated. Failure to adhere to the requirements of the privacy rule may result in civil and criminal penalties.Examples of unethical conduct:
- The principal investigator’s failing to participate in and supervise the design or conduct of a research project.
- The principal investigator’s failing to adequately supervise those conducting the project.
- Failure to maintain confidentially of PHI obtained for the purposes of research by the principal investigator or anyone else assisting with the project.
- The principal investigator’s failing to critically review the results and verify the accuracy of reports.
Reporting results of researchThe results of research should be described in timely, objective, accurate, complete reports and potential conflicts of interest should be identified. Specifically the code of medical ethics and professionalism provides that when reporting on clinical research or experience with a given device or procedure, orthopaedic researchers have an ethical obligation to disclose any financial interest in that procedure or device if the researcher or any institution with which the researcher is connected has received anything of value from its inventor or manufactures.Reports may not disclose individual protected health information without the express permission of the subject.Examples of unethical conduct:
- Failing to provide timely, accurate reports
- Failing to report unfavourable results
- Providing reports that do not contain a sufficient and accurate methodology to replicate the experiments or references to where such information might be obtained.
- Falsifying reports
- Fabricating results
- Reporting results of uncertain or minimal significance unless clearly stated as such.
- Preparing multiple partial reports or duplicate reports of the same work to increase apparent productivity of the investigators; and
- Failing to identify potential conflicts of interest including possible financial benefits to the investigators from research reports.
Authorship and credit for scientific workThe principal investigator of a research study is responsible for ensuring that articles describing the research include appropriate credit for individuals contributing importantly to the research. The authorship policy of the JBJS, which is endorsed by the SAOA, states that each author must have contributed significantly to one or more aspects of the study; its design, data acquisition, analysis and interpretation of data, drafting of the manuscript; critical revision of the manuscript; statistical analysis; and/or supervision. In addition, each author should be able to defend and assume full responsibility for the content of the manuscript regardless of the specific contributions. The sources of financial and technical support and individuals who provide important materials and information should be acknowledged.Examples of unethical conduct:
- Failing to credit co-workers; individuals who have designed the project or who have interpreted the data: individuals or agents that have provided resources to fund the project; or individuals or groups that have previously performed similar research, if such research is valid and appropriate.
- Failing to credit sources of quotations
- Plagiarizing or using others’ work without attribution
- Failing to review and credit relevant previous publications; and
- Including as authors individuals who did not make substantial contributions to the work.
Copyrights and royaltiesTypically, the patent to devices and the copyright to articles written belong to the principal investigator or his research institution or funding corporations. The ownership of patents, the allocation of revenues, copyright and other intellectual property interests among principal investigators, the research institution and the funding corporations and other important issues should be made clear either in standing policies or in clear contracts executed before the commercial support is received. The rewards of commercialization should be fairly allocated.It is ethically acceptable for a principal investigator to receive royalties from a funding corporation for using a particular device or medication the researcher has developed. However, it is unethical for an orthopaedic surgeon-principal investigator to commit to always use a particular product which he or she developed and for which the researcher received royalties, or to fail to disclose to interested parties, including patients, that royalties are received for the use of a device or medication.Example of unethical conduct:
- The principal investigator’s agreeing to always use a device he or she developed.
Research recordsAccurate and complete records of research data should be maintained until there has been sufficient time for critical review. The time will vary with the type of research, but five years after publication is sufficient for most work. It may be required from the principal investigator to specify the length of time that the records will be stored, who will have access to them, the location of the records and precautions to prevent misuse.Example of unethical conduct:
- Failing to maintain accurate complete records of research activity so that replication of the work or verification of the results is difficult or impossible.
Scientific errors; contradictory results and inability to replicate resultsIf errors in the proposal, conduct or reporting of research are identified, the principal investigator has an ethical obligation to report such errors. If the principal investigator or other investigators repeat an experiment and obtain results that contradict the initial report or they are unable to replicate the experiment, the contradictions and inability to replicate an experiment should be reported. If the long-term results of a health research project differ from the initial reported results, the differences should be reported. Scientific publications have a responsibility to publish report of scientific errors, contradictory results and failures to replicate previously reported research.Example of unethical conduct:
- Failing to report any significant scientific error
- Failing to report work that contradicts previously reported date or conclusions
- Failing to report late adverse outcomes for techniques or devices which were introduced with favourable initial experiences.
- Failing to report difficulties in replicating or verifying previous findings; and
- A scientific publication’s failing to publish reports of scientific errors, contradictory results, and failure to replicate previously reported research.
Obligation to report scientific misconduct:Orthopaedic surgeons have an ethical obligation to report scientific misconduct if they become aware of it. A spectrum of activities constitutes scientific misconduct, ranging from duplicate publication at the lower end to fraud and plagiarism at the upper end.Scientific misconduct can broadly be defined to include research fraud (including plagiarism, deception, falsification and/or fabrication of scientific data) as well as other practices that seriously deviate from those that are commonly accepted within the scientific community for proposing, conducting and reporting research.However, while it is clear that unequivocal scientific misconduct must be reported, members of the health research community have a concurrent responsibility to attempt to distinguish between honest error and scientific misconduct. Orthopaedic surgeons must also respect differences in scientific methods and analysis, interpretation and judgement about data.Examples of unethical conduct:
- Failing to identify and report unequivocal instances of scientific misconduct.
- Personally attacking, verbally or in writing, other investigators, based upon differences in methods, analysis, interpretation, judgement or opinion.
- Attempting to discredit or intimidate other investigators because of differences in methods, investigation or interpretation of data.
- Attempting to restrict funding or research, publications or presentation of data because of differences in interpretation; and
- Making accusations of scientific misconduct when honest error may be as likely.

