Will the ‘Secular Priests’ of Bioethics Work Among the Sinners?
by Christopher MacDonald
2003. The American Journal of Bioethics 3(2):W36-W39

In this paper, I explore briefly the "secular priesthood" metaphor often applied to bioethicists. I next ask: if, despite our discomfort with the metaphor, we were to embrace the best aspects of the priesthood(s) - which I identify as the missionaries' willingness to work among sinners and lepers, at their own peril - would we be able to live up to that standard of bravery? I then draw a parallel with the fears of contagion currently be voiced (by Carl Elliott and others), with regard to bioethicists working in or near corporate settings. I argue that such fears may themselves have a number of deleterious effects, and I suggest several possible positive steps in response to that fear.

One of the metaphors that makes those of us within the bioethics community most uncomfortable is that of 'bioethicist as secular priest.' The comparison is not without basis, of course. Ethicists commonly act as confidants, as advisors, and as interpreters of the 'holy texts' of bioethics. But our discomfort with the comparison is also understandable. We hope that, unlike priests, we do not preach (or at least that we keep the preaching to a minimum), and we also hope to be modest in our claims to know the truth. Where the priest can hope to call upon revealed truth, all that the bioethicist can call upon is considered judgment. Secular bioethicists don't want to be compared to Christian, Jewish, or Muslim clerics. No offense is intended here; likely those same clerics would likewise want to make a clear distinction between what we, and they, do.

But the characteristic shared by a number of religious orders that most amazes me, and the one that I think most warrants careful thought as far as comparisons with bioethics are concerned, is the willingness of some orders of the priesthood to undertake work in difficult settings, in places that are dangerous both physically and spiritually. Priests (and I use the term loosely, here, to include holy men and women of many faiths) have been willing to work among the sinners, the lepers, the 'savages.' History shows us, of course, that such work too often reflected an unfortunate ethnocentrism. But the fact remains that such work requires bravery and dedication.

If (or to the extent that) bioethicists are to be compared to priests, who are the modern-day pariahs to whom we will minister? Some will be quick to point, here, to the 'untamed wilds' of the clinical setting, or to the jungles of the Research Ethics Board. But by missionary standards, those settings are tame. The people in those settings are people too much like us (fellow professionals, fellow academics, people with university degrees) for working among them to be considered brave, on a day-to-day basis. Surely, such work presents the opportunity for bravery (see Freedman 1996). Standing up to a powerful clinician or researcher is, as the largely unwritten history of our discipline makes painfully clear, a difficult and sometimes dangerous thing. Ethicists' jobs have been threatened, and even lost, over such things. But those crises are not the bread and butter of our work in these relatively tame lands.

I think an argument can be made that, to the extent to which a comparison is to be made, the real pariahs of modern bioethics - the ones among whom our work involves the most moral and professional peril - are the biotechnology and pharmaceutical companies.

Worries about the risks of contagion involved in working with biotech/pharma were front and center, for example, at the 2001 annual meeting of the Canadian Bioethics Society, held in Winnipeg. Plenary speaker, Carl Elliott,¹ worried aloud about the academic freedom of ethicists in the employ of large corporations, and warned, quite appropriately, against letting such corporations use bioethicists as a way of absolving themselves of responsibility for moral choice. Françoise Baylis, also speaking in a plenary session, reminded us that working in, or even near, such settings may put us in situations that require us to make personal and professional sacrifices in order to do the right thing.² Charles Weijer, in the post-conference session on bioethics and the media, told how the invited editorial he had written at the request of an academic journal had been deemed unsuitable for publication, apparently because his views (by no means idiosyncratic) conflicted with drug company interests.³ And Arthur Schafer told the audience at the post-conference workshop that he thought that the domination of the health research agenda by pharmaceutical company funding was the most urgent ethical challenge in modern bioethics. Similar worries were heard in a number of the presentations made in concurrent sessions.

Worries about the role of bioethicists in corporate employ have also appeared in the popular press. Articles and editorials critical - or at least skeptical - of the role of bioethicists in corporate settings have appeared in the on-line magazine Slate (Saletan 2001), in Christianity Today (n.a., 2001), and in the New York Times (Stolberg 2001).

