Introduction

In the paper “An archeology of corruption in medicine” (2018), Miles Little, Wendy Lipworth, and Ian Kerridge (“the authors” or “Little et al.”) present an account of corruption and describe its prevalent forms in medicine. In presenting an individual-focused account of corruption found within “social entities” (organizations, institutions, and systems), Little et al. argue that these entities are corruptible by nature and that certain individuals are prone to take advantage of the corruptibility of social entities to pursue their own ends. The authors state that this is not preventable, so the way to remedy corruption is via management and, where necessary, punishment. This commentary will briefly lay out the key features and functions of corruption as presented by Little et al., before providing a critical discussion that will focus on whether corruptibility is a necessary feature of social entities. I will propose that it is not a necessary feature, though it may frequently arise where individualistic values are unchecked. Corruption can be prevented within social entities, by enhancing structures that direct toward virtue and which promote and reward cooperation instead of competition.

The Many Mechanisms of Corruption

According to Little et al.’s individual account (by contrast with collectivist or dependence accounts—see Miller 2018), the corruption of social entities has three key features. First, corruption requires a corrupt agent. This is an individual (or perhaps multiple individuals) who stand(s) to benefit from an unfair exchange of material or immaterial goods. Second, this exchange of goods takes place outside of the social norms and community expectations for fair dealing. Third, the agent(s) trade(s) on the credibility and authority of a social entity, thereby leveraging the public’s trust, to achieve their own ends (526). So, corruption is the sort of thing that can happen in and to social entities (organizations, institutions, or systems) which are governed by a set of norms and subject to a set of social expectations. On this account, Little et al. make use of a normative teleological (that is, purpose-driven) understanding of these social entities (Miller 2017, 2018). This posits that social entities are designed to carry out particular “benign or benevolent” purposes (526). The public healthcare system, for example, is teleological in that it is an end-directed system that sets out to achieve better health for everyone through prevention and treatment of illness or injury; and further, it is normative because better health is taken to be a human good. When corruption happens in the public healthcare system, then, agents leverage the trust that society places within them, as actors in this system oriented towards achieving good ends, in order to obtain some private goal, unconnected to the system’s ends.

Interestingly, Little et al. do not mention the effects of an act as being a defining characteristic of corruption. They write that corruption taints the reputations of social entities and arouses public indignation, but undermining trust in a social entity or its ability to meet its purposes is not a defining feature of corruption on their account. This is a departure from other accounts of corruption, which, in finding that corruption is the effect of certain kinds of behaviours, places effects as a defining condition. However, it is clear that Little et al. find that corruption is undesirable because of the kinds of effects it has.

Despite the long-standing public disapprobation of corruption, it seems to be widespread and difficult to eradicate. The authors propose two reasons why this may be. The first has to do with the nature of social entities. The authors argue that organizations, institutions, and systems contain latent opportunities for manipulation by corrupt persons or groups (527). They further state that no social entity can be immune to this; it is simply in the nature of such entities. Social entities are vulnerable to: internal corruption, committed by one employee against another (like hazing or bullying of new members by “elite” members); corruption that works from the inside out (like insider trading); corruption that works from the outside in (such as governmental interference with the judiciary); and two-way corruption, as when parliamentary ministers arrange favours for wealthy constituents with the understanding that both will benefit (votes for favours).

The second reason why corruption persists has to do with human nature. Some people, Little et al. write, who have anti-social habitus or sociopathic tendencies do very well in workplaces and become corrupted by opportunities for self-advancement. Social entities are then “corruptogenic” for these people (528), but these people also have a hand in corrupting the social entities. Little et al.’s analysis thus proposes that corruption results from inherent characteristics of social entities when encountered by sociopathic agents. The opportunities for subverting rules to one’s own ends within social entities reveal themselves to sociopathic persons, and both the social entities and the agents are thereby corrupted.

Little et al. present a number of aspects in which agents can be associated with corruption and say that two of these are specific forms that arise in systems of healthcare and medical research. The first four aspects of corruption can arise in any social entity, and these are: active engagement in corrupt practices; wilful ignorance of the practices taking place, or looking the other way; true ignorance of these practices, which nonetheless taints the agent by the evil-doing of colleagues; and whistle-blowing, which is not corruption itself but happens where one realizes corruption is happening and attempts to halt it (529).

