Keywords

Introduction: Personalized and Precision Medicine as a Sociotechnical Imaginary

The opening paragraphs of this section closely follow the exposition in my report “Sociotechnical Imaginaries : Research and Innovation Policy as Creative Politics”, produced for internal use at the EC-Joint Research Centre at Ispra (Italy) and hitherto not published for a wider audience.

In their much-cited research paper, Jasanoff and Kim (2009) set out to improve the theoretical framework for studying and analysing how states come to delineate the objectives of publicly funded research. To that aim they introduced the concept of sociotechnical imaginaries . Their initial case study was a comparison between US and South Korean post-WW II nuclear power policies, and they defined national sociotechnical imaginaries as “collectively imagined forms of social life and social order reflected in the design and fulfilment of nation-specific scientific and/or technological projects” (Jasanoff and Kim 2009, p. 120). In looser and more colloquial terms, sociotechnical imaginaries can be defined as collective visions of good and attainable future science, technology & society.

Jasanoff’s and Kim’s concept of sociotechnical imaginaries is firmly rooted in Jasanoff’s general analytical perspective of co-production. One may think of this perspective as an analytical lens of describing and interpreting the developmental trajectories of modern science, technology and society, respectively, as mutually entangled with dependencies in all directions, causally as well as with regard to the production of sense and meaning. From the co-production perspective, it makes little sense to study the development of science and technology without a simultaneous study of the development of society, and vice versa. For instance, the development of the life sciences and biomedicine in the late twentieth and early twenty-first century would not be adequately described and understood without taking into account the political investment in the hope in science-driven innovation as a locomotive force for prosperity and economic growth in the same period. One would also need to know about the developments in public and political expectations for public health. Conversely, the political visions for prosperity and health in the emerging bioeconomy of this period would not be adequately interpreted without an understanding of the advances of molecular biology, genetics and biotechnology, to mention a few rapidly evolving fields.

Alessandro Blasimme and Effy Vayena have previously elaborated how precision medicine may be described and interpreted as a sociotechnical imaginary sensu Jasanoff and Kim (Blasimme and Vayena 2016, 2017; Blasimme 2017); even originating as a national sociotechnical imaginary in the US and as part of Obama’s political platform before it was adopted on a global scale, that is, within countries and economies aspiring to the ambitions of the bioeconomy (see also Tarkkala et al. 2019 for a recent analysis).

“Sociotechnical imaginary ” is a critical concept in the sense that it is intended to be helpful in order to gain critical distance to actors’ self-understandings and other commonsensical or naïve understandings. As such it is no different from any other concept of social science. It is important to recall, however, that the word “imaginary” is not meant to have a derogatory connotation, neither in Jasanoff’s sense nor in previous usages (such as with Benedict Anderson or Charles Taylor). The choice of the term “imaginary” does not imply a dismissive value judgement upon validity claims as being unrealistic or lost in fantasy and illusion. Rather, from this perspective, imagination is considered to be a normal and legitimate component of the creation (or rather co-production) of research policies, research trajectories and (other) political decisions. The reason is that there is a difference, if not in essence at least in degree, between decisions on, say, research trajectories, and many other public issues: research is expected to and indeed intends to produce something unforeseen and unforeseeable, namely new knowledge that opens up for new applications. Regular cost-benefit analyses or similar formal decision-making strategies are ill-suited to choose between surprises; indeed, in order for cost-benefit analysis to be legitimate, the outcome space must be known and well-characterized in terms of probabilities or likelihoods. Research policy-making is less a matter of choosing between well-characterised outcomes and more a matter of envisioning potential outcomes and choosing the potentially desirable ones, thereby creating political and scientific momentum to gather resources to try to realize those visions. In the words of Jasanoff and Kim (2009, p. 122):

