'Tell Us What You Want to Do, and We'll Tell You How to Do It Ethically ...

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REFERENCES. Borry, P., Schotsmans, P., and Dierickx, K. 2006. Empirical research in bioethical journals. A quantitative analysis. Journal of Medical Ethics.

Buying Bioethics Research

REFERENCES Borry, P., Schotsmans, P., and Dierickx, K. 2006. Empirical research in bioethical journals. A quantitative analysis. Journal of Medical Ethics 32(4): 240–245. Donohue, J. J. and Levitt, S. 2001. The impact of legalized abortion on crime. Quarterly Journal of Economics 116(2): 379–420. Elliott, C. 2004. Six problems with pharma-funded bioethics. Studies in History and Philosophy of Biological and Biomedical Sciences 35(1): 125–129. Goldenberg, M. J. 2005. Evidence-based ethics? On evidence-based practice and the “empirical turn” from normative bioethics. BMC Medical Ethics 6(11): E1–E9. MacDonald, C. 2003. Will the “secular priests” of bioethics work among the sinners? American Journal of Bioethics 3(2): W13.

Nelson, J. L. 2000. Moral teachings from unexpected quarters. Lessons for bioethics from the social sciences and managed care. Hastings Center Report 30(1): 12–17. Pellegrino, E. D. 1995. The limitation of empirical research in ethics. Journal of Clinical Ethics 6(2): 161–162. Sharpe, V. A. 2002. Science, bioethics, and the public interest: On the need for transparency. Hastings Center Report 32(3): 23– 26. Turner, L. 1998. The greening of bioethics: Corporate funding of bioethics research. Cambridge Quarterly of Healthcare Ethics 7(3): 326– 328. Wiedermann, C. J. 2005. Bioethics, the surviving sepsis campaign, and the industry. Wiener Klinische Wochenschrirft 117(13–14): 442– 444.

‘Tell Us What You Want to Do, and We’ll Tell You How to Do It Ethically’— Academic Bioethics: Routinely Ideological and Occasionally Corrupt Miran Epstein, Queen Mary, University of London There is little doubt that selling philosophical justifications would corrupt academic bioethics and that both nondisclosure as well as disclosure of financial ties could conceal such corruption. The importance of identifying corruption and recognizing its accurate prevalence is beyond dispute. That noted, the question of the impartiality of academic bioethics and its independence in defining its agenda becomes really interesting once one sets aside any obvious examples of what would count as corrupt practices. For if it turned out that the bioethical discourse has been inherently biased and that both its historical success as well as that of its social agent—academic bioethics—have largely depended on the particular nature of that bias, then their representation as routinely impartial and occasionally corrupt would transpire to be biased in and of itself, too. Sharp and colleagues (2008) face such risk, but so do their critics, too (Evans 2008; Resnik 2008; Tsai 2008). Their articles entail such representation. Of course, a serious inquiry into such possibility exceeds the scope of one short commentary. It requires a

meticulous analysis of the sociology and history of every premise, tool, practice, and institution of the bioethical discourse ever since its inception. However, a simplified programmatic sketch and perhaps a few specific examples can still be suggested in this respect. To prevent misunderstanding from the outset, it is emphasized that the bioethical discourse is referred to here as a social construct only. The values, views, and enterprises of individual bioethicists, which may or may not be in harmony with that construct, are of no concern to this discussion. The first question we need to tackle is whether a social discourse can be impartial at all. The question may be made more specific: can its social status rest on reason, or does it universally depend on some social interests? Idealist historians must acknowledge that the fate of a social discourse may happen to depend on some interests. However, they would argue that this does not need to be the case. Some discourses are embraced or rejected by society simply because they comply or do not comply with reason, respectively.

Note on the title: A self-critical depiction of the remit of academic bioethics (Callahan 1992). Address correspondence to Miran Epstein, Academic Unit for Human Science and Medical Ethics, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, 2 Newark St. London E1 2AT, United Kingdom. E-mail: [email protected]

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Materialist historians, in contrast, might agree that a particular discourse may or may not comply with reason. However, they would argue that neither its social status nor the status of the belief that it does or does not comply with reason have anything to do with its ‘real’ philosophical value. The social status of both invariably depends on interaction of historically evolving social interests, so they would argue. Indeed, there is ample evidence that collectives tailor their tools, practices, and ideas based on their interests, not the other way around. The founding father of the sociology of ideas, the great seventeenth century British philosopher Thomas Hobbes, articulated this position probably best. For I doubt not, but if it had been a thing contrary to any man’s right of dominion, or to the interest of men that have dominion, that the three angles of a triangle, should be equal to two angles of a square; that doctrine should have been, if not disputed, yet by the burning of all books of geometry, suppressed, as far as he whom it concerned was able (Hobbes 1996, 70).