The two additional forms of corruption that medicine frequently encounters are: being beholden, by receiving gifts (however small) or grant support; and education or sponsorship, which the authors call the “wooden horse” influence (530). That is, via participating in medical or nursing school curricula, or sponsoring placements or activities, social entities with vested interests can influence healthcare providers to promote these interests. To illustrate the forms of corruption of being beholden and the wooden horse, Little et al. say that the pharmaceutical industry is often engaged in such activities as gift giving, granting, and sponsorship among medical students, practitioners, and researchers. They write that the “pharmaceutical industry is corrupt because it intentionally exploits the good offices of an essential industry for private benefit” (530). Though “essential industry” is somewhat ambiguous here, a plausible reading of this claim is that the pharmaceutical industry has become corrupted because companies and agents inside this industry use the good offices they hold in ways that enrich the private shareholders of pharmaceutical companies and themselves, at the expense of the noble objective of pharmacy, which is to provide medicine to the ill. Pharmacy is, of course, essential to human health, though there are branches of it that seem to move further away from necessity and closer to consumerism.

It is no easy thing to establish that the pharmaceutical industry is itself corrupt or that it is a corrupting influence on the healthcare system. The difficulty is that according to the market-based rules, this industry conducts business in a way that is consistent with industries of its kind, which are dominated by companies owned by shareholders and traded on the open market. If welfarist societies with socialized healthcare did not want pharmaceutical companies to be operating in pursuit of private wealth, then the pharmaceutical industry should in the first instance become publicly-owned, i.e. nationalized.

This comment about private corporations might be premature, however, since we have not yet seen Little et al.’s suggestions for preventing and managing corruption. As noted at the outset, the authors do not think corruption is entirely eradicable, and that is tied to the conviction that corruption inheres in the nature of social entities and the nature of (at least some) humans. It is typical to call for transparency and accountability from our social entities, and while these calls are reasonable, they are “practically impossible to enforce against a determined person” (531). Instead, Little et al. argue, we require redress mechanisms, such as suspending corruptors from their positions; deregistering them if they are medical practitioners; jailing them if this is justified; or assigning them to social service to pay back to society. These punishments are appropriate for both active engagers and the wilfully ignorant, Little et al. write, even though evidence suggests that people who practice corruption are unlikely to benefit from rehabilitation (532). For the broader community, we must raise awareness, as a first step toward apprehending the nature of a real and threatening phenomenon.

Rules, Rawls, and Rorts

I am sympathetic to Little et al.’s conviction that people are easily tempted by the influences of corruption. Since the writing of ancient philosophers, corruption has been associated with our material, mortal being. We are imperfect in our essence—corruptible and corrupting—and because of this we can only create imperfect things. Corruptibility is one kind of imperfection that might arise in the social entities we create (others include inefficiency and unfairness), however it is not a foregone conclusion that every social entity is necessarily corruptible nor that agents will exploit the features that allow for this.

Individual agents are part of what constitutes social entities, but the way that individual agents interact with social entities is complex. One way to think of this interaction is that agents will “play the game” of social entities to pursue their ends as fully as possible and will play according to strategies permitted by the rules and win-conditions. If the rules of the social entity are deformed, then so will be the strategies for winning. Little et al.’s paper presents a compelling vision of corruption when it discusses the dynamics of corruption from the inside (e.g. insider trading in finance) and outside (e.g. government pressure on the judiciary) of a social entity. In such cases, the rules and strategies of the social entities are deformed by forces like the values and expectations of market-based trading; federal or state-level budgets; or the requirements of local economies. Ordinary agents are to some degree at the whim of these dynamics. While they must have their own moral compass, they must also “play their hand” as well as possible within the wider game or possibly face a number of bad outcomes. As such, it is not only sociopaths who would be tempted to become active engagers in corruption. Such people may be difficult barriers to the full eradication of corruption, but lots of people without social pathologies are tempted into corrupt practices as strategies that seem to yield the best outcomes under deformed systems of rules.

While this is plausible in any number of social entities, corruption seems especially disturbing and unacceptable when it appears in public offices and social institutions that are ostensibly created for collective benefit. The concept of public trust is key in delineating corruption on an account of social entities that is teleological or end-directed (Little et al. 2018, 527; Miller 2018). Earlier, I presented a teleological account of a publicly-funded healthcare system, on which account the system was established with the end of improving human health in mind. In order for a publicly-funded healthcare system to be effective it is supposed to have and maintain high public trust. In addition, people who become healthcare providers are expected to have certain motivations and express certain virtues within this role. So, the end of the public healthcare system is first human good, not profit, and the people who work in the system are motivated primarily by achieving human good and perhaps secondarily private wealth.

