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Jessica van der Schalk

The (un)changing doctor-patient relationship

Sapere aude, the famous phrase of Kant generally translated as “dare to know”, could be marked as the institutional start of democratization during the Enlightenment. Man rid himself of his immature beliefs and grounded his life in reason and argument. In the following two centuries, this self-liberation of citizens led to empowerment in most cultural, political and economic institutions. Remarkably, health institutions stayed significantly behind. Healthcare became institutionalized and more widely available, but when it came to understanding our own health, all citizens remained laymen, helpless when confronted with illness. Therefore, scholars and physicians have repeatedly advocated the democratization of the doctor-patient relationship to empower patients and promote their self-reliance. With the advent of digital health and the internet, the empowerment of patients seems to be partially achieved, but not every part of the relationship can or should be democratized.  

Our observations

  • The internet is a great source of health information but searching for an explanation of our symptoms can be a real hassle. Healthcare start-ups such as Ada are trying to address this problem. The company has created an AI-powered tool to help patients with their self-monitoring and health management. Once you have typed in your symptoms and answered a series of questions, the AI calculates and displays the likelihood of possible diseases, based on a growing database that matches your age and gender. The app makes clear it doesn’t officially diagnose, but only supports the process of self-monitoring. 
  • In the digital age, self-tracking for health is no longer the exclusive province of chronic patients or fitness geeks but has become widespread. Almost every smartphone OS has apps to make basic measurements in the background of our daily life. Consequently, even without explicit health goals, we’ve all started to collect valuable health data. On the one hand, these new flows of data have resulted in digitally engaged patients and have increased their autonomy. On the other hand, health data is often privately owned and part of wider disciplinary programs or monetization strategies from companies or states, which does not always empower patients.  
  • Nowadays, placebo effects mainly have a negative connotation, as they are associated with false clinical results. However, according to this article, this reputation is slowly changing. Instead of debunking the non-medical effects, we should embrace the psychological effect of placebos in medical treatments. The underlying argument is that emotions trigger biological processes and should not be seen as something separate or non-relevant. These triggered interactions of neurological, immunological and hormonal processes interfere with medical treatments and could strengthen or diminish their effect. In other words: medical treatments would be more efficient if doctors were aware of the importance of attributes that evoke positive emotions, such as trustworthiness, intimacy, authority, wisdom, etc. Not as something important besides the medical treatment, but as an inherent part of it

Connecting the dots

For more than half a century, scholars have envisioned and advocated the democratization of the doctor-patient relationship. In short, it means the shift from paternalistic doctor-centered medicine to more democratic and patient-centered medicine. While the first is characterized by authority and knowledge asymmetry, the core principles of the second are equality, mutual participation, long-term engagement, the patient-as-a-person (instead of a biological reduction), and shared decisionmaking. These principles should result in clear benefits for the patient: empowerment, autonomy and, importantly, better health outcomes, because who knows the patient better than he knows himself. 

Although the scientific discussion of democratization can be traced back to the ’50s, in the last two decadesdigital health has enabled the empowerment of the patient. It started with the internet and Google. Information about health and disease is only a few mouse clicks away. Within minutes, patients can acquire information about any symptom or disease. And then wearables arrived on the market. To measure is to know. Endowed with wearables and dwelling in environments packed with sensors, citizens now continuously collect health data, monitor biometrics and self-diagnose disease. As well-known cardiologist Topol describes in one of his latest books, the patient is evolving into a sort of COO of his own health

The rise of informed, connected and engaged patients in the daily practice of healthcare has also evokedcriticism of democratization. Physicians who once strongly advocated it have become more reserved because they see patients turning away from expertise, demanding second opinions and overly trusting data. Furthermore, scholars are questioning whether we really want patients to interpret their health datathemselves and stress that we should take into account how this will affect them mentally. All in all, having more digitally engaged and participatory patients is undeniably beneficial to healthcare. Yet, some nuance and differentiation are warranted

First of all, neither of the terms in the equation refer to fixed entities, which means “the physician” and “the patient” don’t exist. Naturally, some relationships might become more democratized than others. A lot of severe conditions demand expertise and clinical interventions, which leaves less space for participation. However, in the treatment of chronic long-term diseases such as diabetes, shared decisionmaking and engaged patients can be extremely helpful. The same holds true for the minor illnesses and everyday care general practitioners and nurses are often occupied with. For them, having well-informed and engaged patients constitutes a good starting point, eases the conversation and speeds up the care process. 

Second, health and disease are becoming more complex and multidimensional. For instance, comorbidity (i.e. when someone is diagnosed with multiple diseases or conditions at the same time) is occurring more frequently and will be one of the main challenges of 21st-century healthcare. In light of the above, it is tempting to perceive democratization as a fruitless campaign with anything more complex than a simple virus or cold:patients simply haven’t studied medicine for eight years. Still, it might be useful to reflect on the participatory role and think about what we can reasonably expect from patients. For example, the mere process of collecting health data and monitoring biometrics, without interpreting the data, is already meaningful. Patients can manage their health database and preselect important metrics, perhaps supported by Artificial Intelligence. This patient-AI alliance could focus on selecting risk factors, early detection, and disease prognosis. The doctor arrives at a later stage. In this scenario, democratization is not so much direct empowerment of the patient, but a telehealth feature that mainly serves to streamline care paths. The ultimate challenge here will be to keep false positives within manageable rates. With everybody connected and always monitoring, we might prevent more, but also detect more, and time is one of the most precious assets in healthcare. Besides the cost of overdiagnosis, it also worries people unduly.

