Nanomedicine and personalised medicine: understanding the personalisation of health care in the molecular era
Abstract
Globally supported by public policy and investment, nanomedicine is presented as an ongoing medical revolution that will radically change the practice of health care from diagnostic to therapeutic, and everything in between. One of nanomedicine's major promises is that of personalised medicine, enabling diagnostics and therapeutics tailored to individual needs and developing a truly ‘patient-friendly’ medical approach. Based on qualitative interviews with nanomedicine researchers in Canada, this article explores the emerging concept of personalised medicine as it becomes entangled with nanomedical research. More precisely, drawing on insights from science studies and the sociology of expectations, it analyses researchers’ perceptions of personalised medicine in the cutting edge of current nanomedicine research. Two perceptions of personalisation are identified; a molecular conception of individuality and a technical conception of personalisation. The article concludes by examining the relationship between the two conceptions and contrasts them with the normative reflex of a more expansive conception of personalised medicine.
Introduction
Envisages life at the molecular level, as a set of intelligible vital mechanisms among molecular entities that can be identified, isolated, manipulated, mobilised, recombined, in new practices of intervention, which are no longer constrained by the apparent normativity of a natural vital order.(Rose 2007: 6)
A second continuity in the trajectory of the molecularisation of medicine (Clarke et al. 2010, Tutton 2014), and the focus of our analysis in this article, is the centrality of personalised medicine in the emerging nanomedicine paradigm. Though the contemporary definition of personalised medicine is the subject of copious debates (Guchet 2015, Pavelić et al. 2015, Pokorska-Bocci et al. 2014), among researchers working in the field, nanomedicine is frequently understood as matching ‘the right drug to the right patient and in some cases even to design the treatment for a patient according to genotype as well as other individual characteristics’ (Jain 2014: 1). The question left open by this definition is the precise meaning of ‘individual characteristics’. Advocates of nanomedicine position it as the true bearer of the promise of personalised medicine by attempting to subsume pharmacogenomics within the nanomedicine paradigm (Boisseau and Loubaton 2011, European Technology Platform in Nanomedicine [ETPN] 2005, 2013, Jain 2014, Jeelani et al. 2014a, 2014b, Kulkarni 2007, Lehner et al. 2013, Logothetidis 2012, Prabhu and Patravale 2012, Ranganathan et al. 2012).
Pharmacogenomics, though lexically associated with genomics, can be traced back to the 1950s’ emergence of pharmacogenetics, which was concerned with exploring the impact of individual variability on drug interaction, that is, metabolism and excretion rates, as well as, of course, therapeutic efficacy (Hedgecoe 2004: 10). With the advent of the Human Genome Project and subsequent advances in genomic and allied sciences, now under the rubric of pharmacogenomics, the original insights of pharmacogenetics were transposed to the genomic scale, linking drug interaction to variation in the human genome (Tutton 2014: 50–2, Wong 2008: 212). At times used interchangeably, sometimes distinguished, frequently disputed (Hedgecoe 2003, Tutton and Jamie 2013: e184, Wong 2008), by the turn of the new millennium pharmacogenomics and pharmacogenetics were both virtually synonymous with personalised medicine (Jain 2014: 1, Pavelić et al. 2015, Pokorska-Bocci et al. 2014). Indeed, most social science work on personalised medicine has associated the latter with pharmacogenomics or pharmacogenetics. It has explored the ‘post-genomic surprise’ of the persistence or reimagining of racial and ethnic categories (Duster 2015, Hunt and Kreiner 2013, Prainsack 2015), the spectre of genetic discrimination in private insurance (Joly et al. 2010), its resonance with neoliberal imaginaries (Dickenson 2013), the negotiation of new somatic risks (Groves 2013), ontological conceptions of disease (Boenink 2010, Timmermans and Buchbinder 2010) and the ‘political’ passage of pharmacogenitics through the clinic (Hedgecoe 2004). Finally, and extremely usefully, scholars have also inserted personalised medicine in the broader processes of ‘biomedicalization’ (Clarke et al. 2010) and have detailed the continuities and discontinuities between contemporary personalisation inflected by genomics and earlier forms of personalisation that date back to the 19th century (Tutton 2014).