The concept of sociotechnical imaginaries builds in part on the growing recognition that the capacity to imagine futures is a crucial constitutive element in social and political life. Imagination is no longer seen as mere fantasy or illusion, but as an important cultural resource that enables new forms of life by projecting positive goals and seeking to attain them. Nor is imagination understood as simply residing in individual minds in the form of aesthetic considerations. Rather, imagination helps produce systems of meaning that enable collective interpretations of social reality; it forms the basis for a shared sense of belonging and attachment to a political community […]. In short, imagination, viewed as “an organized field of social practices”, serves as a key ingredient in making social order.Footnote 1

While Jasanoff’s analytical perspective may have run counter to certain well-established research traditions in social science (such as rational choice theory), it seems to resonate well with the practitioners’ self-understanding that it set out to be critical of. Indeed, the title of an ambitious policy document by ASCO, the American Society of Clinical Oncology, was “Shaping the Future of Oncology: Envisioning Cancer Care in 2030”, in which they stated already in their foreword: “By anticipating the future, we can shape it.” (ASCO 2012, p. 2).

The exact content of the imaginaries of personalized medicine /precision medicine varies across nations, disciplines, policy arenas et cetera. There is “P4 medicine”, in which “participation”, construed as an opportunity and a right for the scientific citizen-patient, is a central part of the imaginary. Blasimme (2017) argued that this ingredient played an important role in the quest for political legitimacy of personalized medicine in the US. There are also more modest visions of personalized medicine that focus on opportunities of incremental progress by means of a somewhat higher degree of tailoring of treatment according to patient characteristics. In this chapter I shall focus on the absolutely not modest version that strongly resonates with the more recent concept of precision medicine . The core of the imaginary to be analysed in this chapter is the idea that healthcare may and will be improved by the application of molecular life sciences combined with big data approaches in order to tailor medical treatments: “the right drug to the right patient, at the right moment and in the right dose” (see, Plutynski in in this volume). The idea is that poor response or harmful side effects of treatment, in particular drug treatment, is due to differences between the biological constitution of the individual patient and the average or general type that previous medical knowledge had as its reference. By knowing all relevant biological parameters of the individual patient, one is then supposed to eliminate uncertainty and obtain precise control over the disease on a par with exact sciences and the (imagined) state of art in physical engineering (see Fig. 1).

Fig. 1
figure 1

Facsimile from ASCO’s vision document for the oncology of the future (2012, p. 5)

Full size image

Sociotechnical imagination departs from mere wishful thinking, however, in its efforts to specify the concomitant developments in scientific, technological, and societal infrastructures and institutions that would be needed to produce the overall desired future. For instance, the mentioned vision exercise of ASCO (2012) goes far to delineate a new healthcare system in which the health data of all cancer patients are part of one universal research project, and there is a complete, seamless merger of cancer care and cancer research (Fig. 1). This vision is not only a matter of change in institutional and professional practice but also profound change in the sick role:

Patients as full partners. Through personalized, patient-friendly HIT tools, patients will have a much greater opportunity to serve as well-informed advocates for their own care. While not every patient will take advantage of these possibilities, most will. By 2030, the results will include a significant shift in the doctor-patient relationship. By the time patients arrive for consultation with an oncologist, most will already know a great deal about their cancer , thanks to personalized information from patient portals in CancerLinQ or other systems. They will expect to contribute to all important decisions about their care, while looking to their physician to suggest alternatives (ASCO 2012, p. 6).

Again, this should not be read as imagination and anticipation and not as prediction – who can predict events in 2030 in a world that seems to produce surprises ever more rapidly? In ASCO’s own words, their use of language is to be seen as speech acts and not truth claims: “By anticipating the future, we can shape it.”

The Imaginary of Precision Medicine Runs Counter to Knowledge

While molecular genetics did not emerge until the latter part of the twentieth century, the hope of curing and eliminating disease and suffering is not new. Already René Descartes postulated that “we might free ourselves from countless diseases of body and of mind, and perhaps even from the infirmity of old age, if we knew enough about their causes and about all the remedies that nature has provided for us.” (Descartes 1637, p. 25).

