Introduction
According to Freitas
nanomedicine is
“ […] (1) the
comprehensive monitoring, control, construction, repair, defense, and
improvement of all human biological systems, working from the molecular
level,
using engineered nanodevices and nanostructures; (2) the science and
technology
of diagnosing, treating, and preventing disease and traumatic injury,
of
relieving pain, and of preserving and improving human health, using
molecular
tools and molecular knowledge of the human body; (3) the employment of
molecular machine systems to address medical problems, using molecular
knowledge to maintain and improve human health at the molecular scale.”
(R. A. Freitas: Nanomedicine,
Vol. I: Basic
Capabilities, Georgetown (Texas) 1999,
p.
418)
Following this vision,
nanomedicine will change in a short, middle, and long term perspective
the life
of individuals and societies in many regards. These changes are of
major
ethical relevance as far as they concern human self awareness, as well
as the
respect, responsibility, and care we owe to each other and to the
environment.
Similar challenges that have been predicted of information technology,
genetics
and brain research have to be grasped in their convergence.
Nanomedicine should
be ethically located, as Freitas does, within a healing
vision without excluding the question of enhancement.
Ethical
Aspects of Nanomedicine on a short, middle, and long
term perspective
The ethics of nanomedicine
can be conceived as prospective responsibility on a short, middle, and
long
term perspective (5, 10, 20 years). But obviously this kind of
predictions are
subject to unexpected breakthroughs.
On a short term perspective nanomedicine faces ethical
questions that
arise mainly from the knowledge gaps
concerning the risks of interventions using:
- Nanomedical products
- Nanocosmetic products
- Nanodelivery vehicles /
systems / implants
- Nanodiagnostic tests
In general, due to the
present lack of knowledge the precautionary principle, i.e., the
responsibility
to take preventive action to avoid harm to human health or the
environment in a
situation where knowledge gaps prevail, should be applied particularly
in case
of the invasive use of nanotechnology
in the human body. There are knowledge gaps with regard to the toxicity
of
nanoparticles and nanomaterials not only for the human body but also
for the
environment.
The dangers of affecting
the human brain with nanotechnology are among the most controversial
ethical
aspects particularly if such interventions are beyond a healing
perspective.
The preservation of human identity should be respected in all such
interventions as well as in research projects dealing with them.
On a middle term perspective nanodevices and
nanomedical products will
be used in all medical fields. This rises ethical questions of
responsibility
at a local and global level. Particularly questions of data protection
and
privacy arise as in the case of genetic testing. Nanodiagnostic tests
will rise
the question of healing expectations that in many cases will not be
fulfilled.
The gap between diagnostic and healing possibilities will affect the
relation
between the physician and the patient concerning informed consent as
well as
the right of the patient not to know. Nanomedical implants, drugs and
treatments will rise the question of justice and fairness in the health
care
system as well as between rich and poor societies (nano
divide) in case such drugs and treatments do not happen to be
better
and cheaper as the ones used today which is one of the promises of
nanomedicine
so far.
There is also
the question of patents in this field, i.e.,
the question whether artificial configurations of chemical elements can
be
considered as inventions.
On a long
term perspective nanotechnology envisages not only the
creation of autonomous nanomachines to
be used inside the human body but the enhancement
and even transformation of the human body and human identity
particularly in
case they were used to modify the human brain.
The use of nanomachines in
the human body implies the risk that due to a damage in the onboard
computer this could not be
appropriately steered. The threat of nanomachines (fighting
nanorobots) will become real not only in war situations but also in
case
they were produced and used by terrorists in everyday life. This could
also
lead to new forms of ubiquitous surveillance and monitoring becoming a
new
threat to privacy and autonomy.
From an ethical viewpoint
it is not desirable to create autonomous
nanomachines as far as they could become not only out of control but
even able
of acting in an own initiative (automated
decision-making) eventually against their human designers. This so
called black goo scenario is at present purely
science fiction but it shows ad limine
not only undesirable but also unacceptable effects of what sometimes is
being
called a transhumanist vision. This
vision becomes a nightmare in case the human race is conceived as
something
capable of being superseded on the basis of nanotechnological self
annihilation. The reverse is a healing
vision in which nanomedicine is viewed at the heart of a human- and life-centered scenario.
This vision is affirmative
towards technology in
general and nanotechnology in particular as far as any technology means
a
transcendence of what is naturally given by creating something
artificial. In
other words, technology belongs to human self understanding. The
ethical limits
of self-manipulation arise at the moment when such changes become a
threat to
human self awareness based on a radical transformation of the human
body. But
this limit leaves a broad field of possible applications that will
concern the enhancement of human capabilities which
are not per se a threat to human
dignity but might lead to a better life through an improvement of
healing
methods, new materials improving the quality of life etc. It is
difficult to
foresee now such positive and negative effects including the gray goo scenario, i.e., the impact of
self-replicating nanomachines in the ecosphere.
Conclusion
The view of the human body
from a nano perspective is basically reductionist similar for instance to the view of the human
brain as a computer, now a nano-computer.
This reductionist view can give rise to the naturalistic fallacy, i.e.,
to the
idea that human phenomena can be changed or influenced at the nano
level
without telling the manipulator what changes are more or less
desirable. It
enforces the misleading belief that all human diseases could eventually
be
treated and eliminated by advanced nanotechnology. The potential
benefits of
nanomedicine are wrongly extrapolated into a view of the human being as
a mere
composition of atoms and molecules. It is hard to believe that on the
basis of
manipulations at the nano level the condition
humaine between birth and death can be changed.
