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What is the best way to go about the biggest global health problems facing the modern world? Should we focus on the individual and make sure no one is left behind, just like the UN’s Sustainable Development Goals state, or should we try to focus on population health? This problem of efficiency and the methods of approach have been very prominent in global health since the inception of the field, but with the introduction of precision medicine, it makes the decisions for public health officials much more difficult.

Precision medicine focuses on individual patients and updating treatment based on individuals’ backgrounds and specific cases, which allows for a “custom-fit” treatment of the patient. This is great for hospitals and treating patients on a smaller scale, but when the task is preventing the spread of malaria in a region with multiple subpopulations, the benefits of precision medicine become obscure. Due to the individual focus that is associated with precision medicine, the focus on population-level treatment ends up being lost, and in global health, this can be a problem. When treating groups of people or somewhat large populations, cost-efficiency and treatment on a large scale are necessary in order to achieve the goals set by the organization working on a solution. Instead of this policy and implementation efficiency focus, precision medicine works to treat the individuals and ends up losing cost-efficiency with the whole population. The extensive use of genomics, genetics, and computer analysis in precision medicine also fail to take into account the intricacies of environmental and socioeconomic effects that are real challenges in a global health setting. So, even though precision medicine provides a great way to treat individual patients and provides a hopeful future for the treatment of specialized cases, especially in developed countries, it does not have the same effect in the context of a developing country, where cost efficiency and financial burden are all key factors in treating as many people as possible.


Edited by: Laura Wang

Graphic Designed by: Amber Smith


References

Kosorok, M. R., & Laber, E. B. (2019). Precision Medicine. Annual Reviews, 263-286. https://www.annualreviews.org/doi/pdf/10.1146/annurev-statistics-030718-105251

Mentis, A.-F. A., Pantelidi, K., Dardiotis, E., Hadjigergiou, G. M., & Petinaki, E. (2018). Precision Medicine and Global Health: The Good, the Bad, and the Ugly. frontiers in Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5861134/



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What does it mean to be human? At the fundamental biological level, we all share a core set of DNA contained inside our cells, and the material held in these cells defines us as “humans.” In fact, we have over 30 trillion cells[1] in our bodies. However, it’s not just cells that reside inside of us–our bodies are also home to a vast array of microorganisms. These bacteria outnumber our cells more than 10 to 1[2]–so on a biological basis, we’re really more bacteria than human. Gross.

These microorganisms that live inside of us, known collectively as our “microbiome,” are an integral part of our health and wellbeing, thought to influence everything from gastrointestinal diseases to our immune system. Our microbiome is also constantly changing. We receive our first set of organisms from our mother as we’re born, transferred through direct skin-to-skin contact. As we interact with the world, we pick up different species of bacteria along the way, diversifying our microbiome as we interact with different environments. While our microbiome changes a lot during childhood, these changes become less and less frequent as we age, though we can still change our microbiome as adults. And because each person’s microbiome is unique, these diverse clusters of organisms can act like living fingerprints, not only identifying an individual but also providing information about their health and wellbeing.

Variation in the microbiome is common among all people and oftentimes benign. However, certain variations in the microbiome are associated with diseases, like Crohn’s disease, colorectal cancer, eczema, and acne, among others. One potential method of treatment, or at least mitigation, involves genetically modifying the microbiome. This movement exists in the context of a new era of precision medicine centered around the individual. For example, genetic engineering technologies attempt to modify the human genome, an integral and unique part of each person’s identity. While there are many methods of altering the microbiome, like dietary changes and fecal transplants, neither has the precision of gene editing, the accuracy of which has already been tested in the editing of various organisms using CRISPR-Cas9 technology. We know it’s possible to edit the human genome–but what if we were to edit the bacterial genome inside of humans? Could we restore a healthy microbiome to individuals whose organismal ecosystem is unbalanced and potentially treat dozens of diseases?

Yes–possibly. But there are also potential consequences to editing our microbiome. First, our microbiome isn’t well understood. While there is ongoing research regarding the effects of altering the microbiome and its potential implications, we currently lack a comprehensive understanding about the human microbiome. Given the pervasiveness of the microbiome in our body and its systems, I would argue that it is unsafe to edit the organisms living inside of us.But what about the future? What if we reach a point where editing the microbiome is not only safe but can also act as a potential treatment for a multitude of ailments? Not so fast. We still don’t know the long-term effects of microbiome-alteration, or whether the change is permanent. Additionally, as more microbiome research is conducted, enough data will eventually be gathered that it could be possible to identify a person and their specific environmental history based on a simple swab of their skin microbiome. What does this mean for our privacy as individuals? What does this mean for convicts or others who might suffer from stigmatization and discrimination? What would you do if, with a simple touch of your hand and some lab experiments, someone could figure out every place you’ve visited in the past week?

There are also questions about access. Like genome editing technology, it’s likely that microbiome-editing, if ever approved for medical use, would have a large, competitive market. Access to these elusive tools would be limited to only a few with the financial resources to afford such treatment, broadly excluding most people and worsening pre-existing socioeconomic disparities.