For philosophers of science it is quite evident that the imaginaries of personalized medicine and precision medicine depend upon, and are built upon, a set of reductionist assumptions. The composition of this set of assumptions will of course depend on the exact content of the imaginary in question. While a given policy report or scientific publication may not adhere to all of the following, and while the list is not likely to be exhaustive, I present below a set of six such assumptions that I personally have encountered during my 25 years of taking part in debates within and around medical and health-related research and policy making (see also Strand 2000; Schei and Strand 2015):

  1. 1.

    In general, illness is reduced to disease. More precisely, there is little or no distinction between the (phenomenological) experience of illness/poor health and the (biological) existence of biological disease in humans; or if the distinction is made, it is assumed that the illness is caused by a corresponding disease and that the illness can be and should be treated, that is, cured or cared for, by curing or otherwise addressing the disease.

  2. 2.

    In general, it is assumed that states of disease are distinct and sharply demarcated states in the sense that they are descriptively identifiable, recognizable, and quantifiable. There are clear demarcations between the normal and the pathological.

  3. 3.

    In general, it is assumed that patients with diseases should be treated by medically correcting pathological biological states, e.g., by fully or partially restoring biological normality.

  4. 4.

    Most often, it is assumed that the relevant entity of disease is confined to the body of the individual patient, and that treatment is and should be an intervention on that body. While the slogan often reads “the right drug at the right dose”, proponents of these imaginaries do not necessary exclude interventions addressing diet or exercise. However, the focus is often on drugs – what the nineteenth century champion of physiology Claude Bernard called “toxic substances” given to correct physiological imbalances and restore normality.

  5. 5.

    In general, it is assumed that there is a “right” way to give medical treatment to persons with disease, and that this right way is preferable to no medical treatment, or treatments that are not directed towards correcting the pathology. A special case of this assumption is the one holding that disease simply is an imbalance of some sort, and the right treatment is that which restores balance.

  6. 6.

    In general, it is assumed that health is such an important value that other personal or societal costs, e.g., of changing norms, expectations and thresholds for taking on a sick role, the role of what it is to be a patient or an individual at risk, are small in comparison. In slightly more involved terms, it is not necessary to pay attention to the hazards of medicalization , or the risk that the costs of medicalization outweigh the health benefits of personalized/precision medicine .

I do not claim that this set of assumptions is the only reasonable formulation. Undoubtedly it would be possible to identify more such assumptions, or slightly different ones, or find specific examples of imaginaries where not all these claims are being made (neither explicitly nor implicitly).

I claimed above that these assumptions are reductionist. By that I have allowed myself to use a broad concept of reductionism : illness is being reduced to disease; disease is being reduced to identifiable pathologies in the individual body; wise governance of life with disease is reduced to medical intervention; the good life is reduced to health. We may add that there sometimes are flavours also of genetic reductionism and upward causation (from molecules to cells; from cells to tissues) in these imaginaries.

We might wish to enter detailed discussions about each of such assumptions. We may entertain detailed, sophisticated conversations with medical scientists and practitioners about biological complexity, epigenetics, upward and downward causation et cetera, going into cutting-edge details from life science research. In this book chapter, however, I wish to do something else: simply state that there is established knowledge in the thought collectives of health science, psychology, philosophy of science, philosophy of medicine, complexity theory, philosophical anthropology and, I expect, other fields that I do not know well, that undermine the set of assumptions 1-6 above. Just to give some examples, Mervyn Susser (1973) introduced the distinction between illness, sickness and disease almost 50 years ago, and there is a huge body of research that shows that these categories are distinct and cannot be reduced to each other (Hofmann 2002). Georges Canguilhem (1966) provided his profound analysis of the non-triviality of the distinction between the normal and the pathological much before. Well-established critiques of medicalization and healthism have been around for decades (Ilich 1975; Skrabanek 1994). For those of us who are familiar with this type of knowledge, we know that there can be disease without illness, illness without suffering, suffering without illness or disease; other values in the good life than health; different concepts of health; ways to live and die with illness and disease that sometimes are better than undergoing treatment, and so on and so forth. If we choose to converse with scientists trained only in the natural sciences or in biologically oriented medicine, or with medical practitioners from conventional medical schools, it may be that our interlocutors are unfamiliar with these sources of knowledge. It may also be that they have little interest in or respect for these bodies of knowledge, which invariably have less in common with the ideals of exact physical science than at least they believe medical science to have. And so we may find it worthwhile to translate our insights into their vocabularies, conceptual schemes and paradigms. Accordingly, we talk and write about epigenetics, complex adaptive systems, mirror neurons et cetera when we could have expressed the same points better in our own thought collectives that allow the vocabularies of the humanities and social sciences. Rather than epigenetics, we could have talked about how the life of a human is imbued with meaning and sense and entangled into the lives of other humans and non-humans, and how each of us meets the existential challenges of defining our sense and purpose, and of coming to terms with and ascribing meaning to our own mortality and vulnerability. For some individuals, as their (our!) minds and bodies become old and weary, perhaps with metastases, or with onset neurodegenerative disease, or simply with our vitality ebbing out, it may or may not be that biological disease interventions could improve quality of life or the capacity to live a good life; it may equally well be that such interventions are irrelevant to the existential challenges of living and dying. The assumptions A-F might have worked if humans were Cartesian machines, but we are not. Even by the Cartesian scheme, we are absolutely not mere machines or mere animals. Already Descartes recognised this in a way so different from the cardboard figure that sometimes is taught in poor classes of philosophy:

So instead of finding ways to preserve life, I have found another much easier and surer way to deal with death, which is not to fear it. But this doesn’t depress me, as it commonly depresses people whose wisdom is drawn entirely from the teaching of others, and rests on foundations that depend only on human prudence and authority (Descartes 1646, p. 183).

To sum up, as activists and citizens, in our mission to improve the world and specifically the institutions and practices of healthcare, we may find it important to translate anti-reductionist insights in order to dissent, challenge and destabilize reductionist imaginaries. When we meet between ourselves, however, as well-read philosophers , this knowledge question is perhaps not so pressing. We know that these assumptions do not hold in the general case.

“We Have Never Been Modern”: On Fantasies and Futures

Let us dwell for a moment, however, on our experiences with engaging with the knowledge question in debates and conversations with the proponents of these reductionist imaginaries. Were they easily impressed? I would be interested to know if they were; in my experience the immediate response varies from rejection to intellectual curiosity while the long-term response, in terms of change in imaginaries, plans and policies, is meagre or absent. In this sense, we may criticize them for promoting fantasies, that is, imaginaries that are irresponsible in their representations of reality as we know it.

Such criticism tends – again, in my experience – not to make a great impression, either. I think there are a number of relatively independent reasons for that. First, there are of course situations in which the conversation does not take place in mutual good faith and in which the interlocutors do not wish to respect the norm of intellectual truthfulness when the outcome of the conversation may be detrimental to their own interests, which could be prospects of profit, power, status or also an identity project or otherwise a psychological or existential matter. There is marketing, hypocrisy and illusion. I am mentioning this not because it is my main experience, but to acknowledge that lack of good faith also is a real phenomenon in this world.

There are more interesting explanations, however, than those ascribing behaviour to interests. One explanation is that of a particular brand of scientism that comes together with reductionism and which creates tensions with intersubjective mutuality and communicative action, to borrow two terms from Habermas. It is the position that validity claims from holders of knowledge that is non-scientific or belonging to other academic fields than those endorsed as appropriately reductionist, in principle are inferior. Accordingly, to the extent that they contradict reductionist positions, truth claims or beliefs, they do not deserve to be taken into serious consideration. More than incommensurability this is perhaps to be likened with sectarianism. This type of attitude is rarely stated in writing. A prominent exception is the introduction to Francis Crick’s (1994) The Astonishing Hypothesis. The hypothesis that Crick finds so bold, astonishing and credible is that humans have no free will; he takes the exact sciences to prove this claim. In the introduction, he reveals that he is aware of the long debates around free will in philosophy and psychology, but simply dismisses them as play with words: “You do not win battles by debating exactly what is meant by the word battle.” (Crick 1994, p. xi). While Crick might be in for surprises if he got to discuss with military strategists, the point of the metaphor is not only clear but revealing: knowledge and power come to the same thing, as Francis Bacon wrote more than 300 years earlier.