Despite the current centrality of the personalised medicine designation, other terms such as individual tailored therapy, integrative health care, medicine based on high-throughput analytics (speedy automated conduct of extremely voluminous numbers of chemical, genomic and pharmacological tests) and predictive medicine have also been associated to personalised medicine; more recently terms such as ‘precise medicine, systems medicine or translational medicine’ have equally entered the fray (Pavelić et al. 2015: 133). In each of the listed areas, attempts are made to position nanomedicine or nanobiology as a crucial driver of the success of personalised medicine (Hood et al. 2004, Khushf 2008, Murday et al. 2009, Riehemann et al. 2009, Vizirianakis and Amanatiadou 2012).
A particularly striking example is found in Jain's (2014) Textbook of Personalized Medicine, in which nanomedicine is defined as the application of nanobiotechnology to medicine (Jain 2012). In a figure titled ‘Relationship of various technologies to personalized medicine’, Jain (2014: 20) unambiguously locates nanobiotechnology as the germinal point of all the relationships. Such efforts were coextensive with the launch of major nanomedicine initiatives or institutes in North America, Europe, Asia, Russia and Africa in the middle of the first decade of the current century (Fenniri 2006: 226, Tibbals 2011: 48–9). These occurred in a context where social commentators, but also scientists, had begun to note that pharmacogenomics’ promises of individualised pharmaceutical care had been overstated and remained under-realised (Tutton 2014: 153–4).
Narratives and images of personalised medicine remain a vibrant but also contested part of the biomedical and genomic discourse and are being taken up and reinvented in a number of emerging social technical practices.(Tutton 2014: 162)
Nanomedicine is without doubt one of the emerging social technical practices attempting to claim a commanding stake in the resilient field of personalised medicine. Accordingly, nanomedicine's proponents have made their own promises, and in some cases inflated the expected benefits. For instance nanomedicine has been positioned by its advocates as the ultimate ‘patient-friendly approach’, customising therapies to individual, needs hence reducing adverse drug reactions (Lammers et al. 2012, Liao and Tsai 2013, Ranganathan et al. 2012). Pharmacogenomics and genetics have pledged to shrink costs and increase the efficacy of pharmaceutical therapies for healthcare systems and to reduce the cost of drug development for pharmaceutical companies (Hedgecoe 2004: 12–3). This was to be accomplished by linking drug development and therapy to data on genomic or genetic variation. Nanomedicine, however, pledges more. It claims to be able to provide the hardware to put the genomic or genetic informational data to more efficacious use, in turn generating more refined data to be processed more quickly in a virtuous recursive loop. This is expected to enable the earlier detection of molecular markers of disease even before the disease manifest itself as a disease. Nanomedicine also foresees the development of nano-carriers that will more effectively and accurately deliver individualised therapeutic agents, while providing real-time imaging, surveillance and analysis of the molecular dynamics associated with pathological processes (Ferrari et al. 2009, Jain 2012, Jeelani et al. 2014b, Logothetidis 2012, Mohandy 2009, Murday et al. 2009, Pan 2013, Patel et al. 2011, Ranganathan et al. 2012, Syed 2014, Vizirianakis and Amanatiadou 2012).
Whereas researchers have been able to assess different aspects of the impact, or lack of impact, of pharmacogenomic and genetic therapies in the clinic, on medical practice and the pharmaceutical industry, as well as on health policy and the broader medical imaginary (Clarke et al. 2010, Dickenson 2013, Hedgecoe 2004, Savard 2013, Tutton 2014), this is not the case for nanomedicine. Nanomedicine has promised much. However, to date there are few examples of successful translation to the clinic (Duncan and Gaspar 2011, Etheridge et al. 2013, ETPN 2013, Juliano 2012, Venkatraman 2014). Gauged against the hype surrounding the launch of nanomedicine initiatives noted above, progress has been very modest (Weissig et al. 2014: 4370). In a 2014 market study published in the International Journal of Nanomedicine, Weissig and his colleagues argue that most of the 43 formulations approved by the Food and Drugs Aministration or related foreign agency publicised as nanopharmaceuticals preceded the nanomedicine initiatives. Noting that only four can reasonably be attributed to the latter, the authors conclude that ‘the true promise of nanoscience for drug development still has to materialize’ (Weissig et al. 2014: 4370). In another recent study reviewing the current ongoing clinical trials in the field of nanopharmaceuticals, Weissig and Guzman-Villanueva (2015) found a surprisingly low number of trials, only two, with materials that show unique nano-based properties, ‘reflecting neither the massive investments made in the field of nanomedicine nor the general hype associated with the term “nano”’ (Weissig and Guzman-Villanueva 2015: 1245). This is not to discount nanomedicine's potential contribution in the future, but merely to recognise that ‘the “culture of promises” of “nano” is gigantic, and associated expectations of medical applications are immense’ while the ‘success of nanomedical research is comparatively moderate and the possible side effects (short and long-term) of nanoscaled particles and configurations remain largely unknown’ (Schillmeier 2015b: 71).
