2050

Is a biocitizen free to act?

The novel highlights scenarios illustrating the rapid management of an accident (allergic reaction, fractured malleolus) and, more generally, medical monitoring: real-time or bedside diagnosis (such as the Microdrop), three-dimensional printing, prediction of blood sugar levels using Synapse, remote communication with doctors, etc. We could retain only this positive aspect of the use of technology, but between the lines of these first chapters, fundamental questions about our relationship with technology and its impact on our lives are emerging.

Indeed, one morning in 2050, everyone will wake up and will be able to see in their daily lives the omnipresence of digital technologies, which will be even more pervasive than today. The man of 2050, permanently connected, will perhaps see the fusion between his body, its relationship to the outside world and the digital universe. Emma's family environment shows the beginnings of a 24-hour connection: questions to Cortex about the weather and the state of the car, the monitoring of the family's sleep through a connected headband, Emma's monitoring bracelet as part of the management of her allergic reaction, and the regular use of VirtU. Thirty years on, the contours of this hyperconnection are predictable. Let's look at that predictability. The process that extends this grip is already underway: it has been accelerated at the global level by the Covid-19 epidemic and by the desire to strengthen health security... at all costs! It is based on stages of habituation through clearly established uses and will eventually raise fundamental questions about the existence of our free will and the responsibility that each of us can be given.

Widespread connection

In 2018, almost half of teenagers in the United States report being online "virtually all day". They are increasingly addicted to notifications, messages - in short, to being "connected". The process of addiction is relatively simple and is based on both the improvement of technologies and the services they provide. There is a definite advantage to using your phone to access a large number of services: being able to connect instantly to your loved ones, knowing if so-and-so has read your message, receiving a reply in your pocket or on the table, having applications that make everyday life or meetings easier, applications that are always at hand, within reach of a click and in real time. Such phenomena give our brains the dopamine rush that keeps us coming back, scrolling, creating a real economy of attention. Connection has also had a multiplier effect: not only have we been connected to close networks (friends, relatives, professional networks) but also to a whole host of individuals that everyone can follow (the network of known strangers) and that we would never have come across in the absence of digital technology. On the basis of this generalised connection and the omnipresence of digital technology, services in the field of health have gradually been added. This has made possible the digital health record, the first remote consultations and a plethora of applications in the field of preventive health, from telemedicine to personalised care. These include, but are not limited to: Bewell Connect, Nouveal, Qare, Implicity, Satelia, Tabac.io, Tilak, Voluntis...

In the context of the Covid crisis, certain solutions, such as the TousAntiCovid application in France or Corona 100m in South Korea, have raised ethical questions since their launch. By being preventive tools to reduce the spread of the virus, politicians have chosen to give priority to protecting the health of the population. These applications are part of a wider process with, on the one hand, a hyper-consumption of digital technology in general and, in an extraordinary context, it creates precedents in terms of applications. Once the crisis is over, the effect of "perennial temporality" even in the long term will be there!

Beyond the proven services provided (health or not) and by associating increasingly intuitive technologies, companies can better identify our interests or our behaviour and send us notifications to continue browsing. This loop has no end and leads to a syndrome known as digital obesity: the addiction gradually sets in, first through positive effects, then in a more impulsive way for those who are connected.

Tools increasingly integrated into the body

Technologically, the tools are becoming simpler and will gradually integrate with the human, avoiding any sudden break and allowing a gradual acceptance of the technologies. The landline phone (an object that has almost disappeared) has given way to the mobile phone, then to the smartphone, a real gateway to the self and to the world. In the next few years (or even decades for routine integration), it is already accepted that the smartphone's functionalities will increasingly be grafted onto us. Examples such as the Apple Watch or Ray Ban Stories are only an intermediate step towards "fusion" with humans. Many innovations are already being tested, such as smart bracelets with a projector that displays the contents of a smartphone on the owner's wrist. Other experiments are underway on speakers with sound transmission by bone or tissue conduction. Eye implants are also being developed to capture images through the blink of an eye. The human being as a connection medium is no longer even science fiction! From these two trends (digital services and embedded technologies), addictive behaviours are developing that naturally make the world described in the pages of the novel possible, if we want it at all. If VirtU becomes a reality, it will be hard not to give in to it.

Addiction on the move

These trends are supported by psychological phenomena such as the ability of the digital to fulfil many existential, narcissistic and social needs. These needs are difficult to satisfy by offline phenomena. For example, the theorisation of FOMO(Fear Of Missing Out) underpins this addiction phenomenon. If permanent connection allows one to fight against this fear of missing out and being excluded from the various social groups with which one identifies, it can also reassure the person through numerous positive feedbacks ("Like", retweets, number of followers) and richer digital interactions than in the physical world. By being constantly connected to friends and being able to 'hang on' to familiar online environments, such as one's Facebook or Instagram page, the feeling of emotional security is artificially reinforced. The fusion between humans and the digital world, both from a physical and behavioural point of view, is based on three mutually supporting pillars: technology, the notion of services rendered and psychology (here, the neuroscience attention process and addiction cycle). Connected technologies will become entities that are so intimately part of us that they will represent an extension of our physical bodies, ultimately a fusion between the digital infrastructure of the information society and our bodies. The more people are able to control their material possessions in the same way that they control their bodies, the more closely these possessions become linked to their selves. Metaverses incorporate the addictive components of such an extension of the self: a virtual and effective escape from stress, among other things, the use of gaming devices, and an extraordinary field of experimentation for oneself and one's avatar.

The confusion then reaches a climax: a virtual extension via the avatars, but real if we consider that the legal dimension is not absent. At the same time, it is an immersion in a virtual reality, but unreal in its relationship to the physical world.

Projected to 2050, this merger raises questions about its consequences from a philosophical point of view. Are we free in 2022? Will we still be free in 2050?