Another explanation belongs more to psychology: knowledge is not necessarily the crucial element when people make up their minds on political issues. This is well known with respect to elections and the general electorate. There is little reason to believe that the scientists, policy-makers, entrepreneurs and other stakeholders who take part in the creation, shaping and promotion of sociotechnical imaginaries are different. The reason that some might express, is some kind of modernist belief in the superior rationality of the scientific and political elites of the modern society; that they indeed are the philosopher-kings, as it were. This belief is in no way confirmed by empirical studies of science in practice, ever since Kuhn. More fundamentally, such modernist beliefs tend themselves to make assumptions about the clean separation between facts and values, and reason and passion, that contemporary philosophy thought collectives to a large degree abandoned with the critiques of positivism. Reductionist types of biomedical science and non-reductionist types of health science are value-laden each in their own way, and when knowledge claims clash, it is by no means certain that it is a case of clean, value-free commensurability and theory choice.

More importantly, there is the sociological explanation that was provided by Steve Rayner (2012) with his concept of socially constructed ignorance. The abstract of his paper begins as follows:

To make sense of the complexity of the world so that they can act, individuals and institutions need to develop simplified, self-consistent versions of that world. The process of doing so means that much of what is known about the world needs to be excluded from those versions, and in particular that knowledge which is in tension or outright contradiction with those versions must be expunged. This is uncomfortable knowledge . The paper describes four implicit strategies which institutions use to keep uncomfortable knowledge at bay: denial, dismissal, diversion and displacement. (Rayner 2012, p. 107).

That is, the institutional situation, and indeed the individuals’ own work, becomes impossible or unbearable if one allows oneself to be confronted by uncomfortable knowledge and acknowledges it. Anti-reductionist insights are instances of uncomfortable knowledge in institutions of health practice and policy that build upon and embody reductionist assumptions.

Finally, and most profoundly, it is important to realize that imaginaries and knowledge claims are different in that imaginaries are descriptions of desired future states while knowledge claims are representations of present reality. Knowledge claims, especially those analogous to impossibility claims – “it is not possible to cure cancer ; it is not possible to make people happy just by giving them a pill” – are subject to the counter-argument that it is not thought to be possible yet, but that in the future, we will have advanced our knowledge and in the course of that process have falsified and rejected our impossibility beliefs. Who would have thought that phenomena such as radioactivity, black holes, moon travel, and the internet were possible? The idea of “the science of the future” implies the idea that some of our present claims to knowledge may turn out to be false and that we should be cautious with giving current knowledge too much weight, especially in decisions in which conservatism might impede progress. If our knowledge is poor (in this sense), it may even be rational under certain circumstances to ignore it and place more emphasis on imaginaries and their corresponding action plans to improve the state of knowledge. Bruno Latour (1993) made the case that “we have never been modern” in this sense; that the development of modernity with its idea of scientific and political progress, indeed rested on the ideologies of scientific objectivity, of the dichotomies between science and politics; facts and values; nature and culture; and reason and passion, while the practices of modernity never assumed or upheld these dichotomies. Although Latour to my knowledge never used the term himself, the ideological work in modern society, what he called the work of purification, was a matter of ideology in the classic sense: of false consciousness.

This explanation does not render the knowledge question irrelevant. The fact that we know now – at least those who have made themselves familiar with it – the importance of the distinction between illness and disease, is not rendered irrelevant by the logical possibility of creating a future where such a distinction does not hold or has no relevance anymore. Likewise, today it is a fact that humans hold dear to them many other values than that of good health. It may be logically possible to create a future in which humans by far value health over any other aspect of life. What is at stake, however, is not just the epistemic question of what is the case and what might become the case, but also the normative question of what is desirable. The philosopher of biology and medicine Wim van der Steen (1995) was always careful to point out that the counterpart to value-laden facts are fact-laden values. The normative questions about what kind of future may be desirable, can be reasonably informed by facts about the present and facts about reasons for valuing aspects of the present. It means, however, that if we wish to engage in conversations about the knowledge question as we called it above in order to engage in the coproduction of imaginaries and the shaping of the future, we are well-advised to acknowledge that it is a normative question as much as a descriptive one.