The future may be presented as if it were today (or at least visible and already known) in a way that can make these futures appear as largely determinant and imminent; in this process, the gap between imagined and actual futures is foreshortened; our attempts at foresight, at anticipation of the future, are thus compacted and compressed.(Williams 2006: 328)
When translated from the public sphere to the confines of local laboratories, expectations and scientific visions of nanomedicine become, principally, technical issues that are addressed through the development of experimental standardised procedures.(Crabu 2014: 59)
necessary to adopt an empirical gaze aimed at understanding how anticipatory scenarios in nanomedicine will break through the walls of research laboratories and contribute to the innovation of biomedical practices.(p. 47)
However, in order for this to happen, the anticipatory scenarios, as they are framed by research scientists, need to be elucidated and analysed, which is the task we set ourselves here.
As noted above, Tutton (2014) has argued that personalisation is a component of broader social, political, cultural and economic processes that have contributed to making the meaning of ‘personalisation’ semantically fluid (Guchet 2015, Pokorska-Bocci et al. 2014). Our qualitative analysis of interview data with nanomedicine research scientists in the provinces of Quebec and Ontario, Canada is aimed at eliciting the contours of the emerging conception(s) of personalisation as envisioned by these scientists. As explained below, nanoscientists and the patterned conceptions of personalisation that inform their vision of nanomedicine contribute to, but do not determine, the social shaping of the emerging nanomedicine paradigm. Theoretically and methodologically we draw on insights from science studies: namely, its critique of linear conceptions of technological innovation, the significance of expectations in the emergence of new socio-technical assemblages, and the manner in which social technical arrangements are the product of ongoing contextualised practices.
We begin by providing a brief overview of some of nanomedicine's technical dimensions. Following our discussion on methods we report our findings, and we identify two conceptions of personalisation. We conclude by tying these two conceptions of personalisation together and raise the normative dimension of the historical use of personalisation and its significance for the emerging conception of personalisation identified by our analysis.
Nanotechnology and nanomedicine
In our methodology section we argue that technical potential alone does not determine the trajectory of emerging technologies. That said, technical potential nonetheless does provide ‘affordances’ – a potential rendered possible by an encounter (Bensaude-Vincent and Loeve 2013: 12) – for its articulation with social processes. Consequently we begin with a brief overview of nanotechnology and nanomedicine.
Definitions of nanotechnology vary, but working with processes and materials at a length scale stretching from 1 to 100 nanometers, where one nanometer equals a billionth of a meter, is a sufficiently capacious definition to encompass the contemporary field of nanotechnology (Bunker et al. 2012: 1583). For many, the natural affinity between nanotechnology and medicine arises from the alignment with, or a convergence towards (Bainbridge 2007), the nano length scale. For instance, the width of a DNA molecule and most cell membranes extend between 2 and 2.5, and 6 and 10 nanometers respectively, while most proteins fall between the range of 1 and 20 nanometers. Consequently, insofar as ‘basic life processes’ are believed to ‘take place on the nanoscale’, nanotechnology provides both an optimal and the ultimate took kit for medicine to intervene in biological systems that are rendered as being ‘inherently composed of nanoscale building blocks’ (Mohandy 2009: B25, Boisseau and Loubaton 2011, Jain 2014).