Recommendation:

The SAOA urges orthopaedic surgeons who participate in health research to review and adopt these ethical tenets. These tenets provide a flexible, ethical framework for the conduct and the publication of research results.

OPINION ON ETHICS AND PROFESSIONALISM

SECOND OR ADDITIONAL MEDICAL OPINIONS IN ORTHOPAEDIC SURGERY

ISSUES RAISED:

What are the ethical oblications involved in relationships between orthopaedic surgeons with respect to providing second or additional medical opinions?
What different types of second or additional medical opinions exist?

APPLICABLE PROVISION OF THE CODE OF MEDICAL ETHICS AND PROFESSIONALISM

1. 1. The physician-patient relationship has a contractual basis and is based on confidentiality, trust and honesty.
  2. Both the patient and the orthopaedic surgeon are free to enter or discontinue the relationship within any constraints of a contract with a third party.
1. 1. The orthopaedic surgeon should render services to the best of his or her ability, but may choose whom he or she will serve.
  2. Having undertaken the care of a patient, the orthopaedic surgeon may not neglect that person.
  3. Unless discharged by the patient, the orthopaedic surgeon may discontinue service only after giving adequate notice to the patient so that the patient can secure alternative care.
1. 1. When a patient submits a proper request for records, the patient is entitled to a copy of such records as they pertain to that patient individually.
1. 1. An orthopaedic surgeon should practice only within the scope of his or her personal education, training and experience.

BACKGROUND :

Patients ultimately control their own personal health care decisions. While some patients may choose to limit their control of choice by enrolling in managed care organizations, all patients have the option to obtain health care from whoever they wish. The physician assumes a contractural obligation in undertaking the care of the patient. The patient the ultimate purchaser, owns and has a right to participate in all decisions in this contract.

Many patients find medical decision-making difficult, particularly regarding advanced medical technology. For this reason and economic pressures to contain costs, the process of seeking a “second opinion” from another physician has developed. While patients have independently sought second or additional medical opinion to confirm medical decisions in the past, the frequency of seeking additional medical opinions has skyrocketed in the past decade. Indeed, some patients now seek the opinions of multiple physicians as a matter of course. In today’s environment, there is a undercurrent of skepticism and distrust that encourages the solicitation of additional medical opinions. To compound this, confusion exists about the medical decision-making process in the lay and health care communities. Second or additional medical opinions sometimes have produced anxiety, frustration, anger and intimidation in patients and physicians alike.

Many questions concerning the ethics of seeking and providing additional medical opinions have been raised. Some actions have resulted in accusations of impropriety and unethical behaviour. While unethical behaviour has occasionally occurred, many times the conflict has arisen from a lack of proper communication and mutual respect between the treating physician and the physician from whom the patient has sought additional information. This conflict raises the specter of “turf”, greed and dishonesty and, when aired in the public forum, does much to discredit the profession.

