Everyone (else) is conflicted.

“It is tempting if all you have is a hammer, to treat every problem as a nail,” the psychologist Abraham Maslow said. Orthopaedic surgeons have more than just hammers — they have saws, clamps, and chisels too. Nonetheless, they may be tempted to see all musculoskeletal complaints as problems amenable to surgical treatment; that is just a byproduct of their training and socialization. They earn their pay by treating musculoskeletal complaints with hammers. For some, fame and academic advancement comes with writing papers exalting the hammer. In short, orthopaedic surgeons are under the sway of “competing interests” long before they accept a free meal, a free pen, or a free vacation. The disclosure policies of many journals and organizations (emphasizing cash and swag from industry) tend to miss that point. Consider the biases that may affect an orthopaedic surgeon who invents a surgical procedure such as the percutaneous fixation of the lumbar facet joints to treat mechanical low back pain. The operation is touted on television and Twitter; the surgeon builds a large practice and the country house that comes with it. The surgeon lectures around the world and publishes scores of articles describing the procedure. For all of these spoils, however, a declaration of competing interests is not required unless the surgeon accepts money from a commercial firm. Clearly, this process of disclosure is inadequate. The process of disclosure may even be counterproductive. Research has shown that the very act of disclosing a conflict could liberate a reporter to skew his presentation. This phenomenon has been termed “moral licensing” [8]. In their 2012 study, Loewenstein and colleagues [8], divided research participants into two groups: Estimators (asked to guess the number of coins in a jar, after viewing the jar briefly and from a distance) and Advisors (subjects who were allowed unlimited time to view the coin jars up close, and in turn, asked to provide advice to the Estimators). In one scenario, the researchers rewarded both the Estimators and the Advisors when the Estimators correctly guessed the number of coins in the jar. For the second iteration, the researchers created a conflict. They rewarded Estimators for accurate guesses, whereas the Advisors were told privately that they would be paid more with each inaccurate guess. Not surprisingly, the Advisors offered bad advice. Interestingly, when the second form was repeated with public acknowledgement that the Advisors were conflicted, the quality of the advice worsened. “The bias was substantially greater when the conflict of interest was disclosed,” Loewenstein and colleagues wrote [8]. Current measures aimed at limiting bias need improvement. Although it may be tempting to treat every problem of bias with an even stronger disclosure process, there are, in fact, better options on the table. Stronger disclosures do not address the moral licensing problem. Exceptionally stringent disclosure policies could even dissuade researchers from publishing in peer-reviewed literature altogether. Biases cannot be eliminated, but they can be balanced. Hence, the proper approach to a potentially biased paper such as “The Bernstein Procedure: Percutaneous Lumbar Facet Fixation for Treatment of Mechanical Low Back Pain” by J. Bernstein MD, is not necessarily to reject it. It is likewise not helpful to inundate the reader with a list of conflicts, real or imagined. The best approach is to publish the paper, “The Safe and Inexpensive Treatment of Mechanical Low Back Pain with NSAIDS and Exercise.” Beyond the issue of personal conflicts of interest, the real bias in the literature is that journal reviewers favor positive results, studies that echo the prevailing paradigms, and findings that support greater clinical activity. In a better world, journals would publish all valid studies regardless of topic, potential interest to readers, or findings [2]. PLoS ONE, a peer-reviewed open access journal, uses this model — although it is far from the publishing standard. For now, editors can do more to combat bias by publishing papers that refute prior studies; papers that investigate “orphan” interventions not generally supported by industry (nonoperative care, generic drugs, off-patent devices); and papers that report negative results [6], even with low power (such that they may be available for meta-analysis). Overall, the best response to potentially biased work is not to festoon it with lengthy and stifling disclosure statements (though if disclosures are to be made, the dollar amounts received should be included as well, as there is a qualitative difference between, say, five hundred dollars and five million dollars). The best response to biased work is to rebut it. As Supreme Court Justice Louis Brandeis said in a case involving potentially dangerous teaching, “The remedy to be applied is more speech, not enforced silence.”