Genetic technologies and artificial intelligence are rapidly changing the landscape of medical practice and patient care. In the emerging field of precision medicine, a patient’s risk factors—especially genetic risk factors—are incorporated into an all-encompassing plan to prevent future disease. But identifying at-risk individuals through technologies such as wearable devices and direct-to-consumer genetic sequencing can undermine the overall experience of health. In The Ethics of Precision Medicine: The Problems of Prevention in Healthcare, Paul Scherz offers suggestions for better implementing precision medicine to treat those currently suffering from or at high risk of disease, while also recognizing that effectively preventing disease depends, ultimately, on addressing the social determinants of health.
The most basic problem of contemporary, or even ancient, medical regimens is that they tend to treat food in the same way that we treat risk-reducing pharmaceuticals. The phenomenon of nutraceuticals and superfoods is perhaps the clearest example of this. Oddly enough, many people replace regulated pharmaceuticals for unregulated chemical supplements as a way to be more natural, though taking a processed pill, especially one whose ingredients may not be what the consumer expects, is not especially natural. Even the nutritional information box on most foods lead in this direction. Food becomes chemistry, a mix of partially hydrogenated fats, differently sourced sugars, protein, vitamins, and preservatives. The aim becomes balancing different intakes in the most healthful way. Food is engaged as the material that keeps the body as machine running. In this model of diet, anything can be eaten at any time as long as the chemical components are balanced in a way that reduces risk.
This reductionist culinary framework can lead to a morbid obsession with health and diet. The person continually counts calories and quantifies nutrients. Anxiety over future disease can influence every meal. Or after a failure to properly address food as risk, regret and guilt assails the person. Risk becomes a task to address episodically at each mealtime, which prevents the formation of a true regimen, a habitual form of life, that the person can engage without ongoing choice. Diet can become merely a version of the risk paradigm that is not mediated through pharmaceuticals.
Moreover, we lack the knowledge to execute risk reduction through food. Whatever my concerns about pharmaceutical research, our knowledge of nutrition is at a far more rudimentary level. It is nearly impossible research to conduct. One would have to ensure that thousands of people maintained a prescribed diet for years if not decades. It is simply unimaginable to maintain that kind of discipline among a large, voluntary study population. Observational studies are filled with errors and confounding factors. If researchers try to observe different groups with different diets (e.g. Okinawans vs. Kansans), they are confronted by the problem of dealing with the confounding effects of all the other aspects of life that differ between these populations. If they try to track diet through self-reports, they are left with data that is widely recognized as inaccurate; people too often forget or misrepresent what they eat. Despite its importance, we lack much of the basic knowledge necessary for a precision diet.
Finally, adopting a proper regimen is only possible if the structures of society allow for it.
Ancient regimen brought other actors besides medicine into the promotion of health. Foremost among these is the state, which shapes the structural constraints of individual regimen. It, along with civil society, helps to shape the human ecology that enables a good form of life. Classical philosophy recognized the importance of civic institutions for preserving a good regimen. For example, many of Plato’s Laws concern setting up social ground rules (land size, military service) that promoted health and virtue. Perhaps the most important aspect is ensuring that policies do not undermine healthy regimens. For a recent example, heavy investment in the highway system rather than mass transit in the 1950s promoted the growth of suburbs that in turn promoted a regimen that did not include physical activity as a daily part of life, such as walking to work. Instead, people were forced into driving and thus needed to set aside special periods for intensive exercise. Similarly, subsidies for corn decrease the price of high fructose corn syrup and corn feed, decreasing the price of sweets and meat. No similar support is given for fruits and vegetables. Such considerations need to be a greater part of public deliberation. As Chapter 11 argued, changes in social structure are necessary for many people to be able to take true responsibility for their health.
A factor that is even more difficult to address comes from the cultural meaning of food. Different social classes’ distinct diets are part of their self-understanding. Pierre Bourdieu chronicled the reasons behind the particular diets of workers and bourgeois in 1960s France. While some of the differences in eating patterns arose simply from the prices of food, much of it resulted from different meanings that food held for different classes. The working-class meal was “characterized by plenty … and above all by freedom,” with abundant, fatty dishes like stews, that nourish. It emphasized the material reality of eating. In contrast, a light diet, like fish, reflects a bourgeois obsession with self-control and refinement. Changing a diet requires changing the cultural meanings that surround food. For the individual, this might even mean taking on a new identity. Optimal health is rarely a sufficient reason for such dramatic changes.
(excerpted from chapter 12)