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Reading "White Coat, Black Hat" and discovering that ethicists might be black hats.

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During one of my trips this spring, I had the opportunity to read Carl Elliott's book White Coat, Black Hat: Adventures on the Dark Side of Medicine. It is not always the case that reading I do for my job also works as riveting reading for air travel, but this book holds its own against any of the appealing options at the airport bookstore. (I actually pounded through the entire thing before cracking open the other book I had with me, The Girl Who Kicked the Hornet's Nest, in case you were wondering.)

Elliott takes up a number of topics of importance in our current understanding of biomedical research and how to do it ethically. He considers the role of human subjects for hire, of ghostwriters in the production of medical papers, of physicians who act as consultants and spokespeople for pharmaceutical companies, and of salespeople for the pharmaceutical companies who interact with scientists and physicians. There are lots of important issues here, engagingly presented and followed to some provocative conclusions. But the chapter of the book that gave me the most to think about, perhaps not surprisingly, is the chapter called "The Ethicists".

You might think, since Elliott is writing a book that points out lots of ways that biomedical research could be more ethical, that he would present a picture where ethicists rush in and solve the problems created by unwitting research scientists, well-meaning physicians, and profit driven pharmaceutical company. However, Elliott presents instead reasons to worry that professional ethicists will contribute to the ethical tangles of the biomedical world rather than sorting them out. Indeed Elliott identifies what seem to be special vulnerabilities in the psyche of the professional ethicist. For example, he writes, "There is no better way to enlist bioethicists in the cause of consumer capitalism than to convince them they are working for social justice." (139-140) Who, after all, could be against social justice? Yet, when efforts on behalf of social justice takes the form of debates on television news programs about fair access to new pharmaceuticals, the big result seems to be free advertising for the companies making those pharmaceuticals. Should bioethicists be accountable for these unforeseen results? This chapter suggests that careful bioethicists ought to foresee them, and to take responsibility.

There is an irony in professionals who see part of their job as pointing out conflicts of interest to others that they may be placing themselves right in the path of equally overwhelming conflicts of interest. Some of these have to do with the practical problem of how to fund their professional work. Universities these days are struggling with reduced budgets, which means they are encouraging their faculty to be more entrepreneurial --- including by cultivating relationships that might lead to donations from the private sector. To the extent that bioethics is seen as relevant to pharmaceutical development, pharmaceutical companies, which have deeper pockets than do universities, are seen as attractive targets for fundraising.

As Elliott notes, bioethicists have seen a great deal of success in this endeavor. He writes,

For the last three decades bioethics has been vigorously generating new centers, new commissions, new journals, and new graduate programs, not to mention a highly politicized role in American public life. In the same way that sociologists saw their fortunes climb during the 1960s as the public eye turned towards social issues like poverty, crime, and education, bioethics started to ascend when medical care and scientific research began generating social questions of their own. As the field grows more prominent, bioethicists are considering a funding model familiar to the realm of business ethics, one that embraces partnership and collaboration with corporate sponsors as long as outright conflict of interest can be managed. ...

Corporate funding present a public relations challenge, of course. It looks unseemly for an ethicist to share in the profits of arms dealers, industrial polluters, or multinationals that exploit the developing world. Credibility is also a concern. Bioethicist teach about pharmaceutical company issues in university classrooms, write about those issues in books and articles, and comment on them in the press. Many bioethicists evaluate industry policies and practices for professional boards, government bodies, and research ethics committees. To critics, this raises legitimate questions about the field of bioethics itself. Where does the authority of ethicists come from, and why are corporations so willing to fund them? (140-141)

That comparison of bioethics to business, by the way, is the kind of thing that gets my attention; one of the spaces frequently assigned for "Business and Professional Ethics" courses at my university is the Arthur Anderson Conference Room. Perhaps this is a permanent teachable moment, but I can't help worry that really the lesson has to do with the vulnerability of the idealistic academic partner in the academic-corporate partnership.

Where does the authority of ethicist come from? I have scrawled in the margin something about appropriate academic credentials and good arguments. But connect this first question to Elliott's second question: why are corporations so willing to fund them? Here, we need to consider the possibility that their credibility and professional status is, in a pragmatic sense, directly linked to corporations paying bioethicists for their labors. What, exactly, are those corporations paying for?

Let's put that last question aside for a moment.

Arguably, the ethicist has some skills and training that render her a potentially useful partner for people trying to work out how to be ethical in the world. One hopes what she says would be informed by some amount of ethical education, serious scholarship, and decision-making strategies grounded in a real academic discipline.

Elliott notes that "[s]ome scholars have recoiled, emphatically rejecting the notion that their voices should count more than others' on ethical affairs." (142) Here, I agree if the claim is, in essence, that the interests of the bioethicists are no more important than others'. Surely the perspectives of others who are not ethicists matter, but one might reasonably expect that ethicists can add value, drawing on their experience in taking those interests, and the interest of other stakeholders, into account to make reasonable ethical decisions.