What Is a Stake? The Possible Impacts of a Fantasy

If we pursue the line of argument that I have sketched above, the pertinent question becomes: what is at stake?

There can be no unique answer to that question and no monopoly on answering it. The formulations of the sociotechnical imaginaries of personalized/precision medicine have their own (explicit and implicit) answers to it: diseases cause tremendous illness and suffering, and by pushing for further advances in biomedicine, the suffering may be reduced.

In the existing, rather shallow political debates on the development of biomedicine, risks to privacy and the spiralling costs are among the foreseen side effects of the merger of biomedicine and big data .

Given the enormous scope and size of the health sector in modern societies, however, there is almost no end to the list of what issues may be at stake. On a level higher than individual economic interest, personal as well as corporate, there is no doubt that the governments in industrialized countries invest hope in personalized/precision medicine as part of the envisioned emergence of a bioeconomy that will replace old, fossil-fuelled industries and take especially Northern and Western countries out of chronic economic stagnation. As an instance of imaginaries of technoscience, personalized/precision medicine both reinforces and borrows credibility from sustained visions of capitalist societies with wealthy and healthy consumers. It is part of what Foucault called biopolitics . This is why the issues of growth, de-growth and post-growth also are at stake. Be it politically incorrect, the question is what effect increased longevity and an increased health sector will have on mankind’s huge challenges of sustainability. How many of us are going to live for very long and how much are we supposed to consume during these lives? I will leave this as an open question.

At the individual level, for those who are facing grave illness and disease in the present, hope and despair are what may be at stake. While there is little reason to believe that the prospect of lethal disease and painful death was less terrifying and appalling to the human beings of the past, the difference now is that the metaphysical catastrophe of the suffering individual, through social media and mass media, may mobilize political power. Brekke and Sirnes (2011) coined the term “the hypersomatic individual” to describe how the fatally ill of our time and culture may succeed in mobilizing so much political attention that even governments may be pressured to increase budgets, change health priorities and even change laws. The hypersomatic individuals approaching their catastrophe, cry out that Science could and should save them, had it not been for political shortcomings (lack of funding, strict regulation of biotechnology, ethics that slows down research):

There are no inherent obstacles or pitfalls of science that could stop the realization of revolutionary cures. Therefore, this is not about science; it is all about politics (p. 356) […] individuals caught in a somatic reality with a shrinking space for action and coping, and the future is seen as determined by medical diagnostics and prognoses. In this general biosocial condition of being “locked in,” there is an urgent need for emergency exits that manifests itself in a fundamental desire to escape the limitations of scientific uncertainties and rational calculations of risk. The main escape route is constructed by conflating time and institutional fields: the future is swallowed by the present, and the scientific by the political. The morally correct political actions will produce fundamental scientific breakthroughs in the present, and thereby create medical alternatives for the paralyzed biocitizens who otherwise have no alternatives (Brekke and Sirnes 2011, pp. 357–358).

The result is that the value of justice as fairness suffers as experiments to treat high-status diseases such as cancer gain resources at the expense of a number of other health problems and social causes.