This brings us to the third point of nuance. In the ultimate sense, democratization refers to the ideal of a mutual and equal relationship with minimized knowledge asymmetry. However, the role of physicians far exceeds their knowledge, they are “healers” in the broadest sense of the word. Healthcare is the sum of effective therapy and moral care. Physicians and nurses always transcend the medical practice in a way. They listen to the patients wishes or worries, guide them through their illness and thereby help people reconcile with their disease. In this context, an unequal and asymmetric relationship isn’t problematic but instead beneficial for patients. It is about the doctor we trust and rely on, and who has a special sort of spiritual or even religious air about him. Furthermore, all his words, procedures or his mere presence could elicit placebo effects. Consequently, the “disenchantment” with the doctor as a result of overly enlightened citizens could undermine the mental care provided by physicians. Of course, the (placebo) effect of healers is modest with most major medical conditions, but especially in long-term chronic disease management, mental healthcare, and psychosomatic pathologies, this beneficial side of an asymmetric doctor-patient relationship should not be underestimated.  

To conclude, if we want to fully reap the benefits of democratization with engaged and well-informed patients, the doctor-patient relationship first needs to be differentiated and dissected. Subsequently, some parts of healthcare systems could be democratized while other parts remain untouched.

Implications

Higher health expectations of demanding patients and extremely engaged health citizens might eventually result in a sort of boutique healthcare, comparable to the currently rising “boutique fitness”. However, part of this trend is the loss of middle-market companies, only very expensive small boutiques (e.g. David Lloyd, Saints and Stars, and Gustav Gym), and low-cost mass-market gyms (e.g. Fit for Free and Basic fit) will survive in this market segment. It is questionable whether this outcome is desirable for healthcare. 
With the advent of digital health, who becomes in control of which health data has become a pivotal topic of debate dividing stakeholders and scholars. Topol argues that if we really want to realize the benefits of the digitally engaged patient, we should give patients the right to own their medical data. He points to blockchain technology and cooperative organizations such as HealthBank to support this transition. By contrastinteroperable data systems and integrated services are perhaps best developed and operated by big tech companies such as Apple. 

Can market forces save the climate?

Despite the pending U.S. withdrawal from the Paris Agreement and the rollback of major climate-related policies, U.S. carbon emissions have continued to decrease. It appears that the influx of cheap shale gas and other market forces play a big role, along with (remaining) public policies against coal-fired power plants and in favor of renewables. Going forward, the question is really whether, in the coming years, the U.S. can continue on its path to lower emissions in the absence of meaningful climate policies.

Our observations

  • According to the International Energy Agency, global energy-related CO2 emissions flatlined in 2019 at 33 gigatons, even though the global economy grew by 2.9%. In part, this is due to mild weather (saving energy for heating and cooling) in a number of large economies and economic slowdown in several developing economies (e.g. China). Energy-related emissions have actually dropped in Europe (5%) and the United States (2.9%), and this is mostly due to the influx of natural gas and renewables in power generation (which accounts for ~40% of total emissions). In the U.S., the carbon intensity of its energy mix has declined steadily over the last 30 years (down by 12%).
  • Along with cleaner power generation, the overall energy intensity of the U.S. economy has dropped 40%from 1990 levels. The latter appears especially relevant and multiple aspects play a role here: offshoring manufacturing (i.e. effectively exporting emissions) and the growth of the services sector, yet there’s also a clear shift away from coal to more energy-efficient natural (shale) gas turbines, more fuel-efficient vehicles.  
  • As with other bi- and multilateral international deals, President Trump has argued that the Paris Agreement is disadvantageous to the U.S., as it would (mildly) force government to take action that could hamper economic growth and result in higher consumer prices. It is, however, questionable whether the U.S. withdrawal from “Paris” will really have an impact on U.S. emissions, as it doesn’tinclude any binding norms. Yet, it is a testament to this administration’s desire to freeze or roll back climate targets and it will send a message to the rest of the world as well. Also, the U.S. is unlikely to continue to contribute to the global Green Climate Fund that is to support developing nations in their efforts to reduce GHG emissions.
  • The Trump administration has rolled back several Obama-era climate-related regulations. Most importantly, this includes the substitution of the Clean Power Plan, which placed (state-specific) limits on emissions from power generation, with the much weaker Affordable Clean Energy act. As for transportation, the administration has frozen the Corporate Average Fuel Economy (CAFE) standardsand manufacturers no longer have to reduce emissions from passenger cars by 5% per year. In addition, the state of California is no longer allowed to set its own (typically stricter) standards.
  • President Trump has been called a “climate nihilist” for whom every utterance about climate change is informed by political interests; anything to please his donors or his voters. With respect to the latter, Republican voters are likely to demand more climate-related action. By now, almost twothirds of Republicans actually believe in climate change and two surveys (one from Pew and another from the American Conservative Coalition) found that between 52 and 67% of young Republican voters indeed want the GOP to do more about climate change.
  • Like Trump, the secretary of the EPA and former coal-industry lobbyist Andrew Wheeler is not an outspoken climate change denier, but he continues to stress that the problem should be left to the free market and improved technology, rather than solutions dictated by government. The same holds true for other Republicans who maintain that government can support technology development, but that it should not impose any limitations on business.
  • Individual states and cities continue to take action against climate change. Recently, more than 250 American mayors have pledged to power their cities with 100% renewable energy by 2035.