Towards a loss of free will and the exercise of choice

La question du libre arbitre entendue comme la disposition de tout être humain à être un sujet autonome, c’est-à-dire capable de signer un contrat et d’assumer ses actes, est une pièce maîtresse du socle social. Être libre, c’est être capable d’exercer des choix, comme celui de voter. L’existence même du libre arbitre a été longtemps débattue par les plus grands philosophes, de son simple état illusoire (Spinoza, Nietzsche) à la nécessaire existence d’un libre arbitre (Thomas d’Aquin). Aucun consensus n’a formellement abouti à ce jour. Néanmoins, au travers des évolutions technologiques en cours et tel que le monde de 2050 se dessine, la question du libre arbitre est fondamentale car elle est un prérequis au maintien de notre socle démocratique. Tout d’abord, comprenons les avancées théoriques au travers de la lecture de nombreux philosophes et des expérimentations en neurosciences. En 1983, le neuroscientifique Benjamin Libet réalise une expérience aux résultats étonnants. Il demande aux participants de son expérience de bouger leurs doigts quand ils le souhaitent, et récolte deux types d’information : le moment où ces participants prennent leur décision de bouger leurs doigts, et le moment où les participants bougent réellement leurs doigts (mesure réalisée à l’aide d’un capteur relié aux doigts des participants). Les résultats de cette expérience signifient que c’est l’activité électrique du cerveau qui prépare le mouvement et commence quatre cents millisecondes avant même que les participants prennent la décision de bouger leurs doigts. Cela témoigne du fait que le signal du cerveau est émis avant que l’homme ait conscience de sa décision. La construction du libre arbitre est donc un mécanisme complexe : de multiples déterminants physiologiques et environnementaux influencent la nature des décisions prises. L’importance de ces déterminants est difficile à mesurer de manière exacte. Ce qu’il nous reste, c’est la faculté de faire des choix, d’évaluer deux options (même de manière imparfaite) et par le choix émis d’exercer, voire d’entraîner son libre arbitre. De manière globale, ces différents déterminants (génétique, éducation, environnement social) ainsi que ce que l’on peut nommer les « flux culturels » agissent en amont de notre libre arbitre. Par « flux culturels », on entend une tendance sociétale forte qui transforme sur le long terme la perception des hommes de certains phénomènes. On peut par exemple citer le principe de précaution qui, depuis plusieurs années, a un impact fort sur les choix des décideurs politiques mais également sur nos propres choix. À cela s’ajoute l’impact considérable des évolutions technologiques qui vont de manière certaine restreindre l’espace, déjà mince, du libre arbitre. Si cet espace est restreint à l’extrême, de telles technologies pourraient menacer les fondements de nos prises de décision et, dans un contexte politique, de la démocratie. Comment cette restriction va-t-elle s’opérer ? C’est ici que se fait le lien avec le monde connecté de 2050 : un monde de solutions grâce à la suggestion constante de recommandations d’achats ou d’actions (sur un parcours en voiture, sur des recommandations culinaires, sur des vêtements à acheter…). L’assemblage de points de données collectés sur plus de cinquante ans aura permis de personnaliser chaque proposition, chaque solution, réduisant d’autant le besoin de réfléchir, de comparer, bref d’exercer son esprit critique. Poussé à son terme, ce « dataïsme » permettra de choisir les éléments principaux d’une vie : ses repas, ses amis, son partenaire… et contrôlera la santé de la personne concernée : surveillance du taux de glycémie et proposition d’ajustements en temps réel, recommandations de traitements en cas de toux… Ici, naissent les prémices de ce que l’on va appeler le « biocitoyen ». Cela peut paraître de la science-fiction. Pourtant, en 2019, le généticien américain George Church envisage la création d’une start-up prenant la forme d’un site de rencontre dont le déterminant pour créer un match serait la compatibilité génétique, c’est-à-dire l’absence de risque de transmettre des maladies génétiques évitables à la descendance du couple formé. La promesse est ambitieuse mais les questions sont nombreuses ! Si sur le fond cela promet une vie a priori plus simple, se pose néanmoins la question de l’impact de cet environnement sur notre capacité en tant qu’homme à décider et être réellement libre de nos choix. Or ce qui disparaît avec la proposition de solutions sur mesure c’est la réflexion préalable, le fait d’avoir conscience de plusieurs choix possibles. C’est la condition même du libre arbitre. Par exemple, si en 2022 nous demandons à Alexa de nous donner les informations du jour, nous sommes soumis au choix de l’algorithme qui alimente l’enceinte connectée qui nous sert d’assistant. Questionner cet algorithme et exercer notre libre arbitre deviendra un effort qui demandera énormément d’énergie.

It is therefore very likely that what we give up and will give up every day will be an ever increasing part of our free will. As individuals, we are therefore dependent on our environment without even realising it. We will no longer be the masters of our actions. They will be constructed in interaction with the environment and our 'will' or 'freedom' will not escape this interdependence. At a critical stage, and this will probably be the case in 2050, we will realise that our environment owns us more than we control it. Our illusion of freedom is an excellent lever to enslave us. The incentive to consume and personalise in our societies is a glaring example. This is how the much desired personalisation will play a trick on us and will be the vector of our servitude to connectivity.

Free will as a determinant of our responsibilities

If we no longer exercise our free will, what can we be held responsible for? Responsibility is indeed linked to the very definition of a capacity to influence and supposes that we are in possession of all our means to choose. Two types of situation particularly raise questions about this question of responsibility. Firstly, there is the responsibility linked to our free will. Let us take the example of Synapse (or any other virtual assistant). The question that arises is how far we delegate and will delegate our choices to a virtual assistant. By definition, the main function of a virtual assistant is to suggest and guide on the basis of data that it consolidates as it is used by millions of users. In 2020, the link between loss of responsibility and the "abusive" use of artificial intelligence has not yet been established. However, if we look ahead to the use of artificial intelligence for most everyday decisions (choosing a car journey, a doctor, a recipe, the best partner, etc.) and a proven improvement in virtual assistants (better recommendations, self-learning technologies, etc.), the question of responsibility arises.

Let's imagine a situation that today is easy to smile about: if my virtual assistant recommends a partner who is 100% right for me, it's a match! Could I turn against "him" if the match doesn't work in real life? And more concretely, who is behind "him"? Is it the designer, the manufacturer, the developer, the operator...? Obviously, this anecdote is credible in other sectors than health, notably banking, real estate or the justice system. There is still no legal framework linked to this boundary that will become blurred between the responsibility of humans and that of these assistants. In 2022, the assignment of responsibility is a matter for human action and is based entirely on freedom of choice. It will therefore be a relatively slow process that will lead to questioning our responsibility and it is likely that as long as the objective (the question put to the assistant) does not come from the assistant, responsibility will be limited to the human in the choice he has to follow or not to follow the recommendations of his assistant.

Within this emerging reflection on legal responsibility, the notion of responsibility for our actions in the case of addiction is also emerging. For the first time, the WHO has recognised screen addiction (and more particularly video games) as a disease. Perpetrators can be found not responsible on medical grounds, such as a diagnosis of a mental disorder. It is considered that these people are not aware of their actions, that their disorders make their behaviour uncontrollable. What will happen with regard to those who are addicted to being online? To assert that free will does not exist, or is becoming less and less so, would ultimately mean asserting that the person is not responsible for his or her actions even in the absence of a specific disorder or dysfunction. This consideration is therefore not possible at the moment for obvious ethical, moral and societal reasons, but should be at the heart of our concerns in the years to come.

The space for freedom and free will is shrinking, but by reinvesting the information and educational dimension of citizens today, by supporting the identification of risky practices, there is a window of opportunity for the bio-citizen to exercise his or her ability to choose, to argue and ultimately to be free.

Transhuman, an impoverished version of the biocitizen?

Theo and Emma challenge us on what will undoubtedly be the dilemmas of our children and the daily life of our grandchildren. The term "transhumanism" will have disappeared to make way for new medical practices, particularly in the field of prevention. The science fiction image of the cyborg that is used today to frighten or to make people dream will have become commonplace in the next twenty years. The temporality between these two periods opens up a space for reflection that is absolutely necessary in order to try, at the level of States, companies and citizens, to imagine the most credible and desirable scenarios. The challenge of these scenarios is to remain responsible (and free to make our own choices) individually and collectively.

Transhumanism: a complex trend.

The word "transhumanism" is far from being a science fiction word. It appeared in the 1960s: " a man who remains a man, but transcends himself by deploying new possibilities of, and for, his human nature". Today it is used to designate a current of thought (and above all of experimentation) that has its roots in California, notably with Ray Kurzweil, an advocate of a total transformation of the human species. It is also the word that makes the headlines of certain newspapers or books to draw attention to the dangers of a transformation and the consequences on humans. This current supports several messages that explain and justify the transhumanist approach. These messages can be read in the Declaration of the International Association of Transhumanists in order to have a broad view of their aspirations.

• "We believe that humanity's potential is still largely unfulfilled. There are possible scenarios that lead to improved, wonderful and eminently desirable human conditions."
• "We recognise that humanity faces serious risks, particularly from the misuse of new technologies [which could lead to] the partial or total loss of what is most precious to us [...]. While all progress is change, not all change is progress.
• "Research efforts are needed to understand these prospects [...], the best way to reduce risks and accelerate beneficial applications. reduce the risks and accelerate the beneficial applications. [...] "
• "Reducing existential risks and developing the means to preserve life and health, to alleviate severe suffering and to improve human foresight and wisdom should be highly funded urgent priorities.
• "Political actors should be guided by a responsible and open moral vision [...], respecting individual rights and autonomy, and showing solidarity and care for the interests and dignity of all citizens of the world. We must also consider our moral responsibilities towards future generations.
• "We defend the welfare of all sentient beings, including humans, non-human animals, and in the future any artificial intellects, modified life forms or other intelligences to which technological and scientific advancement may give rise.
• "We advocate offering individuals a wide freedom of personal choice about how they allow themselves to live. This includes the use of techniques that can be developed to aid memory, concentration and mental energy, life extension therapies, reproductive choice technologies, cryogenic preservation, and many other technologies of possible modification and improvement for the human species. and many other technologies of possible modification and improvement for the human species.