The utopian idea of a
longer life of, say, two or three hundred years on the basis of
nano-manipulation looks at least from the perspective of today’s
political and
economic situation more like a nightmare than a utopia. It can be
considered
also a cynical perspective in view of what should and could be done
with the
help of nanomedicine in order to alleviate real human pain. Such
utopian visions
are misleading not only with regard to the expectations of patients but
also of
the public opinion and of politicians responsible for public funds for
research
projects envisaging such perspectives.
ANNEX
Freitas' on Ethics of Nanomedicine with Short Comments
"The very earliest
nanotechnology-based biomedical systems may be used to help resolve
many difficult scientific questions that remain. They may also be
employed to assist in the brute-force analysis of the most difficult
three-dimensional structures among the 100,000-odd proteins of which
the human body is comprised, or to help ascertain the precise function
of each such protein. But much of this effort should be complete within
the next 20-30 years because the reference human body has a finite
parts list, and these parts are already being sequenced, geometered and
archived at an ever-increasing pace. Once these parts are known, then
the reference human being as a biological system is at least physically
specified to completeness at the molecular level. Thereafter,
nanotechnology-based discovery will consist principally of examining a
particular sick or injured patient to determine how he or she deviates
from molecular reference structures, with the physician then
interpreting these deviations in light of their possible contribution
to, or detraction from, the general health and the explicit preferences
of the patient. In brief, nanomedicine will employ molecular machine
systems to address medical problems, and will use molecular knowledge
to maintain human health at the molecular scale.".
Comment:
The most "revoluationary" changes are, in my view still highly
speculative and expected in the next 20-30 years...
2)
Volitional normative model of disease
http://www.nanomedicine.com/NMI/1.2.2.htm
"The author proposes a ninth view of disease, a new alternative which
seems most suitable for the nanomedical paradigm, called the
"volitional normative" model of disease. As in the "disease idealism"
view, the volitional normative model accepts the premise that health is
the optimal functioning of biological systems. Like the "functional
failure" view, the volitional normative model assumes that optimal
functioning involves the operation of biologically programmed processes.
However, two important
distinctions from these previous views must be made. First, in the
volitional normative model, normal functioning is defined as the
optimal operation of biologically programmed processes as reflected in the
patient's own individual genetic instructions, rather than of
those processes which might be reflected in a generalized population
average or "Platonic ideal" of such instructions; the relative function
of other members of the human population is no longer determinative.
Second, physical condition is regarded as a volitional state, in which the
patient's desires are a crucial element in the definition of health.
This is a continuation of the current trend in which patients
frequently see themselves as active partners in their own care.
In the volitional normative
model, disease is characterized not just as the failure of "optimal"
functioning, but rather as the failure of either (a) "optimal"
functioning or (b) "desired" functioning. Thus disease may result from:
1. a failure to correctly
specify desired bodily function (specification error by the patient),
2. a flawed biological program
design that doesn't meet the specifications (programming design error),
3. flawed execution of the
biological program (execution error),
4. external interference by
disease agents with the design or execution of the biological program
(exogenous error), or
5. traumatic injury or
accident (structural failure).
In the early years of
nanomedicine, volitional physical states will customarily reflect
"default" values which may differ only insignificantly from the
patient's original or natural biological programming. With a more
mature nanomedicine, the patient may gain the ability to
substitute alternative natural programs for many of his
original natural programs. For example, the genes responsible for
appendix morphology or for sickle cell expression might be replaced
with genes that encode other phenotypes, such as the phenotype of an
appendix-free cecum or a phenotype for statistically typical human
erythrocytes.* Many persons will go further, electing an
artificial genetic structure which, say, eliminates
age-related diminution of the secretion of human growth hormone and
other essential endocrines. (The graduated secretion of powerful
proteolytic enzymes, perhaps targeted for gene-expression in
appropriate organs, may reverse and control the accumulation of highly
crosslinked collagenaceous debris; by 1998, many members of the
mainstream medical community were already starting to regard
aging as a treatable condition.)2310,2976-2981
On the other hand, a congenitally blind patient might desire, for
whatever personal reasons, to retain his blindness. Hence his genetic
programs that result in the blindness phenotype would not, for him,
constitute "disease" as long as he fully understands the options and
outcomes that are available to him. (Retaining his blindness while
lacking such understanding might constitute a specification error, and
such a patient might then be considered "diseased.") Whether the broad
pool of volitional human phenotypes will tend to converge or diverge is
unknown, although the most likely outcome is probably a population
distribution (of human biological programs) with a tall, narrow central
peak (e.g., a smaller standard deviation) but with longer tails (e.g.,
exhibiting a small number of more extreme outliers)."
Comment: According to this definiton of "disease", the
"patient's desires" are a crucial point. This means that the question
of autonomy and responsibility of the patient (and not only of the
medical doctor) will probably play an important role in the future, not
only with regard to what will be considered as "a treatable condition"
(such as aging) but also with regard to the decision about "electing an
artificial genetic structure".
3)
Treatment methodology
"The
availability of advanced nanomedical
instrumentalities should not significantly alter the classical medical
treatment methodology, although the patient experiences and outcomes
will be greatly improved. Treatment in the nanomedical era will become faster
and more accurate, efficient, and effective. In clinical
practice, patient treatment customarily includes up to six
distinguishable phases: examination, diagnosis, prognosis, treatment,
validation, and prophylaxis. Let us consider each of these, in turn."
