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Rethinking Exploitation:
A Process-Centered Account
T
he term “exploitation” has gained wide currency in recent discus-
sions of biomedical and research ethics. This is due in no small
measure to the influence of Alan Wertheimer’s path-breaking work
on the topic (Wertheimer 1999, 2011). Wertheimer presented a clear and
compelling non-Marxist account of the concept of exploitation—one
that stressed the connection between exploitation and unfair distributive
outcomes. On this account, when one party exploits another, she takes
advantage of the other to gain unfairly. A number of contemporary bio-
ethicists have accepted Wertheimer’s account of exploitation and have
proceeded to apply it to a range of issues in research ethics (Hawkins and
Emanuel 2008; Miller and Brody 2003; Gbadegesin and Wendler 2006).
Notwithstanding its substantial influence, Wertheimer’s account has
not been subject to much careful critical discussion.1 In this paper, we
present some objections to it. The objections attempt to show that his
Kennedy Institute of Ethics Journal Vol. 23, No. 4, 381–410 © 2013 by The Johns Hopkins University Press
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There are two senses in which Joan is treated unfairly. The first sense is
outcome-based. The outcome of the interaction between Joan and those
conducting the trial is unfair, since (presumably) she does not receive suf-
ficient monetary benefit to compensate her for the risks she is assuming.
The second sense is procedural or process-based. Those conducting the
trial take unfair advantage of Joan’s poor economic circumstances to get
her to agree to participate at the very low rate of compensation they are
offering.
The two senses of unfair treatment illustrated in Trial can be made
more precise. Following Wertheimer, let us say that an interaction has
an unfair outcome if one party is made worse off relative to a normative
baseline that specifies how much each party ought to gain. Determining
the normative baseline in Trial is not a straightforward matter. One would
need to identify the level of benefit2 that would need to be provided to
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the participants in the trial to warrant the risks imposed on them. One
also would need to take into account the magnitude of the benefits that
the researchers and others would receive as a result of their participation.
The difference between this normative baseline level of benefit and $100
would then reflect the extent to which Joan received an unfair share of
the benefits from the interaction. The normative baseline approach to
outcome-based exploitation has the advantage of explaining how mutu-
ally beneficial interactions can still be exploitative. In Trial, after all, Joan
might be better off in absolute terms as a result of her participation in the
trial than she would have been had she not had this option. It all depends
on how desperately she needs the $100.
Process-based considerations, by contrast, do not refer to the outcome
of an exploitative transaction. An interaction is exploitative in the pro-
cess sense if one party plays on a weakness or vulnerability of the other
in order to advance his ends. In Trial, Joan is vulnerable because of her
unfortunate economic circumstances. She is in no position to press for a
higher level of compensation. Those who conduct the trial take advantage
of this vulnerability; and, by so doing, they take unfair advantage of her.
With the distinction between outcome-based and process-based senses
of exploitation in view, we now can consider how they are related. Here
three theses should be distinguished:
Outcome Exclusive Thesis: A transaction is exploitative if, and only if, at
least one party benefits unfairly from the transaction.
Process Exclusive Thesis: A transaction is exploitative if, and only if, one
party plays on a weakness or vulnerability of another to advance his or
her ends.
Inclusive Thesis: A transaction is exploitative if, and only if, one party plays
on a weakness or vulnerability of another to advance his or her ends and
benefits unfairly from the transaction.
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WERTHEIMER’S ACCOUNT
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The lesson Wertheimer draws from the case is “no unfairness in the terms
of the transaction, no exploitation.”
Snow Storm is indeed instructive. We argue below that while Wert-
heimer is correct to judge that there is no exploitation in this case, he errs
in drawing the lesson he draws. The case does not show that an interac-
tion that has a procedural defect, but no unfair distributive upshot, is
not exploitative. It does not show this since, correctly viewed, the case
depicts an interaction that has neither an unfair distributive outcome nor
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a defect in the process of interaction. For this reason, Snow Storm cannot
be used to support the Inclusive Thesis over the Process Exclusive Thesis.
On inspection, the case is interesting because it helps us to see what must
be true for there to be a defect in the process that leads to an exploitative
transaction. To appreciate this point, we need now to consider the main
considerations that support an account of exploitation that is consistent
with the Process Exclusive Thesis.
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(P1) explains why the evil person in the above example exploits his vic-
tim by threatening to kill him. Threats of this kind are disrespectful to
their victims. But the explanation provided by (P1) pretty clearly needs
supplementation. We need to know what makes the use of another dis-
respectful to her.
