Horizon Scan 2024

Abortion

Abortion is a polarised issue, with implications for other areas of medicine like prenatal screening.

New buffer zone laws in England, Wales and Northern Ireland will make it a criminal offence to protest directly outside clinics – Scotland is expected to debate similar measures.

A cross-party amendment to decriminalise abortion in the UK in May 2024 could resurface under the new Labour Government.

Air and plastic pollution

Poor air quality is caused by high concentrations of air pollutants. These can be emitted directly from a source or formed in the atmosphere through chemical reactions. Poor air quality causes damage to human health and ecosystems.

In the UK, air pollution represents the biggest environmental threat to health. It is distributed unequally, exacerbating existing inequalities. Plastic waste contains many toxic substances, such as flame retardants, plasticers and stabilisers. When burned or incinerated, this waste can harm people’s health.

Animal research

Many argue that the use of animals in research is essential for advancing human health. Nonetheless, major funding bodies are supporting moves to incorporate replacement, refinement and reduction (the 3Rs) of animal use in research.

Research about animals is rising, with many studies focusing on animals’ minds and consciousness. The UK’s Animal Sentience Committee advises the government in relation to matters relating to animal welfare, specifically sentience.

Antimicrobial resistance

By 2050, it is estimated that deaths associated with antimicrobial resistance (AMR) will increase to 8.2 million people per year. Drivers of AMR include misuse of antimicrobials, lack of awareness, poor infection control and climate change.

AMR is a global health issue, requiring concerted international efforts to surveil and limit the spread of drug-resistant pathogens. Considering this, tensions arise around global funding priorities, access to new antibiotics and the unequal burdens of disease.

Assisted dying

In the UK, assisting or encouraging another person to end their life is a criminal offence. Proposals to change the law to give terminally ill people the right to end their life have been introduced in the House of Lords and Scottish Parliament and are due to be debated in UK parliament this year.

Assisted dying is a highly complex and ethically charged issue. Tensions arise around autonomy and capacity, professional ethics and the accessibility of end-of-life care.

Current state of the NHS

Since the COVID-19 pandemic, the NHS has faced a significant backlog of care. Over 6.3 million individual patients are waiting for treatment in England alone and the median wait time of 14 weeks is almost double pre-pandemic figures. The NHS regularly identifies priorities, these include reducing wait times for elective care, improving emergency service responsiveness and making community, primary and mental health care more accessible. There is also an overarching focus on reducing inequalities.

a) Healthcare post-Brexit

b) Drug shortages

Diversity in clinical research

Diversity in biomedical research enables researchers to better understand the effectiveness of treatments and medical devices across different groups. Attention has been drawn to the exclusion of female cells and animal models in research. The underrepresentation of populations, such as ethnic minorities, pregnant people and disabled people, may also contribute to health inequalities. Although UK legislation does not require medical research to be representative, funders are introducing inclusive research design as a condition of funding.

Early developmental research

a) Embryo research

Current UK law stipulates that embryos used in research must be destroyed after 14 days. There is growing discussion around how extending this period could improve understanding of early human development.

b) Stem-cell based embryo models

Stem-cell based embryo models (SCBEMs) are 3D structures, derived from stem cells, that exhibit certain features present in human embryos at an early stage of development. SCBEMs might lead to a reduction in basic research on normal embryos, although the latter will always be necessary.

Engineering biology

Engineering biology combines the principles of biology and the tools of engineering to create usable, tangible, economically viable products. The UK Government has highlighted the expansive potential of engineering biology to drive advances across health, agriculture, chemicals, materials, and energy.

A culture of responsible research and innovation (RRI) is required as we address the varied social, cultural, legal and ethical questions that may be raised by different applications of engineering biology.

Equitable access to medicine and therapies

Essential medicines are inaccessible to an estimated 2 billion people worldwide. There are concerns that the current system of medical research and development does not benefit patients equitably and that the development of drugs and vaccinations may be unduly influenced by factors beyond patient need, such as profit. As genomics and precision medicines develop, some have raised questions about equity of access due to cost and lack of diversity in genomic databases.

Farming and agriculture

There is a multiplicity of factors – including non-human animals – and stakeholders that must be considered in policy and practice addressing climate change within the agriculture sector. This includes human health, non-human animal health, and factors such as food security.

a) Food systems
b) Cellular agriculture
c) Genome editing in farmed animals and plants
d) Livestock welfare

Fetal intervention

Surgical interventions can be performed on fetuses in utero to manage life-threatening conditions and prevent disability. These interventions involve complex trade-offs between fetal and maternal benefits and risks.

Ethical questions include in what cases should fetal interventions be offered, and what are the implications for prenatal testing or screening in relation to conditions for which fetal interventions might be a treatment option?