Comment:
The question of how the
speed of diagnosis may influence the patient's moral decision seems to
me also a crucial ethical question and "nano" specific.
4)
Examination
"In
the nanomedical era, taking and analyzing
microbial samples will be much simpler for the practitioner. Such
analysis will be as quick and convenient as the electronic
measurement of body temperature using a tympanic thermometer in a late
20th-century clinical office or hospital. As described in
Chapter 18, the physician faces the patient and pulls from his pocket a
lightweight handheld device resembling a pocket calculator. He unsnaps
a self-sterilizing cordless pencil-sized probe from the side of the
device and inserts the business end of the probe into the
patient's opened mouth in the manner of a tongue depressor.
The ramifying probe tip contains billions of nanoscale molecular assay
receptors mounted on hundreds of self-guiding retractile stalks. Each
receptor is sensitive to one of thousands of specific bacterial
membrane or viral capsid ligands (Section 4.2).* An
acoustic echolocation transceiver provides gross spatial mapping. The
patient says "Ahh," and a few seconds later a three-dimensional
color-coded map of the throat area appears on the display panel that is
held in the doctor's hand. A bright spot marks the exact
location where the first samples are being taken. Underneath the color
map scrolls a continuously updated microflora count, listing in the
leftmost column the names of the ten most numerous microbial and viral
species that have been detected, key biochemical marker codes in the
middle column, and measured population counts in the right column. The
number counts flip up and down a bit as the physician directs probe
stalks to various locations in the pharynx to obtain a representative
sampling, with special attention to sores or any signs of exudate. After
a few more seconds, the data for two of the bacterial species suddenly
highlight in red, indicating the distinctive molecular
signatures of specific toxins or pathological variants. One of these
two species is a known, and unwelcome, hostile pathogen. The diagnosis
is completed, the infectious agent is promptly exterminated (Chapter
19),3233
and a resurvey with the probe several minutes afterwards
reveals no evidence of the pathogen."
Comment: this kind of examination and immediate treatement
poses again the question of speed (and responsibility)
5) Diagnosis
http://www.nanomedicine.com/NMI/1.2.3.2.htm
"Diagnosis
is the determination of the cause and
nature of a disease in order to provide a logical basis for treatment
and prognosis. Traditionally the diagnostic process begins
with a thorough history taken from the patient and a relevant physical
examination. Often this sufficed to make a confident
diagnosis, but the cause of some illnesses remained uncertain without
recourse to additional information such as blood tests or radiological
examinations. Nanotechnology-based diagnosis (Chapter 18) will consist
principally of examining the patient to determine how he or
she deviates from autogenous reference structures and functions, and
then interpreting those deviations as healthy or unhealthy for that
patient.
In
the 20th century, diagnoses frequently involved
a high degree of uncertainty, largely due to the general lack of
comprehensive molecular diagnostic tools. Thus diagnosis would be
guided by statistical analyses; one branch of decision analysis, called
utility analysis, even allowed the patient to participate in the
decisionmaking process.2227
When the correct decision is unclear, urges one textbook, it is well to
remember time-honored Hippocratic aphorisms such as "first, do no harm"
and "common things occur commonly." The eminent Canadian physician Sir
William Osler (1849-1919) lamented that "errors of judgement must occur
in the practice of an art which consists largely in balancing
probabilities." Most doctors would prefer to understand the root cause
of medical problems rather than adopt mere statistical approaches.
Nanomedical
tools will vastly reduce diagnostic
uncertainty. Using nanomedical instrumentalities, doctors will gain
access to unprecedented amounts of information about their patients
including in-office comprehensive genotyping and real-time whole-body
scans for particular bacterial coat markers, tumor cell antigens,
mineral deposits, suspected toxins, hormone imbalances of genetic or
lifestyle origin, and other specified molecules, producing
three-dimensional maps of desired targets with submillimeter spatial
resolution. Embedded in vivo nanomedical data archives (Section 10.2.5,
Chapter 19) can provide onboard storage of regularly updated
self-diagnostic scans, reducing to a minimum the need for symptomatic
interview data from patients who may be unconscious, inarticulate, or
verbose, who may have limited powers of self-analysis or
self-observation and who may have forgotten, suppressed, or amplified
descriptions of symptoms.
Of
course, physicians do not require an exhaustive
survey of the entire body of each patient to molecular detail to make a
valid diagnosis. In any particular case, it is the function of
the trained medical mind to quickly ascertain where and where
not to look in molecular detail. But in the nanomedical era, powerful
tools will be available to allow the practitioner to examine almost any
portion of a patient in as much detail as desired, right down to the
molecular level, with results available in seconds or minutes,
and at reasonable cost (e.g. Section 2.4.2)."
Comment:
Nanotechnologically-based
diagnosis oversees the relevance of traditional diagnosis based on the
"history taken from the patient". Traditional diagnosis being based on
probability leads to ethical considerations such as "first,
do no harm". Nanodiagnosis seems to question this principle or make it
obsolete as far as "errors of judgements" consisting "in balancing
probabilities" could be overcome. But, on the other hand, it is still
"the function of the trained medical mind" that plays an key role when
a decision is taken on what kind of "molecular detail" is taken into
account. Again there is the question of velocity and
comprehensiveness that poses new moral challenges for doctors and
patients. All this, as expected, "at reasonable cost"!