Connecting the dots

Since Donald Trump took office, the United States has shaken off its climate-leadership feathers. Before Trump, being the global superpower and one of the top polluting nations, the U.S. participated in global climate negotiations and, indeed, took steps to reduce its own carbon footprint. In fact, starting shortly after the turn of the millennium, the United States has slowly but surely reduced it carbon emissions. And even though some of the progress can be attributed to offshoring of production and temporary economic downturn, there’s a structural trend of decarbonization of the American economy. And even today, despite the fact that the rhetoric on climate change has shifted completely and much weaker regulations have been implemented, the American economy continues to emit less and less CO2. Together, these dynamics raise the question whether stringent policies are really needed to further reduce its carbon footprint and, as a follow-up question, whether this trend can continue even if President Trump is elected for a second term.

The major gains, if not the only gains, were realized in the power sector. Here, the big story is the (market-driven) rise of shale gas, which has offered a relatively low-cost and stable alternative to coal. At the same time, the balance has also shifted in favor of natural (shale) gas due to environmental norms in relation to, for instance, mercury emissions (which are not directly related to climate change) that raised the operating costs of coal-fired power plants. The Clean Power Plan, which was the major climate-specific tool to push out coal in the future, has probably played a lesser role in recent years. Also, renewable power generation has obviously grownrapidly, but has “only” accounted for about a quarter of the reduction of coal (and some 8% of total power supply). Going forward, the new Affordable Clean Energy act will hardly affect the power sector and current plans to weaken the previously mentioned mercury (and other toxics) standards could indeed halt the decline of coal. More structural, policydriven, progress should come from states or cities. In other sectors, such as the transportation sector, no absolute reductions have been achieved, but there is still a slowdown in emissions’ growth that could be taken as a sign of the (partial) decoupling of economic growth from carbon emissions.

However, it seems that many of these humanistic starting points and principles are being criticized andpressured. First, the ongoing ecological crisis not only requires a radical overhaul of the principles of industrial modernity and economic and societal meta-rules of our socio-technical systems (i.e. a Deep Transition), but could also point to a crisis of our anthropological conception of man. If human beings actively undermine one of our “living conditions”, this might have something to do with our idea that man is at the center of the cosmos and reality. Indeed, this is one of the principles of the emerging paradigm of deep ecology that opts for a radical decentering of the human. Second, it is increasingly doubtful that human nature is being seen as something inherently good, given the problems of rampant socio-economic inequality, poverty and exploitation (of both humans and non-humans). As we own increasingly powerful technologies that create a vulnerable world, more studies are examining an earthly future without the human kind (e.g. omnicide).

So if it’s not government pulling the strings on climate action, can the invisible hand of the free market take care of this problem? It probably can, but only to a certain extent. First, businesses will continue to look for cheaper means of production and this will also entail ways of saving energy (e.g. more efficient airplanes in aviation) or finding cheaper sources of energy that today include (relatively clean) natural gas and sometimesrenewables. Second, consumers increasingly demand more climate-friendly goods and services and this will be a trigger for, at least some, businesses to deliver just that (e.g. vegan food, sustainable clothing and low-emission vehicles). Third, and perhaps most interestingly, recognizing that change is necessary and inevitable in the long run, industries tend to prefer steady and predictable policies that allow them to develop solid strategies and plan their investments. This is why a handful of car manufacturers have struck a deal with the state of California to continue to develop cleaner cars despite the federal government weakening its (CAFE) standards. These companies assume that future governments (and consumers both in the U.S. and elsewhere,as well as foreign governments) will expect them to produce low- and zero-emissions vehicles anyway and, to them, it makes no sense to halt ongoing efforts because of a temporary hiatus in American regulations(although their ambitions are lower than the original CAFE norm).

These drivers will push the U.S. to a lower carbon footprint, but in the end, they will only lead to a further optimization of the current system along the lines of ecological modernization. The real problem here is that the market can only fix problems that are reflected in market prices (e.g. high fuel costs), while the costs of climate change will take effect too far away and over too-great a timespan and will remain externalities without active public intervention (e.g. taxes, emissions trading schemes, environmental standards or other performance targets).

Implications

  • Republican lawmakers facing pressure to “do something for the environment” are most likely to seek legislation that directly favors American citizens without “hampering” business. This will include support schemes for cleantech and limited environmental norms in relation to air and water pollution. Reforestation is also a favored measure among Republicans, including Trump himself.
  • In the absence of meaningful federal action, (blue) states and cities (e.g. NYC) are likely to take more action of their own accord. Yet, it is to be expected that the White House will try to limit their room for maneuvering.
  • While a lot of emissions have been “exported” with offshoring production to emerging economies, the digital economy will result in higher domestic emissions once again. Today, the ICT sector accounts for about 1.5% of the global carbon footprint, but this may rise to 14% in 2040, much of which will come from local data centers.

Parasite signals a multipolar popular culture world

What happened?

In the Oscar academy’s 92-year history, the South-Korean Parasite is the first non-English language film to win the main award of best picture (in total, the movie by Bong Joon-ho won four Oscars). This is a remarkable success, especially when compared to Netflix’s performance at the award show, with 24 nominations, but only winning two Oscars and its most-hyped movie The Irishman not winning any Oscar at all. Immediately, international filmmakers and distributors considered Parasite’s success not just as a case for the Oscars to encompass more than just Western films in the future, but also more general to open the door to global cinema.

What does this mean?

In his acceptance speeches, Bong Joon-ho specifically recognized and quoted the famous American film director Martin Scorsese (director of The Irishman) as his source of inspiration. Also, the movie follows Joseph Campbells hero’s journey, the storyline that is typical for many American movies. Still, Parasite is getting audiences around the world to watch non-English content, something that has been considered a challenge before. Furthermore, in an interview, Bong Joon-ho recognizes that the movie caries very subtle details that Western audiences won’t notice, such as the meaning of the Taiwanese cake shop in the movie, that stands for a failure of trying to make it by working hard and opening up a business. These subtleties like cultural symbols and messages are of particular importance: popular culture like movies are considered important soft power assets and as the world is reaching the end of the Atlantic era, American soft power might be increasingly challenged by soft power from other cultures.  

