What Price Better Health? Hazards of the Research Imperative
http://www.100md.com
《新英格兰医药杂志》
This book is one of the most interesting and detailed among recent efforts to examine the history and modern scope of American medical research. It explores the development of policies that govern experimentation involving human subjects, the rise of medical research institutions and funding sources, the place of industry in promoting research and producing its technological offshoots, the role of the federal government in regulating research, and the philosophical, ethical, and policy issues that are raised by the research enterprise. Even if one does not agree with Callahan's view of the problems that the research establishment generates or with his recommendations for how to correct them, he is a splendid teacher who challenges one to think more crisply and deeply about the purpose and future of medical research.
In medical circles, the term "research" evokes associations with intellectual accomplishment and social benefit. Although Callahan discusses these goods, his focus is on a darker side of research — that is, research as it is pursued to excess by its participants and backers out of a belief in its overriding social importance and that damages the worth and influence of other social values and activities. The central premise of this book is that the pursuit of research has been elevated from a moral good to a moral requirement, one that creates what Callahan refers to in his book as "the research imperative." From seeing the advances that research-based medicine has made in combating disease, scientists and society have concluded that relief from illness is not enough, that only the conquest of illness will do, thus opening the way toward an even greater life span and enhanced biologic function. This conclusion is made possible by a persistent and expanding commitment to research.
Callahan's prescription for the condition he has diagnosed is comprehensive oversight and setting of priorities for the research enterprise along with limitation of its promise of an unboundedly healthful future. This prescription requires, in essence, that excess be curbed by the creation of limits. For ordinary persons, Callahan counsels acceptance of such limits. For example, he would support research on preserving and restoring health but not on lengthening life — "there is no social need to greatly extend life expectancy," he writes. For scientists, he counsels restraint — not pursuing lines of investigation that threaten either important cost barriers or crucial social and moral values.
When an enlargement of one aspect of social striving damages other worthy activities, restraint is justified. But appropriately applying this concept to the search for knowledge is procedurally difficult and conceptually murky. When science is not merely extending the content of an established paradigm but crossing its border into new territory, foreknowledge of where the research will lead ranges from uncertain to nonexistent. To forecast, much less govern, fundamental scientific directions is not now possible. And Callahan's approach to governance — importing methods that deal with costs, benefits, and priorities from disciplines such as technology assessment and experiences such as the Oregon Medicaid rationing program — is flawed. We have problems comparing and influencing the use of existing forms of technology with these methods. How much more difficult it would be to apply these methods to hypothetical innovations. Yet even if our predictive power with respect to scientific directions were to grow unpredictably (and research on this is needed), to what degree should society encumber its basic drive to discover how the world works?
The problem is how to enhance human dignity through restraints, such as those that protect the rights of human research subjects, without damaging the cultural ethos that values transcending the present through the pursuit of knowledge. Callahan's book, as important and provocative as it is, does not resolve this dilemma but furthers the effort to engage with it.
Stanley J. Reiser, M.D., Ph.D.
University of Texas Health Science Center at Houston
Houston, TX 77225
stanley.j.reiser@uth.tmc.edu((California/Milbank Books)
In medical circles, the term "research" evokes associations with intellectual accomplishment and social benefit. Although Callahan discusses these goods, his focus is on a darker side of research — that is, research as it is pursued to excess by its participants and backers out of a belief in its overriding social importance and that damages the worth and influence of other social values and activities. The central premise of this book is that the pursuit of research has been elevated from a moral good to a moral requirement, one that creates what Callahan refers to in his book as "the research imperative." From seeing the advances that research-based medicine has made in combating disease, scientists and society have concluded that relief from illness is not enough, that only the conquest of illness will do, thus opening the way toward an even greater life span and enhanced biologic function. This conclusion is made possible by a persistent and expanding commitment to research.
Callahan's prescription for the condition he has diagnosed is comprehensive oversight and setting of priorities for the research enterprise along with limitation of its promise of an unboundedly healthful future. This prescription requires, in essence, that excess be curbed by the creation of limits. For ordinary persons, Callahan counsels acceptance of such limits. For example, he would support research on preserving and restoring health but not on lengthening life — "there is no social need to greatly extend life expectancy," he writes. For scientists, he counsels restraint — not pursuing lines of investigation that threaten either important cost barriers or crucial social and moral values.
When an enlargement of one aspect of social striving damages other worthy activities, restraint is justified. But appropriately applying this concept to the search for knowledge is procedurally difficult and conceptually murky. When science is not merely extending the content of an established paradigm but crossing its border into new territory, foreknowledge of where the research will lead ranges from uncertain to nonexistent. To forecast, much less govern, fundamental scientific directions is not now possible. And Callahan's approach to governance — importing methods that deal with costs, benefits, and priorities from disciplines such as technology assessment and experiences such as the Oregon Medicaid rationing program — is flawed. We have problems comparing and influencing the use of existing forms of technology with these methods. How much more difficult it would be to apply these methods to hypothetical innovations. Yet even if our predictive power with respect to scientific directions were to grow unpredictably (and research on this is needed), to what degree should society encumber its basic drive to discover how the world works?
The problem is how to enhance human dignity through restraints, such as those that protect the rights of human research subjects, without damaging the cultural ethos that values transcending the present through the pursuit of knowledge. Callahan's book, as important and provocative as it is, does not resolve this dilemma but furthers the effort to engage with it.
Stanley J. Reiser, M.D., Ph.D.
University of Texas Health Science Center at Houston
Houston, TX 77225
stanley.j.reiser@uth.tmc.edu((California/Milbank Books)