6) Prognosis and
Treatment
http://www.nanomedicine.com/NMI/1.2.3.3.htm
"As
in Section
1.2.3.1,
we may compare the therapeutic response to a simple infection at
several different levels of technological competence. Consider a
patient who has been diagnosed with eastern equine encephalitis, a
mosquito- or tick-borne arbovirus. In the 20th century, there was no
specific treatment for this disease. Care was generally supportive,
with the doctor attempting to maintain the patient's heart and lung
function while the infection ran its course. The prognosis was poor.
There was a 50%-75% mortality rate with frequent sequelae including
seizures and paralysis, especially in children.2180
Biotechnologists
proposed a molecular approach to
therapeutics using recombinant DNA technology that was not yet possible
in 1996 but was regarded as likely by the early 21st century:2233
"A
patient enters the hospital with high fever
and intense headaches. A spinal fluid tap is submitted to the molecular
microbiology lab. After screening for several viruses, a species of
equine encephalitis virus is identified that is endemic to a location
recently visited by the patient. A call to the Centers for Disease
Control results in the emergency delivery of a new antiviral agent.
Antisense oligonucleotides are injected into the cerebral spinal fluid.
These small DNA pieces bind directly to the virus and block its further
proliferation. A temporary reservoir giving access to the cerebrospinal
fluid is placed and infusion of this therapeutic molecular inhibitor of
the virus continues for 5 days until signs of encephalitis have passed."
The
nanomedical therapy? As before, a nanomedical
cure for eastern equine encephalitis may be far simpler, less
painful and a great deal quicker. A single therapeutic dose
consisting of ~0.1 cm3 of isotonic saline fluid containing
~10 billion active micron-size virucidal nanodevices, a 10% volumetric
nanodevice suspension, is injected into the cerebrospinal fluid. Each therapeutic
nanorobot has chemical sensors that can unambiguously
recognize fluidborne or in cyto arbovirus particles and, once
recognition has occurred, destroy them and also reverse the cellular
damage. A nanorobot population of this size should be able to destroy
all viral particles and effect needed repairs in at most an hour
(Chapter 19),3233
after which the devices are programmed and equipped either to eliminate
themselves from the body (Chapter 16) or to be manually exfused (e.g.,
nanapheresis; Section
10.3.6)."
Comment: Nanotreatment will be "far simpler, less painful and
a great deal quicker" with... therapeutic nanorobots! This opens the
question of "non-therapeutic" nanorobots and the possibilities of their
misuse as well as the (potential) "side effects" of
therapeutic nanorobots.
7) Validation
and Prophylaxis
http://www.nanomedicine.com/NMI/1.2.3.4.htm
"A
proper therapeutic protocol will include a
procedure for follow-up to ensure that the prescribed treatment was
correctly executed with good results. This step is often neglected in
order to save costs and may be considered unimportant by some
practitioners because approximately 80%-90% of all illnesses
which take patients to the doctor are self-curing or self-limiting.2205
For example, the common cold, most infectious diseases and many minor
injuries are problems that usually will resolve on their own even with
no treatment. In these cases the purpose of treatment is not to provide
a cure, but rather to speed the healing process, improve
comfort, and avoid complications. Many nanomedical treatments will
require supervision and will run quickly to completion, thus
follow-up may come back into vogue. Validation may also be viewed as a
post-treatment re-diagnosis to ensure that no disease remains present
in the patient.
Prophylaxis
is the prevention of disease, typically
including patient education, immunization programs, amelioration of
occupational hazards, and other preventive and public health measures.
In a treatment environment that is rich in effective antibacterial
instrumentalities, those microbes which survive will evolve to produce
only modest or negligible symptoms that are insufficiently annoying to
motivate a patient to seek professional therapeutic relief. It is
well-known that bacteria can modify their behavior over time. For
example, syphilis had a much more fulminating course in the Middle Ages
than it has in the 20th century. Some future strain of the syphilitic
microbe might produce negligible symptoms, but we should still insist
on its eradication because of its potential to revert to its earlier
virulence if allowed to spread unchecked in a more benign form.
Preventative procedures may also be needed to discover, diagnose, and
treat apparently symptomless diseases, and a variety
of molecular-based physiological malfunctions and structural
micropathologies may require nanoscale tools in order to detect them.
With
medical conditions that require ongoing
supervision and adjustment, such as maintaining optimum hormone balance
and minimal accumulation of molecular debris (e.g. anti-aging
medicine), nanoscale monitoring stations may act as onboard cellular
guidance systems, stimulating or suppressing endocrine secretion as
necessary to preserve an ideal state of equilibrium. In some cases,
direct manufacture of compounds not easily produced by ribosomes or
other biological organelles may be required."
Comment:
The need of supervision
of nanomedical treatments seems to pose again the question of
responsibility and speed. The question of "symptomless diseases" opens
the problem of the gap between diagnosis and treatment. Nanomedicine
seems to suggest that there is no uncurable disease. This seems to me a
strong position that may cause delusion in many cases. Which is an
important ethical issue. Nanomedicine may create a "hype" with regard
of curability of "all" diseases.
8) Evolution of
bed-side practice
http://www.nanomedicine.com/NMI/1.2.4.htm
"The
relationship between physician and patient has
been evolving in response to the rapidly changing medical environment.
Two of the most important trends are the decline of traditional holism
(with a concomitant increase in specialization) and the rise of
therapeutic customization in medical practice."
