In a series of posts published over the past couple of weeks the increasingly influential blog Impact Ethics has been preoccupied with the question of whether whoever pays the piper calls the tune. In no small degree this debate is related to similar concerns about the corrupting power of money and wealthy corporations in medical research and practice. Given that this is a bioethical issue and given that the concerns being raised often relate to the same or similar sources of money the debate is an entirely legitimate one. Nevertheless, I have some thoughts about the way in which some of the issues involved are being considered or, rather, with the way certain assumptions are configuring the terms of the debate.
The first example I would like to discuss relates to the post by Alice Dreger. Here she strongly differentiates between judging acts and, rather emotively, judging souls by which she means people or characters. I certainly do not want to suggest that we should go about approving or disproving the souls of certain bioethicists and thereby grant or deny them moral authority. Similarly I do not wish to suggest that bioethicists should not judging, or at least criticise, 'real world' acts. Certainly they should. However, I think it is important to recognise that it is souls who act and as such they can carry out their actions in better or worse ways.
As well as being concerned for the financing of bioethics, Dreger’s comments are organized around a substantive concern for informed consent in biomedical research. Here there has been a specific argument about whether a particular document was sufficiently informative for informed consent to have been possible. However, informed consent is not achieved by documentation alone. In no small part informed consent is a function of the researchers willingness to engage with the potential participant. Researchers must attempt to explain to participants what they are being asked to participate in and to do so in terms they can understand.
The provision of documentation or the delivery of a speech is often going to be insufficient to meets the ends it aims at. Ensuring that an individual is fully informed and therefore able to consent to participating in research is often a function of the researchers good character, a function of them discharging their (ethical) responsibilities with good conscience. No doubt some fail in this regard. But it is, I think, rare for that failure to be a matter of malice.
Of course this does not deny that formal documentation is a necessary part of informed consent. Rather it makes clear that participants in research remain reliant on researchers being 'good souls' and not merely fulfilling the terms and conditions mandated by an IRB. Dreger’s claim that “all we can know is acts” might well be correct, but that is not all that research participants deserve. Furthermore, the fact that all we can know, or subject to formal ethical judgement, is acts does not prevent us from going further when reminding researchers of their moral duty to participents.
Dreger’s comments aside, the main dispute is over funding for bioethicists. On the one hand we have Rob MacDougall, who argues that bioethics should set up ways to manage (financial) conflicts of interest, and on the other we have Carl Elliott who argues this is impossible. Questions about the influence of finance are not new, previously concerns have been raised about funding for bioethical research being attached to bio-scientific and biomedical research projects. Financing bioethics is not a simple matter and it seems inevitable that bioethics, like biomedicine, must find ways to manage potential conflicts of interest.
Of course we might argue that in the case of pharmaceutical companies the potential for conflicts of interest is too great for any management to be effective and we might see the difference of opinion between Elliott and MacDougall as turning on this point. However I would like to draw attention to an particular aspect of this debate: whether or not bioethics is solely an academic activity or a matter of scholarship. MacDougall sets out to talk about ‘academic ethics’ and ‘scholarship’ but ends up being concerned about the profession of bioethics and whether companies have a right to ‘bioethical representation.’
Whilst the original meaning of a profession lies in the idea of making a public declaration is it also linked to academic’s duty to profess their subject, it is why some academic are called professors. However, contemporary uses are not tied to the academy. We might think of professions - such as medicine, law and architecture - as occupations where the practitioner places their knowledge and skills in the service of the client’s ends. Of course they do not simply do so, professions do have larger ethical commitments. However, the point is that professional bioethicists might not be academic bioethicists. Certainly they will have been academically trained but they need not necessarily be academic researchers or scholars. We might think of some hospital based bioethicists as currently being examples of this. Given that many such hospitals are corporate entities we might wonder if a pharmaceutical firm or, perhaps more likely, a biotech or bioresearch company might legitimately employ a professional bioethicist and what their role might be?
This is, of course, different to funding bioethical research or temporarily retaining an academic bioethicist as a ‘consultant’ (either for established or recently established views). However, if such companies were to employ a bioethicist as an in house professional then such individuals would not be, at least not simply be, the moral conscience of a corporate person, they would also need some knowledge of the (relevant) law. However, it sometimes appears as if law - or a law-like view of ethics - is taking over. In the most recent post in the series Kelly Hills, follows Elliott, MacDougall and, one might add, the general trend, in considering ‘applied philosophical (bio)ethics’ and analogous to law. We have comparisons to judges, public interest defenders, professional lawyers working for clients, and law-makers.
I cannot help but think that this emphasis on applied-(bio)ethics-as-law or law-like detracts from the wider potential of bioethics to offer a more satisfying form of moral discourse. For example, consider whether the consulting bioethicist based in a hospital should be confine themselves to the techniques of law, principle and ethical problem-solving or if they might, over time, offer a longer term engagement with the broader moral dimension of medical culture and social norms. The distinction is analogous to Dreger’s desire to focus on acts rather than souls or, if you will, acts rather than the character of individuals, institutions, cultures or societies.
Interestingly Hills makes reference to the broader moral context in which bioethics, (and, for that matter, medicine and law) is unavoidable situated. Any person, profession or institution is able to engage in their own character and the broader moral context, both that set by its own institutionalization and that within which the institution is situated. However, when institutions such as law and medicine, or professionals such as lawyers and medical doctors, engage with this broader moral context they might do so ‘professionally’ or out of a sense of professional concern or duty but what they do is not law or medicine: it is ethics. In contrast when the bioethicist engages with its own institutionalization or its broader moral context they are still doing their day jobs, they are doing so professionally and they are still doing (bio)ethics.
If professing bioethics involves helping medical professionals and medical institutions to reflect on ‘how to live’ then, somewhat idealistically, we might think this is also a task they could fulfil for corporations. It is also a task they, or rather we, must fulfil for ourselves. Certainly all of the posts discussed contribute to this end; reflecting on the internal and external moral context of bioethics. However, if we are to address this question fully then is might benefit from being re-described so as to ask: how should (different) bioethicists live?