DEFINITIONS:

Distinct types of interactions exist involving the gathering of additional medical opinions to which different ethical rules apply. They include:

Consultations with a colleague, initiated by the treating physician, on behalf of and with the implicit consent of the patient, to gain additional diagnostic insight or confirmation in order to continue providing comprehensive treatment plan for the patient.
Referrals to a colleague, initiated by the treating physician, on behalf of and with the consent of the patient, to share the care of the patient in the performance of a specified service. A referral might be temporary or permanent; this decision should b e made between the two physicians at the time of the referral.
Transfers, initiated by the treating physician, to transfer all care of the patient to another physician. There are legal requirements for the treating physician in transferring a patient. The consent of the patient is required.
Withdrawals, initiated by the treating physician, to discharge a patient from his or her care. There are legal requirements for the treating physician who is withdrawing services from a patient. In addition the SAOA’s code of medical ethics provides that “unless discharged by the patient, the orthopaedic surgeon may discontinue services only after giving adequate notice to the patient so that the patient can secure alternative care.”
Second opinions, initiated by a third party payer or insurance company of the insured prior to giving authorization to the physician to perform the procedure in some health insurance contracts. Patients must comply with this requirement to receive full benefit of their contract. The choice of which provider will provide the additional opinion is the sole decision of the insurer.

The patient may seek additional medical opinions by initiating a consultation with another physician concerning his or her care plan or by dismissing the treating physician and transferring all care to another health care professional. The patient’s course of action is entirely within the patient’s prerogative.

ETHICAL CONSIDERATIONS:

The patient has the ultimate decision-making authority in seeking second or additional medical opinions and referrals. Although the patient may choose to give up a certain degree of free choice by participating in managed care plan or by accepting insurance coverage with certain limitations, the choice of the options ultimately remains with the patient.

The SAOA recommends that orthopaedic surgeons observe the following guidelines regarding second or additional medical opinions and referrals:

Any illegal action is unethical. For example, it would be illegal as well as unethical for the orthopaedic surgeon providing the second or additional medical opinion to slander the referring physician if the slanderous information is known or can be proven to be false.
In accepting a patient for consultation, it is ethical for the consulting orthopaedic surgeon to render an opinion and return the patient to the treating physician for continuing care. The consulting orthopaedic surgeon should communicate with patient as well as the referring physician about the opinion.It is unethical for the consulting orthopaedic surgeon to solicit care of the patient. However, at the sole discretion of the patient, the patient may choose to terminate his or her relationship with his or her treating physician and then enter into another treatment relationship with the consulting orthopaedic surgeon. It is not unethical for the consulting orthopaedic surgeon to accept the patient under these circumstances, although some orthopaedic surgeons may choose not to accept the patient because of their personal view that a conflict of interest situation might be created.
When treating a patient referred by a colleague, the accepting orthopaedic surgeon ethically should return the patient to the referring physician after the index care has been rendered unless prior arrangements have been made with the consent of both the referring physician and the patient to transfer the patient’s care permanently. In a referral, professional courtesy dictates that some type of direct communication be given to the referring physician.
In specific cases where orthopaedic surgeons agree to render “second” medical opinions for a third party who then directs patients to them, the assumption of that patient’s care may be prohibited expressly by the terms of the physician’s arrangement with the insurance company. If the patient is independently seeking an additional medical opinion, the orthopaedic surgeon may render an opinion and advise the patient of a treatment plan, provided the contract permits such action. The physician must be aware of the provisions of his/her agreement with the third party.
As an extension of patient autonomy, patients have an ethical right to prompt and complete access to their medical record information unless the physician is bound by a contract with the patient’s third party payer. As a corollary, orthopaedic surgeons who offer second or additional medical opinions at the treating physician’s or the patient’s request also have a right to complete access to this information. In general, the physician legally “owns” the patient’s medical records that he or she maintains. However, this ownership is subject to the patient’s right of privacy and, in legal proceedings, the doctor-patient privilege. It is also subject to the patient’s right to obtain copies of those records or to have copies transferred to another person.It is in the patient’s best medical interest for orthopaedic surgeon to cooperate fully in sharing copies of a patient’s medical records, including physician’s notes, prescriptions, charts, reports, laboratory results, technical information used to assess the patient’s health condition, letters, photographs, X-rays, and diagnostic imaging. This is true whether the patient is referred by one orthopaedic surgeon to another for a consultation or if the patient elects to see another orthopaedic surgeon for continuing treatment.
The orthopaedic surgeon is bound legally and ethically to give his or her best medical opinion, regardless of whether the orthopaedist is the treating physician or the physician who is asked to render a second or additional medical opinion. The best interest of the patient should clearly remain the guiding principle. Ultimately, patients independently may choose their treating physician, request transfers of their care, and dismiss their physician at their own discretion.