Comment:
Both trends seem
important to me also from an ethical viewpoint. (See below)
"Holism is a philosophy which holds that
individuals function as complete units that cannot be reduced merely to
the sum of their parts.2223
It is unarguable that a simplistic reductionist view of
the patient which ignores the complex interactions among the many
cells, tissues, organs, and systems constituting the human body is
deeply flawed. For example, an understanding of the molecular
basis of the contractile proteins of heart muscle will not alone tell
us how heart muscle cells will look or act; knowing only about the
parts of something is not sufficient to predict the behavior of the
whole.2239
However, traditional concepts of holistic medicine go well beyond such
basic systems philosophy -- incorporating requirements for a
consideration of all physical, emotional, social, spiritual,
environmental and economic needs of the patient.
N. Jewson2203
and others2205
have decried the modern shift away from holistic medicine, which is
asserted to have taken place in three historical phases in the West.
The initial phase is identified as the practice of "bedside medicine,"
where wealthy fee-paying clients in the 17th and 18th centuries helped
shape their own diagnosis and treatment by medical practitioners in an
holistic manner. Aspects of the patient's emotional and
spiritual life were seen as central by the practitioner in making a
diagnosis, since most physical treatments were only palliative
and so the doctor had to focus on nonphysical supportive measures. This
frame of reference was progressively replaced during the 19th century
with the trend toward "hospital medicine," wherein
physicians concentrated on generic classifications of diseases that
were manifested in the patient, moving doctors away from the earlier
focus on the individual as a whole person. The 20th century saw the
development of "laboratory medicine," which moved
diagnosis and therapy even further away from the whole patient, "who
came to be medically conceived as little more than a depersonalized
object, comprised of a complex of cells."
A more charitable view is that physicians have
increasingly specialized in treating those physical diseases for which
effective treatments may be readily specified, leaving nonphysical
and nontreatable issues for psychiatrists, social workers, fitness
coaches, priests, lawyers, or other professionals to deal with.
In the 21st century this operational specialization may become
complete, since nanomedicine phenomenologically regards the
human body as an intricately structured machine with trillions
of complex interacting parts, with each part (and each subsystem of
parts) subject to individual scrutiny, repair, and possibly replacement
by artificial technological means. In this new medical cosmology, the
concept of the whole patient almost completely dissolves into a
data-intensive whirlwind of molecular detail at the cellular, tissue,
organ, and systemic levels.
And yet, as in a bygone era, patients
once again will help to shape their own diagnosis and treatment
at the hands of medical practitioners who begin to apply the volitional
normative model of disease (Section 1.2.2) in
their practices. This may breathe new life into the age-old medical
school dictum to "treat the patient as a person" and to "focus on the
sick person" rather than exclusively on the body.2230
The availability of extremely powerful and
transforming molecular technologies also argues for a return to the
romantic and perhaps quaint concept of a single doctor taking care of a
single patient. The potential for interactions among highly potent
nanorobotic instrumentalities argues for diagnostic and therapeutic
"gatekeeping" by a single trusted practitioner in whom
strategic treatment responsibility is vested -- in partnership, of
course, with the patient.
Comment: This means, that
there is, as I already said, an increase of the moral responsibility of
the patient a kind of "paradigm shift" with regard to traditional
medicine relaying on the doctor's view as a "random" one. Is this
"individualistic" kind of medicine also a realistic one? Is it
feasible? Also economically? What does "partnership" with the patient
mean? What is the "responsibility" of nanorobots (and their intrusion!)
in the healing process?
"In science the objective is to understand the
individual occurrence by means of a general law; in medical practice,
knowledge of what is generally the case does not tell the physician how
to treat a particular patient. Thus the problem of how to proceed from
the prototypic case to the individual instance remains to be solved in
a systematic manner by the practitioner.2230
The practitioner of "bedside medicine" in the 17th and
18th centuries had few curative and almost no customized tools at his
disposal -- perhaps a few dozen basic surgical techniques, performed
septically, hazardously, and without anesthesia, and a drug/herbal
formulary consisting of a few hundred substances. For instance, the Edinburgh
Pharmacopoeia of 1803 listed only 222 simples while the London
Pharmacopoeia of 1809 listed fewer than 200 items, most of which
had variable, uncertain, minimal, or nonspecific potency. A few more
options became available to the 19th century medical practitioner,
including complex surgical techniques for specific conditions that
could be performed aseptically with anesthesia and a good chance for
success, a somewhat broader and more efficacious pharmacopeia, vaccines
targeted to several diseases, and an improving diagnostic ability. By
the 20th century, the physician could prescribe from among
tens of thousands of specific drugs to target specific
bacterial, viral, fungal, or parasitic infections; select from among a
very precise array of anesthetic agents, chosen to avoid allergic
responses in particular patients; perform a wide variety of noninvasive
tests and scans for diagnostic purposes to identify very specific
conditions; and perform minimally invasive surgeries directed at many
arbitrary tissue masses as small as 1 mm3 in volume. The
first glimmerings of personalized genetic therapies also began
to appear.
With the arrival of nanomedicine in the 21st century, the
treatment paradigm will complete its transition from coarse-grained,
one-size-fits-all, slow-acting methods to molecularly-precise,
completely customized, speedy and highly-efficacious procedures and
instrumentalities. The irregular shotgun pattern of 18th
century palliatives will evolve during the early 21st century into a
penetrating and perfectly tailored hail of "magic bullets" each
targeting an individual cell or group of cells unique to the individual
patient. The 19th century herbalist John Ayrton Paris could have been
describing the nanomedical future in his popular textbook Pharmacologia,
1840 edition, when he wrote:
"If [a physician] prescribes upon truly scientific
principles, he will rarely in the course of his practice compose two
formulae that shall, in every respect, be perfectly similar, for the
plain reason that he will never meet with two cases exactly alike. Now
let me ask what constitutes the essential difference between the true
physician and his counterfeit between the philosopher and the
empiric? Simply this that the latter exhibits the same medicine in
every disease, however widely each may differ from the other in its
symptoms and character; while the former examines, in the spirit of
philosophic analysis, all the existing peculiarities of his patient,
and of his discord...and then adapts with a sound discretion and with a
correct judgement of his medicinal agents, such means as may best be
calculated to control and correct the patient's morbid condition."
