Ethics, Medical Research, and Medicine: Commercialism versus Environmentalism and Social Justice (review)

What would it take to precipitate a paradigm revolution in bioethics, medicine, and the conduct of medical research? Is such a revolution needed?

While never explicitly invoking Kuhn and his Structure of Scientific Revolutions (1962), Andrew Thompson, Norman Temple, and the contributors to Ethics, Medical Research, and Medicine: Commercialism versus Environmentalism and Social Justice are clearly unhappy with the realm of traditional bioethics "puzzlers." They propose leaving behind the parochial worldview they find to dominate contemporary medicine and bioethics in favor of a broader and more socially conscious "environmental" point of view, and they propose concrete standards to guide medical research within the new perspective.

Let me be clear here, however: what makes this book so interesting is not what it has to say about paradigm shifts. Instead, it is an instance, a case, if you will, of exactly what Kuhn posits will occur in a nascent paradigm revolution: those working within a paradigm uncover anomalies and perceive the possibility of a new paradigm, in which the previously anomalous becomes the expected. In science, and perhaps also in philosophy and ethics, this is the process of discovery, the introduction of a new universe of discourse, which calls into question the very identity of what is important to solve.

As a book aimed at upsetting prevailing paradigms, this collection begins by striking at the core assumptions grounding modern medical research: claiming first, there are no truly "lifesaving technologies" and second, sophisticated and costly new technologies are largely impotent—and sometimes actively harmful—when faced with the real needs of individuals to enhance their health and enrich their lives. "To start with, the term 'lifesaving' is really a misnomer. There is a hint of immortality about it, as if the person whose life is 'saved' lives happily ever after, even eternally; ... The accurate expression is 'life-extending.'" Meanwhile, more valuable activities, such as education, social justice, and environmental protection "lose out to medicine in the competition for available resources" (10).

Proponents of competing paradigms inevitably talk past one another, at least to an extent, since the fundamental values and indeed, perceptions, of the paradigms are incommensurate. Thompson's proposal to let Quality Adjusted Life-Years (QALYs) form the base of calculations to determine whether the public should fund a particular research or treatment probably is an instance of this. Fortunately, Thompson and his collaborators go further: using QALYs but also other measures more esteemed by traditional medicine and bioethics (actual costs, morbidity, mortality, long-term outcomes, side effects, statistical significance, unbiased presentation of findings), they proceed to unearth anomaly after anomaly, dismantling the illusion that current medical and ethical standards adequately serve the ends of public health, individual well-being, and professional integrity.

As Kuhn predicted, the failure of existing rules (principles, standards) is a prelude to the search for new ones. Where new paradigms must prove themselves, and where Thompson is often at his best, is in the offering of alternatives—not only new solutions but also new questions—that obviate such failures and resolve the uncomfortable explanatory crisis.

For example, "Leaping over the Species Gap," (59-73) a chapter authored solely by Thompson, is a powerful and convincing critique of the usefulness of animal models of human disease, with a concise and credible two-page summary of alternatives, ranging from epidemiology to in vitro testing. New drugs and devices, so-called "preventive" screening, and the commercialization of medical research are also handled expertly, using language and methods that resonate with prevailing paradigms while simultaneously revealing their fundamental flaws. The chapter on "The Genomics Revolution in Medicine: A Case of Extreme Information Overload" (147-168), coauthored by Thompson and Norman J. Temple, presents a particularly thorough and extremely provocative examination of the hazards of uncritical acceptance of the high-tech, "progress at all costs" worldview implicit...