I think we should all take these concerns to heart (MacDonald 2003). Certainly I, as a young academic, shiver both at the dangers posed by corporate domination of research agendas (including programs of ostensibly publicly funded research) and at the moral and professional peril represented by lucrative corporate or quasi-corporate employment options. We cannot plausibly claim, at the dawn of the twenty-first century, to be so naïve as to suppose either that vast quantities of corporate money do not shape both health research agendas and public discourse, or indeed that our own views as reflective academics and professionals will not be affected. Corporate money, at least in the current context and in the quantities currently on the table, really does seem capable of imperiling the very soul of bioethics. I, for one, am very likely to steer those troubled waters carefully.

Three worries occur to me, however, when I contemplate the possible results of this tendency to keep our distance. I will outline these very briefly before suggesting some solutions.

1. Intellectual poverty.
Most of us in academia share the belief that the best solutions come from the broadest discussions, discussions that include as many voices as possible. I would argue that this means including corporate voices. This may sound like a joke: surely corporate voices are all too loud. Granted. But I want to hear the real story, not the corporate P.R. story. If we don't understand how corporations work, what drives them, we won't be able to respond to them appropriately - at the level of academic critique, professional practice, or public policy.

2. Practical failure
My next concern with avoiding engagement with the corporate world has its source in the realization that corporate policy may well in fact be where the action is. Many of us in bioethics choose to focus on debates about what would constitute appropriate regulation and other forms of government policy in the realm of healthcare. That's highly appropriate. We absolutely should be concerned with decisions and policies that have the broadest impact. But in the field of biotech, at least (and perhaps health research more generally), government policy will always lag behind corporate practice. We'll always be playing catch-up. It happened with cloning, it happened with stem cell research, and it will happen again. It's not good enough to say "let the corporations do what they will, and we'll regulate it later." We've got to start helping corporations make better decisions in the first place.

3. Potential for criticism of young (especially untenured) academics by their own colleagues.
What would happen to a young researcher who wanted to study biotech companies in sufficient detail to really understand the forces of commercialization? What would befall a junior academic who wanted to understand the ways in which companies respond to different regulatory regimes? In attempting to ground her academic inquiry, she would plausibly seek to get inside one or more companies, to attend board meetings, to tour labs, to eat lunch there. Would she face criticism from colleagues? Would she be stigmatized for her interest in the corporate world?

A generation ago, philosophers and other humanists entered the wards and executive wings of hospitals for the first time. Since then, many have appropriately worried about the 'capture' of bioethics by medicine. If bioethicists are now considered 'insiders' in health care, can they really be effective critics? This is a very good worry. But most have concluded that it's alright if at least some of us work from inside the world of healthcare, the better to understand it and the better to effect change.⁵ Would a junior academic who made a similar choice vis-à-vis the corporate world be supported by her senior colleagues? This worry warrants our careful consideration; we ought not to let good work - in particular, that of bright junior colleagues - become the unintended victim of our well-founded skepticism of the corporate world.

Having outlined three important worries about bioethics' collective tendency to keep its distance from the world of corporate biotech and big pharma, I now move to propose three ways we might begin to improve this situation.

Proposed responses to these worries
1. Focus on procedural mechanisms to mediate conflict of interest.
We need to seek out ways to work more safely in and near the corporate context. Where clerics historically relied upon faith, modern hospitals rely upon 'universal precautions' to minimize the risk of contagion. We in bioethics should follow the latter example. A number of mechanisms exist for moderating risks in situations that threaten to facilitate corruption, or even just cooption. Procedural safeguards are a well-established mechanism for mitigating the problems of conflict of interest that arise, for example, in the activities of Boards of Directors of non-profit organizations (MacDonald et al 2003). Such Boards sometimes include members who, because of their professional, commercial, or research interests, stand to benefit in various ways from decisions taken by the board, and there is legitimate concern about this. Excluding such persons is seldom possible, since they often bring indispensable expertise. Non-profit Boards that take this risk seriously have moved to implement strict policies requiring disclosure of material interests and abstention from decisions in which interests other than those of the organization might interfere. The consensus, here, is that for these organizations, an ongoing relationship with such individuals is important, indeed so important that it is worth finding ways to mitigate the dangers inherent in such relationships. Other mechanisms that might play a role in mitigating the risks of corporate involvement include arms-length performance evaluation, university cross-appointment, and peer-review mechanisms.