Brekke’s and Sirnes’ (2011) analysis focused on political power. At the same time, it seems reasonable to speculate what the developments – real as imaginary – have of impacts on cultural understandings of the good life and the good or bad death (Engen 2017). In this sense, in terms of what is at stake for the human condition, it seems pertinent to invoke the insights from 40 years of discussion of medicalization , since Ilich. Vetlesen (2009) has warned against a medicalized culture that contributes to individual and collective avoidance and denial of the basic conditions of human life such as that we humans are vulnerable and mortal and that we depend on each other and the potentially fragile relationships between us. We may recall the exemplary future patient imagined by ASCO, who should and will devote considerable attention to the scientific understanding and management of her or his disease, even when ill. How will one’s salutogenic potential, that is, one’s bodily and mental resources and potentials to support own health and well-being, change if personalized medicine becomes a reality, or alternatively, the imaginary becomes absorbed into culture and self-understanding? How much attention will be left to create a sense of meaning of one’s condition together with family and friends, to create, develop and experience love in the midst of suffering or as life ebbs out? What role will spirituality be allowed to play in such a culture? How might the conditions change for learning to let go of this life? By stating this multitude of open questions, I do not pretend to know that the impacts will all be negative. Rather, the impacts are in principle uncertain and the attempt to realize such imaginaries is an open-ended social if not civilizational experiment, both what concerns their intended, unintended and unimagined consequences. It is fully imaginable and, I would argue, plausible from a non-reductionist position that the full impacts might become quite undesirable even if some of the reductionist dreams come true.

The New That Cannot Be Born

Antonio Gramsci (1947) famously wrote: “The crisis consists precisely in the fact that the old is dying and the new cannot be born; in this interregnum a great variety of morbid symptoms appear.” What he had in mind was the socioeconomic and political order; the main morbid symptom was fascism.

Together with my colleagues, Anne Bremer (née Blanchard) and Caroline Engen, I have wondered if not Gramsci’s quote also might provide a lens for interpreting the emergence of a “war on cancer ” in the 1970s and the imaginaries of personalized/precision medicine of the 2000s (Blanchard et al. 2017). If these imaginaries are seen as a morbid symptom, what is the old that is dying and the new that cannot be born?

We have argued that the old that is dying may be the Cartesian dream of freeing ourselves “from countless diseases of body and of mind, and perhaps even from the infirmity of old age” (Descartes 1637, p. 25). Above I noted how Descartes himself appeared to be able to distinguish fantasy from reality and wake up from this dream (see also Schei and Strand 2015). The dream lived on, however, as a programme for the abolishment of suffering, death and, more fundamentally, uncertainty. Claude Bernard wrote the following, 200 years after Descartes:

Absolute determinism exists indeed in every vital phenomenon; hence biological science exists also; and consequently the studies to which we are devoting ourselves will not all be useless. General physiology is the basic biological science toward which all others converge. […] By normal activity of its organic units, life exhibits a state of health; by abnormal manifestation of the same units, diseases are characterised; and finally through the organic environment modified by means of certain toxic or medicinal substances, therapeutics enables us to act on the organic units (Bernard 1859, p. 65).

Indeed, it is instructive to read Bernard’s accusations against epidemiology and clinical science for not being truly scientific because they deal with variation and not determinism. While it would require a more detailed analysis than presented in this paper, it should be possible to show not only the reductionism but also the implicit and latent determinism within the imaginaries in particular of precision medicine .

The “old”, then, can be understood as this dream and programme of denial, rejection and declaration of war on suffering and death by means of the weapons of medicine. Its form of dying, of degeneration into morbid symptoms, is the practical reductio ad absurdum when the weapons are turning against the human condition itself, creating threats to our cultural and existential resources and practices for creating good and meaningful lives, as well as absorbing and consuming ever more economic resources to the point where no government or insurance can pay anymore, and social and individual life becomes fully absorbed in a war against death that we are bound to lose.

What is the new that cannot be born yet? It seems to be very simple: The new is to come to peace with our own mortality and vulnerability as a fundamental condition not only for life, but for the good life. It is new, but at the same time, very old, not only the wisdom of Descartes after he woke up from the Cartesian dream; it is of course as old as all written sources, going back to the Old Testament, to the Greek philosophers, to the Daoists; to all traditions that regarded humans as having not only a physical body and an intellectual mind but also something more, sometimes called a soul and sometimes a spiritual life. In this sense it is born, it has always been there, and it still is. Unfortunately, however, the ideological work of purification in modern civilizations demanded that we pretend as if it does not exist. This is the paradox, then, of modern medicine, brought to its climax with precision medicine : It insists on the disenchantment of the world in order to make us believe and opt into a fantasy.