Comment:
The customization of
treatement (and of the "true physician") is a societal (a question
of social justice) and particularly an economic challenge!
"Many other aspects of the physician-patient
relationship, especially as this relationship may evolve in the coming
era of nanomedicine, are important and worthy of extensive discussion.
One such issue is the obligation of both parties in the partnership to
tell the truth. The patient as a fellow human being has every right
to know the truth about his or her biological condition, but
other considerations may enter into the fulfillment of this obligation.2234
Patients have a quite natural anxiety about their own possible death,
and it has been claimed that this anxiety implies that no one can be
truly objective toward his or her own body.2236
Guttentag2234
observes that "telling an unwelcome truth to the unprepared is as
ill-conceived as trying to hide the truth from the prepared."
In the nanomedical era, the sheer number
of "truths" that may become available for disclosure will increase
enormously even as the terminal prognosis becomes rare. For
example, each human being is believed to possess at least 4-10
potentially serious genetic defects; up to 1% of human DNA is of
exogenous viral origin, and as much as 10% of the genome consists of
transposons, discrete sequences that are positionally mobile among the
chromosomes (Chapter 20). Should something be done about this, or not?
What should the average patient make of the news that his physician has
discovered exactly 57 submicron-scale lamellar defects scattered
throughout the compact bone of the caudal epiphysis of the patient's
right humerus? In the nanomedical era, people will gain the
ability to specify their own physical structure to minute detail, but
many patients will not be ready, willing, or able to assume
responsibility for this knowledge. Thus there is no ideal
substitute for the doctor's interpretative abilities and judgements on
the patient's behalf as to the personal significance of specific
diagnostic information. As the great clinician Thomas Addis observed in
another context:2237
"Honesty with patients requires thought and discipline and effort."
Perhaps the single most important aspect of the
physician-patient relationship, in any century, is the
humanistic quality of the good doctor. The patient seeks a
physician who cares about him as a person and will diagnose and
prescribe in a sensitive and compassionate manner, accepting some
degree of obligation to the patient. Speaking to medical students, J.C.
Bennett2238
describes the implicit social contract between doctor and patient that
will still apply in the nanomedical era, as it does today:
"To receive medical care, patients must trust
their bodies and their very lives to physicians, and so to be in an
honest position to give medical care, physicians must earn such radical
trust. Mere technical treatment of disease does not suffice. Patients
must be able reasonably to believe that their physicians care about
them in an extraordinarily personal way. This exchange of care for
trust, while not identical to friendship or love, is equally binding.
From it develops an interdependence that is far from unwholesome;
rather, it potentiates care and promotes healing. Our late twentieth
century sophistication and technologic orientation have too often cost
us warmth, humor, and humanity, leaving us in social isolation. We do
far better as professionals to err on the side of being human with our
patients, than to try to play deus ex machina, the god from the
machine."
Comment:
"To tell the truth" is an
eminent moral category. What happens when "truths" about the body are
uncountable?! If patients will not be ready of willing to assume
responsibility for this knowledge this is indeed a main ethical issue.
The doctor's interpretative ability is still there, also in case of
nanomedicine. This makes the ethical question of nanomedicine in this
regard (!) less new as expected but it is still the question of the
context in which such interpretation of data, telling the truth,
relationship to our own desires of changing our "nature" etc. etc. This
makes the whole view of nanomedicine under a different ethical
perspective, i.e., a stronger burden of responsibility, less relying on
what "is generally considered as illness," discourse with oneself and
with others, with other societies and cultures, on what we think is
good or bad for our health/bodies, the creation of new differences
within societies etc.
"How does a patient
regard his or her own body,
and how might this most intimate of all relationships change in the
nanomedical era? The so-called dualist theory of the human compound, as
originally developed by Descartes and widely accepted today by the
ordinary person, holds that the human being consists of two separate
kinds of thing: the body and the mind or soul. The body acts as a host
or receptacle for the mind. The mind, often called "the ghost in the
machine," is manifested by the brain, which it uses (via the bodily
senses) to acquire and store information about the world and to
integrate this with its genetically-driven imperative to live, thus
resolving internal conflicts among action-choices and expressing these
in what we (in our consciousness) experience as decisive action.
Scientific
medicine has concentrated
primarily on the body. The ancient Roman physician Galen first
dissected and vivisected a variety of animals to increase his knowledge
of anatomy and physiology, and dissection became increasingly important
in the training of physicians and surgeons, and in painting and
sculpture, during the Renaissance. By the late 20th century,
dissection had reached the molecular level, with the insides of the human
cell and nucleus being taken apart and examined by molecular
biologists, literally receptor by receptor. Dissection and the
mechanistic understanding it provides have led some to decry what they
regard as the modern "soulless" view of the human body as a mere
machine.
