One day during my medical training, my professor asked me to withhold giving extra narcotic to our surgical patients, at least until they had been in the recovery room for thirty minutes. He was doing a study, he said. One of my patients emerged from anesthesia in severe pain. I disobeyed orders and gave him fentanyl. When my professor saw what I had done he yelled at me. I didn’t care. I thought it immoral to keep a patient in pain just to help my professor’s futile academic career.

Was I a whistleblower, risking my future to expose injustice? No. I didn’t do anything other than give this one patient fentanyl. There seemed to be no reason to go public on the matter. I assumed my patient’s case was a one-off event.

But what if I had discovered that most of the patients in my professor’s study were emerging from surgery in severe pain? Would I have called the newspapers? I don’t know. I definitely would have complained to my department chairman. But if the chairman had dismissed the matter, while reminding me that I was new and had much to learn, I might have let things slide.

What kind of person does risk everything to expose medical injustice? This is the question that Carl Elliott, both a physician and professor of bioethics, tries to answer in his fascinating new book, The Occasional Human Sacrifice. As Elliott understands, everything is truly at risk. In my case, if I had gone to the newspapers as a junior resident I would have been fired from my position, or given such awful work assignments that I would have been forced to leave on my own. My toxic reputation would have followed me, keeping me from securing a position elsewhere. I might have ended up pumping gas. In fact, more than 30 percent of whistleblowers suffer financial ruin.

Elliott has plenty of scandals to work with. He describes the infamous Tuskegee experiment, where the US Public Health Service lured black men with syphilis into a study that denied them treatment long after a cure for the condition had been found. The study’s organizers simply wanted to see what would happen to the men if they went without therapy. There is Willowbrook, where researchers purposely infected “mentally defective” children with hepatitis virus for study. There is the lesser-known Hutchinson Cancer Research Center scandal, in which cancer patients were lured into being treated with an experimental type of bone marrow transplantation, with disastrous results, even though proven nonexperimental therapy already existed. The University of Cincinnati Medical Center once experimented with total body irradiation, designed to glean useful information for the military, without warning patients in advance about the therapy’s dangerous side effects.

Not all of these scandals occurred before the dawn of society’s bioethical consciousness. The whistleblower in the Hutchinson scandal, for instance, learned about the problem while serving on the Institutional Review Board—one of many oversight bodies set up in the wake of the Tuskegee scandal to prevent such scandals in the future. The Board refused to act, forcing the whistleblower to go public.

Yet Elliott’s focus is not on the scandals, many of which have been described elsewhere, but on the whistleblowers who exposed them. In a fine example of investigative journalism, Elliott tracks these people down to inquire about their motivations and whether, in hindsight, they had any regrets.

Elliott’s interest in the subject should not surprise. He himself was a whistleblower. For seven years he went on a public crusade against his employer, the University of Minnesota, to expose the suicide of a research subject in one of the school’s drug trials. The victim was psychotic when he signed the consent form, but he steadily deteriorated during the drug trial, all while his mother desperately tried to get him out. But the trial’s impersonal machinery chugged inexorably along. Eventually, the man slashed his throat in a bathtub.

Elliott paid a price for his whistleblowing, being ostracized by colleagues—who worked in the school’s Center for Bioethics, no less! When finally vindicated, he says he was not applauded, but only despised even more.

Yet after years spent researching whistleblowers, Elliott is unable to offer a unified theory of whistleblowing—that is, a foundational mindset that all whistleblowers share in common. People are complicated. Their motives can be complicated. Elliot does find that “whistleblowing is the exception, not the rule.” It takes a certain kind of commitment, even fanaticism, to be willing to risk so much in life to expose the truth.

Before the 1970s, according to Elliott, the term whistleblower was almost unknown, which isn’t surprising, given its vague meaning. There was a sense that people who told the world about a hidden transgression were somehow different from “traitors” and “rats,” and that a new word was needed to describe them. Still, whether they were good or bad remained unclear. An early definition of the term failed to distinguish between those who informed the world to get justice and those merely trying to save their own necks. Nor did the term distinguish between those who leaked information in public, at great risk to themselves, and those who did so in secret. Some researchers even described whistleblowing as a form of narcissism. They accused whistleblowers of thinking mostly about themselves and of being secretly proud of the risks they took. “Narcissism moralized,” one writer called it.

But Elliott did not hear narcissism when he interviewed his whistleblowers. Instead, he heard an ethic of honor and shame. “Honor is about your obligations to yourself,” he writes. For whistleblowers to talk about themselves is perfectly natural, he says; such people simply want to live up to their principles.