In addition and crucially, at the nano scale, materials display properties that are absent at larger or smaller length scales due to the dense clustering of atoms on the external surfaces of biological and non-biological nanostructures. This new arena of molecular surface chemistry brings into play new modalities of molecular bonding, tagging and tracking (Marchant 2009: 231). Against the background of the advances in genomic science and its allied fields, the development of tools and processes that enable intervention at the nano scale coupled with the special material properties thus afforded, introduce the possibility of a number of nanomedical innovations. These include novel in vivo and in vitro diagnostic tools (quantum dots, golden nanoparticles, implants, lab-on-a-chip, etc.), advanced drug delivery systems, innovative procedures combining diagnostics and therapy (theranostics) and even new tissue engineering methods (Aspinall and Hamermesh 2007, Boisseau and Loubaton 2011, Bunker et al. 2012, Duncan and Gaspar 2011, Etheridge et al. 2013, ETPN 2005, 2013, Jeelani et al. 2014b, Jain 2014, Juliano 2012, Lehner et al. 2013, Logothetidis 2012, Mironov et al. 2004, Mohandy 2009, Prabhu and Patravale 2012, Ranganathan et al. 2012). This suite of technological potential, however, as we will see below, is currently becoming entangled with particular understandings of personalisation.
Methods
Preceding the qualitative analysis presented below, we generated and analysed a corpus of documents dealing with nanomedicine composed of scholarly articles and grey literature. New documents were added until data saturation was reached. Although, we do not report directly on the analysis of these data here, it informs the methodological approach that we present immediately below. We also draw on findings from the analysis of our corpus to put our interview data in context.
The ubiquity of the term ‘promise’ and cognate terms, in the discourses of nanomedicine, indicates that like many contemporary emerging technologies (López 2008), nanomedicine is entangled in a future-oriented language of hype, which extrapolates, some would say exaggerates, based on perceived present technical potential. In the context of nanomedicine this is recognised even by sympathetic researchers: ‘Too many publications still begin with a phrase ‘widely used for biomedical applications’ whereas in most cases the system has not even entered clinical trial or been tested in vivo … Investigators need to understand and articulate the difference between a lab experiment and a medicine’ (Duncan and Gaspar 2011: 2118). Implicit in the extrapolations that fuel hype is frequently a linear conception of technological development the critique of which has provided the shared bedrock upon which the field of social studies of sciences has been erected (Sismondo 2011).
Due to the shifting nature of social technical dynamics, initial parameters, be they social, political, cultural or technical, can never provide sufficient knowledge regarding their future shape or social impact. Technologies emerge and are sustained through contingent processes of co-production that link the social, political, cultural, economic and the technical in myriad ways. Seen thus, ‘co-production is symmetrical in that it calls attention to the social dimensions of cognitive commitments and understandings, while at the same time underscoring the epistemic and material correlates of social formations’ (Jasanoff 2004: 3). Part of this process of co-production, but clearly not all of it, is embodied in the conceptualisations of practicing scientists, hence our decision to focus our analysis on interview data collected from researchers in the field of nanomedicine.
If hype underwritten by extrapolations of current potential does not have predictive power, it can, nonetheless, have performative power in the here and now. Social studies of science scholars, working within the framework of the sociology of technological expectations, have provided compelling empirical and theoretical evidence of the crucial work performed by hype in the present (Borup et al. 2006, Brown et al. 2000, Brown and Michael 2003, Geels and Smith 2000, Hedgecoe 2003, 2004, Van Lente 1993). Rather than provide a realistic vision of the future, they are ‘future oriented abstractions’ that may organise and modulate action in the present (Van Lente 1993: 286).
The insights of the sociology of technological expectations as well as the critique of linear conceptions of technological development have important methodological consequences for the study of an emerging field such as nanomedicine. Both point to the necessity of exploring the intertwined technical and social processes through which the trajectories of emerging technologies are moulded in real time. In the field of health, such social technical assemblages are, in part, discursively concretised in actors’ particular understanding of what health, disease, and the body are or should be (Clarke et al. 2010). To transpose Tutton's formulation, they exist as an ‘imaginary of personalised medicine’ made up of the ‘speculative, propositional fabric of scientific thought concerned with the application of (2014: 10) nanomedical knowledge’.
It is important to be clear. Our analysis is not concerned with establishing the veracity of our respondents’ future oriented claims, rather we are interested in exploring how these future-oriented claims become intertwined with distinct understandings of personalised medicine. Because nanomedicine's outcomes are not the product of inherent technical potential, nanoscientists’ notions of personalised medicine have the potential to steer, without necessarily determining, developments along particular trajectories. Thus our analysis is couched firmly within qualitative sociology's warrants in the field of social science and medicine – the ‘illumination of the construction of medical beliefs’ (Timmermans 2013: 3).
