Life-And-Death Matters
2004; Project HOPE; Volume: 23; Issue: 2 Linguagem: Inglês
10.1377/hlthaff.23.2.280
ISSN2694-233X
Autores Tópico(s)Ethics in medical practice
ResumoBook Review Health AffairsVol. 23, No. 2: Beyond Managed Care Life-And-Death MattersRobert GoldbergPUBLISHED:March/April 2004Free Accesshttps://doi.org/10.1377/hlthaff.23.2.280AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSPharmaceuticalsDiseasesPrescription drug costsHospital costsCosts and spendingMedical researchDisabilitiesInsurance claimsHIV/AIDSCancerWhat Price Better Health? Hazards of the Research Imperative by Daniel Callahan (Berkeley: University of California Press, 2003), 341 pp., $29.95 When I grow up, I want to be a bioethicist. It would give me the opportunity to weigh in on all manner of life-and-death matters, mostly for liberal foundations and health care companies that are, in the main, irritated by the fact that we spend too much money on health care. The only thing stopping me is that in the end, as bioethicist Daniel Callahan calls for in What Price Better Health? I would be left supporting antismoking campaigns instead of research on a cure for spina bifida. According to Callahan, the research imperative is a philosophical view that regards medical research as more important than any other moral value or as a justification for certain “wrongs,” which for him is the “high” (we never find out relative to what) price of pharmaceuticals. In other words, Callahan believes that people (such as I) who see medical progress as the key to increasing life span, improving the quality of life, easing pain, and boosting productivity also believe that medical research has an absolute moral value that cannot be trumped by other concerns.He explains: “As health has improved, and mortality and disability declined, the drive for research has increased, not decreased. There seems to be no such thing as enough, no level of…health that leads to a reduction in research aspiration. A naïve witness to discussions of American health might think that we have never been worse off, with a long…list of miseries still to be dealt with” (p. 33).On the one hand, Callahan believes that the research imperative is really fueled by a foolish desire by people who are not really sick, who are really healthy, to become absurdly and wastefully healthier still. But what about the fact that most of the research dollars in both the public and private sectors are devoted to finding better ways to prevent, treat, or cure diseases such as AIDS, Alzheimer’s, cancer, heart disease, diabetes, and mental illness? Or that genetic research is allowing scientists to more quickly translate molecular disease mechanisms into potential drugs or vaccines?On the other hand, Callahan believes that “as the success of research…portends, old-fashioned fatalism seems to have, so to speak, received a fatal blow.” There is no reason to accept any disease or disability with stoicism, more’s the pity, according to the author. Either way, Callahan seems to believe that the research imperative moves medical research in a wrong-headed direction: We spend too much money on health care in general instead of more socially useful things.But I digress. The research imperative, Callahan asserts, is to blame for people mistreating human subjects and lab animals alike in medical experiments. In making this assertion, he ignores a whole body of psychological research on the effects of environment on behavior (remember the Zimbardo prison experiment?), let alone the horrific “research” conducted by Nazi scientists on Jews without the research-imperative excuse.But this is not Callahan’s big beef. Rather, he has it in for drug companies, which he complains make way too much money, charge prices that are way too high, and try to get away by invoking the research imperative. Callahan merely asserts that prices are too high without telling us what the right price would be. Would European or Canadian or African prices be the right prices? Would he be willing to put up with lower rates of research and development and restricted access to newer medicines as those countries have? Callahan complains that high prices make drugs unaffordable for the poor. But this is a pointless observation in that without health insurance, medical care for chronic conditions is unaffordable. Indeed, in many cases people fail to take needed medicines even when they have drug coverage. 1 His assertion that drug prices and costs contribute mightily to rising health care costs is wrong on two counts: Hospital spending is the main contributor to total medical expenditures; and drug costs are rising because of increasing use and the introduction of new medicines. 2 Worse, his claim that “just about every common claim about the relationship between research and costs warrants a challenge” is equally specious and prone to error (p. 231). He tries to undermine the body of work by Frank Lichtenberg that demonstrates that “more and better drug[s] significantly reduce hospital stays” (p. 231). Callahan tries to counter this by claiming that in the case of AIDS, hospital stays of one year were not common between 1985 and 1995, and the cost of AIDS-combination drugs, necessary for the rest of a patient’s life, now equals the earlier hospitalization costs (p. 227). In fact, a study by RAND found that the use of the HAART (highly active antiretroviral therapy) combination was associated with a decline in total annual health care costs, from $20,300 in 1996 to $18,300 in 1998. 3Callahan would like to circumscribe the research imperative, to limit or allocate funding only to those projects that we can afford to make available to everyone or to those health goals that to him seem to serve the highest social purpose. Callahan would cut a lot of medical research in favor of behavioral research and public health promotion. One type of funding that he would cut in favor of antiviolence campaigns would be for research to find ways to treat kids with birth defects. Callahan claims that the United States is “behind” other developed countries in indicators of child and maternal health because of social and economic ills, “not because of diseases not yet prevented or cured by a lack of research” (p. 264).Yet the leading causes of death and disability among children ages 0–5 include developmental and genetic conditions that are present at birth, sudden infant death syndrome (SIDS), low birthweight, premature birth, and cancer. All have a genetic component that can play a role in screening, detection, prevention, and treatment. But Callahan seems more concerned about a drug company’s making a buck off of the research imperative and how it adds to overall health care spending. Maybe that’s more important than finding a way to keep kids alive. I’m not a bioethicist, so what do I know?Robert Goldberg is senior fellow and director of the Center for Medical Progress at the Manhattan Institute for Public Policy Research in New York City.NOTES1 K. Gilberg et al., “Analysis of Medication Use Patterns: Apparent Overuse and Underuse of Prescription Drugs for Asthma, Depression, and CHF, Journal of Managed Care Pharmacy 9 , no. 3 ( 2003 ): 232 –237. Crossref, Medline, Google Scholar 2 K. Levit et al., “Health Spending Rebound Continues in 2002,” Health Affairs (Jan/Feb 2004 ): 147 ; and Google Scholar R.W. Dubois et al., “Explaining Drug Spending Trends: Does Perception Match Reality?” Health Affairs (Mar/Apr 2000 ): 231 –239. Google Scholar 3 S.A. Bozzette et al., “HIV Cost and Services Utilization Study Consortium: Expenditures for the Care of HIV-Infected Patients in the Era of Highly Active Antiretroviral Therapy,” New England Journal of Medicine 344 , no. 11 ( 2001 ): 817 –823. Crossref, Medline, Google Scholar Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 1 March 2004 InformationCopyright 2004 by Project HOPE - The People-to-People Health Foundation, Inc.PDF download
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