About the Book
In this lively narrative, Carl Elliott follows the plunge of health care
into the abyss of consumer capitalism. Stories of drug production and research,
drug marketing, and drug sales representatives combine with tales of bioethicists,
professional guinea pigs, and "scientific" ghostwriters to illuminate
the "dark side of medicine."
Elliott's research and experience inform his eye-opening look into how money
has infiltrated our health care system and deception has subverted our medical
professionals. Drawing on his professional experience as well as extensive interviews
with former and current industry professionals, Elliott explores the question
of whether health care and consumerism can go hand-in-hand.
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"Carl Elliott has written a deep, daring and sometimes very funny book
about aspects of medicine you've never seen, and probably never will unless
you take the time to crack this cover
. This book should be required reading
for anyone who has ever been a patient, in other wordsfor everyone."
Lauren Slater, author of Opening Skinner's Box
"Elliott's dim view ought to be a real eye-opener for health-care patients-cum-consumers."
Donna Chavez, Booklist (starred review)
"It's fascinating to read comments from prominent physicians who declaim
the negative influence of industry connections while working as paid consultants
and speakers for those same industries. VERDICT: Enjoyable to read and laced
with sardonic wit, this is an eye-opening work that all consumers of health
care should read." Dick Maxwell, Library Journal
In his superb exposé, Carl Elliott shows how the big drug companies
have bribed and corrupted the medical establishment so that we no longer know
which drugs are effective or why our doctors prescribe them." Marcia
Angell, author of The Truth About the Drug Companies: How They Deceive Us
and What to Do About It
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About the Author
graduating from Davidson College, Carl Elliott earned his MD from the Medical
University of South Carolina and his PhD in philosophy at Glasgow University
in Scotland. He has held positions at a number of institutions in the U.S.,
Canada, New Zealand, and South Africa, including one at the University of Natal
Medical School (now the Nelson R. Mandela School of Medicine), the first medical
school in South Africa for non-white students and one at the Institute for Advanced
Study in Princeton. He currently teaches at the University of Minnesota in the
Center for Bioethics and the Departments of Pediatrics and Philosophy, while
living in Minneapolis with his wife and three children. He has previously served
as the author or editor of six books, including Better Than Well: American
Medicine Meets the American Dream (W.W. Norton, 2003), and Prozac as
a Way of Life (University of North Carolina Press, 2005). His articles have
appeared in the New Yorker, The London Review of Books, Atlantic Monthly,
The American Prospect and the New England Journal of Medicine.
Photo by Caleb Parker.
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Questions for Discussion
Money and Morality:
- "Drug testing has always involved a kind of moral trade-off in which
subjects are asked to takes risks for the good of other people" (p. 16).
Do you think the decision to participate in a study is an altruistic one?
What else could motivate participants besides money? What would motivate you
to take the risks?
- In terms of research on human subjects, Elliott writes that "The dominant
stream in bioethics sees the crucial issues as informed consent. Can the subject
make a free and informed choice about whether to take part in a drug study?"
(p. 146). What constitutes a "free and informed choice"? Does money
skew that definition? What else could compromise it?
- Elliott often brings up the issue of doctors receiving money or gifts from
drug reps, though they claim they are not influenced by them. Former industry
thought leader, David Healy, says "Anyone who says to you that they are
not conflicted by their ties to companies is lying, period
102). Do you believe that doctors are not influenced by their ties? Do you
think anything would change if they were no longer allowed to receive gifts?
Would the information change? Would their decision-making process change?
If not, what else could be done to solve the problem Healy is referring to?
- "Academic physicians talk about the experience of being a KOL [Key
Opinion Leader] the way others might talk about being admitted to a selective
fraternity or an exclusive New York dance club
You are one of the chosen."
(p. 77) Can you think of a position in your line of work that you associate
in the same way? Have you ever or would you ever aspire to reach that position?
Might there be any moral ramifications to the position? Would you still do
- In the 1990s, the development of "script-tracking" reports allowed
drug reps to see exactly what drugs doctors were writing prescriptions for.
Then reps could see the difference between the prescriptions doctors said
they were writing, and the prescriptions they were actually writing. "Doctors
might tell a rep that they were writing prescriptions for, say, Lipitor, when
they weren't. They were just being polite, or saying whatever they thought
would get the rep off their backs" (p. 61). Does it matter if doctors
are being honest with reps or not? What could be the advantages and disadvantages
of their dishonesty?
