¹ I use the term movement because bioethicists have come to use it to describe their own venture which combines the creation of bioethics and widespread social activism to gain control over medicine.

² Edmund Pelligrino notes that numerous philosophers ancient and modern made comments on ethics in medicine, but that bioethics is something distinctly different and of quite recent origin. See his editorial in JAMA (March 3, 1993): 1159.

³ See the writings of Alisdair Maclntyre for a critical view of these movements, especially After Virtue and Whose Justice? Which Rationality? He argues that the liberal societies of the West are morally barren and that the need for such movements is indicative of this.

⁴ Taken from the comments of Judith P. Swazey, “But Was it Bioethics?” Hastings Center Report (November-December 1993) Special Supplement, p. S6. Ramsey’s comments were made at a conference in 1973.

⁵ The Birth of Bioethics Conference was held in Seattle, WA in September of 1992. The conference was primarily retrospective, looking at the origins of the bioethics movement at a Seattle hospital. Many trace the beginning of the movement to a dispute which arose regarding the allocation of kidney dialysis. While current issues were discussed, these took a backseat to the focus on the founders of the field and the issues and developments which enabled the movement to take hold.

⁶ Historian David Rothman writes in Strangers at the Bedside (New York: Basic, 1991): “the record of bioethicists’ influence… makes a convincing case for a fundamental transformation in the substance as well as in the style of medical decision making.”

⁷ I do not see bioethics as a complete success or “ideal.” It has numerous problems and shortcomings. In addition, even though I want to argue that there are some valuable insights which can emerge from looking at bioethics, I don’t see it as a literal model for business ethics to adopt. Numerous differences make it imperative that comparisons be made very carefully. I will argue that there are specific connections or points that can be translated across these two disciplines. My reason for mentioning these 4 points of comparison is to highlight two things: first, the commonality of these goals across both fields, and second, the fact that bioethics’ relative success in achieving these goals makes it a natural source of reference.

⁸ Patricia H. Werhane, Adam Smith and His Legacy for Modern Capitalism.

⁹ Weber, Protestantism and The Spirit of Capitalism.

¹⁰ One can look to the writings of Aristotle and Plato, St. Thomas Aquinas, John Locke, John Stuart Mill, Karl Marx, and others to affirm this connection over the span of Western history.

¹¹ See Werhane’s book on Smith, Robert Solomon’s Ethics and Excellence for examples of the former. On reinterpretations of existing inquiry see Freeman’s books on stakeholders, Freeman and Bowie’s Ethics and Agency Theory, and Gilbert’s The Twilight of Corporate Strategy. Gilbert’s book in particular, gives an outstanding example of how ethicists can master the canonical works of a given field in the study of organizations (he examined the strategy literature), proceed to deconstruct them in terms of ethical critique, and then offer a reconstruction that makes ethics a central part of future inquiry.

¹² A number of competing theories exist regarding the nature of professions, including attribute theory (Talcott Parsons and Ernest Greenwood) and more recent versions that encompass the relationship between clients and professionals (Robert Sokolowski and Eliot Freidson). For a more detailed account of these issues, see William E. Fassett and Andrew C. Wicks, “Is Pharmacy a Profession?” Forthcoming in Ethical Issues in Pharmacy, ed. by Bruce D. Weinstein.

¹³ Greenwood’s attribute theory highlights 5 features that characterize a profession: a systematic body of theory, professional authority, sanction of the community, a code of ethics, and a professional culture.

¹⁴ Some have called this “strategic morality.” The idea is that one can empower employees, create coalitions of stakeholders who are interdependent and mutually supportive, while becoming more productive. In addition, there have been a large number of financially successful organizations with ethically positive objectives that transcend profit making: Ben & Jerry’s, The Body Shop, Merck & Co., Johnson & Johnson, Corning, and others.

¹⁵ The type of efforts I refer to offer a promising start in many cases, but they are far from sufficient. However, the precedent they set is crucial, both for facilitating future efforts by businesses and the public to improve the performance of corporations and to bolster my claims regarding the comparison between business and medicine.

¹⁶ Frederick, Post and Davis, Business and Society, 7th edition (1992).

¹⁷ See a variety of thinkers who hold this view or similar variations, on the centrality of patient interests. N. Levinsky writes “physicians are required to do everything they believe may benefit each patient without regard to costs or other societal considerations,” (from “The Doctor’s Master,” NEJM 311 (1984): 1573). See also the writings of R. Veatch, E. Pelligrino and D. Thomasma, H. Hiatt, T. Beauchamp and J. Childress.