When we read these precepts, we citizens can either rejoice or cry out for the end of the human being as we know it. A survey carried out by Crédoc gives an initial insight into current perceptions: 58% of the 2 000 people questioned think that medical progress should help improve the physical and mental capacities of a healthy person, and 45% think that it should help push back the limits of death. At the same time, 60% of them see no problem in grafting a robotic arm onto a human body! Understanding the trends and scope of the movement is therefore essential to grasp its complexity, scale and impact. Indeed, underlying the declared intentions in terms of ethics and freedom, several objectives characterise this movement: overcoming death, increasing human capacities and developing artificial intelligence (AI). The most radical movement, led by Ray Kurzweil, envisages a life free of disease, old age and death. Humans would have greater sensory powers and tenfold cognitive capacities. Ray Kurzweil develops the idea that it is becoming technically possible to envisage the modelling of our brains and, eventually, the final migration of our existence into hard disks rather than organic bodies. A new man, physically improved, without genetic defects will be born. More generally, the man of the future will be a prototype organism destined to be constantly improved, like a software program with iterative and regular updates. Transhumanists also support the idea that each citizen should be able to decide for himself what modifications he wishes to make to his brain, DNA or body. Since the 1990s, the potential of NBICs has made it possible to envisage the realisation of these transhumanist aspirations on a more or less short scale. The future of humanity is being radically transformed by the assembly of these technologies and yet the reflection on the choices we have to make is still too little present in the public space.

A variety of applications

In concrete terms, there are three types of intervention on humans aimed at increasing their capacities:

• The radical extension of healthy life spans . While average life expectancy is continually increasing, the major challenge in managing an ageing population is to keep it in good health for as long as possible. Thus, a trend that can be linked to transhumanism consists in developing technological or biological solutions to slow down or even cancel ageing. Here again, far from science fiction, such trends are already operational, brought to the general public by biohackers like Josiah Zayner.
• Cognitive augmentation Like the neurological implants used by Emma and Theo, such devices can increase or alter cognitive functions, leading to greater intelligence, creativity or empathy.
• Prosthetic augmentation This third and final type of intervention includes prostheses and implants, the use of virtual reality, control and communication by thought. These systems aim at better health through integrated devices. They can be used following accidents to repair the human body, again with varying degrees of integration.

Extensive ramifications in our daily lives

If we look at these types of interventions more closely, we can establish a varied list of devices that can be linked to the concept of transhumanism. This list allows us to understand that transhumanism cannot be accepted or rejected without thorough questioning and that even if we do not use the term, it is already in practice. The examples that we will take as an illustration and whose "acceptability" we will measure show that transhumanism is already in our daily lives. Each of these examples is a form of augmentation (or external repair) of the body and has now become completely accepted. Quite spontaneously, we would not have the reflex to link them to transhumanism.

• The pacemaker or more recently the Carmatt artificial heart transformsa transplanted patient into a first version of a cyborg.
• The development of a self-adapting brain implant capable of delivering finer and therefore more efficient electrical impulses to relieve the symptoms of Parkinson's disease.
• The wounded soldier, who has had a leg amputated and who benefits from a prosthesis or rather bionic limbs, fitted with electrodes, which can be animated by thought.

In other areas, questions about the ethics of these "transhumanist" practices are beginning to emerge:

• In the military field, most programmes, such as those of the DGA, allow for the augmentation of the combatant on mission: remote sensors, exoskeleton, etc. Ethical questions are beginning to be raised, but the international framework and the policy of deterrence oblige all armies to aim for an 'equivalent' level of efficiency. The next step may be the robot-soldier... Reflections on the limits of these male soldiers are in their infancy in the public arena.
• In 2019, the company Neuralink announced the development of a technology based on neural lace. These are artificial electrodes that attach to neurons and increase the capacity of the brain to strengthen intellectual knowledge, safeguard memory and transmit thoughts without the need to use speech. In 2021, the first tests were carried out on animals. In 2022, Neuralink's competitor, Synchron, enrolled its first human patient in a trial, with a total of six patients with severe paralysis. Synchron uses blood vessels to communicate with the brain.
  The ambitions of Elon Musk, head of Neuralink, go beyond a chip for paraplegics, and therefore beyond the medical field. He aims to give the brain control to manipulate the computer without clicking, talking or moving the eyes. This announcement, which has received very little media coverage, raises the question of what kind of applications will be possible. The question is legitimate because in many cases, the use of new technologies in the medical field is used as a Trojan horse before imagining wider use cases.

Finally, if we end with some last examples, we can see that there is a stronger rejection of certain practices:

• The implant that has been proposed by the company CyborgNest enables the acquisition of an artificial sense and enriches the perception of reality, indicating north in the same way as a compass (the implant vibrates each time it faces the earth's magnetic field).
• A final example is the company NectomeNectome, a start-up founded in 2016 by MIT graduate engineer Robert McIntyre, has developed a chemical embalming process, vitrification, that is capable of preserving a brain in a satisfactory state over the long term. The patient must be dead for the technique (based on cryopreservation) to work. The company has successfully tested preservation on animals such as pigs. Thanks to scientific and technological advances, the start-up's next challenge is to be able to scan the preserved brains and duplicate people's consciousness in a virtual space (a cloud), with the aim of one day being able to load it into a robot or another body shell.

These three cases and their emergence in history show that transhumanism is part of a historical evolution of medical practices and will help shape the man we will be tomorrow. What questions us and pushes us to go further is to understand why some examples are more easily accepted than others. Indeed, if the improvement of living conditions is an integral part of progress as defined since the Enlightenment, the necessary change and questioning comes from the fact that transhumanism aims to modify man in his body. This raises the question of the very definition of humanity and its future. A human being who, thanks to a biological or technological contribution, would see better, run faster, calculate more quickly, can be considered as the result of this progress. We already have people who are smarter, faster and better looking than others. Of course, the fact that this capacity to increase is characteristic of man does not mean that it is always good for him, far from it. These examples raise questions because they call upon our judgement of good and evil, a judgement that is often influenced by culture or religion. Above all, they force us to reflect on the impact of the transhumanist movement, on its scope and on what we can call the tipping point. This point designates the moment when the human being, as we know it today, tilts towards a world where probably everything will have to be redefined: the principles of freedom, equality, responsibility and, on a more global level, governance or the capacity of States to govern.

Companies, states and citizens as determinants of a transhumanist tipping point

To analyse this shift and the influence exerted by the transhumanist trend, it is necessary not to isolate it or reduce it to the purely techno-scientific sphere but, on the contrary, to insert it into our global ecosystem. Only this approach will allow us to avoid utopian answers to the questions posed and to take into account the reality of things, whether scientific, economic or psychological. Let us take the key elements of this ecosystem one by one: the companies involved in this movement and the financial support they receive, the role of the States and the process of acceptance by citizens.

Companies as economic agents of changeover

On the first point, the race is on between the leading companies in the field (Calico, Seismic, Alcor Life Extension) with a proven economic potential for the richest, particularly in the United States and China. It may still be anecdotal, but Alcor's first customers paid 80 000 dollars (72 000 euros) to preserve their brains, and 200 000 dollars (180 000 euros) to preserve their entire bodies. The number of such companies is growing steadily and is based primarily on a rational calculation of economic potential. This rise is also supported by the strength of certain groups that support this research in the health field, but not only. Indeed, enormous fortunes have been amassed in less than twenty years by the founders of the most influential multinationals (Google, Amazon, Facebook, Apple, Microsoft, Baidu, Tencent). These technology giants also make huge profits thanks to their near-monopoly position in their respective markets. These two factors result in a tremendous investment capacity.

