Aaron Ciechanover: the revolution of personalized medicine

Many call personalized medicine the third revolution of medicine, a paradigm shift. The first was the era of incidental discoveries, such as penicillin or aspirin (1900s-1950s). The second revolution was based on the brute force screening of large libraries of chemical compounds (1970s – 2000s) tested to see if they have any effect. And the third started with the sequencing of the genome and is based on personalized medicine.

Broadly speaking, personalized medicine is the tailoring of medical treatments to the characteristics of each patient. Aaron Ciechanover received the Nobel Award in Chemistry in 2004, along with Irwin Rose and Avram Hershko, for the discovery of ubiquitin-mediated protein degradation. During his visit at IBioBA, as member of the Scientific Advisory Board (SAB), he talked with us about personalized medicine, its impact and how, as society, we should foster the debate to understand its benefits and its limits.

“We should encourage [the development of] personalized medicine. It’s going to be specific to the target, it is going to cure more people, it will have less side effects. Take the case of women with breast cancer: they undergo mastectomy, chemotherapy, radiotherapy. We are shooting with big cannons at little flies.  Personalized medicine is a much milder procedure, directly to the problem. It is here but it’s coming with a price and we should understand what the price means from a moral, ethical, religious, cultural and historical point of view”, he says.

Which are the main characteristics of personalized medicine?

It is called the four Ps: personal, predictive, preventive and participatory. Its personal, but it is also predictive, because we can predict the occurrence of certain diseases. And since it is predictive it is also preventive, because if I know what it is going to happen to me in the future then I should do whatever I can to prevent it. For instance, if I know that I have a gene that produces too much cholesterol, then I should start early on to take cholesterol- reducing drugs or avoid certain foods. And, finally, it is participatory: patients should take part in the decision-making process about their own fate.

How can they be part of the decision?

When I started medicine, medicine was pretty authoritative. The doctor was god. Now, patients question more, research online, they know how to ask questions. We should never underestimate the wisdom, experience, and cleverness of the patients. They don’t have to be university graduates in order to understand the situation. Then he is not god anymore but kind of a professional consultant, and he cannot tell a woman to take her breast away, it’s a very personal decision. I can tell her the chances, ‘this is the risk, these are the statistics’, but the decision is between the patients and his/her loved ones.

What about statistics? Now we can say that someone has a certain probability of developing a determined condition, but we cannot provide 100% certainty,

The probability will be solved. It’s a matter of statistics, right now this is new and we don’t have samples large enough. But once we have them, the probability will become more and more certain and the borders will become narrower and narrower.

Which do you feel are the issues and debates that may arise in regards to personalized medicine?

As we advance on the knowledge, statistics will become more significant about the significance of each mutation, and that’s a very important bioethical issue. Imagine two people that fall in love, out of coincidence, because they meet in the bar. In the future they may want to know more about one another, and how their children will look like, and they will want to test one another genetically. Or imagine governments, some might take an interest on this, let’s say, to have a very strong army. Even health insurance companies may also have an interest: ‘We don’t want to insure people that may have this disease’. It will shake our traditional way of life, from marriage to employment, to insurance, to government, everything.

What about fetal screening for diseases?

There comes another issue: gene editing. CRISPR. You may argue: ‘Ok, if there is a defect let’s correct it’. So it has come to the issue of editing babies or embryos? In my opinion it should be banned altogether, we shouldn’t touch it at all. But it is not only about diseases.  Let’s say a mother wants to help her son being a basketball player, or wants him to be Diego Maradona or Pelé. Will she ask to edit the genes to make the boy taller, or faster? So the question is a moral issue: whether the mother has at all a say on the future of the child or whether you have the right to decide over someone other than you.

But as society we are addressing those issues. Last year there was a debate on a paper concerning gene editing in an embryo in China.

And there was a huge protest against it. There are many ways to circumvent gene editing in babies: you just don’t have to do it. If there is a severe disease we can handle it in different ways. But once you are doing gene editing the sky is the limit. If the mother thinks that black hair is a defect, she may want to have blond babies because for her black is intolerable. Or minor defects that are really nothing. So it’s really on the eyes of the beholder, because once we cross the border it’s a slippery slope.

Do you think that as society, worldwide level, we are ready for this debate?

If we are not ready for this debate, then who is ready? Who will discuss our future if not ourselves? If people do not understand the tool, then it then should be explained to them. Society should take its faith in its own hands, and that is my strong belief. We already screen patients looking for mutations of oncogenes for cancer treatment. And the problem is that society somehow expects scientists and physicians to solve this debate but they are professionals, they can consult but they are not here to solve it. It’s an issue to be addressed by the society as a whole, by referendum, by discussion among the public politicians, sociologists, psychologists, philosophers, writers, clergymen, etc. I think we should hurry because science doesn’t wait, and if science doesn’t wait and there is no regulation by the society, then we can expect more cases as the one of embryo editing in China.