¹⁸ GeorgeJ. Agich describes the dominant understanding of the normative core of medicine and business in similar terms. See his “Medicine as a Business and Profession,” Theoretical Medicine, vol. 11 (1990), pp. 311-24.

¹⁹ Indeed, Arnold Relman has argued, “… [M]edical care … is in many ways uniquely unsuited to private enterprise… it cannot meet its responsibilities to society if it is dominated by business interests.” (“What Market Values Are Doing To Medicine,” Atlantic Monthly (March 1992): 106). Similar views have been expressed by Charles Dougherty.

²⁰ Current estimates indicate that between 35-40 million Americans lack adequate access to health care. Particularly disturbing is the fact that a large segment of these include children and families in which parents have full-time employment.

²¹ E. Haavi Morreim, The New Medical Ethics of Medicine’s New Economics (Klewter: 1992): p. 50.

²² Morreim argues that these stakeholders are far from “intruders,” but are instead parties with legitimate interests and important moral reasons for being included in the health care decision-making process (ibid.; pp. 2, 141).

²³ This is especially true of physicians. Among the factors which Dan Brock and Allan Buchanan cite as indications that self-interest—not concern for ill patients—directs their activities: the high level of compensation, the relative preponderance of physicians around middle income and high income areas where access is not a problem, the resistance of physicians and the AMA to proposals that would increase access to health care, the significant number of physicians who refuse to see indigent and HIV positive patients, and the preponderance of examples of over treatment, unnecessary consultations, and overbilling. See Brock and Buchanan, “Ethical Issues in For-Profit Health Care,” in For Profit Enterprise in Health Care [Washington, D.C.: National Academy Press, 1986], ed. by Bradford Gray, p. 241-2. These examples are not meant to demean the importance of physicians in this society or their moral code. Rather, I want to break down any naive assumptions that these moral duties can, or should be, unaffected by the dynamics which affect business activity. We can criticize the above behaviors of physicians behavior as overly self-interested, but that is far different from arguing that physician self-interest could or should play no role at all.

²⁴ Notice that while I argue for similarities in the structure of duties I do not make such a claim in terms of content. There are greater expectations in terms of other-regarding and self-effacing activity for health care workers and institutions than for their counterparts in business. Both G. Agich and H. Morreim argue for reconsideration of the traditional boundaries between medicine and business, between self-interest and serving others. They both support a more complex vision of medicine that makes room for many of the “business” imperatives that I have outlined.

²⁵ This is also how many recent pieces have argued Adam Smith envisioned the notion of self-interest. While pursuing profit can be seen as a moral goal, it must be argued for and defended on these grounds, not as a self-evident objective of the firm which necessarily trumps other moral concerns [such as respect for others, fairness, decency]. Indeed, when one casts self-interest in these terms, it opens up a good deal of debate about how to balance these considerations with other relevant factors. In contrast, the more typical profit-maximization goal as “amoral” or value-free tends to exclude these other considerations and slip into the notion of “greed” that Dennis Levine celebrates.

²⁶ I use the term “consumer” for two reasons. First, patients need to be more informed about and responsible for their health care decisions. Second, they need to be much more aware of the fiscal implications of their choices at the bedside by voting as citizens. These revisions are appropriate because the traditional informational asymmetries and power differential which make the commercial model unacceptable for health care are exaggerated. The emergence of second opinions in medicine and the increased complexity of business decisions has balanced out many of the informational asymmetries and recent legislation has important rights and protection for consumers in the marketplace. For a more detailed account of this argument, see Andrew C. Wicks, “Albert Schweitzer or Ivan Boesky: Why We Should Reject the Dichotomy Between Medicine and Business,” forthcoming in the Journal of Business Ethics.

²⁷ Werhane, “The Ethics of Health Care as a Business.” Business and Professional Ethics Journal, vol. 9:3&4, pp. 7-20.

²⁸ Dan Brock and Allan Buchanan, “Ethical Issues in For-Profit Health Care,” in For Profit Enterprise in Health Care [Washington, D.C.: National Academy Press, 1986], ed. by Bradford Gray, pp. 243-5. Brock and Buchanan maintain that it is too early to tell whether this is happening, since there is currently insufficient data, but the risk of intervention is one of the most realistic and dangerous aspects of a shift toward for-profit organizations in health care. However, such concerns need to be considered alongside the ethical costs of the current system, which are substantial.

²⁹ For medicine, the challenge is do a better job of including the legitimate moral interests of stakeholders other than particular patients and acknowledge that its moral mission is not so divorced from self-interest. For business, the challenges are to improve its performance and do a better job of integrating moral concepts into the practice of business.