Maybe, though, those of us who do ethics for a living just tell ourselves we are engaged in a more or less objective decision-making process. Maybe the job we are doing is less like accounting and more like interpreting pictures in inkblots. As Elliott writes,

But ethical analysis does not really resemble a financial audit. If a company is cooking its books and the accountant closes his eyes to this fact in his audit, the accountant's wrongdoing can be reliably detected and verified by outside monitors. It is not so easy with an ethics consultant. Ethicists have widely divergent views. They come from different religious standpoints, use different theoretical frameworks, and profess different political philosophies. Also free to change their minds at any point. How do you tell the difference between an office consultant who has changed her mind for legitimate reasons and one who has changed her mind for money? (144)

This impression of the fundamental squishiness of the ethicist's stock in trade seems to be reinforced in a quote Elliott takes from biologist-entrepreneur Michael West: "In the field of ethics, there are no ground rules, so it's just one ethicist opinion versus another ethicist's opinion. You're not getting whether someone is right or wrong, because it all depends on who you pick." (144-145)

Here, it will probably not surprise you to learn that I think these claims are only true when the ethicists are doing it wrong.

What, then, would be involved in doing it right? To start with, what one should ask from an ethicist should be more than just an opinion. One should also ask for an argument to support that opinion, an argument that makes reference to important details like interested parties, potential consequences of the various options for action on the table, the obligations the party making the decisions to the stakeholders, and so forth -- not to mention consideration of possible objections to this argument. It is fair, moreover, to ask the ethicist whether the recommended plan of action it is compatible with more than one ethical theory -- or, for example, if it only works in the world we are sharing solely with other Kantians.

This would not make auditing the ethical books as easy as auditing the financial statements, but I think it would demonstrate something like rigor and lend itself to meaningful inspection by others. Along the same lines, I think it would be completely reasonable, in the case that an ethicist has gone on record as changing her mind, to ask for the argument that brought her from one position to the other. It would also be fair to ask, what argument or evidence might bring you back again?

Of course, all of this assumes an ethicist arguing in good faith. It's not clear that what I've described as crucial features of sound ethical reasoning couldn't be mimicked by someone who wanted to appear to be a good ethicist without going to the trouble of actually being one.

And if there's someone offering you money -- maybe a lot of money -- for something that looks like good ethical reasoning, is there a chance you could turn from an ethicist arguing in good faith to one who just looks like she is, perhaps without even being aware of it herself?

Elliott pushes us to examine whether the dangers that may lurk when the private-sector interests are willing to put up money for your ethical insight. Have they made a point of asking for your take primarily because your paper-trail of prior ethical argumentation lines us really well with what they would like an ethicist to say to give them cover to do what they already want to do -- not because it's ethical, necessarily, but because it's profitable or otherwise convenient? You may think your ethical stances are stable because they are well-reasoned (or maybe even right). But how can you be sure that the stability of your stance is not influenced by the size of your consultation paycheck? How can you tell that you have actually been solicited for an honest ethical assessment -- one that, potentially, could be at odds with what the corporation soliciting it wants to hear? If you tell that corporation that a certain course of action would be unethical, do you have any power to prevent them from pursuing that course of action? Do you have an incentive to tell the corporation what it wants to hear, not just to pick up your consulting fee, but to keep a seat at the table where you might hope to have a chance of nudging its behavior in a more ethical direction, even if only incrementally?

None of these are easy questions to answer objectively if you're the ethicist in the scenario.

Indeed, even if money were not part of the equation, the very fact that people at the corporations -- or researchers, or physicians, or whoever it is seeking the ethicists' expertise -- are reaching out to ethicists and identifying them as experts with something worthwhile to contribute might itself make it harder for the ethicists to deliver what they think they should. As Elliott argues, the personal relationships may end up creating conflicts of interest that are at least as hard to manage as those that occur when money changes hands. These people asking for our ethical input seem like good folks, motivated at least in part by goals (like helping people with disease) that are noble. We want them to succeed. And we kind of dig that they seem interested in what we have to say. Because we end up liking them as people, we may find it hard to tell them things they don't want to hear.

And ultimately, Elliott is arguing, barriers to delivering news that people don't want to hear -- whether those barriers come from financial dependence, the professional prestige that comes when your talents are in demand, or developing personal relationships with the people you're advising -- are barriers to being a credible ethicist. Bioethics becomes "the public relations division of modern medicine" (151) rather than carrying on the tradition of gadflies like Socrates. If they were being Socratic gadflies and telling truth to power, Elliott suggests, we would surely be able to find at least a few examples of bioethics who were punished for their candor. Instead, we see the ties between ethicists and the entities they advise growing closer.

This strikes close to home for me, as I aspire to do work in ethics that can have real impacts on the practice of scientific knowledge-building, the training of new scientists, the interaction of scientists with the rest of the world. On the one hand, it seems to help me to understand the details of scientific activity, and the concerns of scientists and scientific trainees. But, if I "go native" in the tribe of science, Elliott seems to be saying that I could end up dropping the ball as far as what it means to make the kind of contribution a proper ethicist should:

Bioethicists have gained recognition largely by carving out roles as trusted advisers. But embracing the role of trusted adviser means forgoing other potential roles, such as that of the critic. It means giving up on pressuring institutions from the outside, in the manner of investigative reporters. As bioethicists seek to become trusted advisers, rather than gadflies or watchdogs, it will not be surprising if they slowly come to resemble the people they are trusted to advise. And when that happens, moral compromise will be unnecessary, because there will be little left to compromise. (170)

This is strong stuff -- the kind of stuff which, if taken seriously, I hope can keep me on track to offer honest advice even when it's not what the people or institutions to whom I'm offering it want to hear. Heeding the warnings of a gadfly like Carl Elliott might just help an ethicist do what she has to do to be able to trust herself.

The views expressed are those of the author and are not necessarily those of Scientific American.

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