MacDougall attempts to frame his argument in support of pharma-funded bioethics against a construct used by Carl Elliott: the legal system. In discussing why bioethicists should not take money from pharma, Elliott uses an analogy of judges who receive a public salary being in an institutional role governed by social norms that require impartiality – an impartiality that is violated by accepting bribes. MacDougall seems to claim that since there is a dispute over the role of bioethicists, there are no social norms governing bioethicists. Therefore, it is not unethical or corrupt for bioethicists to accept industry money:
If we can’t agree on basic matters such as whether bioethicists are more like judges or public interest lawyers in the relevant respects, then … we should probably not implement policies like those suggested by Elliott.
Despite the position that policies should not be implemented without agreement, MacDougall then goes on to assume that bioethicists function like lawyers, suggesting that “both sides” receive bioethical representation.
And therein lies a problem with MacDougall’s argument: bioethics, as Jennifer Miller and William English note, is a field that involves expertise. That expertise is used to argue, interpret, and formulate policy; continuing the legal analogy, bioethicists function not only as lawyers and judges, but also lawmakers.
MacDougall’s scenario of a Wild West free-for-all of funding based on partiality and conflicts-of-interest sets up the bioethicist to be the evil Sheriff in a Western: the person who has consolidated power and through that, reveals his or her corruption. MacDougall seems to want to claim that regulatory policies should not exclude corporate funding while not addressing the concern of Elliott and others: money is power is corruption. While MacDougall does not directly address corruption in his essay, corruption is at the heart of many of the concerns broached by his references when discussing corporate money and bioethics.
The very reality of absolute power corrupting absolutely is the justification for trias politica–separating the government into three branches: the legislative branch, which makes the law; the judicial branch, which interprets and applies the law; and the executive branch, which executes the law. In this way there is a separation of power between those who devise, interpret, and enact legislation. But this is not what MacDougall is arguing; MacDougall’s position of allowing bioethicists to set policy, receive unregulated compensation, and advocate for positions without external accountability quickly sets a course towards corruption.
However, a trias politica-inspired system, with the bioethical equivalent of legislative, judicial, and executive branches, is not an inherently bad idea. The structure–a separation of powers to limit overall influence of any one group within an institution–is echoed in many professional fields beyond politics and law enforcement, including the military and the academy itself. The key requirements of this structure are an accountability system, agreed-upon social norms, and transparency.
Accountability systems require explaining and justifying actions to some authority who has the power to adjudicate actions and enforce punishments. It doesn’t matter if there is an agreed-upon social norm for bioethicists to take industry money when there is no formalized institution of accountability to enforce, via law or punishment, those social norms that exist to prevent corruption. Over the years, it has been suggested that there should be an accrediting board for clinical ethics, but there has been little movement in the field of bioethics towards any single authority akin to medical boards or to the American Bar Association.
Of course, a fundamental roadblock to forming an institutional bioethics accountability system is that there is no single, agreed-upon social norm binding bioethicists together. It is possible to find bioethicists advocating positions that are strictly pro- or anti-: choice; death penalty; physician-assisted suicide; forced medication; and just about any other topic imaginable. MacDougall seems to agree that there is little consensus within the field of bioethics, and therefore takes a position that no policy should be adopted that may exclude voices. However, MacDougall’s solution–a bioethics free-for-all–conflates the bioethicist’s personal worldview with a bioethics-society worldview. That this latter does not exist, does not mean that bioethicists are exempt from the wider social norms of the academy or the culture that they live in. A discussion about what the social norms of bioethics ‘should be’, cannot ignore the larger setting of both academic and social expectations regarding corruption. (For further information, see: Miller, The Morals Foundations of Social Institutions.)
The third component necessary to minimizing corruption is transparency. As Miller et al. note, “widespread corruption can flourish in secretive social and institutional environments.” Anyone familiar with the multiple corruption scandals involving pharmaceutical companies (see Elliott, Goldacre, or the recent pharma issues with bribery in China, for example), or the push-back the AllTrials open data access/accountability group has received, knows how potent an anti-corruption measure transparency is. Indeed, this explains why individuals and corporations who benefit from secrecy fight moves towards transparency. To paraphrase Miller et al., the perfectly corrupt bioethicist is one who maintains an outward appearance of justice and propriety while carrying out his or her corrupt deeds in secret. Can anything be more secret than hiding behind the veil of corporate confidentiality and proprietary data in the world of pay-for bioethicists?
If, with great power comes great responsibility, what does great responsibility come with? Sometimes, great responsibility means acting in such a way as to set aside self-interest – the means of money do not justify the ends of corruption.