Relevant comparisons here might be found in the development of corporate (and professional) codes as well as the increasingly high standards for transparency and accountability in the corporate sector.⁶ Of course, it would be naïve to think that mechanisms such as these can make our worries about corporate bioethics go away. But we need to do much, much more than has been done to date in exploring whether, or the extent to which, such mechanisms can render relations with corporations safe enough to allow this potentially important work to proceed. (In particular, almost none of what has been written on this topic differentiates in any reasonably nuanced way between different types of involvement with corporations; yet we can reasonably expect to find different risks attending activities as diverse as membership on a corporate advisory board, the conducting of staff training seminars, and the writing of advisory or research papers - and, hence, we should look to different proposed forms of prophylaxis for each of these different activities.)

2. Invite corporations to bioethics conferences - not as sponsors, but as interlocutors.
Engaging representatives of corporations in honest debate, away from the glare of the television cameras, is absolutely crucial, for two reasons.

First, inviting corporations to the table is crucial for an improved understanding of corporate motives and corporate aspirations. Any claim that corporations have just one motive (namely profit) and just one aspiration (namely market dominance) is woefully naïve, not to mention insulting. Anyone with more than a passing knowledge of the pharmaceutical industry, for example, knows that corporations in that industry vary a great deal in terms of their apparent motivations and in terms of their behaviour. And the more likely hypothesis concerning the root causes of unethical behaviour on the part of corporations is one analogous to the best explanation of wrong-doing in other institutional contexts: namely, that certain institutional arrangements create incentive structures that encourage good people to do bad things. It is highly unlikely that an adequate understanding of complex issues in health policy will be possible in the absence of an adequate understanding of one of the major players. So we desperately need sound models of the motivational structures of (for example) biotech and pharmaceutical corporations.

Second, inviting corporations to the table is crucial in order for us to gain improved access to the actual levers of power. If we in bioethics seek to effect change, then we must be realistic about where the power to effect change lies. The pace at which biomedicine advances means that many battles will be won or lost long before governments are able to go through the usual process of consulting broadly, placating various interest groups, and arriving at a compromise policy that pleases no one. In the meantime, corporations will go on making decisions; is it better that those decisions don't have the benefit of the insight of the bioethics community? And perhaps I won't be accused of being overly cynical if I were to advance the thesis that, given the access that corporations often have to policy-makers, influencing corporations is itself an excellent way of influencing government policy.

Such involvement by corporations in bioethics conferences would also have the ancillary benefit of opening up for informal peer-review the advice given to corporations by individual bioethicists. Surely our worries - both those that have been published, and those harbored secretly - about what our colleagues on contract to corporations are saying to their employers would be mitigated if we could hear for ourselves the advice being given, in a public forum.

3. Keep "conflict of interest in corporate settings" on the short list of topics to be considered by committees of our national bioethics organizations.
The Canadian Bioethics Society (CBS) Ad Hoc Working Group on Working Conditions for Bioethics has identified bioethicists' involvement in corporate settings as part of its broader mandate.7 And a Joint Task Force on Bioethics Consultation of the American Society for Bioethics and the Humanities (ASBH) and the American Society for Law, Medicine and Ethics (ASMLE) has already issued its conclusions regarding bioethics consultation in the private sector (Brody et al 2002). These committees have had as their primary foci issues related to employment of bioethicists in hospitals, in universities, and in the intersection of those two.8 But many of the same issues - issues of appropriate reporting relationships, of academic freedom, of the ethicist's role within the organization - are bound to arise in corporate contexts, and indeed are among the issues that generate the greatest fears of contagion.

