Primary care medicine (general practice) is, as a generalist discipline, faced with the key challenge of counteracting fragmentation and developing a framework for conceptualizing and approaching patients as whole persons. At the same time, we are today witnessing a strong international focus on the development of personalized medicine that is tailored according to factors defining each person uniquely. This concept is as old as medicine itself. However, while personalized medicine has historically been a humanistic concept, it is today rearticulated in a technological and scientific context, starting with the sequencing of the human genome around the year 2000. Systems biology is a 15 year-old biological movement at the vanguard of this development, with the prime aim of making sense of the genome and its relationship to the whole organism (phenotype) through computational and mathematical modeling. Systems medicine, the focus of this thesis, is the emerging medical application of systems biology to medicine. What is new about systems medicine – and critical to the current argument – is that it promises to further the concept of personalized medicine in a way that is no longer reductionist or gene-centric, but holistic or integrationist. It promises to do justice to the full complexity of human health and disease and to counteract fragmentation in medicine. Thus, it intriguingly promises a new framework for medicine that theoretically seems to fit perfectly with the needs of primary care medicine. Through its new holistic personalization, and a strong focus on patient participation, systems medicine is also envisioned as enabling a new era of predictive and preventive medicine. This concept is often called P4 medicine (predictive, preventive, personalized, participatory). The overarching practical promise of “P4” systems medicine is a revolutionary paradigm shift leading to a better overall utility of medicine, a better balance of benefits and harms. At the same time, systems medicine is envisioned as based in primary care, and its promise of a revolution therefore depends on its ability to meet the challenges of general practice. Crucially, systems medicine emerges at a time when biomedicine, particularly individual-centric preventive medicine, has become a very expansive endeavor that is coming under increasing criticisms for fragmentation and overmedicalization, leading to questionable utility and sustainability.
Although systems medicine is in the process of changing the medical landscape, it exists mostly as a vision. This analysis is based on the premise that development of biomedical visions and promises about the future are important in guiding medical actions and therefore in itself forms an important part of biomedical practice.
The aim of this study is to test systems medicine as a proposed, theoretical framework – its philosophy, visions and promises – against the challenges facing primary care medicine. In particular, it tests the promise of a holistic personalized medicine that will lead to a revolution in the clinical utility of primary care medicine. This task is operationalized through more focused research questions. The underlying objective is to contribute to critical reflection, theory development and quaternary prevention (i.e. prevention of medically induced waste and harm) in general practice.
Material, methods and theory
This thesis is methodologically situated in the medical humanities, drawing on philosophy of science in practice and history. The aim is pursued through a critical, historical-philosophical analysis of a primary material consisting of publications proposing systems medicine as a future framework for primary care, as well as some early empirical results. It draws on a secondary material that describes challenges facing primary care, key philosophical topics and analytical perspectives, as well as research on systems biology and medicine from various fields.
A key finding is that the very concept of holism, which has previously been associated with a humanistic form of personalized medicine, is redefined in systems medicine and given a novel technoscientific meaning. The result is called a technoscientific holism. It is shown how this new holism brings substantial philosophical innovations for understanding and approaching whole persons (papers I and II). In particular, it is argued that the philosophy of systems biologist Denis Noble and the concepts of biological relativity and downward causation, might represent a significant contribution to conceptualizing the relationship between “bio”, “psycho” and “socio” in the biopsychosocial model (paper I). However, despite these constructive theoretical developments, it is argued that systems medicine cannot be expected to fully counteract fragmentation in medicine and become a genuinely holistic, personalized or humanistic medicine. Although it is promised as holistic, it can in practice be no more holistic than its computational and mathematical models. It also still involves a strong molecular focus and continued reductionism. It faces fundamental problems in conceptually and methodologically accounting for living wholes, in integrating all components of the complexity of human health and disease in its models, including what is called “mind” with what is called “body” (papers I, II and III). Concerning its clinical utility, the technoscientific holism of systems medicine corresponds to a “holistic medicalization”. Each person’s whole life process – however complex – is in theory defined in biomedical, technoscientific terms as controllable, pointing towards a situation in which this whole process is underlain a regime of medical control that is holistic as in all-encompassing. It is directed at all levels of functioning, from the molecular to the social, continual throughout life and aimed at managing the whole continuum from cure of disease, via mitigation of risk, to optimization of health. The participatory aspect of systems medicine involves an unprecedented self-medicalization (or ”participatory medicalization”) where each person is expected to perform the needed self-monitoring and self-control (paper II). This profound “holistic medicalization” comes with risks of waste and harm that have so far not been judiciously addressed by the visionaries of systems medicine. It is argued that there is a philosophical and scientific discrepancy between its promises of holism and a revolution in clinical utility on the one hand and the real world complexity, unpredictability and uncontrollability of human biology on the other (papers II and III).
Discussion, conclusion and implications
The above results and arguments are further elaborated and discussed. In conclusion, systems medicine´s overarching promise of a holistic, personalized medicine that will revolutionize the clinical utility of primary care medicine is found to be associated with considerable uncertainty and a lack of focus on potential downsides. As such, it is unreliable. This raises questions as to why visionaries of systems medicine make bold promises, their ethical justification and scientific responsibility. It is argued that the philosophy of systems medicine is shaped not only according to its validity, but also its utility, and that the function of visions and promises is not only to be true or reliable, but to motivate, create positive expectations and attract social, political and economic support. However, while the creation of science visions may be necessary, they also generate actions that may have negative effects. Quaternary preventive medicine has typically lagged behind technoscientific developments. This implies a need for a more proactive, vision-focused quaternary prevention related to the promissory aspect of biomedical science in general and systems medicine in particular. As a basis for such quaternary prevention, a less aggressive, “less is more” strategy for systems medicine is proposed.||nb_NO