Recent theoretical work on exploitation suggests some possibilities for
filling in the picture. Robert Goodin (1987) claims that wrongful exploita-
tion involves taking inappropriate advantage of those who are vulnerable.
Inappropriate advantage-taking of the vulnerable is disrespectful to them.
Goodin then identifies some of the characteristic ways by which exploiters
take inappropriate advantage of the vulnerable. In a similar vein, Ruth
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Sample (2003) claims that “respect for persons is the core requirement
underpinning our judgments of exploitation” and she identifies three ba-
sic forms of disrespect: neglecting what is necessary for the well-being of
those one interacts with, taking advantage of injustices done to them, and
commodifying an aspect of a person that ought not to be commodified.
Both Goodin and Sample make a number of points relevant to an
adequate supplementation of (P1), but we seek a more general supple-
mentation, one that does not simply advert to different ways or forms
of disrespectful treatment, but seeks instead to identify an underlying
explanation for why different kinds of purportedly disrespectful treatment
are exploitative. Consider now the following general supplement to (P1):
A interacts with B in a way that is disrespectful to B if (i) A uses B as an
instrument for advancing A’s ends and (ii) B would not rationally consent
to the interaction with A under favorable conditions. This supplementary
claim appeals to a counterfactual condition that is defined by two key
ideas—“rational consent” and “favorable conditions.” We will not say
much here about the first of these ideas. A person rationally consents
when she is aware of sufficient relevant information and is not impaired
by various incapacities and distorting influences.9 So understood, a person
can rationally consent to an exploitative interaction.
The specification of “favorable conditions” is a more difficult matter. It
must advert to the absence of weaknesses and/or vulnerabilities due both to
personal circumstance (e.g. an agent may have an emotional weakness that
makes him vulnerable) and to extrapersonal circumstance (e.g. an agent
may be in conditions in which she has little or no bargaining power). Cor-
rectly specified, unfavorable conditions frame the context for exploitative
interaction. When one party “plays on” the weakness or vulnerability of
another, he takes advantage of the unfavorable conditions in which the
other finds herself so as to get her to advance his ends on his terms.
The trick is not to read too much into the favorable conditions. In Trial,
Joan is in a circumstance in which she desires $100, but does not have
it. This is, in one sense, an unfavorable circumstance. She would be in a
better situation if she already had the money. But the fact that Joan does
not have the money, and the fact that she desires it, are circumstances that
constitute the occasion for her interaction with those conducting the trial.
We will refer to circumstances of this kind as constitutive conditions. They
establish the occasion for an interaction between two or more parties.
We can contrast these conditions with conditions that affect the quality
or nature of the interaction that takes place between the interacting par-
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ties. These latter conditions are framing conditions, since they frame or
condition the context in which the interaction takes place.10 Using this
distinction, we can say that when we appeal to what a person would ra-
tionally consent to under “favorable conditions” we are referring to the
framing conditions of the interaction and not to the conditions that create
the occasion for the interaction in the first place.
We now can present a more complete account of process-centered
exploitation.
(P2): An interaction between two parties is exploitative if one party, A, in-
teracts with the other, B, under unfavorable framing conditions, in order to
advance A’s ends and it is true that B, under favorable framing conditions,
would not rationally consent to the interaction with A (or consent to the
interaction with A on the same terms).
This account leaves much open for debate. Two people can accept (P2)
and yet disagree over a particular issue in a given context because they
disagree over the correct specification of the relevant framing conditions of
interaction in that context. Yet, irrespective of how the details are worked
out, proponents of (P2) will agree that it is wrong to take advantage of
the fact that others are in unfavorable conditions to advance one’s ends
when it is true that they would not rationally consent to the terms of the
interaction if they were not in these conditions. To treat others in this way
is to treat them disrespectfully.11
As these remarks make plain, (P2) relies on a distinction between actual
and counterfactual consent. This distinction calls for further comment.
If A is the exploiting party and B is the exploited party, then exploitation
can occur with or without the actual consent of B. There are two pos-
sibilities to consider.12
(1) B consents to the interaction, but would not consent to the interaction
under favorable framing conditions.
(2) B does not consent to the interaction, and would not consent to the
interaction under favorable framing conditions.
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How might valid actual consent come apart from rational counter-
factual consent? To answer this question, we have appealed to various
conditions that affect the quality of the interaction between the parties.