The conclusions of the joint ASBH/ASMLE task force, not surprisingly, focused on mechanisms and procedures to mitigate the risks inherent in such employment. In fact, many will be disappointed that the conclusions reached by the joint task force feature the kind of compromise wording so often found in policies devised by committees. But compromise or not, the attention manifested in this report is significant, and it is crucial that our national organizations continue to take the question of corporate bioethics seriously. Lamenting the effect of corporate largess on the integrity of bioethics will not reduce the need of corporations for advice on ethical issues, nor the temptations for bioethicists to engage in that work.

Conclusion
Like it or not, for-profit biotechnology and pharmaceutical companies play a central role in determining the health research that gets done, the health care that gets provided, and even the health policies that get set by governments. And there is genuine peril involved in working within the sphere of influence of companies so well-heeled, and so willing to spend money to get their way. Will we in bioethics deign to work among these sinners, these lepers, these 'savages?' Will the new priests of bioethics rise to the challenge of this uncomfortable metaphor? I hope so. For courage involves not just the willingness to respond to moral dangers when we see them, but also the willingness to place ourselves - with all due discretion - into dangerous situations in the first place.

Notes:

1. See also (Elliot 2001a) and (Elliot 2001b). Interestingly, for my purposes, the former paper by Elliott includes this claim: "I preach this sermon from a position of relative safety, of course." [emphasis added]
2. See also (Freedman, 1996).
3. The editorial in question was eventually published in a different journal. See (Weijer 2002).
4. Saletan's article has been widely cited in papers discussing controversy over the role of bioethics. I'm not sure why, since the main thrust of the paper is merely that on one particular issue, some bioethicists reached a conclusion that Saletan didn't agree with. I don't see why that constitutes much of a critique of the discipline.
5. (Callahan 2001) calls this "the access argument," and claims that the possibility of contagion is "too high a price to pay" for access to corporations.
6. (Elliott 2001a) considers briefly such procedural mechanisms in his article in Hastings (p. 11), but quickly dismisses them as stop-gap measures on the road to the commodification of ethics.
7. The author is a member of the Ad Hoc Working Group. However, the views presented here are the author's alone; they do not necessarily reflect the views of the members of the Working Group, or of the Canadian Bioethics Society. For updates on the Working Group's work, see http://www.bioethics.ca/english/workingconditions/
8. Note that no one expects these committees to conclude that working, for example, as a non-tenured ethicist in a hospital leads to such dire conflicts and ambiguities as to cast doubt on the possibility that such work could be carried out with integrity.

References:
Brody, B., N. Dubler, J. Blustein, A. Caplan, J.P. Kahn, N. Kass, B. Lo, J. Moreno, J. Sugarman, and L. Zoloth. 2002 "Bioethics Consultation in the Private Sector." Hastings Center Report 32:3 14-20.

Callahan D, "Doing Good and Doing Well," 2001. Hastings Center Report 31, no. 2: 19-21.

Elliott, C. 2001(a). "Throwing a Bone to the Watchdog," Hastings Center Report 31, no. 2 (2001): 9-12.

Elliott, C. 2001(b) "Pharma Buys a Conscience," The American Prospect, Sept. 24, 2001

Freedman, B. 1996 "Where are the heroes of bioethics?" Journal of Clinical Ethics; 7(4):297-299.

MacDonald, C. 2003 "Vigilance is vital to avoid conflict of interest." Nature 422 (3 April, 2003) 469.

MacDonald C., M. McDonald, and W. Norman. 2002. "Charitable Conflicts of Interest." Journal of Business Ethics 39:1-2, 67-74..

n.a., 2001. "Wanna Buy a Bioethicist?" Christianity Today, (October 1, 2001) 45:12, p. 32.

Saletan, W. 2001. "The Ethicist's New Clothes," Slate. August 17, 2001. http://slate.msn.com/?id=113959&&

Stolberg, S.G. 2001. "Bioethicists Fall Under Familiar Scrutiny," New York Times, August 2, 2001. (on-line: http://www.nytimes.com/2001/08/02/health/genetics/02BIOE.html)

Weijer, C. 2002 "Placebo trials and tribulations," Canadian Medical Association Journal; 166: 603-4.