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Johnston J, Tabb K, Pacia D, Lee SSJ, Chung WK, Appelbaum PS. Understanding individualised genetic interventions as research-treatment hybrids. JOURNAL OF MEDICAL ETHICS 2024:jme-2023-109729. [PMID: 38925878 DOI: 10.1136/jme-2023-109729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 06/06/2024] [Indexed: 06/28/2024]
Abstract
Until recently, medicine has had little to offer most of the millions of patients suffering from rare and ultrarare genetic conditions. But the development in 2019 of Milasen, the first genetic intervention developed for and administered to a single patient suffering from an ultrarare genetic disorder, has offered hope to patients and families. In addition, Milasen raised a series of conceptual and ethical questions about how individualised genetic interventions should be developed, assessed for safety and efficacy and financially supported. The answers to these questions depend in large part on whether individualised therapies are understood as human subjects research or clinical innovation, different domains of biomedicine that are regulated by different modes of oversight, funding and professional norms. In this article, with development and administration of the drug Milasen as our case study, we argue that at least some individualised genetic therapies are not, as some have argued, either research or treatment. Instead, they are research-treatment hybrids, a category that has both epistemological and pragmatic repercussions for funding, ethics oversight and regulation.
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Affiliation(s)
- Josephine Johnston
- Hastings Center, Garrison, New York, USA
- Bioethics Centre, University of Otago, Dunedin, New Zealand
| | - Kathryn Tabb
- Department of Philosophy, Bard College, Annandale-on-Hudson, New York, USA
| | | | - Sandra Soo-Jin Lee
- Department of Medical Humanities and Ethics, Columbia University, New York, New York, USA
| | - Wendy K Chung
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Paul S Appelbaum
- Department of Psychiatry, Columbia University, New York, New York, USA
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2
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Galasso I. Precision Medicine for Whom? Public Health Outputs from "Genomics England" and "All of Us" to Make Up for Upstream and Downstream Exclusion. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024; 24:71-85. [PMID: 36876959 DOI: 10.1080/15265161.2023.2180108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
This paper problematizes the precision medicine approach embraced by the All of Us Research Program (US) and by Genomics England (UK) in terms of benefits distribution, by arguing that current "diversity and inclusion" efforts do not prevent exclusiveness, unless the framing and scope of the projects are revisited in public health terms. Grounded on document analysis and fieldwork interviews, this paper analyzes efforts to address potential patterns of exclusion upstream (from participating in precision medicine research) and downstream (from benefitting from precision medicine outputs). It argues that efforts for inclusion upstream are not corresponded downstream, and this unbalance jeopardizes the equitable capacities of the projects. It concludes that enhanced focus on socio-environmental determinants of health and aligned public health interventions as precision medicine outputs would be to the benefit of all and especially of those who are most at risk of (upstream as well as downstream) exclusion.
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Peng J, Jury EC, Dönnes P, Ciurtin C. Machine Learning Techniques for Personalised Medicine Approaches in Immune-Mediated Chronic Inflammatory Diseases: Applications and Challenges. Front Pharmacol 2021; 12:720694. [PMID: 34658859 PMCID: PMC8514674 DOI: 10.3389/fphar.2021.720694] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/14/2021] [Indexed: 12/12/2022] Open
Abstract
In the past decade, the emergence of machine learning (ML) applications has led to significant advances towards implementation of personalised medicine approaches for improved health care, due to the exceptional performance of ML models when utilising complex big data. The immune-mediated chronic inflammatory diseases are a group of complex disorders associated with dysregulated immune responses resulting in inflammation affecting various organs and systems. The heterogeneous nature of these diseases poses great challenges for tailored disease management and addressing unmet patient needs. Applying novel ML techniques to the clinical study of chronic inflammatory diseases shows promising results and great potential for precision medicine applications in clinical research and practice. In this review, we highlight the clinical applications of various ML techniques for prediction, diagnosis and prognosis of autoimmune rheumatic diseases, inflammatory bowel disease, autoimmune chronic kidney disease, and multiple sclerosis, as well as ML applications for patient stratification and treatment selection. We highlight the use of ML in drug development, including target identification, validation and drug repurposing, as well as challenges related to data interpretation and validation, and ethical concerns related to the use of artificial intelligence in clinical research.
