Unnecessary surgery has been a focus of health policy concern for decades. Such events are supposed to be prevented by the (a) self-policing of hospital medical staffs, (b) oversight of state medical boards, (c) third-party restrictions on payment, and (d) threat of malpractice lawsuits. While critics may point to failures of will on the part of those responsible for such policing, this case study points to more fundamental problems. The case involved an extension of the diagnosis of Chiari malformation to justify surgery to help relieve symptoms of individuals previously identified as suffering from chronic pain or fatigue syndrome. It illustrates how strenuous efforts to reduce what other members of the medical profession perceived as unnecessary surgery were overcome by (a) uncertainty concerning appropriate diagnosis and treatment, (b) patient desperation-driven self-referrals unrestricted by professional oversight or geographic boundaries, (c) the ambition of a surgeon determined to practice as he or she desired, (d) a business-focused national hospital chain insulated from direct clinical accountability, and (e) the highly profitable nature of the surgery itself.