For example, Google (one of the main architects of this revolution) actively supports transhumanism, notably by sponsoring the Singularity University (headed by Ray Kurzweil) which trains NBIC specialists. Convinced that NBICs will dramatically reduce death in the 21st century, Ray Kurzweil was hired by Google as chief engineer to make the search engine the first true artificial intelligence. Google has also created Calico, which intends to explore never-before-seen technological avenues for delaying and then "killing" death. The transformation of Google into a conglomerate called Alphabet increases its strength in the field of NBIC. Larry Page and Sergei Brin, the co-founders of Google, claim to be transhumanists, who want to enable humans to do away with disease and, if possible, death. Here too, cultural differences explain the progress of certain countries on the subject: it is not insignificant that this trend is developing particularly in California. It is not insignificant that this trend is developing particularly in California, which is pushing the cult of youth far and wide, bringing together many followers of transhumanism as well as companies ready to tackle it from the angle of immortality.

States as catalysts and guarantors of ethics, but with currently limited means Investments such as those made by the companies mentioned above are by their very nature very different from the model of planned research with a targeted objective that naturally comes to mind (such as the Cancer Plan on a State scale). They are based on multiple experiments on an international scale and are increasingly outside the control/pilotage of states, particularly in relation to health issues. It is interesting to note that technology giants are regularly compared to nations, including in terms of performance such as Gross Domestic Product versus turnover or market capitalisation. There is therefore a major issue at stake here for those who do not share the philosophy implicit in this research, which is primarily political and collective: as it is impossible to align investments of this magnitude in a more humanistic sense, it is first and foremost the question of the monitoring and orientation of this research that is raised. However, the state means to do this are limited, late and often rather blind. They are not useless but partial. Inevitably, therefore, this research will progress. Thus, private entities (the GAFAMs in particular or their offshoots) or those under public control (but in authoritarian countries with a different philosophy) now have a capacity to disrupt our societies that is unprecedented in terms of both quantity (number of people affected) and quality (change in lifestyle). We will not be able to prevent them to any great extent, and in some cases they will bring about breakthrough solutions that will be beneficial to humans and patients. State investment in the subject of transhumanism is currently fragmented because the concept is so divisive; and when it is funded, it is from a very specific angle. One example is the Human Brain Project programme with eighty institutions from all over the world (1.19 billion euros), the aim of which is to create a complete digital simulation of the human brain. The project started in October 2013 and will run for ten years. It should be noted that the project is expected to be completed by 2023.

The citizen as a lever for acceptance of the changeover

Finally, the last factor that shows that transhumanism is making great strides is its public acceptance. Debra Whitman's survey of the American population showed that people are quite open to sensory, motor, cognitive or emotional augmentation. Implanting a stimulator to develop sociability and have more friends is acceptable to about 40% of them! If this acceptance seems a little distant at the European level, there are different ways to ask yourself. Ask yourself the questions:

• Are you in favour of the pacemaker?
• Are you in favour of making it possible for a quadriplegic child to walk?
• Are you in favour of deploying robot soldiers to avoid human casualties?

It is likely that the responses are rather positive and this is quite normal ... even moral! It is therefore in this economic, financial and sociological context that many experiments are underway and allow to work on the viability of transhumanist projects, to test technologies in a more deregulated way because at the interface of research between man and machine. The sphere of transhumanism is today free to test its concepts for lack of clear contours and consensus at international and national levels. It is therefore difficult to judge whether a device is good or bad as there are so many experiments with specific purposes that may escape their designers (or be applied to purposes other than medical). The question arises as to the framework for analysis and the elements that can enable us to better understand this movement.

This framework is supported in particular by two debates to be overcome:

• Feasibility: since the technology is accessible or available, these developments must be carried out.
• Legitimacy: since these are health applications, they must be developed.

Risks of deviance: increasing inequality and human impoverishment

There are a number of risks to be considered regarding the impact of these projects and research efforts. It is then up to states to decide whether or not to fund them, and for individuals to decide whether or not to use them. The main risks are the generation of individual inequalities and, at a more collective level, the impoverishment of humans.

The risk of inequality - example of access to education

The risk of inequality is very well addressed through the exchanges between Theo, Emma and their father about equal access to reputable schools without the need for implants. Given that education can and does increasingly take place on an international scale, this scenario should force states to coordinate their efforts to ensure the most equal access to schools possible. Two solutions can then be imagined: the first would be to remove the implant before each exam and the second would be to adapt the tests that can measure skills other than purely robotic ones.

The impoverishment of the human: the quest for invulnerability and its psychological impact

Another risk exists: it is that of the impoverishment of the human being which Thierry Magnin talks about in his latest book. He points out that the transhumanist belief speaks to us of "a human that is certainly augmented in certain functionalities but rather simplified, robotised and ultimately diminished because it is somewhat standardised from functions to be optimised". Absolute control over the body seems to take away the very soul of the human being and render it spiritually bland. What would be the impact of brain implants on the personalities of men thus augmented? What would be their freedom? There is no answer today. Through this risk, it is therefore the whole field of psychology that must be invested in order to understand the heavy impact of certain advances on our minds. Let's take an example: death serves to renew the living (cells are constantly dying). An immortal society would quickly freeze. Jacques Lacan, in a lecture given in 1972 in Louvain, said that if life were endless, man would go mad. Death is not a defeat for the human being. In the indispensable role of limits, a place must therefore be made for this supreme limit which is death. Wisdom would then lead us, a priori, not to desire a society where it would disappear. But it is obvious that on the other hand there would be clients, and this is already the case as we have seen previously.

Let us address a second example: the use of implants. The purely technical vision of the body is problematic when it leads to the undermining of the unconscious that the body expresses, for example, as to the origin of a symptom. The augmentation of man becomes problematic when new techniques are developed at the cost of this oblivion of the human, when we consider that the spiritual and symbolic universe can be reduced to a technical process, when we remove part of our lived reality to conform to our will or to the image we want to give of ourselves.

The lived dimension of the body is a complex concept: it has been presented by phenomenologists (making a distinction between the body we have and the body we are), psychoanalysts (showing that the conscious subject is not master of his own house, that there is an "id" within him that determines him without his knowing it) and many artists or writers. It is thus likely that the individual problems posed by transhumanism have less to do with a technical risk than with an underestimation of the psychological risk or the body's response to these changes. Further analysis in neuroscience and new forms of education would therefore seem to be necessary in order to use this type of new body technology wisely and to measure its full impact. Beyond this type of discourse, the manipulation of the body is sometimes equated with concern for the self, i.e. the image we send to others. This concern is expressed through a modification of the body (for example with cosmetic surgery) in a technical production of the self: one prefers to have a performing, healthy or aesthetic body, rather than being attentive to oneself and one's body. These transhumanist techniques entail the risk of subjection to contemporary norms that encourage us to be ever more efficient, to increase our power. When we take care of ourselves, we do more than make our bodies beautiful and healthy. We are addressing our part of the soul, our part of vulnerability. In his writings, Thierry Magnin also insists on the importance of the vulnerability that characterises us and makes us human. Already in 1950, this gap between the technical potential for increasing our bodies and our psychological capacity to manage it was evoked by Lewis Mumford: "We have multiplied the mechanical demand without in any way multiplying our human capacities to respond to it and react intelligently to it. These capacities are not innate and are acquired through education, with support in this bodily change. It therefore seems that the appearance of transhumanist techniques calls for the constitution of new knowledge, beyond that of ergonomics, as is the case for prostheses, so that each person may be able to decide whether or not to use these techniques and to use them in his or her own interest. For the moment, we are only looking at the individual consequences of this transformation.

The question arises as to the capacity of man to apprehend his transformation and how he is accompanied from a psychological point of view. Whose responsibility or duty is it? The question is open.

