While I am about to close this call for comments, I wish to thank all those who have responded to it. I think the best contribution I could make, far from being a "resolution" of the many issues, is an attempt to clarify the categories that have been used in the discussion, so that we can "virtually" close it with the impression of having made some progress towards at least refining its semantics.
Callahan's work, in fact, is positioned on at least two fronts at once:
- a reflection on the scopes of medicine, which, Roberto Panzarani notes, should be considered in the light of Foucault's work on bio-politics;
- a political proposal on how to manage economic resources that are perceived as limited.
Consequently, the topic of the sustainability of medicine has been interpreted and tackled here from different viewpoints: that of the ethics of medical and scientific research and that of the politics of health care. The various comments deal, in fact, with medical research on the one hand and with the provision of health care on the other.

As for the former, keeping a logical distinction between "scientific research" and its "technological application" helps to better appreciate their reciprocal and complex feedback in the specific case of the health sector. In fact, as things stand, incentives to research come mainly from the market perspectives of its application. This means, as underlines Marcello Cini, that there is very little research on those illnesses (such as tropical ones) that hit a great portion of the world population, which nevertheless does not create "demand" on the pharmaceutical market because of its poverty. A political regulation of innovation, meant as a socially useful application of a scientific discovery, would reverberate in important ways on the incentives for scientific research (in a similar way to what outlined by Alphonse Vajo, about research in the aerospace sector).

As for the latter, most of the comments have tried to reflect and present data relating to the problem of the governance of health care. Limiting myself to quoting only some of the latest comments, I would note the interest to reflect on "the role that volunteer associations can have on prevention", for instance by carrying out mass screenings (Flaminio Musa), as well as "to look more carefully at the mechanisms of interaction between public and private" (Mario Castellaneta), keeping an eye on the ways in which strong economic actors can exert "aggressive marketing" and thus "create and induce needs" which, by escalating costs, can prevent from safeguarding an equitable access for all to quality health care.
The key issue, though implicit in most cases, seems to me that of clarifying the legislative, social, political framework, including its philosophical and anthropological aspects, within which one wants to develop these reflections. For instance the right to health is a constitutional right in Italy but not in other countries. It first and foremost a project of a democratic society to fix the objectives of public health care, as notices Cini. Within this framework, then, social policies such as those of public education and environmental protection have a paramount incidence towards public health: as Michele Castelli stresses, "in the countries where environmental protection and public education are higher, we can find better data about public health as well". As for the issue of the sustainability of medicine, Cini reminds us to carry out a critical analysis of those economic and juridical mechanisms that create the very contexts within which the "costs" of medicine are reckoned: amongst others the issue of patents.
In any case it seems of fundamental importance to distinguish the role of the patient from that of a consumer (as noted by Piero Bassetti during the seminar discussion held with Daniel Callahan at the Bassetti Foundation on 21/02/05), both because of the "asymmetry between the information held by those who provide and those who receive treatment" (Castelli), and because the patient deals with an institutional framework and with starting social conditions that are not those of a free choice of products in an abstract market.

To conclude, it appears that one of the main points emerged so far is the "unavoidable interaction between science and politics" (Castellaneta), and certainly future reflections on responsibility in innovation will have to take this into account.