Marcia Angell’s essay offers a succinct and sobering account of just how extensively market ideology and drug-industry practices have corrupted American medicine. She is wise to let the facts speak for themselves, with a minimum of interpretation or table-pounding.
Yet there is much to be gained from a larger analysis of how academic medicine “creates value” in ways that commercial enterprises cannot. Why is it important that medical research, education, and clinical practice be independent of the marketplace?
Angell indirectly points to the answer by showing how the trustworthiness of academic medicine has been compromised: skewed research priorities, commercially influenced judgments, an over-eagerness to adopt industry interests in education and training, reluctance to assert its own sovereign vision for the future of medicine.
This is a serious indictment that calls for a more coherent way of talking about the value of academic medicine. Market ideology presents a clear, well-developed articulation of how it generates value, and why, therefore, its logic and principles ought to prevail. We all know the catechism: “Private property rights and market exchange provide the necessary incentives to spur competition, innovation, and material progress,” and so on.
And academia? The distinctive value of its independence is not as well developed, or, at least, it is not as clearly communicated. Yet such an articulation is vitally important. Until we state explicitly why it is worth keeping academic medicine free of commercial influence, we will not aggressively fight its annexation by Big Pharma and other industries. It will be seen as an appealingly compliant junior partner whose chief asset is its credibility.
Prior to 1980—when the Reagan-Thatcher ethic of market triumphalism took hold—there was little need for academic medicine actively to differentiate itself from the market order. The two operated in largely different spheres and with their own different goals and ethics. Academia’s autonomy was self-evident.
But since then, as the logic of neoliberal capitalism has expanded to every nook and cranny of our society, anything not nailed down with private-property rights has been vulnerable to appropriation. Hence the sale to corporations of naming rights to public arenas; the attempted sale of human ova and votes on eBay; the trademarking of colors, smells, and even letters; the patenting of mathematical algorithms as embedded in software; and so on. Large realms of life that were once considered inalienable—not for sale—have been relentlessly colonized by the marketplace, with all the social disruptions and moral corruptions that entails.
People who generate value through the commons pursue their self-interests in a different way, and the benefits they generate cannot be measured by money.
Vast swaths of medical knowledge and practice, too, have been privatized and monetized—patents for common medical procedures, one-fifth of the human genome, artificially created life forms, and much else. It should come as no surprise that professional practices and norms have been similarly warped to serve market ends. Much of this transformation has occurred in incremental, deliberately obscure ways. Angell has performed a great public service in making this transformation more explicit and comprehensible.
In so doing, she has helped us to see the unmet challenge within academic medicine: to name and reclaim its moral sovereignty over the vital functions that it, and only it, can perform. I will not presume to suggest how specific reform should be pursued. But I do believe that, whatever paths are taken, academic medicine must assert the value of its independence from market forces. Otherwise its moral stature and expertise will have no foundation.
I have studied the commons as an economic, political, and cultural phenomenon for many years. If one thing is evident, it is that academic medicine historically has functioned, and should function, as a commons. Academic medicine has treated its specialized knowledge and practices as shared resources, ones that have been generated and refined by the medical community itself and therefore should be subject to its rules, values, and ideals. If medical knowledge and practice are instead treated as salable commodities (an example of “enclosure of the commons”), the framework of relationships that makes the medical commons so generative and trustworthy is replaced by short-term, transactional, cash-based relationships.
Academia more resembles a gift economy, a special class of commons in which people make “contributions” to the field (with research, lectures, collegiality, etc.) with no expectation of direct reward. This is not to say that participants in a commons are saintly altruists or do not need to earn a living. It is to say that people who generate value through the commons pursue their self-interests in a different way, and that the significant benefits they generate cannot be measured by money.
Scientists and physicians may earn their living from the market, but their standing and credibility come from their participation in scientific and practitioner commons. Through open collaboration and debate, the community makes a collective reckoning of their contributions to the shared body of knowledge. This is why the findings of academic medicine are seen as so powerful and trustworthy. Yet this, as Angell documents, is precisely what is being short-circuited and corrupted by the pharmaceutical industry.
Understanding academic medicine as a commons helps us appreciate more clearly why it is so important to protect the non-market paradigm of research, education, and clinical care. In this mode, medicine harnesses the power of the scientific method through a transparent, ethical, merit-based process. It mobilizes community judgment and ethical scrutiny. It is insulated from the corrupting influences and self-dealing associated with an unregulated market economy.
Unfortunately, we have not been attentive to the value of academic medicine as a commons. We are suffering mightily as a result. We need to set some meaningful, defensible limits on the ability of markets to govern and manage medical research, education, and clinical practice. We need to demarcate more clearly what sorts of functions can be well served by the marketplace, and what species of value ought to be governed by the logic of the commons.
This is not to say that the market has no role in medicine. It is to say that the market has eclipsed and suppressed the many vital commons-based relationships that we must actively protect if a wholesome, trustworthy system of academic medicine is to survive.