Unlike genome editing technology; however, microbiome-editing has potential group-wide effects. While genome editing at the somatic level only affects the individual who has undergone the treatment, microbiome editing has the potential to rapidly affect hundreds of thousands of people. Edited bacteria could be passed from not only from parent to child, but from person to person via a simple touch or even a doorknob. This ability to pass on genetic changes to others raises strong issues of consent–after all, while one person may have agreed to having genetically-modified bacteria living inside of your body, the others who they come into contact with have not and cannot consent to that invisible and inevitable transmission.

Microbiome editing holds great promise for the future to treat a multitude of chronic diseases. But we should also be cautious as we move forward about the potential harm it could cause to us not only as individuals, but as a society.


Edited By: Elissa Gorman

Graphic Designed By: Eugene Cho


References:

[1] Bianconi, E., Piovesan, A., Facchin, F., Beraudi, A., Casadei, R., Frabetti, F., Vitale, L., Pelleri, M. C., Tassani, S., Piva, F., Perez-Amodio, S., Strippoli, P., & Canaider, S. (2013). An estimation of the number of cells in the human body. Annals of human biology, 40(6), 463–471. https://doi.org/10.3109/03014460.2013.807878

[2] U.S. Department of Health and Human Services (2015). NIH Human Microbiome Project Defines Normal Bacterial Makeup of the Body. National Institutes of Health. https://www.nih.gov/news-events/news-releases/nih-human-microbiome-project-defines-normal-bacterial-makeup-body#:~:text=The%20human%20body%20contains%20trillions,vital%20role%20in%20human%20health.



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With recent advancements in technology, the field of precision medicine has grown significantly, and healthcare workers have a new suite of technologies available for their usage. The concept of precision medicine takes into account countless factors about the patient in question and allows for a more personalized, targeted form of care. One field that precision medicine is already being used in is oncology, a field whose cases are highly-patient specific. This field serves as the prototype of how precision medicine can be used in other areas of medicine, and for better or for worse, will be the first field to face the ethical concerns regarding precision medicine.

One of the key issues with precision medicine in oncology stems from usage of the technology; when physicians study the makeup of a tumor cell to understand how to best adjust their treatment strategies, they unintentionally uncover other information about the patient. These findings, termed “incidental findings,” have been the center of a heated debate regarding patients’ “right to know.” While researchers who stumble into these discoveries have no obligation to report to patients about their incidental findings, with their goal being the creation of general results and not individual results, both physicians and researchers have seen recent pushes to return to patients both actionable and non-actionable incidental findings. In a survey of almost 15,000 people, 92% of participants responded that they would like to see actionable results and 70% of participants responded that they would like to see unactionable results as well.1 Yet, the ideas of the “right not to know” suggest that physicians and researchers should report only what is necessary, which in this case would be cancer related mutations. With various ethical organizations varying in their recommendations for handling these incidental findings, physicians and researchers are often left to simply proceed with caution and act in a way that helps the patient most.1 The “right to know” and the “right not to know” stem from our current and historical preferences and abilities, and play a critical role in the ethics of precision cancer medicine, and are just one of countless ethical challenges.

While there are many challenges for physicians and researchers alike, many challenges stem from their differing goals and perspectives. As seen in the case above with incidental findings, physicians and researchers often have different goals; physicians strive to make choices to ensure that their patient is treated fairly and effectively, while researchers make decisions to ensure that the work they do is both impactful and generalizable. These two different mindsets reveal the crux of the issue with precision cancer medicine: the usage of patient data. Precision medicine, among many other computational tools, is best aided when researchers have access to as much data as possible to learn from and optimize their systems.2 Researchers will almost always gather as much data from as many patients as possible, but physicians will push to ensure that their patients’ data is confidential. While both researchers and doctors are guided by ethics, their ethical principles are often different, and are representative of their goals; doctors are responsible for maintaining clinical practices and high standards of care, whereas researchers are responsible for pushing the field, developing the tools to better treat patients, and in general, good scientific practices.1,2 These different mindsets serve as the basis for many ethical concerns regarding precision medicine, from release of patients’ records and data, informed consent, and other privacy concerns. To best ensure that both fields are improving and successful, a balance needs to be reached to ensure that physicians can ensure the best for their patients and researchers can ensure that their work can improve current practices.

The field of precision cancer medicine is incredibly complex, both in the technical sense and the ethical sense. There are countless ethical issues that stem from both the information in the findings from patients, and the findings themselves. With oncology serving as a forefront in the field of precision medicine, the advancements in scientific and ethical practices in this field will be widespread, further emphasizing the need to ensure that these issues are resolved.2 With researchers and physicians currently having different outlooks, the medical field as a whole must push to strike a balance between the two spheres, and to ensure that the best is achieved for current and future patients.


Edited By: Rishi Chilappa

Graphic Created By: Acelo Worku


References

  1. Winkler EC, Knoppers BM. Ethical challenges of precision cancer medicine. Semin Cancer Biol. 2020 Oct 9:S1044-579X(20)30201-7. doi: 10.1016/j.semcancer.2020.09.009. Epub ahead of print. PMID: 33045356.

  2. Korngiebel DM, Thummel KE, Burke W. Implementing Precision Medicine: The Ethical Challenges. Trends Pharmacol Sci. 2017;38(1):8-14. doi:10.1016/j.tips.2016.11.007

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DMEJ

   Duke Medical Ethics Journal