What’s next?

Indeed, Western streaming platforms are getting ready for this new ‘global cinema’ or multipolar media world reality. Although Netflix is still primarily focusing on American content and its selection of locally-made programs is still small, it is starting to make its (Western) audiences comfortable with subtitles (including the Spanish “Elite”, the French “Call My Agent!”, the German “Dark”, and the Japanese “Atelier”) and ramping up investment in localized foreign language content (particularly in Europe and Asia). This is not only to fight domestic competition by captivating users with high-quality international productions, but also not to risk to be conceived as a boring, uniform platform predominantly broadcasting American content in a world where audiences are ready for more global content.

The failure of U.S. sanctions?

What happened?

As of May 2019, the U.S. has 7967 sanctions in place. For a long time, experts have argued that sanctions are ineffective and have unintended consequences. However, from recent developments in Russia and Venezuela, a more interesting picture emerges. Both countries have adapted to U.S. sanctions in different ways.  

What does this mean?

In Russia, prolonged sanctions have led the government to clean up its financial sector, stimulate domestic production and create a sovereign wealth fund – all with great success: public debt is down to 15%, currency reserves grew by 50% over a few years and agriculture exports are now twice as high as arms exports. Sanctions still harm economic growth by targeting key industrial groupings and FDI, but the Russian economy is strengthening. In Venezuela, as the government has been forced to relax economic restraints, the private sector is flourishing: oil production is stabilizing and imports by private companies overtook those done by the state for the first time in Venezuela’s modern history.

What’s next?

U.S. sanctions have actually been effective by bringing Russia and Venezuela to the brink of economic collapse. However, as countries adapt to sanctions, the U.S. will have to rethink its strategy. The Trump administration already chose different strategies (e.g. trade war with China, accommodation with Russia, assassination of key Iranian figures) to pressure adversaries. Future U.S. administrations are likely to do the same, but could pick (radically) different strategies, such as renewed support for multilateralism, as advocated by Democrats.

Philosophical posthumanism

We are living in age of “posts”: post-truth, post-capitalism, post-colonialism, post-modernism (indeed: also post-postmodernism). But the problems of our time also force us to rethink our view of man, and we are observing weak signals of “post-humanism”: to think beyond the paradigm of humanism that has been dominant in many Western modern thought. We see three strands of a posthumanist paradigm emerging.

Our observations

  • In her book “Philosophical Posthumanism”, Franscesca Ferrando describes that are living in a time of an integral deconstruction of the fixed categories by post-modernism, the epistemological impact of quantum physics, increased role of technology in the formation of human identity leading to hybrid humans. Philosophical posthumanism is the onto-epistemological and ethical approach that uses these insights to discharge modern dualisms and hierarchical legacies and wants to go beyond humanism and anthropocentrism. As such, it is a philosophy of mediation that suits the geological time of the Anthropocene: it focuses on decentering the human from the center of discourse.
  • Karen Barad in her book Meeting the Universe Halfway recognizes agency to the nonhuman realm, based on a relational ontology and agential realism based on insights from quantum physics. The quantum entanglement means that there is no ontological separation between subject and object, but onlyintra-acting agencies between “entangled agencies”. As such, many phenomena “emerge” as a result between various agents and of various sorts (e.g. the Ebola phenomenon was not a virus itself but an interaction of the actual virus with human and non-human actors, such as human bodies, discourses on Africa, global politics, news channels, feelings of fears, medical technology and so on).
  • We have written before that excessive use of digital technology and the proliferation of companies thatare fighting for our attention also mean that we are becoming increasingly distracted. This “attention crisis” puts pressure on the foundations of our moral theory and ideas of freedom, and forces us torethink our ideas about everyday practicesAs such, our digital living worlds are redefining what we mean by concepts like “autonomy”, “agency” and “freedom”.
  • Yuval Harari states that mankind has long been plagued by three main evils: poverty, famine and sickness. By understanding social structures as data processing systems, and given the rapid advances of AI systems and the abundance of digital data, Harari expects that autonomous smart systems could help mankind to get rid of these three evils. As such, we are moving beyond the traditional boundaries of human kind, and transforming from homo sapiens into a homo deus. This belief in the “sanctifying” powers of digital technology is what we have called “technological divination”.
  • Luciano Floridi in his book The Fourth Revolution: How the Infosphere is Reshaping Human Reality as we increasingly interact with the world and with our technology through ICTs (as well as ICTs interacingamongst themselves invisibly), we are going to interpret the world in ICT-friendly terms: informationally. And on the other hand, by creating digital living worlds, we will see the world as inherently informationally. This thinking and acting about and in the world informationally recreates reality as an “infosphere”: the whole informational environment constituted by all informational entities, their properties, interactions, processes, and mutual relations. For example, we increasingly perceive biology as a technology, perceive everybody as a self-tracker, or see football referees as information systems.
  • Last week, in collaboration with Brainwash and Frascati, we speculated about “the future of man” and discussed three different “post-humanist paradigms”: animism, transhumanism, and nihilism.