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Affiliation(s)
- Junjie Peng
- Department of Medicine, Centre for Adolescent Rheumatology Versus Arthritis, University College London, London, United Kingdom
| | - Elizabeth C. Jury
- Department of Medicine, Centre for Adolescent Rheumatology Versus Arthritis, University College London, London, United Kingdom
- Department of Medicine, Centre for Rheumatology Research, University College London, London, United Kingdom
| | | | - Coziana Ciurtin
- Department of Medicine, Centre for Adolescent Rheumatology Versus Arthritis, University College London, London, United Kingdom
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Abstract
I analyze the promised efficacy of Pembrolizumab, an immunotherapy regime under clinical trial for patients with metastatic colorectal cancer. Drawing on anthropological fieldwork with patients and health professionals in a gastrointestinal cancer clinic in London, UK, I tease out the dynamics through which scientists and clinicians assemble personalized technologies to halt cancer growth in patients' bodies; what patients undergo in order to participate in these innovations; and the constraints that restrict the efficacy of these treatments. Beyond examining the treatment possibilities that clinical trials offer, I illuminate some of the gaps made visible when personalization happens from below.
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Townes A, Guerra-Reyes L, Murray M, Rosenberg M, Wright B, Long L, Herbenick D. 'Somebody that looks like me' matters: a qualitative study of black women's preferences for receiving sexual health services in the USA. CULTURE, HEALTH & SEXUALITY 2020; 24:1-15. [PMID: 32996382 DOI: 10.1080/13691058.2020.1818286] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 08/30/2020] [Indexed: 06/11/2023]
Abstract
Research dedicated to understanding the sexual experiences of Black women has historically been framed around adverse outcomes. There are limited data that can be used to understand the lived experiences of Black women related to sexual health care. Twenty-five Black women aged 18- 35 from across nine US states were interviewed to gain insight into their experiences and preferences for receiving sexual health services. Three themes were developed from their accounts: individual and structural barriers affect access to and perceived quality of care; service provider race and gender impact sexual health care experiences; and personalised care improves engagement. Findings suggest the need for culturally informed training for sexual health practitioners working with Black women.
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Affiliation(s)
- Ashley Townes
- Centre for Sexual Health Promotion, Indiana University-Bloomington, Bloomington, IN, USA
| | - Lucia Guerra-Reyes
- Centre for Sexual Health Promotion, Indiana University-Bloomington, Bloomington, IN, USA
- Department of Applied Health Science, School of Public Health, Indiana University-Bloomington, Bloomington, IN, USA
| | - Maresa Murray
- Department of Applied Health Science, School of Public Health, Indiana University-Bloomington, Bloomington, IN, USA
| | - Molly Rosenberg
- Department of Epidemiology and Biostatistics, School of Public Health, Indiana University-Bloomington, Bloomington, IN, USA
| | - Brittanni Wright
- Department of Applied Health Science, School of Public Health, Indiana University-Bloomington, Bloomington, IN, USA
| | - Lauren Long
- Department of Applied Health Science, School of Public Health, Indiana University-Bloomington, Bloomington, IN, USA
| | - Debby Herbenick
- Centre for Sexual Health Promotion, Indiana University-Bloomington, Bloomington, IN, USA
- Department of Applied Health Science, School of Public Health, Indiana University-Bloomington, Bloomington, IN, USA
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Deml MJ, Notter J, Kliem P, Buhl A, Huber BM, Pfeiffer C, Burton-Jeangros C, Tarr PE. “We treat humans, not herds!”: A qualitative study of complementary and alternative medicine (CAM) providers’ individualized approaches to vaccination in Switzerland. Soc Sci Med 2019; 240:112556. [DOI: 10.1016/j.socscimed.2019.112556] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 08/30/2019] [Accepted: 09/12/2019] [Indexed: 11/27/2022]
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Fournier T, Poulain JP. Eating According to One's Genes? Exploring the French Public's Understanding of and Reactions to Personalized Nutrition. QUALITATIVE HEALTH RESEARCH 2018; 28:2195-2207. [PMID: 30132729 DOI: 10.1177/1049732318793417] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
In this article, we analyze qualitatively the understanding of and reactions to personalized nutrition (PN) among the French public. Focus groups were conducted to identify the opinions and discourses about two applications of knowledge from nutritional (epi)genomics: a biotechnology (nutrigenetic testing) and a public awareness campaign (the "first thousand days of life" initiative). Our objective was to understand to what extent PN could lead to changes in eating practices as well as in the representations of food-health relationships within France, a country characterized by a strong commitment to commensality and a certain "nutritional relativism." Although discourses on nutritional genomics testify to a resistance to food medicalization, nutritional epigenomics appears as more performative because it introduces the question of transgenerational transmission, thus parental responsibility.
