What Price Better Health? by Daniel Callahan
Lustig, Andrew
WHAT THE DOCTOR ORDERED What Price Better Health? Hazards of the Research Imperative Daniel Callahan Unversity of Cilifbrnia Press/The Milbaitk Memorial Found, $29.95.335 pp. Andrew...
...What should be the relative priorities of funding for biomedical research as compared with research on the broader social determinants of health...
...Andrew Lustig Bongtime readers of Commonweal know Daniel Callahan as a former editor and frequent contributor to its pages...
...Callahan also reviews the grudging willingness of IWEAL companies to sell cheaper versions of AIDS drugs to developing countries, and their efforts to thwart the introduction of generic drugs in those settings...
...It would be a politics that is not driven by officeholders needing to respond to the highest bidder, including pharmaceutical companies, and thus able to consider constituencies that currently lack effective voice (thus requiring meaningful campaign-finance reform without the post-McCain-Fein-gold loopholes...
...Callahan recommends a "normalizing" strategy with regard to aging and death...
...A "maximizing" strategy seeks to "bring everyone up to what are now the historically longest-known human life spans...
...Medical research, he argues, "tempts us to invest too much hope in it as a way of relieving the human condition, or to divert attention from the social and economic sources of sickness...
...For more than thirty years, Callahan has been a leading contributor to such discussions...
...In those recommendations, Callahan is calling for a different sort of politics than we have seen in recent years...
...While the proportion of drugs in development that are ultimately patented remains quite small, pharmaceutical profits during the 1990s dramatically outpaced those of other industries...
...Here Callahan appeals unabashedly to the requirements of justice, and to the distinctive obligations of the pharmaceutical industry: "Few of us can avoid the use of drugs to preserve our health...
...In his discussion of efforts to forestall aging and death, he outlines three strategies...
...While acknowledging the successes of the NIH, Callahan finds the unquestioned priority accorded biomedical research problematic...
...Callahan is extremely skeptical of the argument made by pharmaceutical companies that they require high profit margins to cover the research and development costs of new drugs, noting that the industry spends "three times as much on marketing and general administrative costs" as it does on research...
...The emphasis should be on preventing premature death and "compressing morbidity," meaning "shortening the period of poor health before death...
...What of Callahan's overall prescriptions for the future of medical research...
...The answers to such questions are not obvious, but Callahan argues persuasively that our current spending priorities are skewed...
...Claims for inevitable progress are often overstated...
...Indeed, he celebrates the successes of medical research and its applications, but he also poses fundamental questions about the "hazards" presented if that research imperative is left unexamined, using the metaphor of "shadows" to describe such dangers...
...Or again, proposals to use embryonic stem cells assume much about the "promise" of such research, while minimizing the moral concerns of those who find it unacceptable...
...This means that the pharmaceutical industry must be judged by other than ordinary market standards...
...More broadly, a normalizing strategy would emphasize universal access to basic care and focus more on the effective medical management of chronic conditions than the endless search for cures...
...In several books during the last decade and a half, Callahan has explored a number of difficult topics-health-care rationing, the meaning of a good death, and ways to make medicine more sustainable and affordable...
...In this book, he explores the cultural assumptions that drive the biomedical "research imperative...
...An "optimizing" strategy seeks to "move the average life expectancy" dramatically beyond its current maximum...
...Callahan's has been a distinctive voice in two crucial respects...
...Callahan is no Luddite...
...Here, I confess to some reservations, though they may merely reflect my pessimism about the current state of politics...
...Throughout this book Callahan's critique is linked to the most fundamental questions: What are the appropriate ends of medicine...
...It is hard for me to imagine the emergence of such a politics in the face of the very trends that Callahan finds troubling...
...there are no alternatives in most cases...
...He and Willard Gaylin, along with other visionaries, established the Hastings Center (still the premier bioethics think tank), convinced that developments in medicine and the life sciences raise fundamental philosophical and policy questions-about human nature, the appropriate ends of medicine, and the requirements of the common good in relation to health care...
...In ten chapters, Callahan reviews the history of research in the United States, surveys recent trends in research spending that he finds excessive, critiques the influence and bottom-line focus of the pharmaceutical industry, and challenges the priorities reflected in current research funding...
...It would be a politics guided by social solidarity as a norm as well as individual freedom...
...Second, while exhibiting scholarly rigor, Callahan has been the exemplary public intellectual by keeping the conversation accessible to nonspecialists...
...Yet the fact that he continues the conversation, with a sense of obvious vocation, may be an affirmation, in its own right, that fundamental change is still possible.nge is still possible...
...Most crucially, he envisions "a health-care system that does not depend on medical research to solve problems that could be solved by better social programs and healthier modes of living a life...
...For example, discovering the locus of a particular "disease" gene says little or nothing about the prospect of clinical applications...
...With a masterly command of the policy and economic literature, Callahan traces the subtler threats posed by the imperative for medical research during the last two decades...
...A "normalizing" strategy seeks to "bring everyone up beyond what would be considered a premature death to what is now the average life expectancy in...developed countries...
...Others esteem Callahan for his role as a founding father of bioethics...
...Callahan recommends the coordination of "research policy with social and health policy" by an approach "that looks at populations rather than individuals and favors increased basic research over (but does not banish) disease-oriented research...
...As a result, biomedical research is deemed an obvious funding priority, with increases in the National Institutes of Health (NIH) budget "running to 10 to 15 percent a year...
...I cannot do justice in brief to the subtlety and persuasiveness of Callahan's analysis, but let me speak briefly to the merits of several of his arguments...
...How important is the pursuit of health relative to other social goods such as education and environmental protection...
...It would be a politics that could encourage broad public discussion and debate about those enduring questions for citizens and societies: Who are our neighbors and what do we owe them...
...Public/private partnerships are now the order of the day, and pharmaceutical companies are effective lobbyists on both sides of the congressional aisle...
...First, he has insisted that issues in bioethics require multidisciplinary exploration because questions about personal or policy choice invariably involve deeper philosophical and cultural assumptions...
Vol. 130 • November 2003 • No. 19
