REFLECTIONS ON ETHICAL ASPECTS OF NANOMEDICINE


Rafael Capurro

  
 
 
     

These reflections on ethical aspects of nanomedicine are followed by excerpts from  R.A. Freitas' opus magnum with short comments.

On ethical aspects of nanotechnology see:
- The Nanoethics Group
- European Group on Ethics and New Technologies to the European Commission
- Bibliography and Links
- Springer Journal on NanoEthics



 

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. FreitasNanomedicine, 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


Freitas' outstanding book on Nanomedicine is quoted from:
http://www.nanomedicine.com/NMI.htm

 

"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)
 
 
9) Specialization and Holistic medicine 
http://www.nanomedicine.com/NMI/1.2.4.1.htm

"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?

 

10) Customized Diagnosis and Therapeutics
http://www.nanomedicine.com/NMI/1.2.4.2.htm

"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!

 
11) The Physician-Patient Relationship
http://www.nanomedicine.com/NMI/1.2.4.3.htm

"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.
 

12) Changing view of the human body
http://www.nanomedicine.com/NMI/1.2.5.htm
 

"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: October 5, 2006  

 
 
     

Copyright © 2006 by Rafael Capurro, all rights reserved. This text may be used and shared in accordance with the fair-use provisions of U.S. and international copyright law, and it may be archived and redistributed in electronic form, provided that the author is notified and no fee is charged for access. Archiving, redistribution, or republication of this text on other terms, in any medium, requires the consent of the author.
 

 
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