The contours of medicine in 2050

Through these few lines, it appears that it is probably a waste of time to try to fight (or support) transhumanism in its entirety. The forces at work (economic, financial, sociological) show that the "process" is well underway. The complexity and heterogeneity of the concept (as evidenced by the many examples cited above) should lead us to ask the question from a different angle: with the advent of NBICs, what kind of medicine and humanity tomorrow? To this end, we propose a framework for ethical analysis of the points to be considered in building new paths for medicine:

The first two are classic in an ethical analysis and remain fundamental:

• The benefit-risk ratio
• The aims

Secondly, the complexity of the subject "transhumanism" and its implications "at the level of the human" invite us to consider three other dimensions:

• The ethics of risk by the endangerment of the "common home" and the tipping point of our humanity. This section is particularly important in order to avoid a solely individual reading of the consequences of these technological advances.
• Taking into account the tipping point is fundamental: it is the point at which the immediate benefit becomes less than the future risks. This question raises the issue of the disproportionate risk taken at a certain point, and the impossibility of going back because the use of these technologies has become part of our habits. The "ratchet" effect, so to speak! The parallel with ecology is undoubtedly relevant: we are now paying for the consequences of decisions taken decades ago. Or to put it another way, we are paying for not having measured the consequences of our consumer activities. And yet, many things can be seen as progress: the car, better food, access to leisure for the middle classes... What should previous generations have done? Ban cruise ships? Force the most polluting industrial companies in terms of_CO2 emissions to reduce their emissions while at the same time generating jobs and consumer goods? Should we sharply increase the taxation of the most polluting products? Should we give up on their comfort and the improvement of their standard of living? The same parallel can be drawn with the tremendous progress we have experienced in the medical field. Every step towards better care, better diagnosis or better treatment is an undeniable advance. Such advances have brought us antibiotics, vaccination, cell therapy (to name but a few) and have saved millions of lives. But where is the limit? At what point do we reach the tipping point where we put our own human lives at risk?
• Taking into account the measuring influence between the function/body and the psyche and the relationship to others.

It is on this last dimension that the concept of the biocitizen takes on meaning. It is a question here of going beyond the physical vision of transhumanism and thinking not about the human being in itself, the individual, but about his or her relationships with others, about what we wish to define in terms of justice and equity, and then returning to what we accept or do not accept in terms of transhumanism. Through this framework, let us give the ethical contours of tomorrow's medicine. If we don't do this, history will probably be written as presented in the novel through the journey of Emma and Theo! A bit scary, isn't it?

In 2050, will we be allowed to get sick?

The question seems surprising, even shocking in 2022. If we ask it again in the same terms for 2050, it forces us to understand the link between technological innovation, adjustments to the care system and, ultimately, changes in the conditions of patient care in a context of probably persistent budgetary tension.

Our health system is currently experiencing a systemic imbalance between the two sides of medicine, prevention and care. 200 billion a year to treat diseases, some of which could have been avoided. They require regular consultations, lifelong treatment and repeated hospitalisations.

From curative to preventive and predictive medicine

Overall, the predominant culture is that of care, even though there is a growing demand for the implementation of prevention policies in many therapeutic areas (mental health, cancers, cardiovascular disorders, etc.). This quasi-institutional demand is coupled with a technological capacity to provide large-scale prevention tools and practices.

A few historical elements help us to understand the nature of the transformation. Curative medicine, which emerged at the beginning of the 19th century, is essentially concerned with the patient's body. It had a therapeutic objective: it dealt with diseases and their treatment. Then, a part of preventive and collective medicine (notably linked to vaccination) developed by superposition. We have reached the dawn of a third radical stage: that of predictive medicine (partly thanks to genetics) and personalised medicine (nutrition, physical activity, sleep, etc.). The example of SNAP in the novel perfectly illustrates this transformation with bio-citizens (and no longer patients) who have a system of credits hosted on their digital health space. SNAP credits reward virtuous behaviours: a full night's sleep, a balanced diet, regular physical activity, not smoking or drinking alcohol. Each behaviour influences the amount of credits available. Depending on individual profiles and genetic susceptibilities, SNAP credits increase or decrease in a highly personalised way. From a conceptual point of view, there is a break in the understanding of the disease. Whereas before, illness came to the individual (following the appearance of symptoms, man 'falls' ill), with predictive medicine it is man who goes towards illness (if he does not look after himself properly, then he becomes ill). He will undoubtedly have the means to prevent genetic diseases by modifying his genome. Alternatively, the system may decide not to give birth to it so as not to bear the burden. It is therefore the bio-citizen who will have to take full responsibility for his or her own health. One of the key notions will henceforth be to "manage" one's health capital before being involved in the care of a declared disease. This change also raises the question of what a healthy person is. There is no clear answer today. It should be noted that Google is working on this question to establish a baseline of what a healthy man is. Based on data collected from 10,000 people, Google wants to "better understand the transition between health and disease".

It is therefore also the general improvement in health that is transforming medicine. The physician's work, which until now has focused on the diagnosis and treatment of diseases, is gradually expanding its objectives to include the maintenance of health.

Technological resources driving this transformation

Technological capabilities make it possible to support preventive practices, to foresee as early as possible the signs of the appearance of a dysfunction, to guide the patient towards the best possible preventive behaviour, or to considerably simplify the follow-up of a patient suffering from a chronic disease that is often multi-mediated.

Pushed to the horizon of 2050, this technological accompaniment takes different forms with, for example, a multitude of sensors, ranging from the inside of our body (based on nanomaterials circulating in our body with a function of tissue repair, or alerts of the appearance of diseases), on us (connected skin, intelligent textiles) to our wider environment (companion systems).

Our state of health will be continuously assessed without us even thinking about it. The part of preventive medicine that is continuously monitored will be totally passive. The data may be external, such as general environmental data collected in the collective space (temperatures, epidemiological data on the circulation of viruses, air quality, etc.). They will make it possible to detect viruses circulating in the air, cold or heat waves in order to adapt the temperature of the premises accordingly or to make recommendations on our movements and the places we would like to frequent.

The other aspect of preventive medicine will address physiological parameters. Quantified self " will be widespread, thanks to AI, via connected bracelets, or even nano-chips with the collection, by ourselves, of data on our health, from the heart rate to the level of oxygen in the blood. Other medical devices will allow us to measure data equivalent to that from thermometers, glucose meters, dermatoscopes, oximeters that will be sent directly to doctors or medical resource centres at a distance. The data transmitted to practitioners will make it possible to speed up diagnoses and, above all, to intervene at a very early stage in the development of pathologies. They will also enable doctors to carry out remote medical monitoring of vital signs. Every day, this fluidity contributes to filling the algorithms with data capable of predicting the number of patients in an epidemic to the day.

The connected medical bracelet is already proving this: insurance companies are offering their customers trackers to find out about their physical activity and lifestyle in great detail. This is the case with an offer from Generali Germany, with discounts on insurance premiums ranging from 11 to 16%. The data concerns many parameters: number of daily steps, caffeine intake, decibels to which the body has been subjected, etc. Any failure to comply is punished by an alert indicating a drop in life expectancy!

Nutrition based on DNA analysis and exploited via artificial intelligence systems analysing our life data and our consumption will also be one of the key parameters of our health capital. The algorithms will analyse the interactions between the metabolism and the nutrients ingested in order to make recommendations on the foods and even the medicines that it is important to consume. Alongside the recommendations, the list of prohibitions, or more precisely of what should not be consumed, should be very long, especially for those who were not careful before the existence of these tools. This is the case of Emma, during her festive tête-à-tête with Gabriel, who receives a notification of dietary advice. Stop the champagne! Progress in the field of genetics, combined with an understanding of the role of food and its quality, will make it possible to monitor patients suffering from diabetes or cardiovascular disease in great detail. This intelligent, tailor-made monitoring will make it possible to optimise prevention by proposing personalised nutritional intakes and therefore an individualised diet, corresponding precisely to each individual's metabolism. 