This said, our analysis and results should not be taken as implying that nanomedicine research scientists are the only actors with their hands on the helm. As we have argued elsewhere, nanomedicine and its emerging conception(s) of personalisation have to be understood in the context of broader changes in technoscience both up and down stream (Noury and López 2016), as well as the broader social forces sustaining the significance of personalisation (Tutton 2014) as they interact with the affordances that emerge across nanoscaled processes (Schillmeier 2015b). Consequently, important as they undoubtedly are, the perceptions of nanomedical researchers cannot be understood as unilaterally stabilising the emerging and contested meaning of nanomedicine. A related caveat follows. The manner in which the research scientists in our sample envision the development of personalised medicine does not altogether capture the full range of the practices that entangle them in the field of nanomedicine. Ethnographic studies of nanomedicine in the laboratory (Crabu 2014) do, and will certainly continue to, generate new insights into the development of nanomedicine (Schillmeier 2015b). Following Schillmeier, our contribution is guided by the epistemological and ethical desire to ‘care about social complexity in nanomedicine’ (2015: 3182). Not included in our analysis, for instance, are key actors such as clinicians and patients, not to mention the ongoing and dynamic patterning of everyday laboratory life and their non-human ‘nano masses’ (Schillmeier 2015b: 65, Crabu 2014: 59). However, an analysis of the broad visions that nanomedical researchers invoke when talking about personalised medicine, is one crucial dimension of nanomedicine's social complexity. Should future ethnographic analyses show that such nano-talk differs from the laboratory's vernacular, as it might, then the gap between the two will be fertile ground for further analysis. Insofar as the biomedical domain envisioned by nanomedicine is the product of ‘the relationship between anticipatory narrations, and local experimental practices’ (Crabu 2014: 60) then it is crucial to document both. In this article we focus on the former.
The results of the qualitative analysis, presented below, are drawn from 20 in-depth semi-structured interviews with university-based Canadian (Quebec and Ontario) researchers in nanomedicine. A Canadian focus is justified due to nanomedicine's status as a priority research area in Canada (Fenniri 2006, Kerr and Wishart 2008, Marcotte and Quirion 2006). While support for nanomedicine initiatives is provided through Canada's federal funding agencies, Canadian Institutes for Health Research (CIHR) and the National Science and Engineering Research Council, provinces such as Alberta, British Colombia, Ontario and Quebec have developed their own provincial level initiatives (Fenniri 2006).
Interviews were conducted in English or in French, lasting between 1.5 to 2 hours. We used a convenience sampling method based on geographical proximity (Quebec). Initially, the sample of researchers was restricted to the most advanced nanomedical laboratories in the province of Quebec (Laval and McGill universities, Montreal School of Engineering, Montreal Polytechnic, universities of Montreal and Sherbrooke). On the advice of several respondents, three further key nanomedicine researchers were added from the University of Toronto, Ontario.
The participants (N = 20) were recruited according to their professional expertise (see Table 1). All head academic laboratories specialising in nanomedical research and have published major articles in peer-reviewed journals. They were contacted personally by email and interviews were conducted in their laboratories. For privacy and confidentiality reasons the names of the participants have been changed. Research expertise is mentioned when it is relevant to the analysis.
| Number of researchers (N = 20) | |
|---|---|
| Field of research | |
| Cellular biology and tissue engineering | 7 |
| In vivo nanosystems, biomarkers, drug, delivery, systems, nanoparticles, nanospheres, nanorobotics | 7 |
| In vitro nanosystems, bioMEMS, biosensors, lab-on-a-chip, nanochips | 6 |
| Researchers by university (N = 20) | |
| Laval University | 4 |
| McGill University | 2 |
| Montreal School of Engineering | 1 |
| Montreal Polytechnic | 6 |
| University of Montreal | 2 |
| University of Sherbrooke | 2 |
| University of Toronto | 3 |
The researchers’ expertise is organised into three general fields of research: cellular biology and engineering, in vivo nanosystems and in vitro nanosystems. These divisions are found in the scholarly literature (Logothetidis 2012, Tibbals 2011) as well as in the grey literature – such as the European Technology Platform on NanoMedicine (ETPN 2005) or the Canadian Initiative in Regenerative Medicine and Nanomedicine (CIHR 2006). Thus, despite the fact that our sample is essentially drawn from Quebec, we are confident that it provides insight into the emerging intersection of personalised medicine and nanoscience in other research settings.
