Daniel Callahan’s book False Hope was translated into Italian two years ago with the title "La medicina impossibile. Le utopie e gli errori della medicina moderna". It took up and studied in detail certain topics, which had emerged from an extensive survey, sponsored in the latter part of the ‘90s by the Hasting Centre and called The Goals of Medicine. Starting from the situation of medicine and research in the US, both the Hasting Centre’s study and Callahan’s book try to take stake, so to say, of the objectives that medicine can and in particular must realistically set itself, without lapsing into utopian perspectives and feeding unjustified expectations.

On December 14 2001, our National Bioethics Committee (NBC) too published an “opinion” focussed on marking out the Scopi, rischi e limiti della medicina (Goals, limits and risks of medicine) (1). This was the last paper produced under Giovanni Berliguer’s leadership; he was recently replaced by Francesco D’Agostino and appointed honorary president of the NBC. The topic discussed in some manner reflects a need dear to Berlinguer, which has often been repeated - “daily” bioethical issues, neglected only too often when compared to matters raised by research and the frontiers of bioethical experimentation, require more time for consideration.
The topic, medicine’s goals, is on the other hand important with regard to its daily nature and the frontiers of medicine itself.
Can medicine be defined once again only in terms of man and, thus, by exclusively therapy-orientated characteristics? Not all medical actions are therapeutic, and they do not always deal with healing. These distinctions have often been highlighted in ethical discussions centring for example on extracorporeal fertilization, euthanasia, voluntary interruption of pregnancy, and also on the so-called sports medicine or aesthetic plastic surgery, where it appears more obvious that not everything doctors really do is targeted at health.
But it is well known that the debate on medicine’s frontiers is complicated today by the difficulty in establishing the very borderlines of health, not considered a mere absence of disease anymore.
If we take up the World Health Organization’s notion of health, unrealistic and yet fascinating – understood “as a condition of perfect physical, mental and social well-being” - and we state that medicine’s goal is health, then we must conclude that medicine deals with everything and nothing is foreign to it.
But this feeling of all-powerfulness smashes to smithereens against the difficulty to establish what well being really is, especially in such a period as ours, which does not consider it possible to trace a dividing line between what belongs to the category of need and the category of the wishful, between what is normal and what is pathological.
How can undefined and potentially unrestrained ambitions that represent the subjective ideal of well being be handled?
Wherever medicine does not define its duties, it will see them established by others, whether they be a civil society, public power, economy or, simply the individual decision of each patient, often a demanding “customer” who believes what the media promises – the said media does not always know the distinction between science and literature.
The relations between society and medicine is, in any case, basic because medicine depends on society, both with regard to its economic means of development and its practical goals, which always have some social effect.
Medicine’s pervasive nature, often revealed by the term “medicalization” of existence, derives also from the fact that, as the very NBC paper recalls, "today, medicine’s daily activities also deal with “non-disease” with both the increasingly extensive room medical theory and practice reserve for “primary” prevention of disease and the large number of individuals who daily, fearing they are sick (…), have investigations performed towards the so-called “secondary” prevention; these examinations only too often prove their “good health” ".

Hence it is no easy task to state medicine’s goals, as it may have seemed at a first glance, and it is at the same time increasingly urgent to do so; we must acknowledge that the NBC’s paper reveals that the Committee is fully aware of this. In fact the paper deals with almost all the key-topics of the medical issue - from the definition of disease to the epistemological evolution of medicine, from the assessment of alternative treatment compared to scientific medicine, to the doctor-patient relationship problem, from the analysis of the limits and risks of medicine to matters of social justice and allocation of funds.
It is hence worth reading because it outlines the current debate’s terms and helps understand the need to mark out precise criteria to define what medicine should and should not be today, because only in this manner can concrete answers be given to certain (even if not all) the problems raised by daily medical practice and the frontiers of medicine itself.
But, after having repeated topics and problems, stressed difficulties and complicated points, the paper closes with a chapter called Sintesi e raccomandazioni (Summary and recommendations) which, besides summarizing the already mentioned, presents no concrete specifications, takes no stand, neither dogmatic nor accounted for, concerning the goals and limits of medicine.
The first point (the summaries and recommendations are developed in eight points) probably holds the only “express” recommendation worth mentioning. After having recalled the topic "of crucial importance" discussed and stated that there is conflict between the diverse conceptions of medicine, the "National Bioethics Committee recommends that medicine should seek a constant dialogue with society, instead of conflict, in order to make medicine aware of the social role it plays and so on". We can only be disappointed by such a conclusion: the large amount of data and information, in fact, gave hopes (False Hopes?) that the members of the NBC had the time and means to make concrete proposals, if not to Europe, at least to the Italian scientific and civil community.
Without being argumentative, there is the temptation to paraphrase the title of this Opinion in order to propose another consideration, on the goals, limits and risks of a National Bioethics Committee.
In other words the goals should be clear, considering the NBC’s item “duties” (2) also specifies that “solutions” which can help make laws must be stated. It would be advisable to develop a detailed study and discussion centring on the intrinsic and extrinsic limits of a National Bioethics Committee, which on the other hand should be conducted by the Committee itself. We can, instead, show the risks an NBC can run into in attempting to perform the difficult duty it is called to carry out. I think they are potentially of three types:
1) the risk of not going beyond the description of the state of the issue and of not succeeding in wording some well accounted for and concrete guidelines;
2) the risk of exercising an arbitrary power to condition public opinion, supporting certain interests presented by majorities that can form inside it;
3) the risk of producing concrete, limited, accounted for and detailed opinions knowing that, in any case, the NBC will have neither the approval of the entire public opinion nor that of all those who have given rise to the theoretical conflict faced. Only the third risk is compatible with an ethical and scientific commitment such as the one expected from the National Bioethics Committee, which has acquitted itself better on other occasions (and with the same members).
Nobody expects the NBC to be the best ethics committee ever and its members to be the best experts, nor are they expected to phrase the best opinion ever.
Citizens would be satisfied with precise, accounted for, clear and circumstantiated opinions. Otherwise, what would be the use of an NBC?
This is probably not a thoroughly weird question.

(Translated by interpres sas )
Adriano Pessina
Cattedra di Bioetica
Università Cattolica di Milano

NOTE

(1) - The text is published in Palazzo Chigi’s website: http://www.palazzochigi.it/bioetica /notizie/notizie_etici.html

(2) - The duties declared are the following:
a) Develop an outline of the programmes, objectives and results of research and experimentation in the field of life sciences and human health, also making use of the power to access the necessary information in operations centres present throughout the nation, and in connection with similar committees established in other countries and other international organizations operating in the sector;
b) Express opinions on and specify solutions, even leading to legislative acts, for ethical and juridical problems that can rise with the progress of research and the discovery of new applications of clinical interest, with due regard for the safety of man’s fundamental rights and dignity and other values as defined in the Constitution and by the international organizations Italy belongs to;
c) Propose control solutions targeted both at the protection of the safety of man and the environment in the production of biological material and at protecting patients treated with genetic engineering products or subject to genic treatment from possible risks;
d) Encourage the drafting of behavioural codes applying to operators in various sectors who encourage giving