Public spending is increasingly devoted to health care and medical research. In his book What Price Better Health? Hazards of the research imperative, Daniel Callahan, a founder of the Hastings Center for Bioethics, questions this development. According to Mr Callahan, society's demand for improved medical treatment can be conceptualized in terms of "the infinity model," which asserts that there is no limit to the benefits of continued medical research. This assertion invokes a moral duty to do medical research--a "'research imperative' ... the felt drive to use research to gain various forms of knowledge for its own sake, or as a motive to achieve a worthy practical end."^{1:p 3}

It is a noble goal to improve health and relieve pain. There is, however, a paradoxical dynamic in the reception of improved health care: research may be the endless frontier, but our striving for better health may be endless as well. Mr Callahan points out: "... the better off we become, the worse we feel; and the worse we feel the more we demand of research; and the more research gives us, the more we ask of it; and when we get what we want we ask for still more."^{1 p 33}

The research imperative should stem from the moral obligation we have to help the suffering of today and tomorrow. For the research imperative to be a moral obligation, not only must failing to do medical research harm people, doing research must also be indispensable in avoiding harm. Mr Callahan questions these assumptions. In countering the argument that more medical research is indispensable, Mr Callahan reminds us that this is but one condition for fulfilling our vision of a good society. He also does not accept the second assumption: that we have a duty to develop more effective medical treatment for future generations. He classifies medical research as an imperfect right--a right that no one has a specific duty to fulfill; to justify medical research by treating it as a perfect right, imposing a duty on us to stave off death and to abolish suffering, is tantamount to corrupting medical science. If death is seen as nothing but the consequence of preventable diseases, we might construe a duty to eradicate these in a "war on death."

The metaphor of war invokes the duty to make sacrifices, thus allowing the pharmaceutical industry to invoke the research imperative to legitimize huge profits. (For more on this see: Callahan D. Costs, Choice, and Equity: Medicine and the Market.) This metaphor also makes it easier to compromise basic ethical principles of research.² Death and suffering are presented as eradicable, rather than integral to human existence.

Mr Callahan advances a "modest proposal" in which medical research recognizes death as a part of life, focuses its attention primarily on combating early-onset diseases, and aims for compressing morbidity and shortening the period of poor health before death. The title of Mr Callahan's book can be read both literally--How much of our resources should be spent on health care, and how much profit should the pharmaceutical companies make?--and metaphorically--How much should be sacrificed in the pursuit of better health from research subjects and from a loss of meaning in human vulnerability and mortality? Inherent in these questions are assumptions that must be questioned. Mr Callahan dismisses the thought that we have a duty to do medical research for the benefit of future generations, in the way preceding generations have made our health care system possible. He must then hold either that there never was such a social contract between generations, or that we stand in a radically different relation to our descendants than our ancestors did. Both of these assumptions need more reflection.

The book is easily understood and well written, but it is unfortunately marked by a journalistic style. Although many aspects of the subject are described and fundamental questions are raised, the discussion lacks a thorough philosophical, sociological, economical, or other methodological approach.

References

1. Callahan D. What price better health? Hazards of the research imperative. Berkeley (CA): University of California Press; 2003.
2. The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Belmont report: Ethical principles and guidelines for the protection of human subjects of research [monograph on the Internet]. Washington (DC): National Institutes of Health Office of Human Subjects Research; 1979 [cited 2006 Nov 9]. Available from: http://ohsr.od.nih.gov/guidelines/belmont.html.