Connecting the dots

In their book “Humanisme”, Bert Gasenbeek and Piet Winkelaar describe five humanist starting points and principles (pp.58-76). First is the that the human is central in the worldview and search for meaning, implying that there are no “afterworlds” or transcendent beings outside human experience and that we know reality and that we can gain objective knowledge of reality and the cosmos using our human senses and knowledge. Second is the positive anthropological view of man, seeing man as a worthy and ethical being upon which we can found moral principles. “Good” are then those things that make life “humane”, and “evil” are those things that make life and reality “inhumane”, and we often do so by using our “humanistic” capabilities, such as art, reasoning, and showing compassion. Third is the idea that every human being is equally worthy, irrespective of race, gender, religion, and so on. Although not every human being has the same physical and mental capabilities, we should have equal opportunities to develop ourselves. The fourth principle stresses human autonomy and individuality, meaning that every human being is a unique being and an identity formed by their own history and personality. The last is the idea of freedom: human beings have an inalienable freedom to act and think irrespective of external determinants (e.g. totalitarian regimes), which also makes us responsible moral agents. In correspondence to these five starting points, Gasenbeek and Winkelaar also describe five humanist principles: i) the emphasis on rational and scientific method and eschewing of superstition and irrational belief, ii) respect and tolerance for other human beings and their freedom, iii) the equality of human beings leads to the political form of democracy and equal rights for citizens, iv) solidarity for others, as well as rights and plights, and v) the principle of self-determination to let people chose to live their own life as they like (e.g. whether to end their lives, the right for abortion).

However, it seems that many of these humanistic starting points and principles are being criticized andpressured. First, the ongoing ecological crisis not only requires a radical overhaul of the principles of industrial modernity and economic and societal meta-rules of our socio-technical systems (i.e. a Deep Transition), but could also point to a crisis of our anthropological conception of man. If human beings actively undermine one of our “living conditions”, this might have something to do with our idea that man is at the center of the cosmos and reality. Indeed, this is one of the principles of the emerging paradigm of deep ecology that opts for a radical decentering of the human. Second, it is increasingly doubtful that human nature is being seen as something inherently good, given the problems of rampant socio-economic inequality, poverty and exploitation (of both humans and non-humans). As we own increasingly powerful technologies that create a vulnerable world, more studies are examining an earthly future without the human kind (e.g. omnicide).

Third, we see that the rise of populism, nationalism and xenophobism increasingly criticize the idea that every human beings is the same, both in an abstract, racist sense (e.g. there is a hierarchical order in human beings) and a concrete, cultural sense (e.g. human cultures are not similar and can be hierarchically moral order). Fourth, the autonomy and individuality of human beings is increasingly pressured. This is because surveillance capitalism undermines individual self-determination and decision-right by steering our behavior and predicting our actions by means of digital and automated systems that adapt to our behavior and emotional data. Furthermore, our “attention crisis’ means that we are increasingly distracted, eroding our sense of autonomy and moral responsibility. Lastly, these developments share in common that they opt for a restriction of human freedom in a certain sense, whether by constraining economic freedom (e.g. taxation, prohibition of certain consumption practices such as meat consumption), as well as political freedoms (e.g. the process of “reglobalization”).

But what do we see as a new paradigm to think beyond humanism and to find an anthropological solution to the problems of our age. The first is “animism”: the belief that we are inherently related to nature and technological beings. As such, we should decenter the human from the center of the universe and develop a new ethics of responsibility and care for both biological and non-biological beings. Transhumanism states that there is no “pure human being” but that human beings and technology co-evolve. Digital does this in particular, and future technologies will continue but radically alter our “human condition” (e.g. living in a metaverse) and redefine what a human being is. Nihilism is another “post-humanist” paradigm: it stresses the inherent sense of meaninglessness and purposelessness of reality and human life, but in its active form urges people to embrace this “absurdity” and realize human potential to the fullest. Importantly, this should not decay in hedonism and irresponsibility (its passive form) but in realizing the inherent. But as human beings are not defined by an essence but have the freedom to choose what to do with their existence, this opens the ethical space of real moral acting and responsibility for our own acting.

Although nihilism, animism and transhumanism differ in certain aspects (e.g. how to relate to technology, how to define moral categories like “responsibility” and “agency”), they share three main tenets of what a future philosophical posthuman paradigm will look like:

1) post-human: a plurality of human experience and the human as many instead of one that does not warrant a universalist approach
2) post-anthropocentric: a decentering of the human in relation to the non-human and that the human species has no ontological privilege in the order of species
3) post-dualist: the awareness that dualism has been employed as a rigid way to define identity in terms of symbolic but excluding dichotomies, such as friend/foe, self/other, us/them, civilized/barbarian

Implications

  • One could claim that all sciences use a certain philosophy of man, especially the social sciences. As such, the “post-humanist turn” will have significant effects on the models and theories of e.g. economics and finance (displacing the homo economics), psychology (animal rationale), or humanities (e.g. the ideal of the autonomous and individual genius shaping world-historical developments).
  • The relational ontology and intra-acting agency postulated by posthumanism is related to other emerging paradigms, such as objected-oriented ontology (OOO), new materialism, and speculative realism. Posthumanism and shares with OOO that hey reject the Cartesian mind/body (i.e. humans as res cogitans and nonhuman animals and inanimate beings as res extensa) dualism. Likewise, new materialism does not pose a division between biology and culture: biology is culturally mediated as much as culture is materialistically constructed, making matter is an ongoing process of materialization that bridges the nature/culture divide into a “natureculture” proposal (e.g. cyborg) and a new materialist theory of entangled nature and culture as we can change ourselves from purely the product of genetic heritage to being a product of technology (like a kind of Lamarckian evolution based on heritage). Posthumanism and speculative realism both stress that objects and subjects, relations and relata (i.e. correlationism) are co-constituted in agential realism and as intra-acting agencies.