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Affiliation(s)
- Tristan Fournier
- 1 Institut de Recherche Interdisciplinaire sur les enjeux Sociaux (Iris), Centre National de la Recherche Scientifique (CNRS), Paris, France
| | - Jean-Pierre Poulain
- 2 Université de Toulouse, Toulouse, France
- 3 Centre d'Etude et de Recherche Travail Organisation Pouvoir (Certop), Centre National de la Recherche Scientifique (CNRS), Toulouse, France
- 4 Laboratoire International Associé (LIA) "Food, Cultures and Health", Centre National de la Recherche Scientifique (CNRS), Taylor's University, Subang Jaya, Malaysia
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Ryan PM, Stanton C, Caplice NM. Bile acids at the cross-roads of gut microbiome-host cardiometabolic interactions. Diabetol Metab Syndr 2017; 9:102. [PMID: 29299069 PMCID: PMC5745752 DOI: 10.1186/s13098-017-0299-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 12/07/2017] [Indexed: 02/07/2023] Open
Abstract
While basic and clinical research over the last several decades has recognized a number of modifiable risk factors associated with cardiometabolic disease progression, additional and alternative biological perspectives may offer novel targets for prevention and treatment of this disease set. There is mounting preclinical and emerging clinical evidence indicating that the mass of metabolically diverse microorganisms which inhabit the human gastrointestinal tract may be implicated in initiation and modulation of cardiovascular and metabolic disease outcomes. The following review will discuss this gut microbiome-host metabolism axis and address newly proposed bile-mediated signaling pathways through which dysregulation of this homeostatic axis may influence host cardiovascular risk. With a central focus on the major nuclear and membrane-bound bile acid receptor ligands, we aim to review the putative impact of microbial bile acid modification on several major phenotypes of metabolic syndrome, from obesity to heart failure. Finally, attempting to synthesize several separate but complementary hypotheses, we will review current directions in preclinical and clinical investigation in this evolving field.
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Affiliation(s)
- Paul M. Ryan
- APC Microbiome Institute, Biosciences Institute, University College Cork, Cork, Ireland
- Centre for Research in Vascular Biology, University College Cork, Co. Cork, Ireland
| | - Catherine Stanton
- APC Microbiome Institute, Biosciences Institute, University College Cork, Cork, Ireland
- Food Biosciences Department, Teagasc Food Research Centre, Moorepark, Fermoy, Co. Cork, Ireland
| | - Noel M. Caplice
- APC Microbiome Institute, Biosciences Institute, University College Cork, Cork, Ireland
- Centre for Research in Vascular Biology, University College Cork, Co. Cork, Ireland
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Nicholls SG, Etchegary H, Carroll JC, Castle D, Lemyre L, Potter BK, Craigie S, Wilson BJ. Attitudes to incorporating genomic risk assessments into population screening programs: the importance of purpose, context and deliberation. BMC Med Genomics 2016; 9:25. [PMID: 27215612 PMCID: PMC4878078 DOI: 10.1186/s12920-016-0186-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 05/12/2016] [Indexed: 12/31/2022] Open
Abstract
Background The use of an overall risk assessment based on genomic information is consistent with precision medicine. Despite the enthusiasm, there is a need for public engagement on the appropriate use of such emerging technologies in order to frame meaningful evaluations of utility, including the practical implementation and acceptability issues that might emerge. Doing so requires the involvement of the end users of these services, including patients, and sections of the public who are the target group for population based screening. In the present study we sought to explore public attitudes to the potential integration of personal genomic profiling within existing population screening programs; and to explore the evolution of these attitudes as part of a deliberative process. Methods We conducted a mixed methods study presented in the format of a deliberative workshop. Participants were drawn from communities in Ottawa, Ontario (ON) and St John’s, Newfoundland and Labrador (NL), Canada. Individuals were approached to take part in a workshop on the incorporation of genomic risk profiling for either colorectal cancer screening (CRC), or newborn screening for type 1 diabetes mellitus (T1DM). Results A total of N = 148 (N = 65 ON, N = 83 NL) participants provided data for analysis. Participants in both groups were supportive of public funding for genomic risk profiling, although participants in the T1DM groups expressed more guarded positive attitudes than participants in the CRC groups. These views were stable throughout the workshop (CRC, p = 0.15, T1DM, p =0.39). Participants were less positive about individual testing, with a significant decrease in support over the course of the workshop (CRC p = 0.02, T1DM, p = 0.003). Common concerns related to access to test results by third parties. Conclusions The findings of this study suggest that members of the target populations for potential genomic profiling tests (designed for screening or risk prediction purposes) can engage in meaningful deliberation about their general acceptability and personal utility. Evaluations of whether a test would be personally useful may depend on the experience of the participants in personal health decision making, the purpose of the test, and the availability of interventions to reduce disease risk. Electronic supplementary material The online version of this article (doi:10.1186/s12920-016-0186-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stuart G Nicholls
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, K1H 8M5, Canada
| | - Holly Etchegary
- Clinical Epidemiology, Memorial University, St John's, NL, Canada
| | - June C Carroll
- Department of Family and Community Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada.,Sydney G. Frankfort Chair in Family Medicine, Toronto, ON, Canada
| | - David Castle
- Vice-President Research, University of Victoria, Victoria, BC, Canada
| | - Louise Lemyre
- School of Psychology, University of Ottawa, Ottawa, ON, Canada
| | - Beth K Potter
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, K1H 8M5, Canada
| | - Samantha Craigie
- Michael G DeGroote National Pain Centre, McMaster University, Hamilton, ON, Canada
| | - Brenda J Wilson
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, K1H 8M5, Canada.
