An elderly patient with osteoarthritis and osteoporosis has minimal improvement on non‑steroidal anti‑inflammatory drugs (NSAIDs). The orthopedic consultant recommends surgery using a new, expensive knee implant and receives a financial benefit per implant, but did not discuss non‑surgical alternatives. Which ethical issue is most relevant?

The Most Relevant Ethical Issue: Conflict of Interest Due to Financial Incentives

The consultant's failure to discuss non-surgical treatment options while receiving financial benefits from surgery and implant use represents a conflict of interest that compromises informed consent and patient-centered care—this is the most ethically problematic issue in this scenario.

Why This is the Primary Ethical Concern

The scenario describes a surgeon who:

• Receives financial compensation per surgery performed 1
• Receives additional payment for using a specific expensive implant under testing 1, 2
• Failed to discuss non-surgical alternatives with the patient 3

This creates a systemic conflict where the surgeon's financial interests directly misalign with the patient's best interests, particularly when evidence-based guidelines mandate that non-surgical options should be exhausted first 3, 4.

The Evidence-Based Treatment Algorithm That Was Bypassed

First-Line Non-Surgical Options (Should Have Been Discussed)

The American Academy of Orthopaedic Surgeons and NICE guidelines establish that the following should be offered before surgical consideration 3, 4:

• Exercise therapy: Quadriceps strengthening and aerobic fitness training (effect size 1.05 for pain reduction, comparable to NSAIDs) 4
• Weight loss: If BMI >25, even 5% reduction significantly improves pain and function 3, 4
• Oral NSAIDs: At lowest effective dose for shortest duration, with gastroprotection 3
• Intra-articular corticosteroid injections: For moderate to severe pain, providing relief up to 3 months 3
• Bracing: Tibiofemoral braces for compartmental disease 4, 5
• Patient education programs: Shown to improve pain outcomes 3, 4

When Surgery Becomes Appropriate

Joint replacement should only be considered when 3, 5:

• Radiographic evidence of knee OA exists AND
• Refractory pain and disability persist despite comprehensive conservative management AND
• Symptoms substantially affect quality of life

Why the Other Options Are Less Central

Option A (Failure to explain surgical risks): While important for informed consent, this is a subset of the broader conflict of interest problem. The financial incentive creates the primary ethical breach that then cascades into inadequate informed consent 1, 2.

Option B (Failure to refer for second opinion): This is not a standard ethical requirement when the primary issue is that surgery itself may be premature 3.

Option D (Recommending surgery for mild condition): The question states "minimal improvement on NSAIDs," not that the condition is mild. However, the key issue is that multiple evidence-based non-surgical options were never discussed, not just the severity assessment 3, 4.

The Specific Conflict of Interest Problem

Financial conflicts of interest are particularly problematic when they become systemic and institutionalized, creating risks not just for individual patients but undermining medical profession integrity 1.

The dual financial incentives here are especially concerning:

1. Per-surgery payment: Creates incentive to operate rather than manage conservatively 1, 2
2. Implant-specific payment for experimental device: Creates incentive to use unproven technology at higher cost 2, 6

Research shows that innovative knee implants must demonstrate ≥50% decrease in long-term failure rates to be cost-effective, and experimental devices carry increased short-term failure risk 6. Using an experimental implant without discussing proven alternatives while receiving financial compensation represents compounded ethical breach 1, 2.

Clinical Practice Implications

The correct approach requires:

• Full disclosure of financial relationships to patients (74% of patients desire this disclosure) 7
• Exhaustive trial of evidence-based non-surgical management before surgical referral 3, 4
• If surgery is indicated, use of proven implants unless experimental devices offer clear evidence-based advantages 6
• Documentation that conservative management has failed before proceeding to arthroplasty 3, 5

Answer: Option C represents the most relevant ethical issue—the financial conflict of interest that biases treatment recommendations away from evidence-based conservative management toward expensive experimental interventions that benefit the surgeon financially 1, 2.