³⁰ I adopt this traditional formulation, and other common terms in this section, because they are so widely used. However, as a pragmatist, I reject the notion of any fundamental division of theory and practice. More specifically, I reject the assumptions implicit in the language of “application” which many ethicists use to describe both business ethics and bioethics.

³¹ Some of the more interesting recent debates about the theory v. practice issue in bioethics can be found in The Journal of Medicine and Philosophy, especially the April 1990 and 1992 issues. For similar discussions in business ethics, see Robbin Derry and Ronald M. Green’s essay “Ethical Theory in Business Ethics: A Critical Assessment,” Journal of Business Ethics, vol. 8 (1989), pp. 521-33.

³² See, for instance, the recent article by Andrew Stark, Harvard Business Review [May-June 1993]. Even though this piece was something of a hatchet job on the field, and was rightly criticized for inaccurately representing the views of many business ethicists, it nevertheless effectively captured what frustrates many about the field: namely, much of the research in business ethics does not make sense to managers or “work” in the context of the modern corporation. That is, it is too theoretical and too unconnected with the “real world” of management. Others have noted this trend within business ethics. Daniel R. Gilbert makes a similar charge about the work of Kenneth Goodpaster, when he argues that Goodpaster sees business ethics as the domain of “experts” (“Respect for Persons, Management Theory, and Business Ethics,” in Business Ethics: The State of The Art, ed. R. Edward Freeman). This approach tends to reinforce the gulf of theory and practice, and provide further support for skeptics like Milton Friedman who argue that managers shouldn’t have to deal with social responsibility (or ethics) because they don’t have the expertise.

³³ See the Presidential Address of the Academy of Management for a discussion of this concern with respect to all the disciplines in business schools. Research has become so idiosyncratic and removed from the context of management as practiced in particular corporations that its’ worth has become questionable. I take this as a welcome warning for ethics and the academy in general, although I certainly fear the extreme of allowing current trends and practices to dictate how research is conducted.

³⁴ See Clinical Ethics, ed. by Barry Hoffmeister, Benjamin Freedman and Gwen Fraser (Clifton, NJ: Humana Press, 1988). For similar discussion in business ethics, see Derry and Green (1989), cf. 31.

³⁵ Daniel Callahan notes the destructive influence of positivism, specifically its tendency to force out discussion of ethics in medicine during the 1930’s. He emphasizes that positivism tends to reinforce the hard (science) vs. soft (ethics) distinction I outline. See his comments in “Why America Accepted Bioethics,” Hastings Center Report. Special Supplement (November-December 1993): S8.

³⁶ Archie Carroll, Lee Preston, Steve Wartick and Phil Cochran, and Tom Jones have all called for or advocated a paradigm for the study of business and society. I have no trouble accepting stakeholder management or corporate social responsibility as a shared framework for debate, particularly as a descriptive device. However, I am uncomfortable with the strong normative overtones of the term “paradigm” and the constraints on the type of inquiry that would then be viewed as legitimate. I have no problem with empirical inquiry, but I reject the positivism which makes so much of organization studies grounded in emprical work. Thus, I see such studies as a limited source of knowledge which has the tendency to distract from the core of ethics and SIM inquiry: normative argument, comparative case analysis, and story. Indeed, a paradigm seems counterproductive.

³⁷ Another problem with using paradigms to do SIM based research is that it attempts to structure the study of value-based inquiry within a methodology that is ill suited to it. Aristotle talks about the degree of certitude ascribable to the study of ethics and contrasts it with that of the natural sciences and mathematics (Nichomachean Ethics, book 1, section 3). Using a paradigm involves implicit assumptions that I am uncomfortable with: it ascribes a degree of certitude to the study of ethics that is inappropriate and it reaffirms that normative, non-empirical inquiry is marginal. While researchers need to carefully define key terms, they should also refuse to disguise legitimate disagreements about their meaning (e.g. by creating an artificial paradigm) or adopt methods of research which tend to exclude normative discourse, the touchstone of ethics and other SIM studies.

³⁸ The work done by Dan Gilbert and Ed Freeman in strategy is particularly noteworthy. Both have mastered the literature in strategy and worked from within to offer internal critiques as well as suggestions for how current approaches are impoverished. They have also indicated how strategy can be reconceptualized to ask better and more useful questions, particularly in terms that integrate ethical concepts. See especially Freeman and Gilbert, Corporate Strategy and The Search for Ethics (Englewood Cliffs, NJ: Prentice Hall, 1988) and Gilbert, The Twilight of Corporate Strategy (New York: Oxford University Press, 1993).

