The Ethics of Professional Ethics

When I was defending my dissertation a few years ago, a committee member asked me how I would respond to a tobacco company who asked me to advise them on the most ethical ways to harvest tobacco grown on farms in South America. I first answered, honestly, that I couldn’t imagine working for a tobacco company, but then I added that the only advice I could think of would be to choose a more ethical product in the first place and then worry about fair treatment of workers, protection of the environment, and so on.

It would, of course, be difficult to make a living as a professional ethicist if you simply Briberyadvised all your clients to go out of business. Accepting a paying job creates a financial conflict of interest from the beginning. If you want to keep your job, you will immediately know the parameters of your possible advice. In the worst case, you will simply be giving rubber-stamp approval to the activities of your boss. In the extreme case of a tobacco company, this conflict may be clear, but other conflicts are much less obvious.

The best problem for an ethicist to have, I think, would be an opportunity to work for a company or organizations with the same goals and values of the ethicist. It would make sense for a vegan ethicist to want to work for a company that sells cruelty-free products. If the company hired an ethicist to determine what practices ere ethical, it would be a perfect situation, but this is a case of an organization seeking out an ethicist whose conclusions are already known. This is hardly an ethics consultation. And just to vary the scenario a little, it is unlikely that a Catholic-owned organization is going to want to hire an ethicists who does not believe in the sanctity of life just as an organization providing contraception services would not want to hire a Catholic ethicists. If you can simply shop for an ethicist who agrees with your actions beforehand, there is no point in hiring an ethicist.

In some cases, companies really do want to seek expert advice on how to proceed on various products and actions. They seek out, naturally, ethicists who share their overall values but have additional training and demonstrated expertise in evaluating ethical quandaries. When helping some one choose between X and Y, ethicists can make a fairly objective evaluation, given that neither choice is presented as the preferred choice. Rather than “Have we been ethical?” the organization is asking, “Which of these two choices is the most ethical way to proceed?” In this case, asking more than one ethicist would seem advisable. Then, the organization is still responsible for its decision, but it is based on more (and more nuanced) information. Still, it is possible for people to use the ethicist for moral cover (“Hey, the ethicist said it is ok, so there!). Providing moral cover for your employer is just never going to look good.

Ethicists can proceed, though, by offering a thorough analysis without necessarily giving a green light to any particular action. With so much training behind them, ethicists should be well prepared to answer questions about agency, autonomy, rights along with background information on previous cases and debates. We don’t need to reinvent the wheel each time a new problem arises.

The professional ethicist can help with questions such as:

  • What are violations of autonomy?
    Is autonomy the only concern?
    What is the importance of narrative in moral decision-making?
    Do men and women operate with different moral frameworks?
    What are moral agents?
    Who is (or should be) of moral concern?
    What is the importance of virtue in organizational ethics?
    Is care necessarily part of ethical deliberation?
    What are positive and negative rights?
    Which moral choices are obligatory and which are supererogatory?
    What is the difference between human rights, human development, and human capabilities?
    Who is responsible for justice?
    Must ethical decisions be impartial (do family and friends matter more)?

It is Time to Shed Sunshine on Informed Consent

Most patients realize doctors receive gifts from the pharmaceutical and device-

A patient having his blood pressure taken by a...
A patient having his blood pressure taken by a physician. (Photo credit: Wikipedia)

manufacturing industry. When we see industry logos on pens, clocks and posters, we don’t assume the doctors ordered these items from the merch page of these companies, but most of us aren’t aware of how lucrative the payments to doctors can be.

A story that ran in the New York Times described the experience of Dr. Alfred J. Tria, who made $940,857 in about two years for promoting products and training doctors in Asia to use them. The article notes that Tria’s experience may be exceptional, but in two and a half years, industry paid out $76 million to doctors practicing in Massachusetts alone.  I’ve been reading about this subject for a while, and even I was surprised that someone could make half a million dollars in a year on a side job.