ADVISORY STATEMENT

COMMUNICATING ADVERSE OUTCOMES

The responsibility to inform a patient of his/her family of an adverse outcome is an inevitable part of the practice of medicine. Adverse events, or disappointing outcomes, do not necessarily occur as a result of an error or negligent care: These results occur for multiple reasons, including uncorrected “unreasonable” expectations, complicating biological factors and course of treatment or surgery that don’t work out as anticipated.

When such an event happens, a patient often wants acknowledgement and understanding, an assurance that the physician will take steps so that the event will not occur again or risks of a similar occurrence will be minimized, an apology (if appropriate) and consideration of the financial impact on the patient.

The SAOA believes that an orthopaedic surgeon should put the interests of the patient first and communicate directly with a patient/family member in an honest, compassionate manner as soon as possible after an adverse event occurs.

Good communication with patients has always been essential in orthopaedic practice and is the cornerstone of the physician-patient relationship. Open honest communication favourable affects patient behaviour, health outcomes, patient satisfaction, and often reduces the incidence of malpractice actions.

After an adverse event occurs, it is the orthopaedic surgeon’s responsibility to assure the event is investigated and all the facts are collected. The patient’s health care need should be addressed as soon as possible.

When an adverse outcome has occurred, the orthopaedic surgeon should communicate in an honest, empathic manner with the patient or his/her family as soon as feasible after the event. During the course of the discussion, the orthopaedic surgeon should refrain from commenting about reasons for the event until a medical investigation is concluded. Currently understood facts related to the patient’s condition should be discussed and follow up with the patient after the investigation is completed should occur. Blame should not be assigned and speculation about the fault should be avoided. An honest disclosure of what happened to the patient will reduce anger and mistrust, as will an apology that avoids a suggestion of fault or conjecture, if appropriate. The orthopaedic surgeon should describe precautions that will be taken so that the risk of the same event happening again will be minimized. The discussion should also include recommendations and steps for follow-up care and an offer to transfer the patient’s care to another physician, if appropriate. An administrator or patient liaison should be present, if possible, both to serve as a witness and to assist with the patient’s resulting needs and requests.

If an error is the cause of the adverse event, the orthopaedic surgeon should co-ordinate with legal counsel to determine the amount of detail that should be provided in any discussion. Some information, such as peer review matters, root cause analysis material, results of disciplinary actions and legal counsel communications are privileged and should not be part of the discussion with the patient. Similarly, if an event could escalate to a claim, expressions of sympathy relating to the pain, suffering or death of a patient made to the patient/family member are not admissible in court as evidence of an admission of liability, whereas statements of fault may well be considered admissible evidence.

The physician-patient relationship is built upon trust and honesty. The SAOA code of medical ethics and professionalism reinforces these principles in section II A which states: “The orthopaedic surgeon should maintain a reputation for truth and honesty. In all professional conduct, the orthopaedic surgeon is expected to provide competent and compassionate patient care, exercise appropriate respect for other health care professionals, and maintain the patient’s best interests as paramount.”

Consistent with these principles, the SAOA urges orthopaedic surgeon to behave in manner consistent with these recommendations when communicating about adverse outcomes with their patients and family members.

ADVISORY STATEMENT

THE IMPORTANCE OF GOOD COMMUNICATION IN THE PHYSICIAN-PATIENT RELATIONSHIP

Good communication with patients has always been essential in orthopaedic practice. It is the cornerstone of the physician-patient relationship. Open, honest communication builds trust and promotes healing. It favourably impacts patient behaviour, health outcomes, patient satisfaction, and often reduces the incidence of malpractice actions. For physicians, good communication with patients can also increase professional satisfaction, enhance community image and provide a competitive economic advantage for the medical practice.

Increasing demands on orthopaedic surgeons in today’s healthcare environment often leave less time to provide care to a greater number of patients. While time constraints can make it difficult to communicate as effectively as one would like, the quality of time spent with the patient remains very important. For this reason, effective patient-focused communication skills are essential. They can be applied quickly and effectively within the normal patient encounter.