In the nanomedical
era, even the
most diehard reductionist must come to see the human body not
merely as a heap of parts but rather as a finely tuned vehicle that is
owned and piloted by a single human mind. As with automobiles,
some body-owners will be more diligent about maintenance, regular
tuneups, and paint jobs than other body-owners. Some will crave the
latest upgrades, while others may prefer a more conservative model that
reliably gets them around town. At either extreme, all human vices and
virtues will be on full display, though one may perhaps anticipate an
increasing pride of corporeal ownership if for no other reason
than because maintenance and repair will become quick, convenient, and
inexpensive.
From this simple analogy
of body-and-mind
to car-and-driver, it might at first appear that the advent of
nanomedical technology will confirm and strengthen the traditional
dualist conception of the body. But closer inspection reveals that the
analogy is at best incomplete, and at worst deeply flawed. This is
because mind, first being necessarily embedded in physical structure
and relying upon that structure for its faithful execution, and second,
this physical structure now being manipulable at the molecular level,
enters also into the purview of our mechanic. Both car and driver may
be modified in the shop. Speaking allegorically, it is as if the
driver, after getting his car a tuneup, emerges from the shop no longer
favoring chocolate but enjoying vanilla instead, or now preferring jazz
over classical, the opposite of before. Such psychological changes may
be either volitional or emergent.
Until the late 20th
century, human progress was
measured almost exclusively in terms of externalities. Food was
gathered, then sown, then manufactured. Shelters had no running water,
then gained outhouses, then indoor plumbing. Natural lighting and
campfires gave way to candles, then oil lamps, then electric
illumination. Finger-counting yielded first to the abacus, then the
mechanical adding machine, and finally to the digital computer. But
throughout all of history, the human body itself has remained largely
untouched by progress. We have always regarded our bodies, evolved by
natural selection, as fundamentally inviolate and immutable -- subject
perhaps to various natural or traumatic degradations, but rarely to any
significant intrinsic improvement on the timescale of human
civilization.
Now we are set to embark
upon an era in which our
natural physiological equipment may for the first time in history
become capable of being altered, improved, augmented, or rendered more
comfortable or convenient, due to advances in medical technology. The
physical human body may be one of the last bastions of "naturalness" (Section 1.3.4).
It will also be one of the last elements in our common worldview to be
modernized.
Our subjective experience
of reality will shift by
subtle degrees. For instance, all objective information about our
physical surroundings has traditionally arrived in the conscious mind
via the various natural senses such as hearing, sight, and smell. In
the nanomedical era, machine-mediated sensory modalities may permit
direct perception of physical phenomena well removed from our bodies in
both time and space, or which are qualitatively or quantitatively
inaccessible to our original natural senses. Perception will gradually
expand to incorporate nonphysical phenomena including abstract models
of mental software, purely artificial constructs of simulated or
enhanced realities,2991
and even the mental states of others. Such new perceptions will
inevitably alter the way our minds process information.
But the winds of change
will sweep deeper still,
into our very souls. Like ants oblivious to the collective purpose of
their colony, the billions of neurons in the human brain are all busily
buzzing, wholly ignorant of the emergent plan. This is the physical,
mechanical world of our electrochemical hardware. People also have
thoughts, feelings, emotions, and volitions, a higher level in the data
processing hierarchy which in turn is equally oblivious of the brain
cells. We can happily think while being totally unaware of any help
from our neurons. But nanomedicine will give us unprecedented systemic
multilevel access to our internal physical and mental states, including
real-time operating parameters of our own organs, tissues, and cells,
and, if desired, the activities of small groups of (or even individual)
neurons. Diverse parts of our selves previously closed to our attention
may slowly conjoin and enter our conscious awareness.
Will this access promote
an integrated identity or
lead to hopeless confusion, or worse? Marvin Minsky, in his collection
of essays The Society of Mind,2982
persuasively argues that our selves or identities are in fact networks
of semi-autonomous neurological "agencies" which sometimes cooperate
and sometimes compete with one another. We think of ourselves as
singular "persons," but we also experience "conflicting desires" and
"differing viewpoints" within our minds that are, in Minsky's view, a
direct experience of the multiplicity of our brain's neurostructures.
Other models of the human mind2988-2990,3728
suggest that our internal mental states, prospectively transparent via
nanomedical augmentation,2992,2993
are diverse and intricate; Julian Jaynes2983
is one of many writers who have drawn attention to profound dichotomies
between the two cerebral hemispheres. The component-oriented
personality models of Freud (e.g. ego/id/superego),2984
Jung (e.g. archetypes),2985
and Rank (e.g. will/counterwill),2986
and the identification of 4541 distinct personality traits by Allport
and Odbert2987
warn us that full access to our brain's architecture could be perilous.
More seriously, most of
us suppose that we are
endowed with free will. But if choices by free will
are simply the resolution of conflicts of neurological subsystems, and
we become consciously aware of those subsystems and are able to
intervene in their processes, do we run the risk of runaway
instabilities at the deepest levels of what we presently call our
"minds"? Will we find that these instabilities are profound
counterparts to the maladies we currently designate as epilepsy, or
psychosomatic illnesses? In any redesigns of our brains
which would involve opening doors to, quite literally, the
ultrastructure of our thoughts, we could become "naked to ourselves" in
ways that we can only vaguely speculate about at present. Along with
any other dangers we might encounter, this will raise entirely new
issues of the proper role of psychotherapy and the sanctity of personal
privacy.2996
Repairs to the brain may
be carefully monitored to
ensure quality control and to verify intended results, as already
proposed in another context.3000
Major modifications might be strictly regulated, both to prevent abuse
by unscrupulous third parties and also to forestall accidental or
volitional alterations that could render the patient a significant
threat to society. Nanomedical alterations to the brain and other
physical systems may give us vastly expanded freedom to be who we
choose to be (Section
1.3.4), along with increased responsibility to make wise and
informed choices. The ethical and legal aspects of these questions, as
well as the scientific and psychological ones, are extremely important
and should be thoroughly debated in the years and decades that lie
ahead."