³⁹ Edmund Pelligrino agrees that there is already a significant degree of diversity in theoretical models and that this is likely to increase over time. See his comments in JAMA (March 3, 1993): 1158.

⁴⁰ The presentations by Tom Beauchamp, H. Tristam Engelhardt and Stanley Hauerwas in the session on theory at the Birth of Bioethics conference illustrated some of the profound disagreements in the field. See also The Journal of Medicine and Philosophy for ongoing disagreements, especially in vol. 15, no. 2 (April 1990).

⁴¹ I have little trouble with the field developing a consensus on certain issues (e.g. that insider trading is unethical) or frameworks (such as the stakeholder model). Indeed, such agreement seems necessary for the field to “make progress” and serve its role as conversation partner to practitioners. However, this constitutes something far less normative and systematic than the term “paradigm” would suggest. To the extent that some researchers would hold onto this term to describe such smaller-scale agreements, I would discourage use of the term ‘paradigm.’

⁴² In bioethics, see the work of Stanley Hauerwas who argues that the tradition of the virtues is central to the practice of medicine and that principle/rule based approaches are misguided and destructive. In contrast, James Childress and Tom Beauchamp argue that principle, casuistic and virtue-based approaches are complimentary and each provide important insight about the moral dimensions of medicine.

⁴³ Debates about the nature of “expertise” of ethicists abound in bioethics: issues of whether ethics consultants ought to be simply sounding boards or directively guide the resolution of disputes, whether such activity should stay strictly within the bounds of widespread agreement or lead practitioners through unsettled territory, whether ethics consultants ought to be ethicists with some clinical experience or clinicians with some ethics training. For disputes about this question of expertise see Clinical Ethics, Arthur Caplan’s comments at the Birth of Bioethics meeting, and Pelligrino’s editorial in JAMA (August 12, 1988): 838. For discussions on the role of ethics consultation in a hospital setting, see Ethics Consultation in Health Care, ed. by John Fletcher, Norman Quist and Albert R. Jonsen (Ann Arbor, Michigan: Health Administration Press, 1989).

⁴⁴ While I don’t think ethicists should be embarrassed about consulting with businesses and being paid well to do so, the whole issue raises questions about the image of the field. Many critics argue that consultation and handsome compensation for it are ethically problematic. Given the need to maintain the integrity of the field and open the possibilities for its future involvement in shaping the institutional landscape of practice, it behooves ethicists to establish very clear guidelines regarding both the ends and the legitimate means of consultation.

⁴⁵ Stanley Hauerwas, in particular, has talked on several occasions about “Why Medicine Doesn’t Need Medical Ethics.” Others have commented that gaining institutional roles has limited possibilities for critique. Daniel Callahan’s comments at the Birth of Bioethics meeting suggest a similar concern about bioethics losing its critical edge.

⁴⁶ Richard DeGeorge has argued that these two tasks are independent and that the success of the field in one may spoil its success in the other [see his essay, “Will Success Spoil Business Ethics?” in Business Ethics: The State of The Art, ed. by R. Edward Freeman]. I would argue that it behooves us to think about the two dimensions as fundamentally interconnected. I take seriously his concern that in the rush to make ethics “relevant” consulting ethics may be taken over by apologists of the status quo and end up merely inculcating already existing norms of practice, without the more probing and critical inquiry typical of academic business ethics. Although I am clearly pushing for more connection in research to the practice of business, I do not want business ethics to stop asking hard questions or challenging the basic assumptions and practices of American capitalism. I see the possibility of being radical and relevant at the same time (for instance, I see Freeman, Gilbert and Solomon all as proposing rather radical ideas for business, yet each do so in ways that are clearly practicable and workable in the context of contemporary American capitalism).

⁴⁷ While I have already talked about the problems of bridging the gap between academic inquiry and that of business practitioners, this is an important aspect of that issue. In particular, as businesses become increasingly horizontal and responsive to change, and academicians in business push this trend, it is odd that the structure of the academy remains as hierarchical and disjointed as ever. It is no wonder that inquiry is becoming increasingly irrelevant if we are not able to do more to flatten our own hierarchies and work across disciplines to create the kinds of insights that are needed to help practitioners address the challenges of the day.

⁴⁸ As an indicator of this phenomenon in both business ethics and bioethics, it is worth noting that I had a difficult time publishing this and another piece which spanned the two fields—in both instances because the essays didn’t focus exclusively on one of the two audiences in question. I spoke with editors of leading publications in both fields who looked at these pieces. They agreed that the pieces were worthy of publishing somewhere, but that without a major revision to make it a “business ethics” or “bioethics” piece, they could not accept it.