As mentioned, these include two broad categories of factors—one that
involves the extrapersonal circumstances of the parties and the other the
personal vulnerabilities or weaknesses of the parties. Both categories of
factors can condition the consent of the interaction. With extrapersonal
circumstances, this fact is easy to illustrate. Exploitation often occurs
when one party is backed up against the wall and does not have a genuine
option to refuse the interaction.13 In such a situation, it is possible for a
person to validly consent to the interaction, but it is instructive to ask
whether she would consent if she were not subject to that kind of pressure.
With personal vulnerabilities and weaknesses, the issue is more delicate.
In some cases, the exploiter takes advantage of a weakness of another to
advance an end and the weakness is quite incidental to who the person is.
For example, one can exploit a person’s poor mathematical abilities to sell
him an insurance policy at an unfair price. Here we can ask whether the
person would consent to buy the policy if he had adequate mathematical
abilities. But some personal vulnerabilities are more tightly bound up with
a person’ identity and it may not be possible always to determine what a
person would consent to if he didn’t have the vulnerability in question.
For example, suppose a person is very trusting by nature and one just can’t
imagine what he would be like without his trusting disposition. Presum-
ably, an exploiter could play on this trait to get this person to serve his ends,
but in asking what he would consent to under favorable conditions, we
cannot imagine him in the relevant situation since we cannot imagine him
without his trusting disposition. One response to this problem is to ask if
the person, with his trusting disposition, would consent to the interaction
if he were aware that the other party was playing on it for advantage. If
the answer were yes, then exploitation plausibly would not occur.
This raises a further issue. If we construe exploitation in terms of (P2),
then whether a given interaction is exploitative will vary depending on
the beliefs and preferences of the parties involved. Consider Trial again.
If Joan would not consent to participate in the study on the terms offered
to her under favorable conditions, then the transaction between her and
those conducting the trial will count as exploitative. However, if she
would consent to do so on those same terms under favorable conditions,
then no exploitation will have occurred. Suppose that, contrary to the
description given above, Joan has altruistic concern for future patients.
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Let us say that A exploits B tout court when A transacts with B on terms
that are harmful or unfair to B. . . . But we can also say that A exploits B as
a decision maker when A gets B to agree to a transaction to which B would
or might not agree if B were to give fully voluntary consent, whatever the
effects of the transaction on B’s (other) interests. (1999, p. 254)
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price of $100. He comes across Alex, who needs his assistance and, as it
turns out, owes him $300 from a previous interaction. (Alex has made it
plain that he has no intention of ever paying back the money.) Mark proposes
to rescue Alex, but only if Alex agrees to pay him an exorbitant price of
$400 upfront. Alex reluctantly agrees, as he needs the assistance and there
are no other people around to help him.
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BORDERLINE CASES
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Karen does not gain from the interaction. The outcome of the interaction
is fairer—the burdens of blood donation are shared more fairly—than it
would have been had Karen not intervened, but Karen herself does not
profit as a result. Still, Karen does take advantage of a vulnerability of
Rebecca’s to get her to do what she wants her to do. Furthermore, if it is
true, as we stipulated in the example,21 that Rebecca has a moral right to
refuse to give blood, then it is plausible to think that it is at least pro tanto
wrong to exploit a vulnerability of hers in order to pressure her to do so.
One response to Pint of Blood is to say that Karen treats Rebecca
wrongly, but that she does not exploit her. The case depicts an unusual
case of blackmail. Karen manipulates Rebecca and treats her disrespect-
fully, but she does not thereby exploit her. There is, in fact, a considerable
overlap between cases of exploitation and cases of disrespectful manipula-
tion. And manipulation is sometimes defined in terms that make it appear
essentially exploitative (Feinberg 1988, p. 179). But one might insist that
exploitation always involves gain to the exploiter, whereas manipulation
can occur when the manipulator gains nothing. Accordingly, one could
insist that Karen manipulates, but does not exploit, Rebecca in the case
under consideration.
Against this, we think the case plausibly depicts an exploitative interac-
tion.22 Not every instance of disrespectful manipulation is an instance of
exploitation. One party might manipulate another to get her to advance an
end, but if this end is one that the manipulated party would accept under
favorable conditions, then the manipulation would not be exploitative,
even if it remained disrespectful. But in Pint of Blood we are assuming
that Rebecca would not rationally consent to give blood under favorable
conditions. The case depicts exploitation since it involves the same kind
of disrespectful treatment that is present in more standard instances of
exploitative interaction. Karen plays on a vulnerability of Rebecca’s in
order to get her to advance Karen’s end—an end which is, in this case,
directed toward the establishment of a morally laudable state of affairs,
yet one that Rebecca has a moral right to resist.