- On page 49, Elliott makes the comparison that "Like lobbyists, expert
witnesses, or hit men, medical writers are instruments in a much larger enterprise.
Their job is neither to support nor question the enterprise, but to play their
small part as effectively as possible." What is he implying by these
comparisons? How much moral responsibility should medical ghostwriters bear
for their work? Is it unfair to expect them to bear any?
- On page 115, Elliott reveals that "Although some PSAs [Public Service
Announcements] are sponsored by nonprofit groups, many are backed by corporations."
Do you think this matters? Does it make the warnings on the PSAs any less
- On page 132, Elliott describes the efforts of two pharmaceutical companies,
along with the Alzheimer's Association, in raising awareness of Alzheimer's
disease. The companies' intention was to aid in the marketing of their drug
Aricept, "a drug intended to slow the progression of Alzheimer's disease."
Though the advocacy group and the companies seem to have different motives,
do you think the motives or the results matter more? Should patient advocacy
groups be wary of working with such companies or should they be grateful for
the increased awareness regardless of the intentions?
Conflict of Interest:
- In discussing the effects of their industry ties on thought leaders, Elliott
writes that "Most of the thought leaders investigated by Grassley have
managed to retain their academic positions, even in the face of withering
criticism" (p. 107). Should thought leaders be allowed to retain their
academic positions? Why or why not?
- On page 156, Elliott lists a number of bioethics centers that are funded
with pharmaceutical industry money. Later, he writes that "as bioethicists
seek to become trusted advisers, rather than gadflies or watchdogs, it will
not be surprising if they slowly come to resemble the people they are trusted
to advise" (p. 170). Why do you think pharmaceutical companies would
want to fund bioethics? Do you see this as a conflict of interest? What is
compromised when bioethicists begin to advise the marketers?
- Stacy Carter describes how she was "so caught up in the moral crusade
against cigarettes that she did not notice that the crusade was backed by
a pharmaceutical company with its own commercial interests" (p. 116).
Because the commercial interest coincided with the public/societal interest,
does it cheapen the cause in some way? Do you think taking money from an organization
indicates an endorsement of it? How would Carter's work have been different
if the industry was not backing it?
- In a case like Prozac, when the drug causes an increased risk of suicide
"on rare occasions," (p. 98) should the risk be made more public?
Do you think it is likely that it will "frighten depressed patients from
taking medication for their illness and increase the rate of suicide"
(p. 101) as some doctors claim? Is it worth risking on either side?
- After one research subject died during a study, two bioethicists at the
institution where he died wrote an opinion editorial in which "they lamented
the fact that [the study's] death might slow the pace of medical research
by leading to tighter regulation" (p. 152). Could these men have been
PR agents protecting the reputation of their own employers? Does quick research
or responsible bureaucracy save more lives? Are there other ways to keep the
pharmaceutical companies honest and ethical?
- In the case of the "sting operation" against the institutional
review board, Coast IRB, "it was Coast IRB that had been victimized,
Dueber claimed. 'Innocent victims of this country cannot be lawfully defrauded
by the government'" (p. 160). How do you feel about this argument? How
far should the government be allowed to go? How else could the IRB have been
- "From the very start, drugmakers have tried to design marketing tools
that resemble, as closely as possible, the vehicles that transmit empirical
evidence: medical journals, scientific articles, abstracts, symposia, conferences,
slide shows, and grand-rounds presentations" (p. 26). Do you think it
is good for such marketing to be permitted, or should it be banned from these
media? How should drugs be marketed, if at all?
- On page 62, Elliott explains that a "newer, regimented style of selling
began to replace the improvisational, more personal style of the old-school
reps. Whatever was left of an ethic of service gave way to ethic of salesmanship."
What does he mean by "ethic of service" and "ethic of salesmanship"?
Is an "ethic of service" better or worse than an "ethic of
salesmanship"? How so?
