Following the money. Foreword.

Follow the money is a versatile phrase; the term can be used as an exhortation, designate a pathway, or denote a lifestyle choice. When it comes to health care, following the money is at least part of the sine qua non for anyone seeking to understand how this complex sector of the US economy has arrived at its present sorry state. It's not hard to conclude that a country which allocates 13.7% of its GDP to health care,1 yet ranks down at #37 on the World Health Organization's listing of global health systems,2 has not been spending its money wisely. Things may get a whole lot better - or a whole lot worse - now that Congress has enacted the Patient Protection and Affordable Care Act of 20103, but in any event things will most definitely be different. The essays in this Symposium all contribute to an understanding of how different they could turn out to be. Popular wisdom has it that the term follow the money originated with Deep Throat in the Watergate Era - at least Hal Holbrook uttered those words when playing the character in the film version of All the President's Men. But as Professor David Hyman notes in his article for this issue,4 the phrase appears nowhere in any of Bob Woodward and Carl Bernstein's Watergate writings, nor does it show up in Woodward's interview notes for his meetings with his clandestine source. The movie's screenwriter has finally concluded that he probably thrust those words into Deep Throat's mouth all on his own.5 This symposium contains articles by an impressive group of health law scholars, extremely knowledgeable about health care economics and financing. They need quote no Deep Throats about the way the US and other health sectors actually function, for they have been doing their own hard work researching, writing and teaching about health care delivery for many decades. Thus they have unique authority to analyze and comment upon the role of money in health sector, and each of them has put his or her own special spin on the topic. The great pleasure for me in writing this Foreword has been to see how each one of them has taken up the topic of money and run with it, in ways both predictable and unexpected. And just for fun, I've tried to figure out whether each of these talented scholars has approached the subject as the potential pathway, exhortation or lifestyle choice with which I framed this essay. Professor Robin Wilson's meticulously-documented contribution to this symposium, The Death of Jesse Gelsinger: New Evidence of the Influence of Money and Prestige in Human Research, is at first easy to pigeonhole as a straightforward response to an exhortation to follow the money. Her article draws upon reams of evidence, accumulated for a high-profile lawsuit, that never really saw the light of day because the case settled so quickly. She did indeed follow the significant sums of money a biotech company poured into the financing of a Phase I gene therapy clinical trial at the University of Pennsylvania, all the way through Penn's organizational chart and procedures, and her comprehensive account constitutes legal investigative reporting and analysis at its very best. Professor Wilson dug deeply into the circumstances surrounding Jesse Gelsinger's highly-publicized 1999 death during the clinical trial, where both the principal investigator and the sponsoring institution had substantial financial investment in the technology at issue. Her persistence in ferreting out and exposing the financial and other facts of this tragic case, and the conflicts they engendered that may have affected Jesse's fate, has provided the research community and the rest of the world an invaluable reminder that conflicts of interest will always breed suspicion about ulterior motives. But perhaps more importantly, her work spotlights the cozy research relationships between industry and academe - lifestyle choices, in the framing terminology of this Foreword - that can compromise both the process and the product of scientific investigation. …