It is also possible that private companies will enter the market for personalised diet management. Several parameters confirm this: rapid tests will be available (such as saliva tests for DNA analysis), sensors will be able to continuously analyse various physiological parameters, and a sales promise could be an improvement in health with a benefit for the patient (improvement of his or her health capital) and the customer (discount, loyalty programme, etc.). It is already possible in 2022 to offer different prices depending on our state of health. Good health bonuses" are already a reality with proposals made in Germany (Generali) and the United States (the insurer John Hancock via its Vitality offer). In parallel with these personal tools, the public health system will set up a personal account with a centralised patient file, linked to his or her smartphone and to all the devices (medical or otherwise) that constantly and automatically collect all this health data. This data is protected, unified and accessible under regulatory constraints.

Each patient has a health history known to all institutions, if they grant access! This history includes both numerical data (blood pressure, heart rate, blood glucose level) and contextual data (consultations and diagnoses are transcribed live by an AI).

It will be possible for everyone to regularly self-measure the consumption of their health capital. Depending on their physical and cognitive capacities, their nutritional status, their deviation from the norm, and later on with age, their ability to move around, their memory, their sight and hearing for example. The interest of this follow-up, in parallel with prevention, is to constantly identify the points on which each individual can work to maintain his or her health, to age less quickly and to keep away from diseases.

For this measure to be possible, the introduction of numerous standards based on biomarkers ("signatures") of biological ageing (genes, metabolism, telomeres, etc.) is foreseeable in order to objectify the foreseeable risks linked to age or to the genetic and epigenetic capital of each individual. For this system to work and for prevention to be effective, it is highly likely that, alongside private health management services, the public, partly for economic reasons, will make it compulsory to attach to monitoring systems or at least to centralise data.

First question: in 2050, could we imagine that all these technologies exist? That clinical studies demonstrate the effectiveness of certain prevention tools? That the State would not at least constrain their use, i.e. the collection and centralisation of data? On this last question, it is likely that no!

Indeed, thanks to this permanent monitoring, it will have been demonstrated that the individual will be less and less ill: our voice assistant will alert us when it detects an anomaly, with a suggested protocol to follow.Prevention will have become the norm and the risk of falling ill measurable in mostcases.

In the long run, we would be moving towards an ideal system, a decline in illnesses, linked to better prevention, and eventually there would only be accidents to treat. We will move from symptomatic medicine (you have pain, we seek a prescription) to predictive and personalised medicine. Predictive, because the doctor will follow our evolution in real time, and anticipate problems that might occur, by reading physiological signals and biomarkers. Personalised, because as everyone reacts differently to the intake of a particular substance, tomorrow we will be able to find the most suitable molecules for a particular patient thanks to biomarkers, AI, molecular biology and genetics.

Second question: in 2050, when this predictive medicine is developed and the tools are effective, how will people who fall "voluntarily" ill be treated?

"Voluntarily" here means anyone who has not followed the recommendations of the various medical monitoring tools. We have seen that medicine is essentially preventive in 2050. However, there are still cases in which medicine must play a curative role: for the treatment of diseases and in the case of unforeseeable accidents that have become very rare, fortunately!

Indeed, to avoid an "accident", the individual will have a duty to take responsibility for herself, to optimise her individualised approach to prevention and to use her health data assets to achieve this. Their ability to do so will determine the financial terms of their care, and if they do not meet the standards, they may have to finance the resulting health costs themselves. The economic constraint and the availability of technology thus create a much less ideal world, where the individual must not fall ill at the risk of having access to essential interventions de-reimbursed. Accidents, yes, but not just any accident!

Indeed, once the data is available, it seems unreasonable to think that we will not use it to encourage people to be healthier. Why should we pay for the treatment of diseases when they are preventable? What "accidents of the road" will we accept to pay for and on the basis of what criteria? Will there be a health points licence? How would it be adapted for everyone according to our profile and behaviour?

Is a system in which decisions about care would be taken on the basis of AI, in which citizens' behaviour would be evaluated and ranked, and in which a "score" would allow access to advantages (such as priority access to hospitals, better reimbursement), or, on the contrary, would expose people to sanctions, the logical next step? Our model of solidarity-based health care, protecting the most fragile and most at risk, will be shaken up in this context. The consequences of the transition from "patient" to "bio-citizen" will be much more profound and peripheral than a simple improvement of our current system. The prospect of increasingly individualised medicine, without prior reflection, conceptually endangers a humanist vision of health and raises the question of solidarity with sick, weak people who have drawn on bad genes.

In this context, we should give the citizen freedom with regard to his or her health, i.e. allow him or her to choose between different options: perfect compliance with recommendations, minimal compliance but with respect for a baseline to be defined that does not endanger others, and in a longer term dimension, a right to make mistakes, perhaps two rights... with, why not, the possibility of remedial training or health education. Here again, a balance must be struck between the individual and the collective dimension of health.

Tomorrow, all bio-citizens?

The story of Emma and her family illustrates the profound transformations in medical care and outlines the contours of a new health system. The medical events presented in this fiction show us examples of tools (drone delivery, Cardiopulse, Microdrop), applications (VirtU) and medical processes (from Emma's care in a Primary Care Home during her allergic reaction to the Biochip plan) that are likely to be applied in the coming decades. In parallel with these technologies, early diagnosis and predictive medicine will have become widespread, as shown by examples in the novel: diagnosis of malignant melanoma from the first signs of a lesion, diagnosis of Parkinson's disease from the age of 30, preventive monitoring of all "biocitizens" in their behaviour. The life of Emma and her family also raises two questions about the equality of opportunity that this situation creates.

• Will the knowledge of our heritage (genome, proteome, metabolome, exposome...) of each citizen lead to a stratification of the population into classes, some of which would be disadvantaged in their access to care?
• Will access to technology and its various updates be a vector of social fracture? If Emma had not used her implant, would she have doomed her chances of success?

In order to continue thinking about anticipating these upheavals, it is important to have an overall view of the elements that will constitute medicine in 2050 (and probably earlier). We cannot predict exactly what the health care system will look like in thirty years' time. But by drawing on the threads of current medical advances, we can write a credible scenario and use it as a basis for reflection.

Patients and doctors as agents of transformation

Technological advances and associated changes are taking place at an ever increasing pace. What seemed like science fiction a few years ago (brain implants, predictive tests, etc.) is now fully feasible, even if not everything is reliable in all cases. The barriers to entry are not technological. Just think of printing a splint at home: technically it is possible today! The rapid acceleration of these technological developments (artificial intelligence, robotics, 3D printing of biomaterials, etc.) is transforming man not only physically but also psychologically and behaviourally. This last aspect is still very little addressed for research purposes. These two types of impact explain why the evolution of health care systems is taking place gradually and without any possible return. These elements of changeover are also supported by the behaviour of the patient himself. In a way, they maintain this dynamic of change.

In parallel with this change in the human-patient relationship, technologies are also transforming the daily life of the doctor, both through the tools he uses and through his relationship with the patient. This capillary advance of technology by both the patient and the doctor is the foundation of the future healthcare system. Only a few elements of the outline are still really in the hands of the public authorities, and of course to varying degrees in different countries. If we study and prepare the medicine of tomorrow by focusing only on its technological component, we are only addressing the emerging part of the changes underway.

All-technology health

Four of the most important technologies will have a major impact on our approach and organisation of medicine as we know it today. We have selected them because they have a global impact on a given country (access to telemedicine for all) or because they profoundly change medical care (shift from curative to preventive care). Their impact will be all the greater as they are fed by an exponential quantity of health data analysed by artificial intelligence algorithms. This list is obviously not exhaustive but it points to the major areas of upheaval:

• Implants and nanobots (for drug delivery). In the long term, these technologies make it possible to imagine the so-called augmented human and the human-machine connection.
• Telemedicine and remote access to diagnosis. Take the example of Pager. It is an Internet platform and a mobile application that allows emergency calls to be made from anywhere by means of geolocation. It is a form of Uber. But instead of a taxi driver arriving, a doctor comes to pick you up and rescue you.

