Bioethicists turn critical spotlight on themselves
Like it or not, the business of ethics is changing
As the practice of bioethics expands beyond the traditional hospital setting, it is becoming even more important that bioethics professionals develop a process to critically examine their own practice in much the same way they critique the practices of others.
Does accepting payment for bioethics consulting necessarily compromise the professional advice given? For whom should bioethicists offer consultation? Are there any inappropriate venues? And in what ways do health care environments, personal achievement, and prestige affect the practice of bioethics?
These are some of the many questions that experts in the field are beginning to ask of themselves and others as both health care and medical ethics rapidly expand beyond traditional horizons.
"Bioethicists, usually philosophers and humanists, were traditionally asked to go into the hospitals and take a look at difficult clinical cases. And, the model of clinical ethics consultation is based on that paradigm," says Laurie Zoloth, professor of social ethics and Jewish philosophy at San Francisco State University in California.
"While there was interest, at that time, in whether you could be paid directly or not — it never reached the pitch that it has recently. Now, bioethicists are being asked by biotech companies and pharmaceutical companies to do the same thing, to come into an unfamiliar venue where there are significant ethical issues and bioethical issues, and take a look at these."
Is it appropriate?
Zoloth was one of several academic bioethicists contributing to a series of essays examining the "business of bioethics" in a recent issue of The Hastings Center Report.1 She finds it interesting that, for years, bioethics professionals have been urging pharmaceutical corporations and third-party payers to critically examine ethical issues, but, now that they are asking for help, there is a great deal of debate over the appropriate way to do this.
"Now, the private sector takes us seriously and says, OK, come take a look, tell us what you think,’" she says. "Once we are asked to go, the question becomes, Do you do it for free? Do you take money for it?’ Suddenly, you are in a different world."
Payment isn’t the only issue, she adds. Many bioethicists are concerned over requests that they sign privacy and confidentiality agreements. "It is not that we are unfamiliar with privacy and confidentiality, that is supposed to be our business," she continues. "Suddenly, we are in a world where the first thing one does is sign a nondisclosure form, which feels different. Actually, it is not that different from not disclosing your patients’ information, or not disclosing research results prematurely. But, it does take people aback."
Payment and the power to corrupt
Some ethicists have argued against accepting payment for private bioethics consultations. Money, they argue, would inherently compromise the process — in ways subtle and not-so-subtle, the consultant would be less likely to criticize the "employer." Zoloth doesn’t agree.
"If it should all be pro bono, then we shouldn’t take money from foundations or universities or anybody," she says. "Many people work as clinical ethicists in hospitals. Should you say, Pay me a de minimis amount, half of what I make at a hospital, or the same rate as what I make at a hospital?’ Why is that different? A large hospital asks for my opinion and pays a certain rate, and a pharmaceutical company asks for my opinion and does as well. All money comes from somewhere."
The debate about payment is largely confined to academic circles, where bioethicists can "afford" to discuss pro bono work because they have tenured faculty positions with major universities. That discussion fails to consider the health care professionals who may have both a background in clinical and ethical study and now make their living in the private sector, she admits.
Jon R. Hendrix, EdD, retired professor of biology and science education at Ball State University in Indianapolis, founded the school’s Human Genetics and Bioethics Education Laboratory, and served for nine years as a member of a hospital ethics committee. He now runs a private bioethics consulting business that works with two community hospital systems.
His consulting is both corporate and clinical — helping the systems develop ethical business policies and helping the standing ethics committees resolve difficult clinical problems. "It’s a constant battle," he says of the need for consultants to examine the context of working relationships. "It must be a constant battle; we are human beings and are subject to all of the frailties thereof. The interest of people who listen to you in a group, the feedback you get, all of these are subtle motivators."
Zoloth agrees that money is not the only element with the power to compromise.
"The questions I am interested in have less to do with money," she says. "I think one can be tempted by money, but I think it is pretty easy, especially if you are an academic and you have tenure, to say, Oh, well, I’ll do it for very little money, or I’ll do it for no money,’ that we should all do it pro bono. I don’t think even that solves the problem. I have seen principals get up in meetings and talk about all their work and get all of the secondary benefits, for their careers and their publications, because they have done the work. Even if they don’t get a dime, they have the access to power and the access to secret knowledge. For me, I wanted to push us to look not only at the issue of money, but to look at the issue of how we handle, and are shaped by, the kinds of consultations that we do."