A central worry about corruption is that a public office or system can or will be subverted in order to secure pre-selected outcomes favourable to a particular party or set of parties. Dissecting corruption in this context brings to mind John Rawls’ second principle of justice, aka the difference principle. This is the principle of fair equality of opportunity and justified inequalities: any public office is to be open to all members of the society, and if there are unequal gains attached to holding that office then its existence and carrying out the functions of the office must be to the benefit of everyone in society and especially the worst off (Rawls 1971). Corruption, especially systemic corruption, is unjust on a Rawlsian account of basic social institutions. Instances of private profit gained from public office, including those in the bureaucracy, often have the characteristics of (a) not benefitting everyone equally but exclusively benefitting the office-holder and profit-offering party, (b) reinforcing the inequalities that pre-exist the deal, such as ability to pay for favours or wield influence in other ways, and (c) in some cases (such as some funding-for-votes scandals) undermining fair equality of opportunity by securing political support in covert and undemocratic ways.

When excavating sites of corruption, it becomes apparent that a significant source of corruptibility lies in societal values that prioritize individual success and private wealth accumulation. Whether we think about ministers of parliament, police forces, or hospital managers, the common theme in corruption is that private persons are pursuing their interests by strategies formed within the context in which they operate, toward goals that are shaped and constrained by systems of exchange and materialistic value orderings. The capitalist system, for example, is a competitive one, constantly driving one person against another in the market. Rawls provides market-friendly resources for analysing this flaw in the system. Greed for money and power may well be a difficult vice to uproot in the competitive market context, but one way to address corruption in many of its ordinary manifestations is to increase base-level welfare and distributional fairness: enforce proper taxation of private and corporate wealth, fund our public systems (including medical and educational) to a level above sufficiency, and pay people liveable wages. In general, we should be creating structures of society under which it is easier (that is, more attractive a means for achieving one’s ends) to be virtuous and resist corruption, than to be vicious and commit or promote corruption.

Rules as Structures for Virtue

Though we find ourselves in a competitive market system, we human beings are an essentially cooperative species (Bowles, 2011). We work together readily, compromise, and follow rules. Another way to prevent corruption, then, is to establish good rules and keep a collective eye on them for signs of deformity. Building good sets of rules within which people go about achieving their individual and collective ends is a part of creating stable and integral social entities. Such good sets of rules can be described as part of what creates the “structures of virtue” (Daly, 2011)—they establish that the range of strategies that individual agents can pursue in order to succeed at achieving their ends are strategies more consisting of virtues (desirable, pro-social, praiseworthy characteristics) than of vices.

Strengthening structures of virtue could address some forms of corruption that Little et al. described in medicine. The line between what counts as certain forms of corrupting influence from the pharmaceutical industry and what counts as marketing is unclear in the paper. Forms of interaction like gift giving (of small things like pens or bags or bigger things like funding) or “wooden horses” of sponsoring educational events, seem ambiguous. Of course marketing has an influence on people, but to describe all marketing influence as corruption seems to weaken the term. In the cases Little et al. discuss, pharmaceutical companies undertake gift giving and wooden horse behaviour seemingly in order to have more of their products prescribed. If we consider this to be a special case of problematic marketing that either is or comes near to corruption, then we should consider ways to support physicians in resisting the sense of obligation to pharmaceutical companies that the gift-giving or wooden horses might give rise to. While there are some who become physicians specifically to earn a high income, many people are drawn to medicine by the promise of helping other people. This good instinct needs protection and encouragement. A way to support physicians in resisting influence could come through building solidarity between them, by creating ways to show strength in numbers when saying “no” to all gifts, even as small as pens. We could also enhance collective notions of responsibility and of the good to which we are aiming through the integrity of the public healthcare system.

Arguably, some public systems of healthcare (e.g. in the United Kingdom, Australia, and parts of Canada) have a bigger issue on their hands than the influence of the pharmaceutical companies and that is the corrupting influence of an encroaching private health insurance system. A superior system of rules than those currently in place is needed to rectify the leeching of the public system by the private. Those rules should be written to underscore solidarity and reciprocity among the public and reaffirm that we are each contributing to a collective good when we do things like pay our taxes. Cooperative attitudes and the noble motives of physicians currently wither under the strain of a stretched, under-resourced public system of healthcare. This is not inevitable nor necessary but rather the result of successive purposeful decisions made by governments. So, the system is currently wide open to corrupting influence, but it need not be so. Different decisions about the rules by which public healthcare systems operate, including putting an end to parasitic private insurance systems, would help reinforce the systems themselves and the agents operating within them against corrupting influences.

While Little et al. may be right that corruptible beings will create corruptible institutions and organizations, even in our imperfect state we could provide structures that support and tend toward virtue and justice. We live in an unnecessarily imperfect and unequal world. The cooperative and collective solutions to many forms of corruption and vice are within our reach, and in fact, within our nature.