THE SAOA URGES ORTHOPAEDIC SURGEONS TO USE PATIENT-FOCUSED COMMUNICATION SKILLS DURING THEIR DIRECT PATIENT ENCOUNTERS. THESE INCLUDE:

SHOWING EMPATHY AND RESPECT
LISTENING ATTENTIVELY
ELICITING CONCERNS AND CALMING FEARS
ANSWERING QUESTIONS HONESTLY
INFORMING AND EDUCATING PATIENTS ABOUT TREATMENT OPTIONS AND THE COURSE OF CARE
INVOLVING PATIENTS IN DECISIONS CONCERNING THEIR MEDICAL CARE
DEMONSTRATING SENSITIVITY TO PATIENTS’ CULTURAL AND ETHNIC DIVERSITY

When time counts, it is the quality and not necessarily the quantity of physician-patient communication that is vital. To the patient, quality is often measured by how well the physician listens and acknowledges patient concerns. It is measured by how thoroughly the physician explains the diagnosis and treatment options, and how well the physician involves the patient in decisions concerning his or her care. These factors play an important part in the way patients perceive, recall and evaluate their visits with the physician.

THE SAOA BELIEVES THAT ORTHOPAEDIC SURGEONS MUST PLACE AN EMPHASIS ON GOOD COMMUNICATION WITH PATIENTS AND THE QUALITY OF THE INTERACTION, ESPECIALLY WHEN TIME IS LIMITED.

Good communication between the orthopaedic surgeon and the patient can be an effective risk management tool. While poor treatment outcome is one of the primary causes of malpractice actions, poor communication is also a factor in a majority of cases. Patients who sue often cite the failure of physician to listen or the physician’s unwillingness to answer questions. Patients who are well informed about treatment options, the course of care, expected outcomes and possible complications are more satisfied patients, and are less likely to file malpractice claims.

INFORMED CONSENT:

COMPONENTS OF INFORMED CONSENT:The orthopaedic surgeon should follow the process of obtaining informed consent when he/she communicates with patients regarding treatment alternatives and receives permission to proceed with treatment. Informed consent is the autonomous authorization obtained from a patient after the surgeon explains and describes the:
- Nature of the problem
- Alternative treatments
- Anticipated benefits of treatments
- Risks and side effects of treatments
- Consequences of no treatment
The surgeon is legally bound to disclose any information which the patient needs to know to make an informed decision about a recommended course of treatment. As long as the adult patient has the capacity to understand the information provided by the surgeon, he/she also has the right to refuse treatment even if it will save life or limb.
DOCUMENTATION:Documentation of consent is critically important. In addition to the consent form, which is signed by the patient or guardian and a witness, the surgeon should document on the chart that he/she has obtained consent according to the guidelines listed above, that the patient or guardian understands the explanation and all of their questions have been answered, and that they wish to proceed with the recommended treatment. The SAOA recommends that the surgeon “sign the site”, or agree upon and mark the planned surgical site together prior to surgery.In some instances the physician is required to obtain pre-operative consent from the patient for the operating room attendance of people who are not members of the Health Care Team. This may include representatives of Biomaterial or implant device manufacturers or other observers. The surgeon should be familiar with any regulations requiring permission for observers in the operating room. Surgeons should also obtain consent for intra-operative medical photography for the purpose of documenting the patient’s condition.
MINORS:Minors have greater legal protection than adults, and cannot legally provide consent for treatment until they have reached the age of majority. Instead, consent for minors is provided by their legal guardian, usually the parents.This does not, however, mean that minors are ignored during the process of obtaining informed consent for elective surgery. Minors fall into three categories regarding their capacity to participate in the informed consent process:
1. No capacity to participate (infants, toddlers, children with severe developmental delay)
2. Developing capacity (school age children)
3. Capable decision makers (older adolescents)
It is suggested that the surgeon obtain written assent or permission from older adolescents before proceeding with elective surgery. This assent is not binding, and is not valid without the guardian’s consent, but obtaining it shows that the surgeon supports and respects the adolescent’s decision-making abilities, thereby fostering their participation and cooperation with the treatment plan. Children with developing capacity should be involved in the process of informed consent to the extent of their desires and capabilities: for instance they may be allowed to choose the colour of their cast.

One of the additional protections provided by the law to minors is their right to receive limb- or life-saving treatment even when this treatment is refused by the guardian. Thus the surgeon may provide, for example, a blood transfusion to the child of parents who refuse this treatment, if he/she believes that the child’s life is at risk without the transfusion. The surgeon should be familiar with the institutional and legal processes they should follow when providing limb-or life-saving treatment to a child against the wishes of the child’s parents.

