Volume 19 Number 1 Winter 2002

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"It could be that companies
don't sponsor clinical trials
unless they are pretty sure
that the outcome will be good"
- Bioethicist Mildred Cho

An ethical path
by Christopher Vaughan
Photo by Jackie Bonhart

As a professional bioethicist, Mildred Cho's work is never done

Mildred Cho, PhD, is friendly, slight and soft-spoken — not the sort of person you would think could make university presidents or pharmaceutical company CEOs anxious. Nonetheless, Cho, who received her Stanford PhD in 1992, has authored a number of widely publicized research papers that do just that. Examples of her research include findings showing that clinical trials funded by drug companies show positive results more often than trials with funds from independent sources and that most universities’ ethics policies are not sufficient to protect the integrity of the institution. The power of her work is strengthened by the way she presents her findings. Cho sticks to simple, verifiable facts and when those facts raise uncomfortable questions, she holds back from suggesting broad remedies or painting any parties as the bad guys. C0ho’s style is mirrored in many of the researchers at the Stanford Center for Biomedical Ethics. "The Stanford center has a heavy emphasis on empirical research," says Cho. "We don’t have a lot of philosophers here — people tend to come from a technical background like medicine or biology."

Although Cho has followed a standard academic path for a biomedical researcher, ethical questions intrigued her throughout her career. By chance or by choice she has always happened to be where the biggest ethical questions in biological research are being hashed out. For example, Cho was studying biology as an undergraduate at MIT just when the city of Cambridge, Mass., was debating its controversial ban on experiments in genetic engineering. Later she arrived at Stanford University School of Medicine to study pharmacology exactly when Stanford researchers were initiating pioneering experiments in another controversial area: gene therapy.

After earning her doctorate in pharmacology, she was awarded a Pew fellowship in health policy at the University of California-San Francisco. After that followed another fellowship, at the Center for Health Care Evaluation at the Palo Alto Veterans Affairs Medical Center, before Cho took a position at the biomedical ethics center.

Demand for Cho’s skills as a bioethicist continues to boom. Nowadays she finds herself spending many hours in airports and on airplanes, traveling to attend conferences and meet clients such as the National Institutes of Health. She enjoys her work but has little time for much else. "What I really enjoy doing when I’m not working is getting to walk outside and stand on ground that isn’t covered with concrete," Cho says. "I have low standards," she jokes.

One of the first large projects Cho took part in at the biomedical ethics center was the group’s study of how tests for the breast cancer genes BRCA1 and BRCA2 changed the ethical landscape of health care. A complexity of the issue was that, at the time, there was very little that women who tested positive for the gene could do to lower their risk of breast cancer, short of getting preventive mastectomies. The group tackled the question of whether it was ethical for doctors to recommend that patients get such tests.

"The breast cancer study has been a good model for other genetic disorders for which we now have tests," Cho says. For instance, she says, she is studying the implications of a test for a gene that leads to familial, late-onset deafness. "It’s really not clear what the medical management strategies should be or even whether the condition should be considered a disease at all."

Another area of study for Cho is how conflicts of interest affect the conduct of clinical research. She feels that the work she has done merely opens up the field for more inquiry. Though one of her studies illuminated a potential problem — that drug trials funded by pharmaceutical companies were more likely to have positive outcomes — it doesn’t explain the anomaly. "It could be that companies don’t sponsor clinical trials unless they are pretty sure that the outcome will be good," Cho says. "The frustration in this sort of research is that there are too many good questions to answer."

That frustration is sure to increase as the pace of genetic discovery accelerates. The sequencing of the human genome and the mapping of important genetic variations should lead to many new genetic tests, some perhaps even for genes linked to behavioral characteristics.

"We are trying to be anticipatory about how people might be stigmatized — or not," Cho says. Genetic tests in the future might not only find genes for disorders, she points out, but might be able to pinpoint genes that people might be happy to be labeled with, like genes associated with happiness or intelligence. "We are trying to look at ways in which genetic labels might result in discrimination but also at ways in which genetic labels change people’s self-identification."

The rapid pace of genetic research also holds the danger that researchers will be tempted to cut ethical corners out of a fear of being left behind by other scientists. That explains why ethicists, Cho says, sometimes get the feeling that they are treated like the "science police."

A hopeful sign, however, is that in the last decade most scientists have become more open to working with ethicists on their research projects, she says. "Sometimes a researcher will even come in before he starts a project, when he is just thinking about it, to talk about what he wants to do. That never would have happened 10 years ago."

SM

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