Where are all the bioethicists when you need them?

Is biomedical ethics just casual talk? Is it merely medical etiquette, philosophical window dressing, full of empty rituals and little substance? Do doctors take ethics seriously? What should we expect from bioethicists when the ethical practice of medicine is at stake?

One cannot ignore these questions in the aftermath of a shameful saga – ‘upon which it is difficult to speak, and impossible to be silent’ – that unfolded over the election of a president-elect of the World Medical Association (WMA). ¹

The WMA is an international association of doctors established in the aftermath of Nazi medicine to ‘work for the highest possible standards of ethical behaviour and care by physicians at all times.’ ² In keeping with its goal to provide ‘ethical guidance to physicians,’ the WMA ‘has adopted global policy statements on a range of ethical issues’ including the International code of medical ethics, and the Declarations of Geneva and Helsinki. ³

The annual assembly of the WMA, hosted by the Indian Medical Association in New Delhi on October, 2009, featured ‘the unopposed election in his own country’ of Ketan Desai, [then] president of the Medical Council of India (MCI) as president-elect of the WMA. ⁴ Six months later, in April 2010, Desai was arrested on charges of seeking a bribe of 20 million rupees (£296,000; €350,000; $450 000). ^5,6 No stranger to accusations of unethical behaviour, Desai was ousted from his position as president of the MCI in 2001 by order of the Delhi High Court, ^7–9 which observed that Desai and his family had ‘received unexplained payments totalling 6.5 million rupees (£92,000; €105,000; $150,000).’ ¹ The Supreme Court of India dismissed this case against Desai as no evidence was found that he had ‘extended official favours to those from whom he had received payments.’ Eventually Desai was reinstated as head of the MCI in 2009. ⁵

Reports of corruption and new bribery charges against Desai in 2010 led the government of India to disband MCI and re-establish it with a new board of governors. Undeterred by being removed as president of the MCI for a second time, WMA president-elect Desai, who had been jailed on the bribery charges, obtained bail and was about to assume his position as the new president of the WMA at its annual assembly in Canada. The MCI's new board of governors revoked Desai's license to practice medicine and informed the WMA that ‘It would be a travesty of justice if Desai, who has brought disgrace to the medical profession, is allowed to take charge as the president of the World Medical Association.’ ¹ When the annual assembly of the WMA met in Vancouver, Canada, in October 2010, the president-elect of the WMA was found ‘unable to carry out his duties’ and his ‘inauguration’ as president was ‘suspended indefinitely.’ ¹⁰ In an extraordinary election, Wonchat Subhachaturas from Thailand was elected as president of the WMA.

This incident – ignored or unnoticed by doctors, professional medical associations, and other stakeholders – deserves careful reflection by all who are concerned about the cause of ethics in medicine. That an ethically compromised doctor became president of a medical council or professional association is shameful but not impossible in a country like India, where corruption is endemic. ⁹ It is difficult to believe, however, that no one in the WMA knew about Desai's past record given the fact that his removal from the MCI was reported in both national and international medical journals. ^7–9

The case of Desai, and the anemic reaction to his election and suspension, raise several questions about the place of bioethics in medicine:

How could an ethically challenged doctor become the president-elect of the WMA?

Is ethics simply a look-good decorative badge on the white coat?

What will prevent this kind of ethical lapse from being repeated?

This case is not about a single person or a professional association, but rather about the integrity of the medical profession and the place of ethics in medicine. Regrettably, there is no indication – at least publicly – that Desai's case generated any introspection on the part of the WMA. Corruption was noticeably absent from the agenda when the WMA adopted a number of resolutions on several health-related issues in their assembly. Is it not an ethical imperative for a professional association of the stature of the WMA to come clean and explain their position?

Where have the guardians of morality in medicine gone?

The modern-day incarnation of medical ethics appeared in the Western world some four decades ago, in the aftermath of several revelations about the inhumanity of medicine. Since then, the field of bioethics has increasingly become part of the landscape of health and medicine. The place of bioethics in medicine was confirmed by promulgation of ‘the Universal Declaration of Bioethics and Human Rights’ in 2005. If bioethicists are now the guardians of medical ethics, how is it that they have nothing to say about medical corruption?