Predictive genomic testing. By early 2020, it is estimated that over 26 million people will have used private companies such as

• 23andMe or Ancestry to have their DNA sequenced for information about their origins and/or potential disease markers.
• Medical assistants incorporating artificial intelligence algorithms (surgical robots and decision support software).

Digital health start-ups are already developing at high speed. These include companies such as Project IO, which offers 3D-printed prostheses; Medwand, which is developing a device that measures multiple physiological constants in patients to facilitate teleconsultations; CrowdMed, a collaborative service for solving complex medical cases; and SkinVision, which uses a smartphone to spot melanomas on the skin... Beyond the start-ups, the giants of the technology industry (the famous GAFAMs and their Asian equivalents, the BATXs) have also all shown an interest in the digital health and risk prevention/prediction sector. Google, via its parent company Alphabet, has launched Verily and various entities around AI and deep learning (Deepmind Health, which is interested in pharmaceutical research in particular), mapping of the human body (Baseline project), optimisation of cancer treatment (Calico project). Google has also formed several alliances with large pharmaceutical groups (e.g. Sanofi for diabetes). The health branch of the conglomerate, called Google Health, will have over seven hundred employees in 2021.

• Apple for its part announced in March 2018 that health was a strategic development focus for the firm. Apple has launched a development kit for health applications (HealthKit), a programme dedicated to researchers (ResearchKit) and a programme for sharing information between patients and doctors (CareKit). The fourth generation Apple Watch incorporates algorithms for detecting atrial fibrillation. In 2002, Apple unveiled an advertisement presenting the Watch as a crucial object that can save lives.
• Meta (formerly Facebook) gives access to its subscribers' data to some companies developing predictive models of epidemics, such as SickWeather or Accuweather, and has developed a specific advertising format for pharmaceutical companies (to mention adverse effects). The group is also active in detecting mild to moderate signs of depression by analysing online behaviour. It has also established itself as a promoter of access to quality health information.
• Finally, Amazon is the largest health data host in the United States. Jeff Bezos' company has also launched the Amazon Care telemedicine programme for the benefit of its employees and, since 2022, for other companies in several cities: New York, San Francisco, Chicago and Miami.

Given the power of these companies, they are increasing the pressure both on states to accelerate this transition and on the individual human/patient to be monitored, to share their data and to have an advantage in using these many tools.

From patient to biocitizen

The biocitizen: patient without suffering Connectivity is the first element widely mentioned in the novel. Today, such connected objects, and tomorrow implants, will make it possible to follow the evolution of certain medical parameters directly in the body. The applications and sensors will be in our possession, more than in the doctor's possession, so that literally we will carry with us (on our wrists or in our bodies) all the capabilities of a diagnostic laboratory and rapid care unit. For example, the US company Profusa offers Lumee, a fingertip implantable device that monitors tissue oxygenation in real time. Perhaps a first step towards integrated monitoring of a large number of parameters?

In parallel with this evolution, the position of the 'patient' man will strongly evolve. Let us remember that the very term patient comes from the Latin patiens: who endures, who endures, adjectived from patior: to suffer, to bear, to endure. Gradually, patients will be able to access their own genetic data and have access to key information for the management of their health capital. This access to medical information will make them directly responsible for and involved in their health care. Paradoxically enough, while the excessive digitalisation of health care provision risks disempowering the patient by diverting some of the decision-making process, we can expect individual decisions on diet, exercise or smoking to be increasingly used in these same decisions. Patients will in a way break free from a doctor-centred medical regime. The very term patient (in the etymological sense) will therefore no longer be entirely adequate. This transformation is underway, but it has only just begun. Siri (Apple), Cortana (Microsoft) and Watson (IBM) are capable of responding very appropriately to the interlocutor's questions by analysing his or her question and searching the "Big Data" for intelligent answers. Despite a level of performance that is often considered unsatisfactory, in the next few years these voice assistants will offer intelligent support for any medical question and make the patient more informed. They will be able to take on the role of "knower", on the same level as the doctor. Even if inequalities will remain in the access and understanding of one's own medical data and information, this trend is a real groundswell.

The patient will also have easier access to communities of experts or patients (such as Patients like me, Smart patients, Carenity or CrowdMed) that will allow him/her to share and increase access to medical knowledge. As a result of this connection and real-time monitoring, tomorrow's patient will be made aware of the importance of his or her health capital and of monitoring it throughout his or her life. Added to this is the rapid development of predictive tests which will no longer upset the sick patient but each individual in the management of their health.

The bio-citizen: prescient man Let's take a closer look at these tests. Predictive tests are already marketed in the United States. After a veto on their medical interpretation in 2013, in April 2017 the FDA (Food and Drug Administration) authorised the company 23andMe to sell predictive DNA tests to individuals. The procedure is simple: for 99 dollars (rate 2022), the customer sends a saliva sample to a specialised sequencing laboratory. A few days later, they receive a personalised genetic assessment. The result is a personalised genetic profile that shows the percentage of risk for various diseases, such as Alzheimer's or breast cancer. As access to these tests is possible on an international scale, it is highly likely that they will develop rapidly, both within a highly regulated framework (for example, by prescription in the case of family history) and more freely through the multiplication of private companies equivalent to 23andM that sell these tests to consumers. As a direct consequence of this development in access to knowledge of one's own genome and the risks of developing a particular pathology, people are faced with data that can change the way they see their lives. Very few studies have gone into the subject of the psychological repercussions of such tests. They are generally carried out on very limited cohorts of around one hundred people.

With regard to these tests, several control points need to be examined: from the reliability of the test to the type of results, from the protocol for announcing the results to the associated medical management. Different types of diseases can be diagnosed or rather predicted but a distinction must be made between those that are entirely identifiable by genetic manifestations (Huntington's disease) and polyfactorial diseases where several genes are involved in the development of the disease. In the latter case, the results are provided in the form of probabilities and not the certainty of a life "described" in advance. The question is therefore how to interpret the results. Indeed, it is not because you have a mutation in a predisposition gene that you will necessarily develop this or that disease. The explanation that will be given and the level of understanding of patients will be important elements of future care systems. Everyone, regardless of their background, will need to understand what two parameters correspond to:

• The percentage of risk that the algorithm gives.
• The type of disease to which the person will be exposed. The decision to intervene will vary depending on the condition in question, the treatments available or the actions the patient may decide to take to reduce this risk.

Depending on the way the test is carried out, i.e. whether the sample is sent to a private company or whether it is carried out as part of a medical follow-up, the capacity and understanding of the result by the patient will not be the same. Let's look at the case of the discovery of a mutation in a gene that detects a pathology. What will be the consequences of obtaining such information in advance? Many examples (e.g. Huntington's disease) have shown that all life choices are influenced by the disease: In the same way, for a patient who is not at genetic risk of breast or ovarian cancer, we can think that the absence of questioning regarding possible prophylactic surgery and a less intense rhythm of surveillance will be an element that induces a positive perception of the patient. It is therefore the most important choices of a life that will be upset in advance, hence the importance of the reliability of the result and the types of pathology that can be diagnosed. The current data therefore show appropriate psychological reactions. The results will in all cases lead to classic reactionary symptoms that can be anticipated such as anxiety, depression or guilt. In the majority of cases, these symptoms are merely the expression of a 'normal' reaction to major information and fade away in an average of three months. Support is therefore key to prepare for the understanding of the tests, their impact on both the personal and family levels, and for taking preventive action if it is justified. Furthermore, genomic consumer tests are not currently robust enough to be used as a diagnostic tool.

Two tests from two different companies on the same patient may give significantly different results. This is likely to improve, but the notion of liability and the psychological impact of such companies in the event of an erroneous test must be anticipated.

