In many respects, Empire of Pain is a story of what happens when personal ambition intersects with social and medical history. The American dream prizes personal ambition—an ideal that the Sacklers seemed poised to live up to. Isaac and Sophie Sackler were among the many immigrants driven to the United States; Sophie’s hopes that her sons would become doctors were common: “there was a sense that doctors were morally upright, and it was a vocation that served the public good” (17). Growing up, Arthur Sackler’s high school for talented students was full of fellow immigrants determined to succeed in life. Arthur decided early on that his talents belonged in business as well as medicine. He would be proven correct, since his talent for medical advertising launched a new industry.

But ambition divorced from ethics is a recipe for corruption, greed, and other problems. Where both Isaac and Arthur Sackler had a strong sense that moral worth was a key part of an individual’s merits, successive generations of the Sackler family were more concerned with maintaining status. For example, though Richard Sackler “admired his uncle Arthur” (147), he was more concerned with establishing himself as a generator of wealth.