A Dutch food success story

In the past, floods and famines pushed the Dutch to create large-scale infrastructural projects or to transform entire sectors. Today, again, climate change can serve as a shared formative experience that can lead the country to take initiatives to ramp up food- water and climate mitigation expertise, not only serving only its own people, but also creating a new Dutch success story that can be exported to the world.

Our observations

  • The Netherlands is well-known for its innovation and expertise in multiple domains of agriculture. The Westland region (‘the glass city’) is famous for its horticulture in glasshouses, Enkhuizen is dubbed Seed Valley, Wageningen is called ‘Food Valley’ as the nation’s agrifood ecosystem, Texel is known for its saline farming and seaweed industry, and the current ministry of agriculture envisions the Netherlands to become a leader in circular agriculture.
  • Furthermore, the Netherlands is poised to become a frontrunner in food for an urban world with its Randstad agriculture. Rotterdam’s food cluster is a model that receives attention in an increasing urbanized world and the Netherlands has a leading position in the field of urban farming systems, being specialized in indoor farming equipment and knowledge.
  • The Dutch food sector’s annual turnover is €140 billion, it accounts for 10% of all jobs and contributes nearly 10% in added value to the economy. But more than a contribution to the economy, the food innovation and expertise of the Netherlands is also a way for the country to position itself as a strong food nation in a world of increasing food insecurity and climate change.
  • We are beginning to understand the complex nexus between food security, climate change, conflict and migration. Climate change and conflict have been major contributors to food insecurity in the world. In addition, there isdirect link between food insecurity and migration. Since more than half of the global population live in food insecure countries, a small increase of food insecurity can already lead to mass displacement of peopleFood is thus increasingly becoming a matter of national security to countries around the globe.
  • The Dutch already play an important role as a food nation with its many public and private partnerships with many different countries in the field of food- and water management and climate mitigation. The so-called Dutch Diamond approach, in which government, business and knowledge institutions work together is known for this.
  • There is a dominant narrative of the Netherlands as ‘the tiny country that feeds the world’, however we wrote before that the Dutch agrofood sector is not relying on a sustainable model. Trade volume is no longer a future-proof measure of Dutch export performances and the trade agenda could be further broadened by including services, knowledge and investments.

Connecting the dots

In 1421, a massive flood at European shores of North Sea caused the dikes to break in a number of places, killing thousands of people in the Netherlands. What became known as the poldermodel was an answer to the disaster, a system based on pragmatic, unideological cooperation among all sorts of public and private parties to protect themselves against the water. In 1953, massive floods again struck the country. As a response, the government invested in an immense infrastructural project: the Delta Works. Similarly, during the Second World War, the Dutch suffered from a hunger winter that resulted in a large-scale transformation of the way the country produced food. The shared experience of the 1944-45 famine is seen as an important trigger for the revolution of agriculture that followed after the war, with the minister of agriculture, Sicco Mansholt as the key figure in initiating the revolution. The agro-food sector became capable not just in feeding the Dutch, but also millions more around the world. What was a Dutch weakness, the low-lying country next to the sea in the first case or the lack of access to food in the second, became a Dutch strength because of large-scale investments and innovation. But today the Dutch agricultural success story is increasingly being perceived as a problem.

As a leader of the first Green Revolution, which ramped up food production globally, the environment has paid a heavy toll: soil quality, air quality and biodiversity deteriorated in the Netherlands. As the effects of climate change and environmental damage caused by farming take their toll, evidence shows that the productivity gains of the first Green Revolution will begin to plateau amid accumulated environmental problems. Because of this, a second Green Revolution is needed to intensify agricultural production in a sustainable manner. Again, a common crisis or sense of urgency might ignite change in the way the Dutch grow food, such as the current climate emergency that has been called out by many Dutch cities or the nationwide nitrogen crisis.

We wrote before that there are multiple signs that point to this next shift in agriculture. Indeed, today, a second green revolution is brewing to make the Dutch agro-food sector future-proof. Over the last years, the emissions per pig or cow, the use of artificial fertilizers and the environmental impact of farms have declined. However, more is needed to turn the tide of an unsustainable agro-food model and if the Netherlands succeeds, this will again not only result in a viable agro-food sector, but also as a way to position the nation as a frontrunner of the next Green Revolution. Multiple elements combined could make the Netherlands well-positioned to do so.

First, the Netherlands is a small densely populated delta and has shown in the historical cases of the Deltawerken and the agricultural revolution that it can effectively cooperate with all the necessary parties and make the large-scale infrastructural investments to transform the way the country deals with food or water. Since the Netherlands is a small country, this is indeed an advantage to operationalize such large ideas and provide inspiration to the rest of the world. The Randstad can be regarded as one big, stable city that can be fed by the rest of the country.

Second, the Netherlands has the expertise and innovation capacity and technology needed for the next Green Revolution. For instance, in this new agricultural model, circular agriculture and precision farming will be key.

Finally, along with innovation, the Netherlands has to have an exnovation strategy. The question is whether the country will have to go through the formative experience of a next (climate or food) crisis, before it starts rebuilding systems. After the Second World War, the agro-food sector almost started from scratch, but the choices made then, still have a major influence on the current food system and the country has a large incumbent sector that makes transitions harder. Transition studies show that societal challenges, such as the economic crisis or climate change, offer an opening to reconsider systems. Although innovation is necessary, exnovation, or the destabilization of the existing system is a precondition for transitions. A case in point is the German energy transition. Nuclear disasters in Chernobyl and Fukushima ignited the sentiment among German citizens to switch to other energy sources. Similarly, as plant-based protein production is hampered by the strong livestock industry, and growing consumer awareness can push the sector to make the transition. In leading the transition towards plant-based protein, the Netherlands could have a large impact on the sustainability of food production worldwide and write a new Dutch success story.