Under certain circumstances, minors are legally allowed to provide informed consent for their own treatment. The most common circumstance encountered by physicians is when minors have a condition for which they may fail to seek treatment if parental consent was required such as pregnancy, sexually transmitted disease, substance or alcohol abuse or a psychiatric condition. Minors with these conditions may have concomitant problems, complicating the issue of their capacity to provide consent. Because the conditions for which minors are emancipated vary, the orthopaedic surgeon should familiarize him/her self which the specific requirements of the country in which they practice.

The SAOA urges orthopaedic surgeons to provide information and education to their patients about treatment alternatives, and the course of care, especially expectations for surgical outcomes. Discussing the risks of surgery and possible complications in a kind and compassionate manner, can create realistic expectations on the part of the patient, increase patient satisfaction, and minimize the risk of malpractice claims.

ADVISORY STATEMENT

ORTHOPAEDIC MEDICAL TESTIMONY

Orthopaedic surgeons are frequently called upon to provide orthopaedic medical testimony in legal or administrative proceedings. In some jurisdictions, criteria for medical witnesses may be inadequate and as a result, unqualified physicians may testify as orthopaedic expert witnesses. It is in the public interest that orthopaedic medical testimony be readily available and objective.

The code of medical ethics and professionalism of the SAOA provides that:

‘Orthopaedic surgeons are frequently called upon to provide expert medical testimony in courts of law. In providing testimony, the orthopaedic surgeon should ensure that the testimony provided is non-partisan, scientifically correct and clinically accurate. The orthopaedic surgeon should not testify concerning matters about which the orthopaedic surgeon is not knowledgeable. It is unethical for an orthopaedic surgeon to accept compensation that is contingent upon the outcome of litigation.’

The SAOA believes that, consistent with the code of medical ethics and professionalism and to limit uninformed and possibly misleading testimony, individuals providing orthopaedic medical testimony should be qualified for their role and should follow a clear and consistent set of ethical guidelines.

ORTHOPAEDIC TREATING PHYSICIANS

As a citizen and a professional with special training and experience, the treating orthopaedic surgeon has an ethical and legal obligation to provide reasonably required factual or administrative testimony. If the orthopaedic surgeon’s patient has a legal claim and requests his or her treating physician’s assistance, the orthopaedic surgeon should furnish medical evidence, with the patient’s consent, in order to secure the patient’s legal rights. The orthopaedic treating physician has an ethical obligation to provide truthful, scientifically correct and clinically accurate testimony and is entitled to reasonable compensation for the time spent to prepare and give testimony. A request for unreasonable compensation by the treating orthopaedic surgeon may be a de facto refusal to testify, and may be considered unethical.

The treating orthopaedic surgeon may become an expert witness, but is not ethically bound to do so.

ORTHOPAEDIC EXPERT WITNESS : QUALIFICATIONS

The orthopaedic expert witness should have a current, valid and unrestricted license to practice orthopaedics. He/she should be a qualified surgeon registered as such with the HPCSA.
The orthopaedic expert witness should be familiar with the clinical practice, the applicable standard of care and the relevant facts and history of the case at the time of the incident.
The orthopaedic expert witness should be engaged in the active practice and/or teaching of orthopaedic surgery or be able to demonstrate familiarity with present practices.

ORTHOPAEDIST TESTIMONY: GUIDELINES FOR BEHAVIOUR

The orthopaedist providing opinions and/or factual testimony should review and testify fairly and impartially and should not adopt an advocacy or partisan position.
The orthopaedic expert witness should be knowledgeable regarding concepts and practices relevant to commonly accepted standard of care at the time of the incident. The attorney for the party who calls the orthopaedist should be informed of all favourable and unfavourable information developed in the orthopaedist’s evaluation of the case.
The orthopaedic surgeon is obligated to state the basis of the testimony, to indicate if he or she is expressing a personal view, to state if this opinion differs from current commonly-accepted evidence based practice, and to acknowledge if differing opinions exists.
Compensation for providing testimony should be reasonable and commensurate with the time and effort required preparing for the deposition and appearing in court. It is unethical to link compensation to the outcome of the case.
The expert witness should be aware that failure to provide complete and truthful testimony may result in criminal prosecution for perjury, civil suits for negligence, and revocation or suspension of his or her professional license.

Principles of Medical Ethics