The claim that the social fate of discourses, including the bioethical discourse, universally depends on social interests means that they are never impartial. However, it does not mean that they are necessarily biased. That depends on the nature of the underlying ecology of interests. The social fate of the Euclidean geometry, for example, seems to have depended on ecologies of agonistic interests only. It is probably not biased, then. In contrast, if antagonistic interests were involved, the prevailing discourse would necessarily reflect relations of power. Put differently, it would be biased. Moreover, the very same relations of power would tend to embrace a representation of the discourse that concealed its bias. Such representation would be biased, too. It should be stressed that the possibility that both the discourse as well as its representation were based on consensus does not by itself preclude bias. Consensuses that reflect agonistic interests only are not biased, while those that reflect antagonistic interests—e.g., a consensus between a robber and his victim whereby money is traded for life—are. The frequent appeal of academic bioethics to ‘public consultation’ and ‘informed consensus’ presupposes that such practices provide the choice of the public with legitimacy precisely because they preclude bias. This cannot be taken for granted, however, as the consensus between the robber and his victim indicates. If one stakeholder forced others into some disadvantaged social positions, and thereby subordinated their interests to his own, then the evolving consensus will have been the result of a fundamental coercion. The same applies to the representation of such consensus as a reflection of nothing but the Rousseauian ‘general will’. Antonio Gramsci ([1929–1935] 1971) refers to the interest of the dominant stakeholder and the consensus formed among dominant and subordinate stakeholders as hegemonic interest and hegemony, respectively, and Marxian schools of thought refer to hegemonic consensus as ideology. An ideological discourse may or may not contain ‘really’ true or good statements, but it is necessarily false in one sense: its selfprofessed role is not in accord with its objective, i.e., social, role.

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While the degree, if at all, to which the bioethical discourse, and hence its social agent, have been ‘hegemonic’ and ‘ideological’ could only be determined based on a comprehensive study, there is a good reason to suspect that normative discourses in general—and large part of the bioethical discourse has been normative—are essentially hegemonic and ideological. After all, normative statements are formed only under circumstances that reflect antagonistic interests. Ecologies involving agonistic interests only have no need to resort to such statements. They employ others. The following cases may demonstrate this point. The bioethical discourse of distributive justice in healthcare, for example, presupposes scarcity of resources. As such, it deals almost exclusively with ‘better’ versus ‘worse’ ways of rationing. In reality, however, there is no scarcity. Indeed, the economic crises of the past century have consistently resulted, at least in part, from overproduction, not underproduction. And we have not said anything yet about the unrealized productive potential of mankind. The problem of financing healthcare is thus ultimately a direct result of the increasingly unequal distribution of social wealth, an issue which academic bioethics has traditionally refused to tackle (‘that’s a political issue, not a bioethical one’). Historian David Rothman confirms this observation. . . . [Philosophy], not the social sciences, [became] the preeminent discipline among academics coming into the field of medicine. This, in turn, meant that principles of individual ethics, not broader assessment of the exercise of power in society, would dominate the intellectual discourse around medicine (Rothman 2003, 221).

In view of this point, the possibility that, contrary to its official intentions, the bioethical discourse of distributive justice has made the transition from the welfarist healthcare system to the neo-liberal one medically and publicly palatable should not be dismissed. Another example is the consistent focus of academic bioethics on the practices of biomedical science versus its reluctance to challenge its agenda. As a result of this, virtually every new technology could expect to sooner or later receive its blessing. Whether this has always been good for researchees, patients, and consumers is debatable, but it surely has always been good for business. Additional instances reflecting the ideological function of the bioethical discourse have recently been described by the author (Epstein 2007a; Epstein 2007b, Epstein 2007c). They consistently seem to suggest that the bioethical discourse, and hence academic bioethics, owe their historical success not so much to the abolition of medical paternalism as to its replacement by the more subtle, and yet no less ruthless, neo-paternalism of the free market. Similar suspicions have been raised by others as well already some time ago (Fox and Swazey 1984). Arthur Caplan describes their underlying logic as follows. Moral expertise, at least as reflected in the writings of many who work in applied ethics, appears to isolate moral issues from the social contexts in which they arise in order to make

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conceptual analysis possible. Moral expertise thus is bankrupt because it becomes nothing more than apologia for the norms of the dominant class. Moral experts, as Hegel once warned, are doomed to be nothing more than conceptual handmaidens to the powerful and dominant within society (Caplan 1992, 26).

