A Guided Tour of Modern Medicine’s Underbelly

By ABIGAIL ZUGER, M.D.

“Adventures on the dark side of medicine” — now that sounds like a lot of fun. A few juicy stories about black-market organs, fingerprint erasure, murder and mayhem in the I.C.U. would make a welcome change from the usual humdrum stuff of hospital and clinic, where the big events are a drug that doesn’t work properly, or a visit from a pharmaceutical salesman that screws up the entire afternoon schedule.

But no: In Dr. Carl Elliott’s survey of all that is shifty in modern medicine, those humdrum events are exactly what make up medicine’s dark side. And, indeed, Dr. Elliott’s entertaining and extremely readable essays will have you convinced that in comparison to the shenanigans that go into the creation of a single prescription pill, fingerprint erasure might actually be a little dull. After all, what is more sinister than the dubious mechanics of the ordinary, the sausage factory behind the breakfast special?

A physician who specializes in philosophy and ethics, Dr. Elliott hails from that quiet zone of medicine where much of the job involves thinking about, talking about and doling out medications. Hence his primary focus is on the ever-evolving relationship between the high art of medicine and the big business of drugs.

Some of his material has, at this point, been reviewed ad nauseam in the daily press and in books by others, so most readers will be familiar with the bad habits of Big Pharma when it comes to subtle data manipulation, high-pressure salesmanship and lavish gifts. Mighty and expensive are the efforts to guide the hands that write the prescriptions. But Dr. Elliott also spends time in places where few other authors have ventured.

Doctors get pens and trinkets, football tickets, junkets to beach resorts. Less visible are the large sums handed over in “I’m going to make you a star” projects to groom them as trusted faces and voices in the service of some drug. Education and advertisement merge in these elaborate ventures, as the paid professor travels the country, lecturing about disease and, incidentally, the treatment thereof.

These “key opinion leaders” are bad enough, but who would ever imagine that the curricula vitae of many academic physicians (those on a medical school faculty) are packed with journal articles actually written by ghostwriters sponsored by pharmaceutical companies?

“Nobody expects American politicians to write their own speeches anymore,” Dr. Elliott reminds us, “and nobody expects celebrities to write their own memoirs.” Apparently doctors have now joined the ranks of the charismatic talking heads, mouthing the words of others.

And just as “professor” generally describes someone who writes his or her own sentences, “ethicist” generally describes someone who dwells (or at least works) on an unusually high moral plane. But Dr. Elliott also takes a brief and very informative excursion into the world of the medical ethicists. Once they were highly principled, underpaid gadflies, trying to sort out medical decision making. Now they are part of a booming industry, and, speaking of industry, their ties to the pharmaceutical industry are many and complex. Many companies now hire their own ethicists. But who guards those guards?

Meanwhile, at the bottom of the pharmaceutical totem pole are the folks who make it all happen: the people who volunteer to test new chemicals for safety before they are let loose on the general public.

John le Carré’s book “The Constant Gardener” touched on some of the issues that arise when big companies pay very poor people to test their drugs. Dr. Elliott didn’t have to head to Africa to report this story, however: the Northeast corridor provided ample material.

In Philadelphia he found a group of professional “guinea pigs,” as they call themselves, sequestered in a hospital’s clinical research unit while they were testing a prospective new drug. It was one long pajama party: “We were just gorging ourselves at 2 a.m. on Cheez Doodles,” one guinea pig told him. Only one problem: Those were contraband doodles. The drug under investigation required stringent dietary restrictions, which the subjects were systematically violating. So much for the science of drug evaluation.

Some guinea pigs are activists — one has founded an industry magazine, Guinea Pig Zero. Probably more typical, unfortunately, are the subjects who spent time in a drug testing site in Miami, the largest in the country until it was shut down for fire and safety violations. Many of them were illegal immigrants, packed into shabby, overcrowded rooms with minimal supervision.

“Guinea pigs do not do things in exchange for money so much as they allow things to be done to them,” Dr. Elliott points out. “There are not many other jobs where this is the case.” Yet for all the job’s built-in vulnerability, there is little monitoring of either the subjects’ health or the data’s validity.

What a world, what a world, as the melting witch said in “The Wizard of Oz.” But there is one small consolation: at least Dr. Elliott didn’t have to call his book “White Coat, Black Heart.” Now that would have been depressing. The bottom line is that much of what he describes is simply the big business of medicine as we have allowed it to take shape. His bad actors are mostly just that: actors caught up in a script not of their own devising. They all come home in the evening, take off their black hats and hang up their white coats, just regular working stiffs out to make a buck.

WHITE COAT, BLACK HATAdventures on the Dark Side of Medicine. By Dr. Carl Elliott. Beacon Press. 224 pages. $24.95.