- Elliott describes the interaction between the reps and the doctors as "an
elaborate theatrical dance" in which "if, by accident, the real
purpose of the exchange is revealed
the masks and costumes suddenly drop
off and the actors come face to face with one another as they really are"
(p. 65). Do you think this is an accurate analogy? Would it be better if the
masks were always off? What would that system look like, and how would it
- According to Elliott, "Patients are being replaced by health-care consumers"
(p. 71) as the industry becomes more market-driven. Do you see yourself as
a patient or a health-care consumer? How does this shape your perception about
the health care you receive?
- Edward Bernays, who revolutionized the concept of Public Relations, "mastered
the art of selling without the appearance of salesmanship. It was his gift
to see how social conditions could be manipulated in order to increase sales
in ways that were invisible to the customer" (p. 119). Do you ever feel
like you are susceptible to this kind of manipulation? How do you think you
could avoid being manipulated in this way?
- On page 135, Elliott writes that "In the world of medicine, there seem
to be two broad categories of people who see the drug industry as a problem.
One group sees the issue in formal, bureaucratic terms
.For a handful
of people, however, the discomfort with industry influence seems more visceral.
Their necks prickle when they hear patients called 'customers' or a hospital
unit referred to as a 'revenue generator.'" Do you fall into either of
these categories? Which one? Can you expand on them? Do you think there are
- What is Elliott's purpose in writing this book? What does he hope to unveil?
How does he expect us to respond?
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By the Author:
"Should journals publish industry-funded bioethics articles?" The
Lancet, July 7, 2005.
"Six Problems with Pharma-Funded Bioethics," Studies in the History
and Philosophy of Biological and Biomedical Sciences 35, 2004.
"Not-So-Public Relations: How the drug industry is branding itself with
bioethics," Slate, December 15, 2003.
Elliott C. Pharma Goes to the Laundry: Public Relations and the Business of
Medical Education, The Hastings Center Report 2004, 34(5): 18-23.
*Elliott C. Pappworth's Guinea Pigs, Biosocieties, (2008), 3: 147-149.
*Elliott C, Abadie R. Exploiting a Research Underclass in Phase I Clinical
Trials, New England Journal of Medicine 2008 (May 29); 358:22, 2316-17.
Referenced in the Book:
Office of Inspector General, Department of Health and Human Services, "Recruiting
Human Subjects: Pressures in Industry-Sponsored Clinical Research,"
Washington D.C., June 2000, 13.
Wilson, Duff and Natasha Singer, "Ghostwriting
is Called Rife in Medical Journals." New York Times, September
Simon, John, "Blockbusters
to the Rescue." Fortune, January 31, 2006.
Shamoo, Adil and Elizabeth Woeckner, "Research
Ethics Boards: No Data on Quality of For-Profit or Non-Profit IRBs."
PLoS Medicine 3, 2006.
Smith, Richard. Medical
Journals Are an Extension of the Marketing Arm of Pharmaceutical Companies.
PLoS Medicine 2(5), 2005
Horton, Richard. The Dawn of McScience. New York Review of Books 51(4): 7-9,
Carlat, Daniel, Dr.
Drug Rep, New York Times Magazine, Nov 25, 2007
The Truth About the Drug Companies: How They Deceive Us and What to Do About
It by Marcia Angell (Random House, 2004)
Hooked: Ethics, The Medical profession and the Pharmaceutical Industry.
Howard Brody, Rowman and Littlefield, 2006
Medical Research for Hire: The Political Economy of Pharmaceutical Clinical
Trials, Jill Fisher, Rutgers University Press, 2009
The Professional Guinea Pig: Big Pharma and the Risky World of Human Subjects,
Roberto Abadie, Duke University Press, 2010
When Experiments Travel: Clinical trials and the Global Search for Human
Subjects, Adriana Petryna, Princeton University Press, 2009.
On the take: How medicine's complicity with big business can endanger your
health. Jerome Kassirer, Oxford University Press, 2004
The Trouble with Medical Journals, Richard Smith, Oxford University
Anatomy of an Epidemic, Magic Bullets, Psychiatric Drugs, and the Astonishing
Rise of Mental Illness in America, Robert Whitaker, Crown, 2010.
Manufacturing Depression: The Secret History of a Modern Disease, Gary
Greenberg, Simon and Schuster 2010
The Creation of Psychopharmacology, David Healy, Harvard, 2004
Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer, Shannon
Brownlee, Bloomsbury 2008
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