Epstein, M. 2007c. The ethics of poverty and the poverty of ethics: The case of Palestinian prisoners in Israel seeking to sell their kidneys in order to feed their children.Journal of Medical Ethics 33:473– 474.

The possibility that academic bioethics has routinely been “a conceptual handmaiden” and only occasionally corrupt should concern us no less than the opposite case. !

Fox, R. and Swazey, J. 1984. Medical morality is not bioethics— Medical ethics in China and the United States. Perspectives in Biology and Medicine 27:336–360.

REFERENCES

Gramsci, A. [1929–1935] 1971. Selection from the prison notebooks, ed. Q. Hoare and G. Nowell Smith. New York, NY: International.

Callahan, D. 1992. Why America accepted bioethics. Address to the Birth of Bioethics Conference. Seattle, WA, September 23–24, 1992. Hastings Center Report 23(6): 58–59. Caplan, A. L. 1992. If I were a rich man could I buy a pancreas? And other essays on the ethic of health care. Bloomington: Indiana University Press, 26. Epstein, M. 2007a. Legitimizing the shameful: End-of-life ethics and the political economy of death. Bioethics 21(1): 23–31. Epstein, M. 2007b. Legal and institutional fictions in medical ethics: A common, and yet largely overlooked, phenomenon. Journal of Medical Ethics 33(6): 362–364.

Evans, J. H. 2008. In Search of a measure of industry funding. American Journal of Bioethics 8(8): 59–60.

Hobbes, T. [1651] 1996. Leviathan. Oxford, England: Oxford University Press. I.11.21 Resnik, D. B. 2008. Hidden sources of private industry funding. American Journal of Bioethics 8(8): 60–61. Rothman, D. J. [1991] 2003. Strangers at the bedside: A history of how law and bioethics transformed medical decision making. New York, NY: Aldine de Grutyer; 221. Sharp, R. Scott, A., Landy, D., and Kicklighter, L. 2008. Who’s buying bioethics research? American Journal of Bioethics 8(8): 54–58. Tsai, A. 2008. Who’s buying normative bioethics research?American Journal of Bioethics 8(8): 62–63

Does Money Make Bioethics go ‘Round? Raymond G. De Vries, University of Michigan Carla C. Keirns, University of Michigan Money, money, money, money, A mark, a yen, a buck or a pound, That clinking, clanking clunking sound is all that makes the world go round, It makes the world go round. “Money, Money,” from Cabaret

Money is the stuff of life; it is the medium of exchange that we use to buy food, clothes, warmth in the winter, cool in the summer, and the fuel that moves us around the planet. Of course money makes the world go ‘round, but does it, Sharp and his colleagues (2008) want to know, make bioethics go ‘round? We all agree that there are things money cannot buy – happiness, love, contentment – but are there things money can, but should not, buy? How about health care? Citizens in the countries of the developed world (with one notable exception) have decided that while the market may work

its magic in producing high quality, low-cost computers, it is not the appropriate mechanism to govern access to the life-giving resources of medicine. How about medical research? Improvements in health care often are the result of the diligent, and costly, labors of medical researchers. Someone has to pay for this important work. But, as we now know, money has a way of corrupting research. An enterprising muckraker could easily sell subscriptions to a “scandal-ofthe-month” club newsletter, documenting the many cases where drug and medical device companies put profits before people. Think, for example, of Vioxx, the International Early Lung Cancer Action Program (Resnick, 2008), or Vytorin (Lemmens, 2004). What about bioethics? We know that money can be used to buy bioethics, but should it? This is the question that troubles Carl Elliott (2005), Leigh Turner (2004), Virginia Sharpe (2002), and others. Being empirically oriented, Sharp and

Raymond G. De Vries, Bioethics Program, University of Michigan, 300 North Ingalls Street, Rm 7C27, Ann Arbor, MI 48109. E-mail: [email protected]

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