In a slightly different type of payout, Oregon recently concluded a court case against two doctors who “put heart implants into patients without telling them that a manufacturer’s training program put a sales representative into the operating room.” The doctors would receive between $400 and $1,250 each time they completed a surgery using Biotronik defibrillators and pacemakers. The state argued that patients should know when doctors’ recommendations may not be based entirely on the needs of the patient. One of the doctors in the case earned more than $131,000 from 2007 to 2011 through implant surgeries. Doctors also received speaking fees, expensive meals, and other gifts.

As part of the Affordable Care Act (Obamacare), the Sunshine Act now requires industry to start collecting data on payments to doctors now, and the information will be made available to the public next year on a government website. This will enable patients to learn how much their doctor receives from the industry each year, though there may still be hidden incentives.

For example, doctors may be in profit-sharing arrangements with facilities or they may actually be the owners of the facility. A recent study by Dr. Matthew Lungren found that doctors who had a financial stake at an imaging facility ordered tests with negative results at a much higher rate (33 percent) than doctors with no financial stake. In other words, it appears that doctors order unneeded tests because they are making money off of them, not because the patients need them. Lundgren suggests that patients should ask whether they are being referred to a facility in which the doctor has a financial stake. I say the doctor should volunteer the information.

Beginning next year, the Sunshine Act will make it much easier for patients to discover their doctors’ financial relationships with industry, and I’m thrilled for this development. For those who think Obamacare is a complete disaster, just take a minute to relish this one positive development.  Still, I think the movement should go further. I think financial disclosure should be part of the informed consent process. When your doctor is telling you all the risks and benefits of treatment, I think he or she should also say, “I get paid $1,000 to do this surgery,” “I will make $100 off this MRI,” or “I own stock in the company conducting this medical research.”

I believe patients want this information, and I don’t think they feel it is their responsibility to search for it. True informed consent is only possible in light of complete financial disclosure.

Corporate funding of research.

Many of us are suspicious of health and safety claims based on research funded by corporations that get rich off public confidence in the health and safety of their products. I don’t really trust manufacturers of drugs or genetically modified foods to tell me that they are safe. I also would feel better hearing that an oil spill is no threat to life or environment from someone other than the company that spilled the oil. (Many people seem to have made one inexplicable exception to this rule, which I will mention in the postscript.)

Further, when corporations fund research projects or labs, they gain control over what information is published. The scientists involved may have enough integrity to conduct rigorous research, but unwanted results are likely to be suppressed, especially if they will hurt the bottom line. This may be justified by claiming that only “useful” data need be published, but negative data can also be useful and can avoid wasted money and energy. If one researcher finds that something doesn’t work, publishing that data can help others avoid the same mistakes. Of course, researchers do share data, but some studies are also suppressed. Publication of misleading data and suppression of useful data are two possible hazards of corporations funding research that will affect their bottom line.

On the other hand, if corporations are the ones to benefit from research, it seems they should bear the cost of supporting labs, scientists, and related endeavors. Of course, some research is in the public interest, and I believe the public should fund it, which may be the topic of another blog. To avoid obvious conflicts of interest in research, companies should not be permitted to hire and promote researchers directly. Funding should go in to a pool and be dispersed anonymously to research labs, scientists, and universities. For profit labs could still exist, but researchers should not be beholden to a specific entity. It was not that long ago that much university research was conducted in this manner. In that sense my proposal is regressive, not progressive.

Postscript: When people get sick, many of them demand the latest drug available, even if it hasn’t been tested thoroughly. They seem to feel that their suffering from the disease is always going to be worse than the effects of the drug. I recently had a student (not a medical student) argue vehemently with me that no one had ever died during a drug trial. For those who know anything about drug trials, this over confidence is baffling, but I fear many share his optimism regarding the safety and effectiveness of experimental drugs. If you don’t know this already, let me tell you that drug testing is there for a reason; not every drug tested turns out to be safe and effective.