What in the hell's happened to you George? I said when I saw him. His right arm was bandaged to the shoulder, the crook of his left arm looked like overdone bacon, his lips were blistered, his nose was shiny with grease and swollen out of shape and his right ear was red and thickened.
They want me to go back to work, he said. They told me if I didn't go back I wouldn't get paid. I want to see you. (1)
George--the central character in William Carlos Williams' story "The Paid Nurse"--is speaking with his doctor. Earlier in the day he had been cleaning metal disks by rinsing them in a pail of flammable solvent and placing them in a two hundred degree oven. He knew this was dangerous work, but his boss insisted. George describes the events that followed: "I hadn't hardly started when, blup! it happened ... I smelt burnt hair and cloth and saw my gloves blazing." His co-workers put out the flames and took him to the nurse. "She called the [company] doctor but he didn't come any nearer than six feet from me. That's not very bad, he said." The nurse agreed with the doctor, put tannic acid on George's fight arm, and demanded he go back to work. "And by the way, she said, don't go to any other doctor." (2)
Williams' account of George's mistreatment at the hands of caregivers on the company payroll is instructive for those watching how the pharmaceutical industry is working with bioethicists. Williams does not suggest that the nurse and doctor were greedy people, anxious to render diagnoses favorable to the company in exchange for money. In fact, Williams tells us nothing about the character of the caregivers; instead, he focuses our attention on the way financial incentives color medical judgment and constrain behavior.
"The Paid Nurse" shows us how the financial arrangements of caregiving shape the care given. Is the advice bioethicists give to the drug and medical device industries also shaped by the way bioethicists are paid? Clearly, bioethicists are not naive about the way money, can influence scholarly work and medical advice--witness the large bioethical literature on conflicts of interest and the efforts of bioethicists to structure their consulting relationships to minimize the role of money in shaping their recommendations. Examples of the latter include: the use of disclosure, complex schemes for funding ethics advisory boards, and the designation of the money for project support as an "unrestricted gift" rather than as funding for work with an agreed-upon deliverable. Unfortunately, none of these arrangements solves the conflict of interest problem. Lacking consensus on what must be disclosed, disclosure can be nothing more than an empty ritual. Innovative funding schemes, such as irrevocable trusts that prevent a company from disbursing the funding depending on how much k likes the bioethicists' advice, are a step in the right direction, (3) but they must be very carefully crafted to efface the potential tensions of serving two masters--of being ethical advisor to the corporation and advocate for the experimental subject. And to a sociologist, the designation of project funding as a "gift" creates problems of obligation that can be more severe than those written into contracts. (4)
Because of the private nature of bioethics consultation, we know very little about how ethicists are selected, what advice is given, what issues are fired, what rationales are raised and discarded, or how interests are balanced. In a few instances, however, bioethicists have offered descriptions of their consulting work in peer-reviewed publications and on the web. Two such cases are particularly interesting. Both involve ethicists supported by funding from the drug company Eli Lilly; the fist involves the ethics of research, the second focuses on ethical problems in clinical practice.
In the late 1990s, Eli Lilly faced an ethical problem. The public learned about Lilly's problem via an article in the Wall Street Journal that article described the company's use of homeless alcoholics for Phase I trials of new drugs--trials designed to test a new drug's toxicity. …