One of the underlying themes I return to frequently on Medical Humanities Blog is whether genetics at the present has a pronounced effect on population health. This empirical question is important to a normative inquiry that I am most interested in, regarding the priority to which we should order goals as they relate to health. If we posit, for example, that compressing certain health inequities is a normative goal, the empirical question of which policies and practices we are most justified in believing will satisfy the criterion turns out to be critically important. This follows partly from Deborah Stone's observation that policy is inevitably contested space, and there are always opportunity and switching costs that must be expended on meeting any policy objective, even if there is no outright opposition to the putative objective. One obvious example of an empirical proposition which has important consequences for a prioritarian assessment of how best to allocate scarce resources to population health objectives is Sir Geoffrey Rose's prevention paradox, which Peter Allebeck nicely explains here:
The key messages of Geoffrey Rose may be summarized as follows: the distribution of risk levels for major determinants of disease follows a continuum in which the high-risk persons are at the extreme end. A large number of persons with moderately increased risk levels contribute more cases than a small number with extreme risk levels. Thus, interventions targeting the general population, aiming at shifting the risk curve to the left, are more effective than interventions targeting high-risk groups. This latter is called the prevention paradox, since it is not the individuals with moderately elevated risk that have the greatest benefit from such interventions.
The paradox consists of the fact that the least advantaged here -- the groups who tend to be at highest levels of risk -- seems to command normative priority, and yet Rose's analysis suggests that doing so will have a lesser impact on population health than interventions targeted at the general population (and hence the population of less than highest-risk). So there is an argument from a population health perspective for directing more resources to the general population than the most high-risk, who tend to be those populations suffering from the most deprivation.
This is not to be mistaken for the naturalistic fallacy. What we ought to do certainly does not follow from descriptive claims, even powerful ones like those developed by the likes of Geoffrey Rose and, e.g., Michael Marmot. The metaethical point here is simply that the "is" informs (but never determines) the "ought," which ought to be entirely uncontroversial, in my mind. (Humanists like Montaigne certainly thought so!).
My argument, based in part on arguments made by Richard Lewontin, and Claudia Chaufan (and also influenced strongly by Evelyn Fox Keller's framework for thinking about genes and metaphors), is that the best evidence suggests that the scientific practice of genetics in its current state has only a weak connection with population health. The argument is even sounder when applied to populations in the developed world, who have even less chance to benefit in the reasonably foreseeable future from developments in the genetic sciences.
None of this supports an argument that we ought not study genetics. But if there is reason to believe that the praxis of genetic science has only an attenuated connection to population health, one which is in the reasonably foreseeable future not likely to compress health inequities or affect the structural foundations of health, the pressing normative question becomes why is such significant social and economic capital being devoted to the praxis of genetic science? (I assume without argument that my empirical claim here, that we spend comparatively significant amounts of money on genetics in comparison to, say, capital expended on ameliorating the social determinants of health. If able readers dispute this assumption, they are welcome to respond in the comments).
All of this is a buildup to an interesting article authored by Nicholas Wade in the New York Times entitled A Decade Later, Genetic Map Yields Few New Cures. Wade writes
Ten years after President Bill Clinton announced that the first draft of the human genome was complete, medicine has yet to see any large part of the promised benefits.
A nice, direct lede. The entire article is worth reading in full, and I won't excerpt it much here save to note that it is reasonably well-written, and is quite relevant to the arguments discussed above. I was perhaps most struck by the quote from Harold Varmus, who is both a Nobel laureate and a former director of the NIH:
"Genomics is a way to do science, not medicine."
This is an intriguing distinction, and seems salient to the empirical question identified above as most interesting to me: the connection, in the reasonably foreseeable future between genetic research and population health (the irreducibly speculative nature of the claims of a powerful connection at some time t in the future is epistemically shaky, and the shakiness is itself an important criterion for evaluating the weight of the claim).