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by Daniel Callahan
University of California Press, 2003
Review by Lawrence D. Hultgren, Ph.D. on Sep 22nd 2004

What Price Better Health?

As the amount spent on medical research each year soars toward the trillions, in close chase is a national ethics debate about what researchers should or should not do. However, if Daniel Callahan's observations in his new book What Price Better Health? Hazards of the Research Imperative are correct, that ethical discussion is lagging further and further behind, and the future prospect of any kind of meaningful debate over the ethics of scientific research is nil. Callahan, Director of the International Program at the Hastings Center and Senior Fellow at the Harvard Medical School, believes that an emerging "research imperative" is cutting off public debate about science and, perhaps more importantly, holding discussion about ethical issues in research hostage.

Callahan begins his argument by chronicling the emergence of what he singles out as the 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" (3). He believes that this research imperative "can be potent enough to invite the temptation to go too far, thus undermining itself, and where the benefits of research appear so self-evident that they need no defense" (259). In subsequent chapters, Callahan confronts what he considers to be important empirical and normative implications of the research imperative. He looks at reproductive cloning as an example of the misuse of the research argument to justify the pursuit of wrongful ends. He discusses the use of human subjects in research without informed consent to show how the imperative can be used to legitimize debased means. Using the emerging embryonic stem cell debate as an example, Callahan argues that the research imperative can be invoked to justify controversial research. From Callahan's perspective, another deployment of the research imperative is discovered in the pharmaceutical industry's rationalization for high prices and huge profits. And he contends that the claim of the research imperative to reduce or stabilize health care costs paradoxically pushes them up!

The common denominator to all of Callahan's examples is the notion that medical research in our culture has assumed the nature of an imperative or command. Paralleling the more familiar "technological imperative," our author believes that the research imperative assumes the "necessity" of medical research and claims "that the importance of research should overcome moral values" (3). But this description leads us to ask, what kind of imperative is medical research?

We know from our time spent with Immanuel Kant, that imperatives can be either hypothetical or categorical. A hypothetical imperative is a conditional command. For example, one might argue that if we wish to remain healthy, then we need medical research. Thus, if Callahan is alluding to research as a hypothetical imperative, it is not justified in itself, but as a means to an end; whether it ought to stay in force as a command depends on whether the end it helps attain is desired or required. The opposite of a hypothetical command is a categorical imperative, which is unconditional and is both required and justified as an end in itself.

Although Callahan eschews Kantian language, it does seem appropriate here. Callahan discerns a research imperative at work in our culture that is not solely hypothetical in the Kantian sense, enjoining actions only as a means to an end and implying a conditional necessity. Rather, argues Callahan, research in medicine has emerged as a categorical imperative which enjoins research actions for their own sake and, it is assumed, involves absolute moral necessity: "Medical research is now treated as if it is an independent actor, with its own force and momentum for the good" (261). Throughout his book, Callahan cites examples of claims "about the 'necessity' of research, or the 'moral obligation' to pursue certain kinds of research, or the overpowering 'promise' of research to relieve suffering, a goal not to be denied; or the 'need to relieve suffering' as a justification for the high price of pharmaceuticals" (3). "That kind of reasoning," he concludes," is the research imperative in its most naked - and hazardous - form, the end unapologetically justifying the means" (58).

Devoting an entire chapter to this issue, Chapter 3. Is Research A Moral Obligation?, Callahan questions the assumption of the research imperative that better health care is always worth pursuing and that gaining greater knowledge is an intrinsic good. Showing that these are optional goals, Callahan concludes that medical research is not a moral imperative. Health care, he argues, is only one of a panoply of human goods: "We ought to act in a beneficent way toward our fellow citizens, but there are many ways of doing that, and medical research can claim no more of us than many ways of doing spending our time and resources" (60).

Callahan seems to be suggesting as well that if you ought to do something, then it has to be the case that you are able to do that thing (that is, ought-implies-can). Since we are finite beings, medical research can neither rid of us of our mortality nor ignore our aging. Therefore, he concludes that the research imperative cannot be categorical in the Kantian sense, enjoining actions as ends in themselves and implying a moral obligation.  

Having dismissed the possibility of research as a categorical imperative, we can ask if the research imperative ought to survive as a hypothetical imperative. If a language of "imperative" applies to research in medicine, perhaps Callahan is suggesting that the research imperative is better understood as a hypothetical command. In other words, should the research imperative receive the blessings of utility - its means justified by its end? Here, again, Callahan thinks not. "It is not the U. S. that needs medical research for its survival and flourishing...." (262) . He chronicles a lack of a good fit between the research enterprise and the provision of health care which underscores "the fact that much, even if not all, research increases health care costs with only a marginal gain to population health" (252). Thus, research is not unconditionally binding, or categorical; it is merely conditionally or provisionally binding, or a hypothetical imperative.

Thus, the idea of a research imperative in medicine does not appear to have as tight a grip on the culture of medical research as Callahan proffers. At the very least, Callahan's own analysis suggests that using the language of imperatives, either hypothetical or categorical, is not very illuminating of the "trajectory of research goals."

Although Callahan admits at the outset that the idea of a research imperative is "a somewhat elusive concept," it may be even more elusive than even he believes. Furthermore, Callahan argues, "When the research imperative acts as a moral bludgeon, turning a moral good into a moral obligation and then into a call to arms - to level other values in the name of reducing suffering, it goes too far" (259-60). But has it gone too far? Curiously enough, Callahan admits that "[medical research] has no fundamental flaws or dread disease. Medical research is an essentially healthy, valid, and vitally important activity" (2). Furthermore, although he wants to anchor the research imperative in larger cultural attitudes and values, he admits that the problem is not really pervasive. "I am by no means claiming," he writes, "that most researchers or ethicists hold such views" (58). Thus, the idea that there is an unlimited moral imperative to pursue medical research is neither as deeply rooted in our culture nor quite as hazardous as Callahan initially proposes.

Medical research may not be the imperative that Callahan claims. However, in his book, he asks some hard, important ontological questions about our human finitude and the wisdom of uncritically accepting the twin goals of much of traditional research: forestalling death and relieving the burden of aging. But even here there is a subtle undertow to Callahan's argument that seems to pulls us toward an old-fashioned fatalism and a stoical acceptance of disease and disability. One of Callahan's criticisms of the research agenda is that it often ignores the prospect of illness, the certainty of pain and suffering, and the inevitability of death. Accepting a "'ragged edge of progress' - that point where our present knowledge and technology run out, with illness and death returning" (66), Callahan concludes "that death itself is not an appropriate medical target, and that there is no social need to greatly extend life expectancy" (84). No doubt readers of this book with disease or disability will not agree with the author that we may be doing all that we can or that we need less medical research.


2004  Larry D. Hultgren

Larry Hultgren describes himself as follows:

A.B. Grinnell College majoring in Philosophy and Religion; Ph.D. Vanderbilt University in Philosophy. Currently Professor of Philosophy at Virginia Wesleyan College, Norfolk, VA. Since I am at a liberal arts college, my teaching runs the gamut of philosophy offerings. I am especially interested in interdisciplinary pursuits, and I direct the college's Social Ecology Program and our innovative PORTfolio Project, which attempts to bring the liberal arts to life for our students by connecting the classroom with real world experiences. I also serve on the Bioethics Committee of the Children's Hospital of the King's Daughters in Norfolk, VA, and serve on the Board of Directors of the Bioethics Network of Southeast Virginia.