The Big Shilling: Ethics in the Age of Corporate Medicine

Review of White Coat, Black Hat: Adventures on the Dark Side of Medicine by Carl Elliott.

Beacon Press, 2010. 213 pages. $24.95 (Hardcover).

The commercial provenance of claims about the innovativeness and safety of medicines renders them liable to skepticism. The patina from the endlessly told and retold legends of the scientific heroism of drug companies that brought us penicillin, insulin, polio vaccine, chlorpromazine and other wonders between the 1920s and the 1950s began to fade in the last decade of the twentieth century in the wake of scandals too numerous and discoveries too few. The acceleration of marketing-inspired wrongdoings as the pharmaceuticals blockbuster era has progressed has attracted many academic and journalistic exposés. Those committed to this cause have likely read a solid shelf of critical inquiries written in a similar vein as Carl Elliott’s new book, White Coat, Black Hat: Adventures on the Dark Side of Medicine.

Is there really a need for yet another exposé or academic analysis of the subject? Those of you who said ‘no’ are, with my apologies, missing the point. New books, articles and blogposts keep being written because the commercial takeover of medicine is not slowing down, but the opposite; it is accelerating and globalizing.

The hope embodied in books such as Elliott’s is that a critical mass of studies and investigative reports might eventually topple the system of corruption that has wrought many human tragedies and financial fiascoes. Each has been associated with over-marketing of pharma-branded entities (to include both drugs and the diseases mongered to absorb them) touched upon in Elliott’s book: Abilify, Bextra, Celebrex, Celexa, Cymbalta, Detrol, erectile dysfunction, Fen-Phen, GERD, Lexapro, Neurontin, Nexium, overactive bladder, pediatric bipolar disorder, Premarin, Prempro, Prilosec, Propulsid, Risperdal, Seroquel, social anxiety disorder, Trovan, Vioxx, Xigris, Zelnorm, Zoloft, and Zyprexa. Other violations, injustices and ironies (bioethicists for hire, e.g.) are detailed.

The question for a book review is: What novel approach(es) does the author contribute towards undermining the foundation of “empire,” as he calls it? Will his effort do any good?

One of Elliott’s weapons is accessible writing. Several of the chapters in White Coat, Black Hat have appeared in such venues as The New Yorker and The Atlantic. One can quibble over the allure of the title, but after that it’s smooth sailing. Elliott’s narrative strategy is to build upon interviews with people who at one point in their careers were (or in some cases remain) in the employ of the pharmaceutical industry. These men and women became disillusioned either following the realization that they were skating on ethically dubious ice in their work or that they had altogether become dupes of industry. As simultaneous insiders and outsiders, these people make useful and articulate informants against the marketing-dominated industry. Some, such as Michael Oldani, a former Pfizer rep and contributor to this blog, have themselves become persuasive critics of big pharma.

The device works well: White Coat, Black Hat is a sincere and eloquent salvo that can serve as a good first stop for readers who have not been paying attention to the inimical trends of commercial influences upon medicine. The narration is appealing and trustworthy. One feels at ease in the hands of a trained ethicist who can parse the issues surrounding conflicts of interest, and an MD (also son and brother of MDs) who bemoans the decline of honor in his profession.

Elliott organizes the text around two powerful themes. The first is how pharmaceutical companies conceal their deceptions by distancing themselves from the actual promotion of drugs. Many people have become suspicious of claims made directly by drug companies, so marketers arrange for scientists, doctors, pharmacists, newscasters, bioethicists and others to do the selling for them. Second, he argues that doctors are often complicit in the effort to bring drugs to patients by reprehensible means. Other critics have fingered physicians as part of the problem, but Elliott blames doctors outright for their venality, greed and arrogance. There may indeed be good reason to start focusing more on doctors when thinking about how to mend the excesses of pharmaceuticals marketing. As Arnold Relman has argued in the most recent issue of the New York Review of Books, real healthcare reform must center on changing physician behavior, since it is they who ultimately make most of the decisions about the use of medical resources, including pharmaceuticals.

Elliott reproaches others besides doctors. Chapter by chapter he identifies guilty parties in order of appearance in the drama of bringing a drug from the marketer’s imagination to the consumer’s body.