Implications

  • As we wrote before, food security has regained attention as a geopolitical risk again. Food expertise of Wageningen, seeds from Enkhuizen, etc. are geopolitical assets in a world of increasing food insecurity. Currently, food policy is conducted separately by the ministries of Agriculture and Foreign Affairs. But by thinking in terms of geopolitics, these ministries could formulate a Dutch food strategy, enabling the country to remain a food nation as well as to contribute to tackling global food challenges.
  • The Dutch livestock industry is already showing to embrace the transition to plant-based protein, multiple incumbents are rebuilding their facilities.

 

Smart Tattoos

What happened?

Tattoo-like medical sensors are being developed as low-cost and practical alternatives to more cumbersome blood tests, wearables or implantable devices. These sensors, which are either applied to our skin like a temporary tattoo or injected beneath the skin like a real tattoo, can deliver real time and continuous measurements of, for instance, electrolytes and metabolites in sweat, plasma, saliva or tear fluid. Such sensors are already used by diabetes patients to monitor their glucose levels and the future may see many more applications, even including markers related to (types of) cancer.

What does this mean?

The patch-like sensors are highly flexible, stretchable sensors and can last for weeks, virtually unnoticed. They provide rich data on a range of parameters. Most use electrochemical techniques to measure a physiological parameter and connect to a separate device to store and display results. Others are able to measure minute movements and can be used as elaborate activity trackers (e.g. in rehabilitation processes) and can also be used to generate power for other sensors (i.e. energy harvesting). In another class of sensors, experiments are also ongoing with ink-like material, such as engineered human cellsthat change color in response to specific molecules. These are thus actual tattoos that produce directly visible “measurements” on the surface of human skin.

What’s next?

These temporary tattoos and sub-skin injections augment our skin with an additional interface. While our skin can already display embarrassment or nerves (blushing) and other emotions such as fear (goose bumps) as well as more serious conditions (so-called flushing), these applications create new possibilities to quantify ourselves. Obviously, most applications will be strictly medical and applied only to those with a direct medical need, but on a more speculative note, we can imagine how these kinds of tattoos could end up becoming interactive body decorations or even be put to more malign use as, for example, publicly visible lie detectors or alcohol testers.

Imagining the metaverse

What happened?

In December, HBO announced plans to make a TV series adaptation of the cyberpunk novel Snow Crash (1992). In the nineties, the book turned into an instant cyberpunk classic. The book describes a dystopian future in which citizens escape the harsh physical world using a type of goggles to enter a virtual reality world called the metaverse. The author Neil Stephenson portrays the metaverse as a 3D real-time rendered environment where people can be whoever they want using virtual avatars, build their own house, hang out with random people and drink virtual beers in bars. 

What does this mean?

The role of the novel can hardly be underestimated. As we mentioned before, the book has become an important element of the narrative of big tech. Many tech entrepreneurs have claimed that reading the book guided them in setting the direction for the future of their companies. The book inspired LindenLab owner Philip Rosedale to create Second Life and some claim it was once required reading for new Facebook employees. Furthermore, the novel both embodies and reinforces the transhumanistic belief that we can transcend our biological bodies and enhance our lives using technology. The metaverse liberates us from the physical realm and heralds the start of a new phase for the human race. Evolution has only just begun, transhumanists claim. 

What’s next?

In a recent article, Matthew Ball – an internet essayist and metaverse expert – explores how the metaverse will develop in real life. Ultimately, besides technical challenges and economic momentum, the future of the metaverse will be equally determined by the imagination of the culture. We might best describe this future as an interplay between art, evolution, and capital. What the metaverse will eventually look like is impossible to predict and there is nothing yet that resembles a metaverse as the one envisioned in Snow Crash or, more recently, Ready Player One (2018). However, art and science-fiction help to popularize and imagine virtual reality and thereby create momentum for specific technologies to develop and to steer the evolution of technology into a certain direction. With VR struggling to live up to high expectations, the upcoming Snow Crash series might boost VR and inspire a new generation to take the next steps and take technology forwards. 

The U.S. and China fall victim to Thucydides’ Trap

War between the U.S. and China is not inevitable, but it may be more likely than we think. Thucydides’ Trap provides a lens for understanding conflict between the U.S. and China. They have fallen victim to a recurrent dynamic in which the emergence of a rising power instills fear in the ruling power. In the history of 16 of such rivalries, only 4 averted war. What lies ahead?

Our observations

  • In the book Destined for War: Can America and China Escape Thucydides’ Trap? author Graham Allison explores the history of conflict between ruling powers (like the U.S), and rising powers (like China). He argues that the U.S. and China are currently on a collision course for war – unless both parties take difficult and painful actions to avert it. His argument is based on the history of 16 rivalries of which 12 ended up in war.
  • Since the turn of the century, U.S. foreign policy has slowly shifted to a more confrontational approach towards China. The Trans-Pacific Partnership, introduced by president Obama, was already designed to contain China’s growing economic power, just like president Trump’s more aggressive trade war.
  • The decoupling of the U.S. and Chinese economies has also been underway for some time. It has already occurred in terms of the internet and GPS: China has banned U.S. tech companies for years, mandates that certain data be stored on Chinese servers and recently completed its 35-satellite network. Financial decoupling is also underway: U.S. senators introduced legislation last June to force Chinese firms to comply with regulations or withdraw from U.S. financial markets.
  • Through territorial disputes, trade wars and military build-ups, the center of global geopolitical friction has already moved to East Asia.
  • The RAND Corporation publishes the “S.-China Military Scorecard”, which examines U.S. and Chinese military capabilities. The report finds that China already has an “advantage” or “approximate parity” in 6 of the 9 areas of conventional capability: for instance, in achieving air superiority and preventing an opponent from using space-based weapons.
  • We have previously noted that during hegemonic shifts of capitalism, the ruling financial power clashes with the rising economic power.

