I wish to thank those who have so far responded to the call for comments. I shall try and assess the discussion so far, however partial the results may be at this stage, starting from some considerations on the comments posted.

One first point of reflection was the necessity to find ways of making clear the various areas affected by the debate (Magda Nirenstein). In fact, as noted by Giovanni Felice Azzone in his review of False Hopes ("Quale medicina e quale assistenza sanitaria?") posing problems that pertain the organization of health care in terms of "scopes and nature of medicine" is neither neutral nor exempt from criticism.
Callahan's analysis combines an anthropological rethinking of illness, especially in the affluent Western societies, with pragmatic considerations about the management of health care. This is certainly linked with the wider need for an ample "cultural, humanistic, historical and pedagogical change about the development of the life sciences", which requires a "cognitive overstepping of the mechanical logics of science that belonged to the industrial age" (Paolo Manzelli). Moreover, as medical anthropology has shown, there are different cultures of illness and of well-being, variously tied to the socio-cultural relations in which they are embedded. Callahan's thesis seems to require a re-education of the citizen-patient, a dimension that could also compete with the current "prevailing of the technical aspects of care over the anthropological ones" (Maurizio de Filippis).
Nevertheless, the issue of setting "limits" has raised several doubts, in as much as "posing limits" may well "leave space for imposition" (Nirenstein), or lead to "painful choices" (as in the case quoted by Marlene di Costanzo, of a rare illness that is "incurable" because of the economic inconvenience of producing the drug against it, and not for the absence of socio-technical solutions for it), or allow de facto that "only the privileged can access some solutions" (Mario Castellaneta).
In fact, when we step from bioethics to the issues of practicing and managing health care, politics and governance come to the fore. For instance, we could reflect analytically on the implications of just one of the questions raised by Alessandra Grazia: "how, and to which extent, do we owe the power of choosing and of deciding?" Who should decide? Who should approve the criteria employed to decide? How can the citizens be involved in a satisfactory and engaging debite on how to choose? How can the medical community be involved? How can the operators of the health care system be involved?
More than one comment refers to the issue of how to allocate resources (Nirenstein), as a way of tackling the economic sustainability of health care. For instance Edoardo Jacucci asks which role could be played by Information and Communication Technologies (ICT) in an efficient management of health care - in particular, in the process of its industrialization: rationalisation, automation, etc. (Daniele Navarra notes how this aspect is tightly linked to a legislative rethinking of the health systems that touches upon the aspects of regulation, funding and provision of health care). The underlying question is, are there not any margins to push the "sustainability" threshold of health care any further (at least in its purely economic aspect)? For instance, one could study new criteria to allocate, distribute or even increment the resources currently devoted to this sector. In this respect, Maurizio de Filippis notes the need to "balance the current trend that turns hospitals into firms, by monitoring the critical aspects of the public health system, which is full of contradictions but also of untapped energies" and by adopting "policies for the preservation of health that stress an equitable distribution of access to care as well as the unavoidable economic logics".
Also in this respect, then, the problem cannot be solved in a reductionist way, because economic constraints have political origins, and are linked not only to issues of administrative efficiency (how much use do costly diagnostic machineries actually get?) but also to several other debates, including for instance those about the intellectual property of drugs, or the admissible length of patents, etc. (see Marcello Cini's article "Vite a rischio nell'era dei brevetti", Il Manifesto 28/08/01, quoted, in this site, inside the thread on the Precautionary Principle). Even if we wished to keep the price market as a regulatory model of the health system, we also need to consider that this model includes a crucial mediating figure - that of the doctor - who authorises or authoritatively advises the patient to consume some drugs and services (and not others) through the tool of the prescription.
Hence posing the issue of the sustainability of health care in terms of the efficiency, or even of the "ethics of public administration" (Nirenstein), refers us back to other issues: Which political and philosophical conception of social solidarity do we hold? Which model of citizenship do we employ? Which level of analysis do we hold as ultimate (economic efficiency, or dignity of life, or social harmony.) in order to shape our conception of health care?
We also need to consider which actions are needed in the various realms of everyday and professional life in order to invest on efficient hygiene practices and on the preservation of public health, so that we can play down the role of more "interventionist" medicines. The social policies needed in this case are very long-term ones, which require huge efforts of planning and implementation, not least at the cultural level (let's think for instance of the need for educating on healthy eating). But they do not imply higher consumption (of drugs, technologies etc.), hence they are less attractive to the pharmaceutical industry. Such preventive medicine, therefore, could only be implemented within a universalist model of public health, and would be little appetizing for the health industry.
In other words, if on the one hand one can thoroughly agree on the fact that we should not medicalise what are in fact social problems, on the other hand such problems must be faced by some other responsible agency. So, for instance, in order to increment "preventive medicine over therapy" (Giuseppe Lanzavecchia) we need to invest on the environmental causes of illness. This means to engage seriously and pervasively against both global factors (e.g. air pollution, which is being much debated in the media these very days, but is never treated as a social and medical priority, that deserves bold and innovative decisions), and local factors, which may interest specific groups of people (such as workers of unhealthy industrial units). The policy choice of reducing public intervention on statistically rare diseases, which may nevertheless hit specific professional communities, should then be counterbalanced by a virtuous policy of preserving health in work settings.
The debate on the "ethical" sustainability of medicine (and not on the economic sustainability of health care) is in many ways distinct. On this aspects we have had different and dissonant voices. On the one hand one does not accept to surrender "ethics to the market" (Giorgio Buzzi). Due to a potentially infinite capacity for demand and to souring expectations (Giuseppe Belleri) the market is already capable of offering drugs that are not designed to cure, but to promise better performances to the healthy (Buzzi). One the other hand Lanzavecchia is not repelled by the "transhumanist" perspective - which was recently criticised by Francis Fukuyama on Corriere della Sera (10/02/05) - and spurs us to embrace "new and bold decisions that leave aside the prejudices of the past, ignoring any so-called precautionary principle". Others prefer to notice the implicit synergy between souring social expectations and the excessive optimism that is associated with certain sectors of scientific research (whether genomics or stem cell research) (Giuseppe Belleri).
Certainly several points worthy of debate have been raised, and we hope that these can be addressed in the discussion of the imminent Lecture by Daniel Callahan, invited by the Bassetti Foundation on 21st February. This Call for Comments will remain open for a few days after the Lecture, in order to allow those who wish so to add their comments or rejoinders.