Gender Identity

Following the 2024 Cass Review, NHS England are planning up to eight new gender services for children and to review adult services. A temporary ban on puberty-suppressing hormones for minors, outside of clinical research, has been renewed.

With greater visibility and acceptance of people with divergent gender identities, ongoing debates about the rights of trans and non-binary individuals focus on single-sex spaces, Gender Recognition Certificates and access to puberty blockers.

Global warming

The world is warming faster than at any point in recorded history. Between February 2023 and January 2024, the average global temperature finally exceeded pre-industrial levels by 1.5°C. The world is currently on track to reach almost 3°C above pre-industrial levels by the end of the century. This is having adverse outcomes on humans and animals for example, it is causing an increase in waterborne and infectious diseases, and an increasing number of people are facing unprecedented heat extremes.

Health data

The digitisation of health data and expanding methods of collection, such as wearables, self-tracking apps and direct-to-consumer genome sequencing, have increased the amount and availability of health data for research.

This brings with it challenges around data protection and cyber security, as well as ethical considerations around trust, accountability and consent. Some have also drawn attention to a ‘digital divide’, in terms of whose data is collected and who benefits from data-driven approaches and outputs.

Health screening

Screening for diseases such as heart disease, diabetes and cancer can enable early diagnosis and intervention and reduce morbidity and mortality. However, all health screening also has potential harms, including over-diagnosis and treatment, uncertainty in results, anxiety, stigma and false reassurance.

The UK National Screening Committee advises ministers and the NHS on whether a screening programme is appropriate. They consider potential benefits and harms, cost effectiveness, fair resource allocation and equity of access.

In/fertility provision

In England, a ‘postcode lottery’ exists for access to fertility treatment, meaning many patients are unable to access the number of IVF rounds on the NHS that is recommended for their age group.

A recent intervention developed by the Progress Educational Trust helps patients understand what level of fertility provision their Integrated Care Board provides. It is argued that more should be done to ensure equal access to fertility treatment.

Innovation and digitisation in health and care

Innovation and digitisation present an opportunity to support health and social care services in the face of growing demands and staff shortages. Current applications include remote monitoring, virtual wards, electronic health records and smart alarms to keep track of medication. In the future, AI-powered administrative and diagnostic technologies could free up clinical time and boost productivity. Improving digital infrastructure and training, as well as working collaboratively with the public and different communities will be key in new implementing technologies effectively.

Maternal, perinatal and neonatal health

Evidence shows that neonatal mortality rates are increasing in England and Wales. Higher rates of stillbirth and neonatal mortality are seen amongst those who face existing health inequalities, particularly ethnic minority groups and those living in deprived areas.

In 2023 the Care Quality Commission found that of all the hospital services it inspects, maternity units fared worse. 41% of clinical negligence claims paid out by the NHS are maternity-related.

Mental health and technology

Mental health apps, portable brain stimulation devices, immersive technologies, digital phenotyping, and AI-driven predictive analytics all have potential to provide flexible and tailored mental health support.

At the same time, mental health technologies raise ethical concerns relating to reductions in face-to-face contact; the effectiveness, quality, and safety of care; cost, access and potential exacerbation of health inequalities; and data privacy and security.

Microbiome research

The microbiome contains bacteria, viruses, and fungi that constitute 1-3% of our body mass, with roles in immune function, disease mechanisms, and infant development.

Microbiome research reframes the human body as an ecosystem. Growing interest in this field includes direct-to-consumer microbiome tests and microbiome-based treatments such as dietary supplements and faecal transplants. Ethical issues include how we manage identity, privacy and ownership in relation to microbiome data and commercial products.

Mitochondrial donation treatment

Mitochondria provide cells with energy to function properly. Errors in mitochondrial DNA (mtDNA) can cause serious, life-limiting disorders. IVF techniques known as mitochondrial replacement therapy can be used to replace faulty mtDNA with healthy mtDNA from a donor’s egg, preventing disorders being inherited.

Only the UK and Australia have legalised this procedure, but it has also been carried out in countries including Ukraine, Spain and Greece, that don’t have relevant laws.

Non-communicable diseases

Non-communicable diseases (NCDs) like cardiovascular disease, cancer and diabetes represent 74% of all deaths globally. Tobacco use, physical inactivity, air pollution, harmful alcohol use and unhealthy diets are all associated with a higher risk of NCDs.

Recent efforts to reduce the prevalence of NCDs include the ‘sugar tax’, a levy applied to soft drinks to reduce sugar consumption and the prevalence of childhood obesity. Interventions like this highlight tensions between individual freedoms and public health.

Research culture

Research culture shapes who is involved in research, what is researched, and how it is conducted and communicated. Concerns relating to research culture centre around inclusivity and equity, research integrity, barriers to collaboration and career longevity. Transparency, regarding what research is being conducted, how it is funded, and what the benefits are, is also key to accountability.