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Guchet X. What's in a word? The person of personalized (nano)medicine. Nanomedicine (Lond) 2015; 10:3167-79. [DOI: 10.2217/nnm.15.145] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Personalized medicine has recently become a main goal for healthcare policy. It is often defined as the tailoring of diagnosis and therapies to the genetic profile of each patient, and as such it is supposed to overcome the major thorny issues at stake in biomedicine today. This challenging program is primarily carried out by new approaches in biomedical imaging, molecular analysis, drug delivery and follow-up, taking more and more advantage of nanotechnology. However, in current literature and debates, the term ‘personalized medicine’ appears to be polysemous. The paper examines this polysemy. It links it to rival epistemic and technological choices in research programs, and it finally argues that this techno-epistemic plurality echoes conflicting expectations and values among today's biomedicine actors.
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Affiliation(s)
- Xavier Guchet
- Department of Philosophy, COSTECH (EA 2223), University of Technology of Compiègne (UTC), France
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Billaud M, Guchet X. [The invention of personalized medicine, between technological upheavals and utopia]. Med Sci (Paris) 2015; 31:797-803. [PMID: 26340841 DOI: 10.1051/medsci/20153108020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
The idea of personalized medicine raises a series of questions. If one considers that the physician takes into account the uniqueness of his patient in the frame of the medical consultation, is the definition of medicine as "personalized" not a pleonasm? If not, why has this ambiguous denomination been adopted? In addition, is this form of medicine a novel discipline capable of revolutionizing therapeutic approaches as claimed in its accompanying discourses or is it in continuity with the molecular conception of biomedicine? Rather than attempting to directly answer these questions, we focused our attention on the organizing concepts, the technological breakthroughs and the transformations in medical practices that characterize this medicine. Following this brief analysis, it appears that the choice of a term as equivocal as personalized medicine and the emphasis on the antagonistic notions of revolution and continuity in medicine are the signs of reshuffling that is emerging between actors in the health care system, in academia and in pharmaceutical companies.
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Affiliation(s)
- Marc Billaud
- Institut Albert Bonniot, CRI Inserm/UJF U823, université Grenoble Alpes, rond point de la Chantourne, Grenoble, F-38042, France
| | - Xavier Guchet
- Université Paris I, Panthéon Sorbonne, Paris, France
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Nicholls SG, Wilson BJ, Castle D, Etchegary H, Carroll JC. Personalized medicine and genome-based treatments: Why personalized medicine ≠ individualized treatments. ACTA ACUST UNITED AC 2014. [DOI: 10.1177/1477750914558556] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The sequencing of the human genome and decreasing costs of sequencing technology have led to the notion of ‘personalized medicine’. This has been taken by some authors to indicate that personalized medicine will provide individualized treatments solely based on one’s DNA sequence. We argue this is overly optimistic and misconstrues the notion of personalization. Such interpretations fail to account for economic, policy and structural constraints on the delivery of healthcare. Furthermore, notions of individualization based on genomic data potentially take us down the road of genetic reductionism obscuring the role of environmental factors in disease and ill health. We propose that one should see personalized medicine as a way of using personal genomic information to stratify individuals into subpopulations and suggest that personalized medicine be seen within a broader idea of personalized healthcare, reflecting healthcare that integrates personal genomic data into cultural, environmental and personal contexts.
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Affiliation(s)
| | | | | | | | - JC Carroll
- Mount Sinai Hospital, University of Toronto, Canada
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