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