Consider next a case that involves paternalistic concern that a person
is morally at liberty to resist.
Physician: David is physically weak and ill. He visits his physician, who
recommends a particular procedure that is in David’s best medical interests.
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Despite being fully informed about the procedure and the consequences of
forgoing it, David refuses the procedure. However, his physician is able to
pressure David into agreeing to the procedure in part by taking advantage
of the trust David places in him and in part by taking advantage of David’s
weak condition and his consequent lack of motivation to resist this pressure.
Wertheimer would allow that the physician in this case takes advantage
of the patient, but he would deny that this constitutes exploitation (Wert-
heimer 1999, p. 254). Since the physician acts so as to benefit the patient
and not himself, there is no exploitation. Let us assume that both David
and his physician share the end of doing what is in David’s best medical
interests, but they disagree as to whether the procedure in question will
serve that end. Clearly, the physician fails to respect the autonomy of his
patient. But this failure, it may be thought, does not amount to exploita-
tion.
We think that while Physician does not depict a standard or typical
case of exploitation, it does, in fact, depict an instance of it. The physi-
cian takes unfair advantage of a vulnerability of his patient to get him
to do something that the patient would not consent to under favorable
conditions, viz. conditions in which David was not in a weakened state.
The moral defect in the interaction between David and his physician, ac-
cordingly, is a form of the disrespectful treatment that is present in more
standard cases of exploitation.
The cases discussed in this section—Pint of Blood and Physician—are
very unusual cases. But they illustrate an important point. There is a dif-
ference between taking advantage of someone so as to benefit oneself and
taking advantage of someone so as to advance an end that one has. Quite
often, the two go together, since quite often a person’s ends are tightly
linked to her welfare. But, as the cases illustrate, the two can come apart;
and when they do, we need to decide whether taking unfair advantage of
the weaknesses or vulnerabilities of others to advance ends that one has,
but they don’t, constitutes morally objectionable behavior of the kind that
the concept of exploitation is meant to pick out.23
In passing, we note one further implication of our disagreement with
Wertheimer on this issue. Sometimes one party, A, exploits another party,
B, for the sake of gains to a third party, C. This can occur in clinical re-
search. Investigators can exploit research participants not for their own
benefit, but for the benefit of future patients. Wertheimer agrees. He calls
exploitation of this kind “mediated exploitation” (1999, p. 210). But the
term “mediated” here is not particularly apt. A mediator is an agent who
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UNCERTAINTY IN RESEARCH
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them, even when the researchers know that this hope is not a realistic one
(Jansen 2006, Martin 2008). Or, alternatively, researchers (who often are
also physicians) may take advantage of the trust that participants place
in them, however misplaced this trust may be. In different ways, and
involving different degrees of manipulation, researchers can take unfair
advantage of the vulnerabilities of research participants to advance their
ends. Such treatment would constitute exploitation on the process exclusive
account that we have defended. But so long as the trial in question was
an equipoise trial, it is hard to see how it would qualify as exploitation
on an outcome-centered account of the concept.
The exploitation that can occur in an equipoise trial does not come at the
expense of the medical interests of the participants. By hypothesis, they are
not receiving inferior medical care. However, it remains the case that they
can be treated disrespectfully by others. Their vulnerabilities, and the fact
that they may be in a desperate condition,28 can be taken advantage of by
others to advance ends that they do not share. Just as Fair Bet depicts an
exploitative interaction in the absence of an unfair distributive outcome,
so too an equipoise trial can be exploitative in the absence of an unfair
ex ante distribution of risks and anticipated benefits.
In pressing this point, we do not need to endorse the requirement of
equipoise in clinical research. Some have argued that this requirement
should be replaced by a less stringent requirement that holds that, in ad-
dition to other requirements like informed consent, an ethical trial must
have a favorable balance of risks and benefits (Miller and Brody 2007).
The point we are making here, however, applies with the same or greater
force to a trial that satisfies this less demanding favorable risk/benefit re-
quirement. For participation in such a trial could be contrary to the best
medical interests of at least some of the participants, providing the risks it
imposed were not too excessive and the anticipated benefits it yielded were
sufficiently high. The same possibilities for exploitative treatment discussed
above then would apply to these trials, but in addition there would be
the concern that the participants’ own medical interests, from an ex ante
standpoint, were being set back as a result of the interaction. Still, if the
favorable risk/benefit requirement ensures that the distribution of risks
and anticipated benefits is not unfair (as proponents of the requirement
insist), then the trials would not involve outcome-based exploitation. As a
consequence, trials that satisfy the favorable risk/benefit requirement could
not be judged to be exploitative on an inclusive, or outcome-exclusive,
view of the concept, despite exhibiting the kind of process-based defects
to which we have called attention.
