The century is approaching its conclusion in a climate of growing tension. Conflict springs up between individual rights and collective duties, between local roots and cosmopolitism. It is present in the tension between economic development and the safeguard of the environment, the aggression of global markets and the desire to protect fragile economies, the pressures of emigration from poor countries and unemployment in the more advanced nations. There is renewed bloodshed between ethnic, religious, cultural and economic groups, and between nations.
However, as the International Commission on Peace and Food reminds us, "the perspective the world seeks must be based on a greater understanding of the inextricable linkages between peace, democratization, development, equity and the environment. None of these great goals can be achieved, without corresponding progress towards the others. [...] What are the foundations of this new intellectual perspective and what sort of strategies, actions and results will it lead to? It requires a change in the way we look at and think of familiar things like war, developing countries, democracy, agriculture, industrialization. First, we have to awaken from the millennia-old nightmare that war is a natural and inevitable part of human existence, which can perhaps be mitigated or kept far from our shores, but never really mastered or eliminated. [...] Most of all, the new perspective the world seeks should be based on a recognition that humankind is the master of its own destiny, that the external limits are not binding on us if we tap the unlimited creative potential of our own inner human resourcefulness".
These recommendations are the starting point of the debate among the Nobel Laureates and international experts gathering in Milan, to discuss how to transform conflict into an occasion for dialogue, growth and innovation.
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Ethics of Predictive Medicine
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Friday 6 December 1996
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The discovery thirty years ago of numerous links between the genes of the major HLA histocompatibility complex and many diseases led the way to the concept of predictive medicine (Dausset, 1972). Since then, the concept has spread, and today its impact on medical practice, thanks to the spectacular development of our knowledge of the human genome, is greater than ever. The enormous benefits that this will generate are to be welcomed, but we must also underscore the psychological and social harm it can cause.
By definition, predictive medicine is practised on healthy, or apparently healthy, individuals, seeking to identify any genetic defects that may predispose them to developing a given disease. It means identifying the genes responsible for the predisposition or resistance to polygenic diseases, i.e. those caused by the unfortunate or lucky outcome in an individual of the "interplay of genes" that favour the development of or resistance to diseases common to industrial society, such as hypertension, coronary diseases, diabetes, obesity and even cancer in its various forms.
We must emphasise that predictive medicine is probabilistic, enabling us to measure the risk that an individual runs. Moreover, unlike preventive medicine - which is often global in scope, such as vaccination - predictive medicine is individual and personalised.
Predictive medicine provides a warning: it warns a healthy person of his weak points and enables that person to adopt appropriate cures, if there are any, to pay attention to daily hygiene and diet, to choose a profession suited to his physical make-up and to conduct regular diagnostic screening in order to be able to begin any necessary therapy from the very outset.
Predictive medicine also has the great advantage of being able to reassure those who fear they are at risk of developing the diseases that may recur in their family.
The ethical problems lie on three levels:
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The first is that of the individual himself. Respect for his independence, i.e. of his freedom to choose whether to undergo diagnostic screening, must be total. His decision should be taken after having received clear and complete information about its implications. Individual autonomy also means being able to choose whether to be told the results of the screening. Obviously, there is a risk that more fragile individuals may develop a state of permanent anxiety.
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The second level regards the individual within his family and social environment. If the identification of a gene requires that the entire family be tested, the family itself must give its complete agreement after having received the fullest information possible.
- The third plane regards society as a whole, and here equally broad precautions are necessary. The confidentiality of the results of genetic testing must be closely protected.
Obviously, today, as it takes its very first steps, predictive medicine still encounters many barriers and limitations. For example, the cost of screening can be prohibitive.
To avoid premature use or abuse of predictive testing, the French Academy of Medicine recently recommended the creation of groups of geneticists and specialists from every major medical discipline (cardiovascular disorders, neurological problems, tumours, and so on) charged with monitoring the appropriateness of introducing specific predictive tests for given diseases, the quality level of such tests and the ethical problems they raise.
Despite the obstacles and limits, many of which are only temporary, predictive medicine will gradually spread to all pathologies thanks to the rapid progress of the study of human genetics.
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