Two support levers are therefore essential to avoid a social divide linked to the understanding and management of these tests:

• The form of the announcement and the support provided by the doctors.
• Good information about the consequences of genetic testing and the treatment and prevention possibilities that follow from the results. Such measures are essential to be put in place prior to the decision to carry out such tests.

The existence or otherwise of preventive measures according to the diseases identified is thus a key element to be taken into account in order to ensure a certain equality of access not to care, but to the understanding of data for health management. In conclusion, although the psychological risk (not negligible, but controllable in the long term) does not appear to be a brake on the adoption of this type of test, we must not underestimate what their widespread use may involve: a mass of information and no doubt emotions to be channelled in the face of a multitude of predictions; a possible divide in access to and understanding of these tests; and a more global risk of political, or even private, control. Indeed, there are examples of large-scale "genetic profiling" programmes being launched. In China, researchers at the Beijing Genomics Institute (BGI) have launched a major sequencing programme for gifted people because they want to determine the genetic variations that favour people with high IQs. The data from these tests is therefore vital for its own sake, but in the future (and in some countries it already is) it may become a bio-political and insurance issue. In the long run, knowing an individual's life course in advance will be as important for the patient as for the system.

The reinvention of the medical profession

As we have just seen, the doctor will have a fundamental role in helping people to understand this type of test, perhaps only in a transitional phase, before being replaced by " the voice in his ear "! The doctor's habits will also be profoundly changed by the tools he or she will have at his or her disposal to carry out his or her work, by the medical problems that will be partly new (increased importance of prevention), and by the patient's behaviour as mentioned above. The "new technologies" are involved in diagnostic assistance (artificial intelligence), technical procedures (surgical robotics) and consultation (telemedicine). The organisation and working principles of medicine are set to change. Technologies will enrich, complete or replace some of these acts. Computer algorithms will replace doctors for many diagnostic tasks. These algorithms will be based on huge data sets to, for example, better manage chronic diseases (diabetes, shingles, high blood pressure, etc.). In addition to this initial technological upheaval, there will be the informed patient or simply the ' consultant ' who consults on improving or maintaining his or her health. Joël de Rosnay uses the term "life advisors" to describe the function of the doctor of the future.

By opening up the possibility of automating tedious and delicate tasks, robotics, artificial intelligence and related technologies are continuing and amplifying trends that have been at work for more than 25 years. Consequently, the whole definition of medicine will have to be questioned more than ever at the heart of our health care system. It is likely that many medical professions will see their practice transformed by these contributions. New professions will be needed: neuroengineers, "life counsellors", to accompany these changes and other specialties will see their current practices profoundly reformatted (dermatology, ophthalmology for example). E-Med's equivalents in the novel will become part of our medical environment. These new contributions will make it possible to bring elements of response to the growing problem of medical deserts by moving part of the acts of the doctor towards the carers and from the carers towards the patient himself.

The future of the doctor and of our health system as a whole may then be shifted into a world that is still difficult to imagine, given that our habits seem to be unchanging in this field. It is a whole new medicine that will evolve before our eyes: predictive medicine that will address augmented humans who are concerned about and potentially forced to manage their health capital as best they can.

We are therefore gradually entering a turning point where the technology will be sufficiently mature to trigger a new approach to patient monitoring and medical care.

The birth of the bio-citizen will be based on science and technology. Repaired by new organs developed in vitro or in silico. Accompanied by personalised prevention programmes based on what we know about the person: Physiology, genome, dietary habits, exposome... Connected and monitored by sensors so minimally invasive that we forget they are there, giving a panopticon of real-time information on blood sugar, heartbeat, sleep quality, blood oxygen saturation levels... Modelled and digitised into an alter ego of 0s and 1s on which we will be able to prognosticate the response to a new therapy, based on its "digital twin".

In a linear anticipation, this techno-abundance of information will make it possible to predict and interpret the signs of the appearance of a dysfunction at an increasingly early stage, to guide the bio-citizen towards the best possible behaviour as a preventive measure, or to considerably simplify the monitoring of a patient suffering from a chronic disease or an elderly person suffering from a multi-medical condition. To achieve this, it will be necessary to know the individual and to collect a large quantity and quality of data. All this information will be stored in both private (from bathroom scales to connected patches) and public spaces (such as My Health Space, which will eventually become a personal health data vault), against a backdrop of persistent budgetary tension.

This new approach is characterised by the role, and one day the greater responsibilities, that the system gives to the patient in his or her health: whether it is a question of his or her journey, his or her experience, or the famous "centricity" that is exercised around the patient. With these responsibilities may come new duties that each citizen will have to respect. This is where the notion of biocitizenship comes from. This concept designates a person (healthy or sick!) who benefits from rights relating to his or her health in the State to which he or she belongs, but also from duties.

The future redefinition of the health system

The healthcare system will therefore be completely revamped in the coming years. The objectives of this transformation will be clear: reduction of care or therapy, speed, personalisation and dedicated assistance, real-time operation (telemedicine), proximity interventions (Walk-in Clinic for example) and control of one's health status. All of these elements lead to a new picture of tomorrow's medicine with changes in the current players in the health sector. We have seen the main individual repercussions (whether for the patient or the doctor), but what about collectively? What is at stake in this movement? What role should states play? This transition to the collective is complex and strongly depends on the political and cultural context of the states concerned. Coordination bodies at international level will undoubtedly be necessary, as the issues will go beyond the State framework.

From Biocitizens to Biopolitics

For the birth of the biocitizen, there must also be a form of political will, which we will call biopolitics, to place life in good health as a point of arbitration for political decisions. The recent example of the Covid crisis with the decision taken in France to privilege measures with a health effect rather than economic necessity is a first example. One by one, the decisions taken during this health crisis are becoming embodiments of biopolitics: the mask, the free PCR tests, the reinforced confinement of EHPADs, the tracing of clusters and the monitoring by the ARS of contact cases on a national scale, the health information messages in the public space... The list of health subjects that are becoming more important in personal and public life is growing. While this crisis has undoubtedly highlighted an extremely powerful biopolitical parenthesis, it is also indicative of a deeper trend towards putting health and life first. This underlying trend is intertwined with the technological capacities for prevention, personalisation and improvement of care described above.

This convergence of trends, with 'health value' at the centre of power on the one hand, and technological capabilities on the other, will be the basis for the lasting advent of biopolitics and the gradual institutionalisation of the biocitizen.

A third fundamental trend will reinforce this pattern, namely the preservation of life on Earth; indeed, the preservation of the Earth. Although today the themes of "health and sustainable development" still seem distant in the public debate, they come together in the notion of "One Health" with the awareness of the close links between human health, animal health and the global ecological state.

The notion of biopolitics is certainly not new and was first stated in 1976 by Michel Foucault, in the last chapter of The Will to Know, 'Right to Life and Death'. In this chapter, the various forms of biopower are discussed from a historical perspective, with an analysis of the management of epidemics (exclusion of the leper, inclusion of the plague-stricken) and comes down to an administration of the human as a living being rather than as a commodity: proliferation, births, mortality, health...

This first very "biological" conception, the "zoè" is to be overcome with the "bios" coming from the Greek "life" (the lived life, the culture, the social). Bios" must challenge us on this new era of biopolitics that is coming with the importance of questioning what we mean by promoting and preserving health. Is it health in the biological sense (physiological parameters defined by standards, absence of disease, improving longevity, etc.) or "living well", with a first circle of biological metrics, but also what life includes in terms of social links, the power of empathy, the relationship with others, even with the living, but also with death? Living is not reduced to being preserved from biological death.

The advent of the biocitizen could become that of the zoe, of a biological and mechanical being who lives, but who only lives. If we now take up the question of political contours, in the sense of human values and the model of society, we can collectively serve a model of biopolitics that includes support for the most fragile, care for others, respect for freedom, and the promotion of social and cultural links.

At that point, a bio-citizen is born, who has duties to preserve his or her health, but is not limited to health.