Research subjects (Chapter 1)–“guinea pigs”–subject themselves to dangerous Phase I clinical trials in exchange for meager wages; incredibly corrupt contract research organizations and doctors recruit subjects and implement the studies in circumstances that are shocking in their cruelty and in their lack of conformity to good scientific standards. Ghostwriters (Chapter 2) do the work of fashioning manuscripts to look like objective scientific studies rather than the promotional materials they are; aspiring academics are happy to advance their careers and line their pockets by agreeing to serve as authors. “Detail men,” or drug reps (Chapter 3), have only to flirt, be friendly, and wine & dine doctors in order to get them to prescribe the drugs; doctors’ greed is the perfect counterpart to the drug rep’s pitch.

Here’s a passage describing the intercourse (not too strong a word, I gather) implied between rep and doctor:

“When an encounter between a doctor and a rep goes well, it is a delicate ritual of pretense and self-deception. Drug reps pretend that they are giving doctors impartial information. Doctors pretend that they take it seriously. Drug reps must try their best to influence doctors, while doctors must tell themselves that they are not being influenced. Drug reps must act as if they are not salespeople, while doctors must act as if they are not customers. And if, by accident, the real purpose of the exchange is revealed, the result is like an elaborate theatrical dance in which the masks and costumes suddenly drop off and the actors come face to face with one another as they really are. Nobody wants to see that happen” [p. 64].

And so on with “thought leaders,” or influential MDs who consult and sell for drug companies in exchange for career- and lifestyle-enhancing gifts (Chapter 4); “flacks,” or PR firms that help engineer positive public opinion for drugs by manipulating the news media, among other techniques (Chapter 5); and last but hardly least bioethicists who work as paid consultants to the industry to help get clinical trials approved, among other services (Chapter 6).

I found the bioethics chapter to be the freshest material in the book and the most personally informed and nuanced. Elliott is in this case reflecting on his own academic discipline and on the dubious choice some of his peers have made to sell their services to drug companies. Because of a natural confluence between Elliott’s own preoccupation with conflict of interest and the fact that this is probably what should be bothering bioethicists in the employ of the pharmaceutical industry most of all, this chapter fits most easily into Elliott’s implied solution for fixing the problem: keeping white coats and black hats away from each other.

Does the naming names approach to finding fault in the relationship between medicine and the pharmaceutical industry (which would find easy correlate in the worlds of medical device and testing technologies) represent Elliott’s total conception of the problem, or is it just a convenient narrative device? If the former, then there are two limitations one can raise.

When we look at pharmaceutical companies’ ethical violations, we tend to conclude that greed, as reflected in excessive marketing, and individual unethical decisions are to blame. To some degree, they are, but we should not lose sight of the nonprosecutable organizational norms that lie behind these abuses and that both fuel ethical breaches and dampen the impetus to develop innovative products. By organizational norms, I mean the marketing practices that have at their back sound managerial principles, marketing’s peculiar but accepted form of apprehending market needs, and the unrelenting requirement to adapt to a patent-driven competitive commercial environment.

What should strike us most in the marketing practices that have come to light in various court trials is how routine they appear to be. The spectacle of the trials is in this sense a distraction, since it focuses our attention on violations. But the violations stem from marketing practices that are not at all covert—in fact, they are positively embraced. (I have discussed some of these issues on Somatosphere here and here, and in print here, and here.) In other words, finding culprits who might be singled out and condemned for complicity in the over-selling of pharmaceuticals may be a necessary but insufficient step towards fixing the problem.

The same is true of too great an emphasis on conflicts of interest (COI). In her 2002 Reith Lecture series entitled “A Question of Trust,” English philosopher Onora O’Neill points up two ethical quandaries of living in the information age. The first is that “as the quantity of (mis)information available rises…as the difficulty of knowing whether a well-publicised claim is a credible claim increases, it is simply harder to place trust reasonably” ( The second is that attempts to improve transparency and openness in the hopes of making claims more trustworthy not only have a tendency not to work, they often backfire because they compel deceivers to conceal their deceptions more cunningly.

The empirical elaboration of this dynamic is topic for another day, if for no other reason than because optimism about reforming medicine by eradicating conflicts of interest is only implicit in Elliott’s text. What is most important is that Elliott’s book successfully informs and fires up the debate on what is wrong in the contemporary relationship between drug companies and American medicine. It is up to us to absorb his insights and combine them with what we already know in the attempt to mend a medical establishment currently geared to serving the interests of commerce rather than ours.

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