The Uncertain Future of Medicine

Patients standing in their pharmacy astonished and worried, because they have been told that their prescriptions are unavailable. Such shortages of standard medicines such as antibiotics or L-Dopa have been rare for a long time in Germany. Fortunately, these incidents are relatively few, so there’s no need to fear that patients will flock in the streets to die due to a lack of medication. However, these unforeseen delivery difficulties are hardly compatible with the ideal of a solidarity-based healthcare system supposed to provide every patient with the best available treatment, relative to the patient’s needs not his or her financial capabilities. Other areas of healthcare are also falling behind the usual, cherished standards: waiting times for urgent diagnostic tests and surgeries are increasing considerably, and there is a shortage of qualified personnel. Additionally, there is an ever increasing lack of money—money for investments, for innovations, and for the day to day operations of the healthcare system.

Healthcare is in crisis—in Germany as well as other countries of the global North having healthcare systems with a similar ideal of providing the best available treatment to all patients! The German government now committed to repair and reform the national healthcare system—as did the previous government and the one before and before and so on. Thus, with each legislative period, the state of affairs is reassessed, commissions are set up, experts are heard, and reports are written. These reports often assess the recommendations of the last report very critically, while being less dismissive towards the older ones, sometimes even reviving recommendations from the past. The goal of the reforms is to stabilize the finances of the healthcare system—with limited success, as costs continue to rise and the contribution revenue is shrinking. The middle class, which has largely borne the financial burden of the healthcare system in recent decades, is thinning out. Moreover, signs are emerging of a global elite, whose members could easily weaken the solidarity-based system by purchasing the best healthcare services on the global market. As a result, a two-tier medical system—one for the wealthy and one for the poor—could emerge, with corresponding doctors for the rich and “poor doctors” for the less fortunate. The well-cultivated image of a doctor who serves all those in need equally would no longer be realistic.

We have become so accustomed to the existing healthcare system with its high standards for everyone that it is easy to lose sight of the fact that it is a relatively recent development that began just over 150 years ago. The emergence of this modern healthcare system is by no means solely the result of successful medical research and practice. Societal developments—such as the rise of modern mass democracy—have played a significant role in the formation of a general, institutionally secured healthcare system.

Much suggests that the tremendous success story of medicine will continue into the future. The new possibilities to intervene in human biology more deeply and precisely than ever before hold enormous potential to improve the understanding and treatment of diseases. Modern programming methods—such as machine learning and artificial intelligence—allow for the use of vast amounts of health-related data for the diagnosis and therapy of diseases. These and other approaches in current medical research raise questions that are of societal significance, extending beyond the narrower realm of science. Among scientists, it has largely become accepted that such often normative questions cannot be answered by science alone but should be addressed jointly with politics and society. Here again, it becomes apparent that while ‘successful science’ is one of the most compelling arguments for promoting scientific medicine, it alone cannot guarantee the necessary financial and institutional frameworks.

Medicine is not an isolated sector of society but is closely interwoven with it. The principles by which a society’s political order is structured will therefore also influence the organization of the healthcare system embedded in that society. An authoritarian state like China can easily impose medically questionable measures to contain the COVID-19 pandemic—such as forcing megacities like Shanghai into weeks-long lockdowns. In contrast, much less stringent measures in Western democracies already lead to partly massive and even violent protests, and are sometimes overturned by courts.

Just as healthcare is closely connected to society, so too is medical research. The majority of this research is funded with public money. The main reason for this is that society hopes to gain social benefits from this investment in medical research. Although the connection between practical benefits and public funding seems plausible, its implementation raises many questions—such as how ‘social benefit’ should be measured, by what criteria the available funds should be allocated, and who is allowed to participate in this negotiation and distribution process.

Scientific progress, especially in groundbreaking discoveries or inventions, takes new directions, which often means that previously accepted hypotheses or theories are questioned. This frequently leads to controversial discussions among experts about the validity of a discovery or invention. Without free and critical discussion, even of controversial topics, science would likely develop much more slowly and less successfully. A key demand on the government is to secure places for scientific freedom of thought and the exchange of ideas (within the limits of freedom of speech, of course). Developments such as the so-called cancel culture and the recent protests, particularly at American universities, show that freedom of thought must be protected against destructive developments outside and inside the university.

It can be noted that medical research in liberal democracies has a certain credibility. By comparison, if one considers how China’s autocratic leadership suppresses and silences critics of its COVID strategy while implementing draconian and scientifically questionable measures to contain the pandemic as a 'people's war against the virus,' it becomes clear what we stand to lose. The fantasies of then president Donald Trump regarding his competence as the top COVID fighter show how quickly a system of scientific advice to society, proven over decades, can come under pressure.

The hope that successful medical research alone is enough to secure its own financial and institutional future is deceptive. On the one hand, other societal sectors, such as education or national defense, have their own success narratives, with which modern medicine competes for societal and political attention. On the other hand, events beyond the control of science—such as a war—can occur, potentially diverting societal attention away from science.

Whether medicine will succeed in overcoming the challenges it faces on its path into the future remains to be seen. Given the success of modern medical science, the effort is certainly worthwhile.

For a more detailed discussion of these and other problems connected to the development of a future medicine see: Felix Thiele (2024). Medizin im Wandel. Aufbruch in eine ungewisse Zukunft. Brill/Mentis.