One reason may be that bioethicists themselves have come under scrutiny for falling short of their responsibility in maintaining the highest standards of integrity. Hired by the for-profit pharmaceutical corporations, ¹¹ bioethicists have engaged in a number of activities – with serious conflicts of interest – including, for example, acting as ‘key opinion leaders’ in marketing strategies, ¹² sitting on for-profit institutional review boards (IRBs), ¹³ justifying research with vulnerable populations including the use of homeless people in phase one trials, ¹⁴ and writing industry-funded research articles. ¹⁵ There is a sad and painful irony here: bioethicists love to talk about ‘justice,’ but have been part of the injustices of the healthcare industry. Apparently corporate money influences not only medical science, but also the nature and scope of bioethics. ^12,13,15,16

Can corruption also buy a conscience?

We are not the first to point out that corruption can kill (literally) and that medical education, research, and healthcare are tainted by corrupt practices. ^17–19 Corruption in the health sector appears in a variety of ways, including, for example, selling fake medicines; paying ‘cut money’ for hospital supplies; bribery of medical professionals for approval of private medical colleges (it is on this charge that the president-elect of the WMA was arrested); overbilling on insurance claims; colluding with pharmaceutical companies in drug research and the siphoning of public-health funds. Existence of corruption in the healthcare system may not be surprising; given that the world spends more than three trillion dollars a year on health services, ¹⁷ it is an attractive target for abuse.

Unfortunately, corruption often determines the difference between life and death, good health and suffering. Not surprisingly, the poor suffer most. Three of the UN's eight Millennium Development Goals – intended to reduce poverty by half by 2015 – relate directly to health: reducing child mortality, improving maternal health, and combating HIV/AIDS, malaria and other diseases. Corruption in the healthcare system has been implicated as one of the culprits for non-fulfillment of these goals by the target date. ¹⁷ Corruption also exacerbates the harm of natural disasters. Consider, for example, the earthquake in Haiti, where the death toll was directly related to corruption: buildings certified as earthquake-resistant were not properly constructed because of lack of oversight in a system plagued by corruption. ¹⁸ Further, a transnational study found that the quality of government – i.e., the inverse of corruption – was positively associated with higher life expectancy, lower mortality rates for children and mothers, and higher levels of subjective feelings of health. ¹⁹

Only a few brave souls or organizations like Transparency International have been willing to tackle corruption in healthcare. For the most part, the bioethics community has remained silent. Why?

Have bioethicists lost the passion to make the world a better place by playing a strong and credible ‘watchdog’ role in medicine?

Do philosophers and bioethicists find it more important and/or intellectually satisfying to solve esoteric puzzles – like, for example, the moral status of a part-human-part-animal embryo – rather than taking on ‘dull’ issues like poverty, health inequality or medical corruption?

Bioethicists have spent a great deal of time arguing about the ethical validity of ‘moral universalism’ as opposed to ‘ethical relativism.’ Perhaps the contending camps in this debate could agree that corruption is truly an un-ethical ‘universal principle’ that permeates the healthcare delivery system globally and needs to be challenged.

A notable editorial in the Lancet – ‘Where are all the philosophers when you need them?’ – underscored the importance of philosophy in shaping public health policy by addressing public health failures. ²⁰ The suffering of humanity at large – the poor, the disadvantaged and the vulnerable – in the face of medical corruption leads to a second version of this question: ‘Where are all the bioethicists when you need them?’ Why are bioethicists ignoring the harm caused by corruption in healthcare? Why are bioethicists failing to take a leadership role in shaping the moral landscape of medicine?

The 2010 World Congress of Bioethics in Singapore did not include a single session on corruption in healthcare. The 2012 World Congress of Bioethics – ‘Bioethics for the Future and Future of Bioethics’ – can usher in a new era by putting corruption in health sector on its agenda, discussing and creating policies to address this immoral practice. Bioethicists can learn from the example of scientists who took a stand (despite some resistance) on climate change.

In its original incarnation, bioethics was intended to be ‘pro-active’ – using moral reflection to make the world a better place to live. In a world where corruption is a threat to human life and the source of much agony, suffering and death, bioethicists can and must play their roles in guiding the moral vision of medicine, a practice that is intricately connected with individual well-being and social good. There is no room for complacence – history will not forgive any such failure in moral duty.

DECLARATIONS

Competing interests

John J Gillon works for the Attorney, Patent and Trademark Office, U.S. Department of Commerce. The views and opinions expressed here are those of the author and do not reflect the view of the government of the United States or any of its agencies

Funding

This Essay had no external funding sources

Ethical approval

Not required

Guarantor

RDV

Contributorship

SC prepared the first draft; JJG and RDV contributed important suggestions, comments and edits. All coauthors engaged in modification, revision and final preparation of this Essay

Acknowledgements

We are thankful to Renee C Fox (University of Pennsylvania), Carl Elliott (University of Minnesota) for helpful suggestions and critical comments