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Part V: Progress and Its Problems The Future of Alzheimer Disease
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PART V Progress and Its Problems The Future of Alzheimer Disease Inside every large problem are a dozen small ones struggling to get out. This corollary to Murphy’s law might well seem applicable to progress in Alzheimer disease (AD), except that in this case it is difficult to discern if the problems solved are bigger than the ones set loose. The chapters in this section consider the tremendous prospects for progress in the biomedical science of AD, particularly in the area of molecular genetics. But they also consider the sorts of challenges this progress may create in the realms of politics and ethics. Larry Altstiel and Steven Paul provide a cogent description of recent progress. Their chapter describes how molecular biology has revolutionized AD research, surveying the current state of the field and the prospects for developing therapeutic agents that not only relieve some of the symptoms of cognitive decline but also slow disease progression and reduce its incidence. The identification of specific gene mutations and proteins involved in AD, the development of a transgenic mouse to test new drugs that models both AD pathology and cognitive decline, and explorations of the role of estrogen in the maintenance of the neurons affected by AD—all these provide ample reason to hope that new and effective therapeutic strategies will be developed in the foreseeable future. Although these strategies are a result of the ‘‘new biology,’’ Altstiel and Paul point to their connection to the foundational clinical studies carried out by Alzheimer and his contemporaries. They conclude that the tradition of painstaking clinical observation is as important in the age of molecular biology as it was in Alzheimer’s time. For all its obvious promise, what sort of problems might such prog- 258 Concepts of Alzheimer Disease ress create? In the first place, there are problems that may be characterized as the inadequacy of politics and policy to keep up with the exponential growth of knowledge and technical capacity. Scientific progress in understanding the biological mechanisms of AD, creating diagnostic technologies, and developing treatment strategies occurs at a dizzying rate. But consensus—or even informed discussion—about what to do with new knowledge and technology comes slowly at best. Robert Cooke-Deegan’s chapter describes the tremendous progress in the field of molecular genetics in the last few years, and he agrees with others that it is poised to make even greater strides in the near future. But he also discusses how such progress raises daunting challenges to existing policy arrangements, such as the potential for tests to determine genetic susceptibility to AD to segregate private-sector long-term care insurance markets in the United States, undermining the system just as it is about to undergo the strain of the aging of the baby boom generation. He discusses how entirely new issues, which policy makers have scarcely begun to consider, are created as well—issues such as the potential claim of volunteer subjects of genetic studies to a share of the profits that are increasingly being reaped in the development of new biotechnologies that have been developed only through the use of their tissues and family histories. Beyond these issues of how best to manage the fruits of scientific progress, it is possible to ask more fundamental questions: Is there a fundamental antipathy between biomedicine’s rational, reductive, and instrumental approach to the complex problem of dementia and the sort of relational, spiritual, and aesthetic approach that Stephen Post argues (see Chapter 13) is necessary to respect the human integrity of the demented? Does the intense focus of resources and the fixing of all hope on the development of effective treatment at the molecular level impoverish the cultural and spiritual resources needed to care for the demented ? Peter Whitehouse explores these issue by raising the specter of the postmodern—arguing that there are both limits and dangers to our knowledge and our ability to control the world in order to solve the problem of dementia. Noting that dominant approaches to dementia have historically alternated between the social and the biological, Whitehouse considers whether, despite the heady prospect for progress of molecular biology, social approaches to the problem of dementia may again become prominent. He concludes by suggesting that ‘‘quality of life’’ may be a concept that can frame dementia in a way that allows us to bring the resources of biological, social, and spiritual approaches to bear on the problem. [44.204.164.147] Project...