The results reported here are part of a larger research project concerned with elucidating the sociocultural dimensions of the attempt to frame nanomedicine as a cross-cutting model of health care (Noury 2016, Noury and Lafontaine 2014). In this article, we focus on the participants’ perceptions of the concept of personalised medicine in the context of its application in nanomedical research, the rationale of which has been developed above. The interview questions on ‘personalisation’ addressed the following areas: (i) the definition and specificity of the concept of personalised medicine; (ii) the role of nanomedicine in the development of personalised medicine; and (iii) the doctor-patient relationship in the context of (nano) personalised treatments. Interview data were originally coded along these three basic themes. In a subsequent analysis, we identified less-aggregated categories to reflect participants’ perceptions. The interviews were transcribed verbatim and data imported into the qualitative data analysis software, NVivo 9. The excerpts from interviews found in the results section below, offer illustrative examples of our respondents’ typical perceptions, rather than individual perceptions. They point to the patterned nature of the understanding of personalised medicine in our sample.
Results
Two major themes emerged from the analysis of the interview data constituting the core of the notion of personalisation among our respondents: (i) a molecular conception of personalisation, and (ii) a technical conception of personalisation. We discuss each of these in turn.
The molecular conception of personalisation
Personalised medicine refers to the idea that before, you had one-size-fits-all drugs; [now] we're going to be able to define a profile for each patient that takes into account his or her genetic heritage and metabolism. For one patient it will take more for others less [of the drug] and yet for others we will know in advance that the drug will have no effect. That is the idea. You have a product designed for the patient's specificity and not a one-size-fits-all product. The personalisation aspect is central to nanomedicine. For me, it's a real concept that will require new tool such as contrast nanoagents, nanosensors, etc. They will help us with diagnosis … It's not a personalisation in the interpersonal or psychological sense. It's really a personalisation in the biological variability sense.
Firstly, following the furrow ploughed by pharmacogenomics and genetics and the molecularisation of medicine more broadly, personalised medicine in the excerpt is defined in opposition to the ‘one-size-fits-all’ conception of therapy. Secondly, not only is personalisation identified as a decisive feature of nanomedicine, it is through nano tools – that is, contrast nanoagents and nanosensors – that personalised medicine will be realised. These tools do not yet exist in a clinical context, but there is no uncertainty regarding their imminent arrival. Finally, Michael S. is careful to restrict the meaning of personalisation, reserving it for biological variability and excluding the interpersonal and psychological. Such semantic parsing is significant and necessary because more expansive conceptions of personalisation tend to circulate among broader programmatic views of personalisation, particularly in healthcare policy (European Alliance for Personalised Medicine 2014). As demonstrated by Pokorska-Bocci et al.'s (2014) exhaustive analysis of the semantic networks in which personalised medicine and cognate terms appear, the meaning of personalised medicine is by no means settled. It flows in a continuum from the narrow definition staked out by Michael S. to where ‘the term encompasses a broad range of medical, scientific, technological and sociopsychological aspects affecting current and future medicine and healthcare’ (Pokorska-Bocci et al. 2014: 3).
Personalised medicine in its more extensive sense is contrasted to the population health model that is concerned with ‘the health outcomes of a group of individuals’ (Kingdig and Stoddart 2003: 380) and the principle of ‘one cure for all’ (Pavelić et al. 2015: 134). It is also seen as a corrective to the fragmentation of medicine into subspecialties that has prevented the development of ‘a comprehensive view of the patient as a person and his or her overall functions’ (Pavelić et al. 2015: 134). Consequently, it is claimed that personalised medicine will allow clinicians to refocus ‘attention on the person being treated’ to tackle ‘their specific disease in the context of their overall profile’ (Pavelić et al. 2015: 134). However, our analysis of our interview data with researchers shows no sign that this more expansive meaning of personalisation is emerging in their research practices. Quite the contrary, the manner in which our respondents talked about the future development of personalisation does not fundamentally put into question the population health model, nor does it include the sociopsychological dimensions so dear to advocates of the more expansive understanding of personalisation.