Comment: The analogy between the
nanomedical era and the car-driven one suggests again an increase of
individual responsibility as well as the need for societal rules. If
the human body is not seen any more as something "natural" and with a
special right for its protection, as stated for instance in many EU
declarations, then we are dealing with a major ethical challenge due to
the rise of nanomedicine. This includes the "redesign of our brains"
which is related to a main ethical principle, namely autonomy, as well
as to the question of free will and privacy.
12) Naturophilia
http://www.nanomedicine.com/NMI/1.3.4.htm
"According to the dictionary, "artificial" usually
means "made by man, rather than occurring in nature." More usefully,
Herbert Simon2301
defines the artificial as that which is designed, expresses goals, and
possesses external purposes. The artificial is controlled and serves
its creators' purposes, subject to the universal laws of physics. Kevin
Kelly381
defines the natural as "out of control." Nature is evolved, not
designed, and serves no goal or external purpose save its own survival.
Nature, lacking intent, is amoral -- it simply is.2299
By building the artificial, observes Postrel, "we do not overthrow
nature, but cooperate with it, using nature's own art to create new
natural forms. Our artifice alters the path of nature, but it does not
end it, for nature has no stopping point, no final shape. It is a
process, not an end."
Some naturophilist writers have decried the
increasing "medicalization of society" in which formerly natural
functions have come to be regarded as medical conditions requiring
intervention or treatment.2204,2302-2308
However, history suggests that naturophilia is usually undermined by
any new medical technology that offers clear, safe, and immediate
benefits to patients. For example, prior to 1842, intense pain was
viewed as the natural outcome of being cut with a scalpel during
surgery. It had always been so -- how could it ever be otherwise? The
invention of anesthesia in 1842 (Section 1.2.1.9.2)
suddenly altered this natural outcome and replaced it with a less
painful artificial outcome, despite anguished cries from naturophiles
within the medical community that eliminating pain might somehow
diminish the human character."
...
1. Addictions --
2. Allergies and Intolerances --
3. Minor Physical Annoyances --
4. Undiscovered Infectious Agents --
5. Unwanted Syndromes --
6. Psychological Traits -- Psychological
traits which, if identified by a patient as undesirable, might be
subject to genetic or physiological modification could include: sexual
preference (6-10% of the adult population is homosexual);1604
shyness or boldness;2332
acquisitive or altruistic propensity; misanthropy or philanthropy;
theistic or atheistic orientation; loquacity or dourness; childhood
imprinting; criminal propensity (up to 1-5% of the population); various
recognized personality disorders that affect ~10% of the population2122
such as antisocial, paranoid, schizotypal, histrionic, narcissistic,
avoidant, dependent, obsessive-compulsive, and passive-aggressive
disorders; panic attacks (experienced at least once by ~33% of all
adults each year);1604
and phobic disorders such as social phobias (~13% of the population),
specific phobias including fear of large animals (zoophobia), snakes
(ophidiophobia), spiders (arachnophobia), needles (belonephobia,3272
~10%), the dark (noctiphobia or scotophobia), or strangers (xenophobia)
(total ~5.7%), the fear of blood or hemophobia (~5%), agoraphobia
(~2.8%),1604
and other unusual phobias2223
such as the fears of certain colors (chromophobia), daylight
(phengophobia), girls (parthenophobia), men (androphobia), stars in the
sky (siderophobia), the number thirteen (triskaidekaphobia), and even
the fear of developing a phobia (phobophobia).
The above sampling of minor afflictions, almost
all considered "natural" in 1998, may come to be regarded as
commonplace correctable medical conditions in the nanomedical era. By
the time such petty annoyances are deemed worthy of immediate
treatment, biotechnology and nanomedicine already will have defeated
the most fearsome illnesses of the late 20th century2310
and will have moved on to other challenges.2311,2864,2973
Naturophiles may dissent, but the emerging trend from medical
biotechnology is to characterize health, not as a static standard, but
rather as a condition defined by the lives that people want to lead.
Affirming the volitional normative model of disease (Section 1.2.2),
Virginia Postrel concludes:2299
"Different
goals will produce different choices about trade-offs and standards.
What makes a condition unhealthy is not that it is
unnatural but that it interferes with human purposes.
Revering nature [would mean] sacrificing the purposes of individuals to
preserve the world as given. It [would require] that we force people to
live with biological conditions that trouble them, whether diseases
such as cystic fibrosis or schizophrenia, disabilities such as myopia
or crooked teeth, or simply less beauty, intelligence,
happiness, or grace than could be achieved through artifice.
In a world where it's no big deal to take hormone therapy, Viagra, or
Prozac, to have a face lift, or to know a child's sex before birth, a
world in which even such radical interventions as sex-change operations
and heart transplants have failed to turn society upside down, it
is extremely difficult to argue that medical innovations are dangerous
simply because they fool Mother Nature."
Comment: This definition of health is an eminent ethical
one. The main outcome of nanomedicine seems to be the increase of
personal responsibility of people for what they believe to be "healthy"
of "good" for them and for future generations. The ethical challenge is
how to prepare our society to take this kind of responsibilty. The
moral argument is not that these possibilities are "against nature" but
that they may interfere with reasons/purposes of other persons.
Last
update: August 25, 2017
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