The concept of honor tends to confuse the modern democratic mind, associating it as we do with feudal aristocratic life. Whistleblowers seem to exemplify a kind of modern-day code of honor, Elliott writes. Yet what is its basis? During the landed gentry epoch, the honor code was a mixture of class duty and warrior ethos. In the case of whistleblowers, its basis seems less clear.

Upon reading through Elliott’s accounts of whistleblowing, I thought I spotted a trend: a religious commitment expressed at an early age that exerted itself later in life on the whistleblower’s conscience, long after any official commitment to religion had waned. Two whistleblowers in Elliott’s story had a strong Catholic upbringing. A third had been a strong believer in the Disciples of Christ. A fourth had taught Bible class and aspired to be a Presbyterian medical missionary. Unswerving commitment to a cause, absolute belief in what is right, total determination in the pursuit of justice—the whistleblowers may have had these relevant traits implanted in them early on through religious belief. After all, even Robespierre and Stalin aspired in their early years to enter the seminary and become priests.

Yet the religious angle probably falls short as an explanation for the whistleblower’s fanatical single-mindedness. While some of the book’s whistleblowers were raised in the church, including Elliott himself, it was often in the way that many people of their generation were. One whistleblower even insists it was his strong Italian immigrant community, and not religion, that formed his sense of moral duty.

More plausibly, Elliott’s whistleblowers might be described as inhabiting ideological fanaticism’s bright side. Given their basis of thought, their soil of conviction, and their strong opinions on politics and justice, a compulsion to blow the whistle seems to have grown inside them naturally, alongside their ideological belief system. And it was not always progressive ideology that animated them. The whistleblower in the Tuskegee scandal, for instance, seems to have had strong conservative leanings. Yet all the whistleblowers seem to have had an unyielding aspect to their conscience, grounded in some firm conception of justice—which always connects somehow to ideology.

Elliott himself exemplifies this determination to correct injustice, rooted somehow in ideology, and that sometimes spills over into fanaticism, which even he good-naturedly admits. Although Watergate happened fifty years ago, he says Nixon remains “a permanent fixture of my psychological architecture.” He dislikes Nixon intensely and opens his first chapter with this point. Books about Watergate fill his office, he says. Campaign posters from 1972 line his office walls. His daughter, he reports, thinks he is obsessed with Nixon.

Alongside this ideology emerged fanatical behavior during his whistleblowing campaign, which even he admits now was a bit over the top. “Did I actually build a black coffin for a group of students in white coats to carry into a meeting of the Board of Regents?” he writes. Did he really think it was a wise move to publish a picture of his daughter holding a guinea pig while wearing a rubber pig mask and a University of Minnesota lab coat with money spilling out of the pockets? To be in thrall to an ideology is to experience a kind of wineless drunkenness, and when drunk, we often do things we think silly afterward.

Perhaps whistleblowing is a trait in human nature distributed according to a bell curve, just as, for example, an outgoing personality is. It is impossible to predict who will express the trait, or why. True, certain environments may be more conducive to releasing one’s inner whistleblower. As Elliott observes, people are more likely to follow their conscience and become whistleblowers if they don’t feel isolated or alone in their dissent. But predicting who will become a whistleblower, or explaining what precisely compels a whistleblower to risk all, seems beyond the ability of social science to comprehend. Indeed, according to Elliott, what the whistleblowers he interviewed shared was not even a common character trait, but simply a common experience.

Since whistleblowing may just be a part of life, it might be useful here to mention another relevant point about life, which is that life isn’t always fair. For a whistleblower, personal disaster likely awaits. In one study, more than 82 percent of whistleblowers who reported fraud were fired, quit under duress, or were punished in some way. Many never worked again.

In contrast, many of those who commit the injustice emerge from their scandals unscathed. Some of the villains in his accounts went on to have huge careers and win big prizes. The fact that many of these villains had Ivy League backgrounds testifies as to why the French have two words for higher learning. One is for “instruction,” which you get when you go to Yale or to plumbing school; you learn basic facts and procedures. The other is for “education,” which comes from your family, molds character, and helps influence whether you become a good person or a monster. Some of the people in charge of these scandalous research programs seem to have been well-instructed but poorly educated.

Finally, there is institutional inertia, or that tendency within an institution to stay quiet in the face of injustice because everyone else stays quiet, because the institution’s solid reputation inclines employees to give the institution and all things associated with it the benefit of the doubt, and because the responsibility for any particular action is so dispersed throughout the institution that blame hardly ever falls on any one person individually. In Elliott’s book, even supposed paragons of virtue, such as the US Public Health Service and prestigious universities, were tripped up by this truth about life.

Elliott’s whistleblowers deserve praise. Most of them basically threw themselves on barbed wire to shut down these unethical studies so that more patients would not get hurt. But they did not, and could not, change the order of things.