Carl Elliott is the author of Better than Well: American Medicine Meets the American Dream and White Coat, Black Hat: Adventures on the Dark Side of Medicine. He is coeditor of The Last Physician: Walker Percy and the Moral Life of Medicine. A recipient of a Guggenheim Fellowship and a National Endowment for the Humanities Public Scholar Award, he lives in Minnesota.
In The Occasional Human Sacrifice: Medical Experimentation and the Price of Saying No (W.W. Norton, 2024), bioethicist Carl Elliot begins his ethical exploration into whistleblowing in medical practice and research, surprisingly, with a personal account. Working within a discipline that has historically sought to separate subjective insights from detached analyses of putatively objective principles and systems of thought, Elliot details his experiences, calling attention to a psychiatric research study at his home institution that appeared to contribute to the suicide of one its participants. He recounts the painstaking process of bringing the injustice to light and holding his institution to account, only to find himself progressively ostracized, denigrated and ultimately thoroughly disillusioned. With this introduction, Elliot reconciles the deeply entrenched obstacles to doing right by patients in a field that professes to hold this ethic as paramount, and the collateral social, professional and moral damage this path can incur.
Elliot’s anecdote lends a degree of urgency to his project and augurs his mode of inquiry. He is ultimately interested in people and their individual moral experiences, not merely in systems, institutions or ideas, as contemporary bioethics is wont to emphasize. And while past accounts delving into clinical abuse in research have focused primarily on perpetrators and, to a lesser degree, victims, Elliot’s attention is on the whistleblowers themselves.
His two primary questions, while not stated explicitly, are:
• How does someone come to be the type of person who decides to implicate and oppose powerful systems at such great personal cost?
• How do these individuals retrospectively understand their decisions and the entailed implications?
Elliot homes in on the experiences of whistleblowers involved in six infamous instances of egregious ethical violation in medical research and practice, ranging from the Tuskegee Syphilis Study to the reckless exploits of the transplant surgeon Paolo Macchiarini at the renowned Karolinska Institute in Sweden. While he is careful to avoid casting these individuals as tidy moral exemplars, Elliot’s reflections seem to suggest a common rationale for their decisions: for these people, there was no conscionable alternative to blowing the whistle—one could simply not live with oneself as a bystander or complicit agent.
And yet this clarion moral resolve did not result in heroic spoils falling to those courageous whistleblowers who took on corrupt systems at steep personal risk. Instead, like Elliot, most experienced professional stagnation, relational isolation and profound moral residue stemming from these decisions. While none of these individuals outright regretted their decision, it is clear their retrospective interpretations are fraught with anger, guilt and confusion.
This leads to a discomfiting implicit conclusion—that if, indeed, whistleblowers are to be considered heroes, they are of the tragic, rather than the triumphalist, sort. Those of a consequentialist persuasion—which Elliot seems to suggest constitutes the majority in medicine and the sciences—would likely read this account and come away disinclined to ever blow the proverbial whistle, given the personal and professional toll this act ineluctably seems to entail.
Yet it is precisely this comfortable, default utilitarian ethic that Elliot attempts to unmask and challenge. Given the significant hierarchical, bureaucratic and capitalistic presumptions of contemporary medical training and practice, the prospects for earnest, conscientious reflection and moral action that contravene prevailing institutional priorities are bleak. And this impulse to toe the party line, to acquiesce to the expectations of one’s superiors, to prioritize efficiency at the expense of moral consideration, is honed not in the egregious cases Elliot discusses, but in the quotidian responsibilities of the fledgling trainee. When the medical student, like Elliot was, is expected to perform a gynecologic exam on an unconscious patient without consent, or to carry out a morbid procedure without adequate training, can she reasonably be expected to abstain? When the intern, buried in clerical and bureaucratic responsibilities and seeking to garner respect among her peers, witnesses inappropriate language used by her senior resident in caring for a “difficult” patient, is it possible for her to intervene or call her senior to account? If the answer is no, what are the implications for her moral formation and initiation into the practice of medicine, where such ethical tensions may take different forms as she ascends the hierarchy, but never fully resolve? As Elliot puts it,
Part of what makes medical training so unnerving is how frequently you are thrust into new settings in which you don’t really know how to behave. Nothing in your previous life has prepared you to euthanatize a dog in the physiology laboratory or help deliver a round of electroconvulsive therapy on a nonconsenting patient or attempt an episiotomy on a sixteen-year-old girl without anesthesia. Is this normal? Are we supposed to be doing this? Maybe but maybe not. It’s hard to tell. Your gut reaction is often a combination of anxiety, revulsion, and social discomfort. Most people learn to suppress the reaction. A rare few learn from it.
The power of Elliot’s exploration in The Occasional Human Sacrifice: Medical Experimentation and the Price of Saying No lies in the recognition that these moral dilemmas are less the exception than the rule for medical practitioners seeking to care for individual patients within systems predicated on money, power and efficiency. How one comes to be the sort of person who “learns from it”—who possesses the moral wherewithal and fortitude to step back and critically consider the good in competition with these three powerful alternative ends—remains a vexing question throughout Elliot’s account.
He concludes it is better to see and mourn than not see at all. This may not sit well with those ambitiously seeking to simultaneously care well for individuals and fix broken systems. But such is the nature of tragedy—it is better for one to shed tears than to never open one’s eyes at all.—Ben Frush
Ben Frush, MD is trained in internal medicine, pediatrics, and palliative care. He is a post-doctoral fellow in the McDonald Agape Fellowship in Bioethics at the Kennedy Institute of Ethics at Georgetown University.