[A]s I understand it, personalised treatment means that if I have a woman with breast cancer, I'm going to perform a genetic analysis on her and on the tumour cells to see how they will react to this or that treatment, to see if she has a particular genetic resistance. After that, I'm going to screen her biological and genetic profile and that of the disease, in order to determine which treatment is best suited for the target. (Margaret D.)
We can already adjust the drug dosage to suit the patient's weight, but personalised medicine goes far beyond that. For example, a patient's tumour expresses particular antigens. We will know very early to which subgroup the patient belongs, enabling us to individualise many of the patient's parameters. It will be a specific patient different from another one … we will be able to take into account the specificity of the patient to design a treatment with small variations. We're going to have new decisional tools adapted to the multiples parameters of the patient.(Peter B.)
[I]llness in this respect becomes not so much a matter of experience, but the possibility of developing disease according to one's genetics; genetic variants, or polymorphisms, therefore become equivalent to disease and illness.(2013: 199)
Following Nikolas Rose's observation on ‘molecular biopolitics’ (Rose 2007), Savard remarks that this focus on the molecular categorisation of the individual in personalised medicine is powered by biopolitical assumptions about ‘the power of genetic knowledge and about an individual's responsibility for his or her health’ (Savard 2013: 199). Consequently, in the context of personalised medicine, ‘responsibility for good health is shifted from the state and collectives to the individual, such that the individual is now “responsible” for his or her health or disease’ (Savard 2013: 199). As observed by several authors drawing on the work of Foucault (2004), this new individual responsibility for one's own genetic heritage resonates more broadly with the neoliberal ideology of self-government and consumer rationality in health care, where rational patients are made responsible for their good health (Clarke et al. 2010, Dickenson 2013, Lupton 1995, Metz and Kirkland 2010, Rose 2007).
To conclude this section, let us add that the restriction of personalisation to this narrow concept – that is, the assignment of individuals to molecular subgroups – is striking due to the role that the notion of personalised medicine has played historically. Tutton shows that throughout the 19th and 20th century personalised medicine has been invoked, in different ways, as a counterpoint to the various medical trends that have aspired to a technologised and reductive biomedicine (Tutton 2012, Tutton and Jamie 2013). Today, the semantic valence of this counterpoint continues to be heard in the more extensive meaning of personalisation that promises a nanomedicine that holistically focuses on the individual. It is sufficiently present that, as we saw above, Michael S. and other respondents feel the need to police the boundary of personalisation by explicitly excluding the interpersonal and the psychological. However if researchers in their everyday practice understand personalisation in this narrow sense, as is the case in our sample, it is unlikely they will contribute to the development of personalised medicine in its expansive meaning.
A ‘very technical’ conception of personalisation
Will it be a personalised medicine in the sense of a more personal relationship between the patient and the doctor? The fact is that it will be a very technical personalisation.
Theranostic nanomedicine is really an alliance between imaging and therapeutics, that is to say having an imaging device travelling through the body to the tumour … we will be able to watch it on a screen and release the active component directly on the tumour site via an external source.
Through theranostics we will be able to both see and control. We will control precisely where the drug is going and release it at the right place because we will be able to see it happening. It is interesting because we will exert control through vision. We will have remote control and be able change direction at the last moment.(Peter B.)
Reality into a code through the unacknowledged medium of metaphor, a focus on the molecular [nano] scale provides a view of reality in which the richness of matter resolves into rearrangeable patterns of information.(Black 2014: 102)
Proves to not be anything like the complex ordering of fixed units or substances as the parlance of ‘atom by atom’ suggests. Rather, it requires the fragile handling of environmentally sensitive, emergent processes of mediation that often contradict and/or compromise the intended effects (e.g., being ineffective or toxic) of the researcher.(Schillmeier 2015b: 71)
Seen from the perspective of its enmeshment and dispersal in such local practices, nanomedical research does not appear as ‘the direct manipulation of matter at an atomic level’, but as ‘the development of techniques and methods for the creation of devices for molecular intervention, or rather the shaping of “programmable”, clinically relevant and promising entities’ (Crabu 2014: 59). The extent to which the broad stylistic vision evidenced by our analysis conflicts with or becomes aligned with the exigencies of actual laboratory work, is one that still needs to be determined and invites future research.