 

Connecting the dots

The idea of Thucydides’ Trap, based on the ancient Greek soldier Thucydides who, during the Peloponnesian Wars, believed that conflict between ruling Sparta and rising Athens was inevitable, may sound deterministic. However, we should take Graham Allison’s argument seriously: war is not inevitable, but both the U.S. and China have to take extremely difficult measures to prevent war. Currently they are not doing so, which means they are on a collision course for war.
In the history of the 16 rivalries between ruling and rising powers, the same psychological dynamic has unfolded. As the rising power grows more confident, its emergence instills fear in the ruling power. The former believes that it is not treated fairly because the international system, dominated by the latter, does not reflect the new balance of power. As the rising power believes that its rise is harmless and others have nothing to fear, it is increasingly blind to the fear of the ruling power. In this situation, hubris clashes with paranoia. Both powers are increasingly prone to take measures that (sometimes unintentionally) signal malicious intent to the other. Take, for instance, the lead up to the First World War. A British weapons program built new battleships (the Dreadnought) in 1906. This led Germany to widen the Kiel Canal, allowing German battleships to move quickly from the Baltic to the North Sea. A British Admiral (John Fisher) predicted that war with Germany would come when the widening of the canal was finished – the war began one month after the canal had been completed. As ruling Britain and rising Germany collided, the latter took a measure to protect itself, which the former interpreted as an existential threat. As both countries did too little to avert war, their collision became violent.

Four rivalries did not end up in war and they provide some clues for the future of the U.S. and China relationship. First, in the late 15th century, Portugal and Spain averted war because there were plentiful resources to be divided: Pope Alexander VI drew a line to divide the Western Hemisphere into Portuguese and Spanish territories. Second, in the early 20th century, Britain and the U.S. averted war because the ruling power was confronted with a bigger threat: the rise of Germany pushed Britain to accept U.S. hegemony. Third, during the Cold War, war was averted because both countries transformed a tense dynamic with a high risk of escalation into a diplomatic framework with recognized spheres of influence underpinned by mutual assured destruction (MAD) – until the rising power collapsed. Fourth, after German reunification, war between a rising Germany and Britain and France was averted because Germany was embedded in international European institutions.
What is the most likely timeline for the coming years? In the short-term, tensions are likely to remain high as both countries are testing the waters: U.S. assertiveness, decoupling and military investments will accelerate. In the medium-term, it is possible that the relationship reaches a phase of stabilization, similar to the Cold War and the Thirty Years’ Peace between Athens and Sparta, which will always be a “fragile peace” because the underlying power dynamics do not change. However, before conflict will stabilize, the U.S. and China will focus on defining their spheres of influence, which will raise tensions especially across East Asia (e.g. Korea, Taiwan, Japan, and later, Southeast Asia).

Implications

  • The coming years will determine the spheres of influence of the U.S. and China. Currently, the U.S. holds significant influence in Korea and Taiwan. As China grows more powerful, it will try to pull these countries into its sphere of influence.

  • As there will be no continent to be divided (i.e. Portugal versus Spain), there will be no bigger threat to the U.S. than China (Britain versus the U.S.), and there will be no constraining multilateral institution (i.e. Germany versus Britain and France), it is likely that conflict will only be stabilized through diplomatic frameworks similar to the Cold War that divide spheres of influence.

  • In the absence of attempts to stabilize the relationship (e.g. Trump puts more pressure on China after he gets reelected), the likelihood of a violent incident (e.g. in the South China Sea) will grow ever more likely.

Commercial DNA databases in search of a new business model

What happened?

Privately held companies Ancestry and 23andMe hold some of the world’s largest collections of human DNA. These companies were able to build such large databases in a short time because millions of people bought their DNA kits in order to find out about their ancestors, potential health issues or other personal traits that can be found in someone’s DNA. However, by now the initial hype surrounding their services has faded and sales have stagnated, forcing 23andMe to lay off 100 people.

What does this mean?

In part, the decline of these companies may be related to growing privacy concerns among the general public. More likely, their problems also arise from the fact that they have little to sell beyond a single test and, as it stands, they have no recurring revenue from their early adopters. In response, these companies are looking to develop new tests for their existing customer base. These tests could cover other diseases and may even include traits of our personality. The CEO of 23andME, for example, says she’s determined to make inexpensive genetic information available without medical professions getting in the way. At the same, these companies try to connect with pharmaceutical companies and academic research groups so that they can create precision medicine together. So, in order to stay profitable, these companies expand their activities and collaborations with third parties.

What’s next?

The privacy matters that come with surrendering one’s DNA to a private business are still underexposed considering the depth of the (potential) information and the scale of the databases that are built by these companies. Although, for example, 23andMe promises to safeguard this private information, there are already a few examples in which a large DNA collection of a privately held company was used for purposes that its consumers didn’t anticipate. In the case of the golden state killer, for example, the FBI gained access to the database of GEDmatch that could find the suspect even though he never participated in a GEDmatch test (some relatives did). When these companies are in need of new business, their data-filled treasure chests will be extremely valuable for, amongst others, health insurers, the pharmaceutical industry and governments. We can easily imagine how this could result in a slippery slope as privacy concerns are challenged by potential society and commercial gains.