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NOTES
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8. The mobster might, for example, believe that it is always morally wrong to
torture another human being, even though he is prepared to engage in murder
at will.
9. For an illuminating discussion of a range of impairments and incapacities
that compromise rational choice see Feinberg 1986, pp. 269–344.
10. In Trial the fact that there is not a less burdensome alternative way for Joan
to acquire the money would be a framing condition of the interaction, for
example.
11. Compare this claim to Wood’s claim: “Proper respect for others is violated
when we treat their vulnerabilities as opportunities to advance our own
interests or projects” (1995, pp. 151–152).
12. In a third possibility B does not consent, but would do so under favorable
framing conditions. Here the interaction often would be wrong, but not
exploitative. Sometimes, however, the interaction would not even be wrong.
This will be true in cases in which B lacks capacity to consent in the actual
situation, but would consent in the relevant counterfactual situation.
13. This point is central to the account of exploitation presented in Valdman
2009.
14. We say more about the relation between altruism and exploitation below.
15. For suggestive remarks along these lines, although not in the context of
exploitation, see Williams’s account of the “critical theory test” (2002, pp.
225–232).
16. Here is an example. Suppose B has borrowed a vase from A and has decided
that he will not return it to her. A points out to B that he is morally required
to return the vase, but B is unmoved. A knows, however, that B has an exces-
sive concern about what some third person, C, thinks about him. As B really
ought not care so much about what C thinks, this is a personal weakness. If
A plays on it to get B to return the vase—C will think less well of B if B does
not return the vase and both A and B know this—then his doing so would
be manipulative, but not manipulative in a way that is disrespectful to B. Or
so we believe.
17. This is a simplification. As we explain below, there may be cases in which a
person is not at moral liberty to refuse the interaction in question, but has
a moral right to refuse the interaction. In such cases, the person can be the
victim of exploitation.
18. So the interaction in question is not an example of what Feinberg calls
“double-stranded cases,” cases in which “A exploits B by doing x, while
during the same time period of A’s activity, B exploits A by doing the distinct
and unrelated act Y” (Feinberg 1988, p. 195).
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19. One might respond by insisting that exploitation always requires that one
party gain unfairly—all things considered—from the interaction. Then one
might allow that interactions of the kind here depicted can be pro tanto
morally wrong, even if this condition is not met, but insist that they are not
properly characterized as exploitative. But this stipulation looks to be ad
hoc, designed merely to get around the problem exposed by the canceling
argument.
20. Suppose, however, that a stranded motorist in Snow Storm has unusual views.
Under favorable conditions, he would not consent to being rescued even at a
fair price. He would consent to rescue only if he were charged substantially
less than the fair price. Accordingly, if the entrepreneur rescues him, and if
he consents to the rescue under actual conditions, then would he have been
exploited in any way? We think that the answer depends on whether the
entrepreneur has a duty to rescue the motorist. If he does, then he does not
exploit him, as he is merely acting in accord with duty. If he does not, then
he exploits him, but the moral wrong of the exploitation is likely outweighed
by the benefits conferred by the interaction.
21. For discussion see Enoch 2002. See also Otsuka 2008 discussing the specific
case of the moral right to refuse to give blood when it is one’s moral duty to
do so.
22. Blackmail is often cited as an instance of exploitation. See Feinberg 1988,
pp. 238–274.
23. Here we are in broad agreement with Wood (1995). He writes that “exploi-
tation consists in the exploiter’s using something about the person for the
exploiter’s ends by playing on some weakness or vulnerability in that person”
(p. 147). Note the emphasis on the exploiter’s ends as opposed to his interests.
24. The therapeutic misconception has been extensively discussed in the litera-
ture on research ethics. See, for example, Appelbaum et al. 1987 and Dresser
2002.
25. For discussion of this issue see Hampton 1993, pp. 135–165.
26. For the sake of simplicity, we limit our discussion here to research in devel-
oped countries.
27. For the seminal defense of the principle of equipoise, see Fried 1974. See also
Freedman 1987.
28. For example, the participants may be cancer patients and they may realize
that they have no chance for cure with standard available treatment.
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