The act of touching to diagnose the patient is disappearing. It's declining. Now one has remote non-invasive imaging. It's obvious that theranostic nanoagents move us away …. Nanomedicine is the next logical step after endoscopy. One heads this way… toward remote imaging and therapeutic devices. Yes, I think one moves away.(Mary P.)
For a new generation, ‘going to war’ doesn't mean shipping off to some forsaken place to fight in a muddy foxhole but a daily commute in your Toyota Camry to sit behind a computer.(Singer, in Benjamin 2013: 86–7)
In the pilot's hand is the joystick, guiding the drone as it soars above Afghanistan, Iraq, or some other battlefield, the sensor operator controls the cameras that bring the battlefield into full view to gain intelligence and hunt down targets.(Benjamin 2013: 84)
The physical distance between the pilot and the battlefield is akin to the technical distance, implied above by both Peter B. and Nicholas L., between the prospective recipient of a theranostic device and the clinician controlling it. Personalisation here cannot be understood in its expansive sense – as referring to a biopsychosocial entity – rather it refers to the singularity of an individual's internal nano-scale terrain, technically rendered as a theatre of operation through nanomedicine's imaginary. As another respondent reiterated: ‘With theranostics, it's not an “individual” relationship, but a technical one. One has a technical relationship with a patient’ (David D., nanodrug delivery).
Conclusion
The analysis of our respondents’ extrapolations of the future of nanomedicine has been concerned with elucidating the understandings of personalisation that these visions contain. We have identified two distinct senses of personalisation: the first, a molecular conception, whereby personalisation refers to the stratification of individuals in population groups linked to particular molecular categories. The second, a very technical conception, understands personalisation as the capacity to treat individual lesions with nano-enabled molecular precision. The visions of (nano) personalised medicine shared by our participants comprise more than just new personalised technological solutions. They echo a broader vision of the conception of medicine itself linked to a larger process of laying new epistemological and ethical foundations of health care, based on the molecular and technoscientific logics identified by the seminal works of Rose (2007) and Clarke et al. (2010).
As we have seen, the first understanding of personalisation is in effect taken over from pharmacogenomics and genetics, where personalisation refers to the distributions of individuals into subpopulations characterised by linkages between genotypes and specific diseases (Tutton 2012: 1726). What nanomedicine adds to existing conceptions of personalised medicine, or the manner it makes this paradigm its own, is the prospect of heightened molecular precision. Incubated within the notion of molecular precision is the second conception of personalisation that we identified, namely, the ability to use theranostic devices – or similar nano-platforms – to treat individual lesions. It is important to note that although in this second conception the semantic weight of personalisation is shifted onto the precision and control that theranostics promises, the diagnostic function of theranostic devices is built on and presupposes the first sense of personalisation, that is to say, the stratification of patients into molecular subgroups. This is why our respondents could make reference to both without contradiction.
In our discussion of the results, we have noted that both conceptions of personalisation fall short of the more expansive notions that promise to treat individuals as biopsychosocial entities. The normative reflex of this broader conception of personalisation makes reference to a ‘patient-centred care’ in which clinicians are attuned to their patients’ perspective and practice the art of clinical judgement (Tutton 2012: 1721). However, our analysis reveals that the latter view has little traction among the nanomedicine researchers in our sample, for whom personalisation, and its concomitant promise of precision, is associated with technical assemblages that distance them from the idea of patient-centred care. Nonetheless, it is crucial not to extend our findings to the laboratory nor extrapolate them towards the future.
Further research is required to understand what happens to these anticipatory visions as they become entangled with the social technical assemblages in the cross-scalar dynamics of the laboratory, not to mention when the latter are translated to the clinic. Similarly, if the precision that the nanomedical imaginary promises is fuelled by nanotechnology's central conceit of molecular precision, the actual social technical dynamics in the laboratory are likely to generate more local conceptions of precision. The interaction between competing conceptions of precision will not only have consequences for how nanomedicine is broadly envisioned but will also contribute to how personalisation is practiced in the clinic.
Acknowledgements
The authors would like to thank the participants of the study for their time and generosity. Without their participation and their insights, this article would not have been possible. We are also grateful to the referees for their careful reading of the manuscript and for their enormously useful comments. The study was funded by the Fonds de Recherche Société et Culture du Québec.