It’s a complicated area, notes Hendrix. In his arrangements with the hospital systems, he charges a flat rate that is paid out of money from a hospital foundation, he notes. Therefore, he feels able to agree or disagree or challenge decisions the hospitals want to make.
However, he has seen how other arrangements, both financial and organizational, would make it difficult to remain objective. "There are some hospitals that have chosen, after the Joint Commission came up with the requirement that you have a formalized method of resolving ethical issues, some have chosen to just pick a consultant [to perform this function]," he says. "And, some have just picked a consultant they know will agree with them, as long as that consultant is being paid."
More than decision making
Frequently, the consultants end up feeling that it is their job to simply come in and render the "ethical" decision, Hendrix says. "I maintain that a good bioesthetician in a group dynamic learns to ask questions, rather than immediately give solutions, learn to be a real questioner and draw forth solutions from the group, rather than impose solutions yourself," he says. "You are there really as a facilitator helping them meet this need. There are bioestheticians who have literally come in and said, This is what I recommend,’ and that scares the living daylights out of me because it is such a values imposition. It never allows for growth in the community for which you are working."
Maintaining the humility’ of bioethics
The key to preserving one’s own equilibrium is to self-impose a system of checks and balances, Zoloth believes. "Some of the ideas that I had, are that you don’t do it alone," she says. "Where you have a large group of people, and you can ask and answer questions. It is always important to work with ethics committees, and to work with colleagues, so that you aren’t the lone gun being hired like in the Wild West to come in and fix something. You are part of a moral community and you are accountable to somebody. You should always have the sense that it is not you vs. the company. It is you, and the company, and the society, and it is the society to which you are responsible."
Disclosure to others of the work you are doing is also important, she says. "It is extremely important to disclose who you consult for and how you’ve done the consultations," she says. "You shouldn’t be ashamed of any work you do — they ought not to be ashamed of consulting a bioethicist and you ought not to be ashamed of having spoken to a company. And, I think future clients have a right to know who you’ve worked for, if you are talking about a particular drug or technology, if you have previous experience with that."
Identify the parameters
And, in going into consultations, it is important to very clearly spell out what is expected by both parties at the outset, says Hendrix.
"You need to very carefully spell out the parameters of that consultation so that you are not roped into doing things that you are not, first of all, adequately prepared to deal with, and secondly, qualified to deal with," he says. "There are some things I may feel qualified to do, but feel that I have not been given enough time to be adequately prepared to deal with. I think that when you are doing consulting, you need to know some of the parameters, and whether the time constraints allow you to do that. Do some real thinking about that before you go into a group."
It is high time that bioethicists examined their own practice in much the same way they examine the practices of companies, health systems, and hospitals, she says. "I do think it is important that we turn our attention, as a field, to the work that we do. We often critique others, and it is important to turn that focus on ourselves as well. We have spoken a lot about conflicts of interest with researchers, and while I think it is legitimate for us to raise this issue, we also ought to raise the issue of conflict of interest with one another."
Reference
1. Elliott C, Donaldson T, Zoloth L, et al. Bioethics in Business. The Hastings Center Report 2001; 31:9-24.
Further reading
• Aulisio MP, Arnold RM, Youngner SJ. Health care ethics consultation: Nature, goals, and competencies. A position paper from the Society for Health and Human Values — Society for Bioethics Consultation Task Force on Standards for Bioethics Consultation. Ann Intern Med 2000; 133:59-69.
• Aulisio MP, Arnold RM, Youngner SJ. Moving the conversation forward. J Clin Ethics 1999; 10:49-56. Review.
Sources
• Jon R. Hendrix, 107 Glasgow Drive, Edinburgh, IN 46124.
• Laurie Zoloth, San Francisco State University, Department of Jewish Studies, 1600 Holloway Ave., San Francisco, CA 94132.
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