Particular areas of interest include:
a) Research assessment
b) Research equity and access
c) Research credibility

Surrogacy

The UK Law Commissions’ proposed legal reforms on surrogacy include clarifying rules on payments to surrogates, safeguarding children born through international arrangements and establishing intended parents’ parental rights at birth.

The new Government will decide whether to adopt these proposals. In the UK, surrogacy is only permitted if the surrogate is not paid, or only paid expenses. Surrogacy is banned in many countries including France, Germany, Italy, Spain and Bulgaria.

Sustainability of research, healthcare and systems

The UK has a target of reaching net zero by 2050 and new interim targets to reduce emissions by 78% by 2035. Achieving these requires urgent and decisive action and a combining of offsetting and emission reduction.

The transition will require socio- and economic transformation, not just technological change and organisations such as the NHS and its supply chains must embed ethics as part of this pursuit.

The built environment

The built environment refers to the human-made elements of our surroundings. The construction, design and use of buildings and urban spaces has implications for carbon emissions and resource consumption, the natural environment, and health. Nature-based solutions, such as the creation of park and garden areas, can benefit health by improving air quality, reducing temperatures and promoting physical and mental wellbeing. However, in the UK there are clear inequalities in access to green spaces, particularly within socioeconomically deprived areas.

Whole population mental health services

In the UK, demand for mental health support has grown significantly in recent years. Attention has been drawn to population-wide inequalities in mental health and in access to care.

In 2023, NHS England launched the Patient and Carer Race Equality Framework, to reduce racial inequality in mental health services. The new Government has committed to modernising the Mental Health Act, created over 40 years ago.

Zoonotic diseases

Zoonotic diseases can be transmitted between animals and humans, either by direct contact or via a vector (such as mosquitoes), and represent a major global health challenge. It is estimated that 75% of emerging diseases have zoonotic origins. Zoonotic disease outbreaks are linked to human activities such as urbanisation, deforestation, livestock farming, plastic pollution, hunting and wildmeat consumption.

One Health has been adopted as one approach to managing zoonotic diseases which recognises the interconnectedness of humans, animals and the broader environment.

AI & Genomics

Many key advances in genomics have been made possible by machine and deep learning techniques, and AI-powered genomics has emerged as a distinct specialised field and area of commercial interest.

Current and future applications of AI in genomic research include in protein and drug development, optimisation of genome editing techniques and prediction of individual disease risk and drug responses. However, there is considerable uncertainty around the accuracy of predictions due to biased datasets and the influence of environmental factors.

AI in clinical practice

AI applications are being explored across healthcare, including in the detection and diagnosis of disease, the management of chronic conditions, and assisting in clinical decision-making.

These technologies often present new ethical and regulatory challenges around transparency, patient safety, data privacy and bias encoded in algorithms. The MHRA’s AI Airlock, launched in 2024, is a pilot regulatory sandbox which brings together different regulators to ‘stress test’ regulatory approaches and inform future regulation of AI as a medical device.

AI in drug discovery

The drug discovery process is expensive and uncertain, costing an estimated $2.5 billion per new drug, with only a 9-14% chance of regulatory approval from phase 1 trials.

Research is investigating the use of AI techniques to enhance drug target identification, optimise small molecule and vaccine design, and assess drug safety. Challenges and concerns include trust in AI, intellectual property, dataset diversity, and equitable access for researchers.

Digital Twins

Digital twins (DTs) are computational models of a physical object or system, used to model the effect of different conditions and optimise decision-making. DTs have potential uses across healthcare, from simulating an individual’s organ to modelling wards and whole hospitals.

DTs generated at birth could act as life-long health companions, enabling early diagnosis, informing lifestyle choices and guiding treatment. At the same time, DTs could undermine the clinicians’ decision-making status and raise questions around accountability and responsibility.

Ecology and biodiversity 

It is not just human health that is impacted by climate change, the health of non-human animals and the conservation of the wider environment are also under threat. Human health is also dependent on the non-human world. Evidence shows that natural habitats and biodiversity are being adversely impacted on land and in the ocean, some of which is irreversible (e.g. due to permafrost thaw). It will be important to include multispecies and emphasise the moral value of the non-human world.

Emerging neurotechnology

Neurotechnologies include brain-computer interfaces (BCIs), non-invasive vagus nerve stimulation and deep brain stimulation. These technologies have current and potential applications in treating a range of neurophysiological, neuropsychiatric, and neurological conditions.

Emerging research raises issues around safety, post-trial access, and patient and participant rights. Neurotechnology has implications for personhood – perceptions of self, identity, agency and the ability to exercise autonomy authentically. Attention has also been drawn to the legal status and protection of neural data and ‘neurorights’, including mental privacy.

In-vitro derived gametogenesis

Creating human sperm and egg cells in vitro could offer a route to parenthood for infertile couples or individuals, same-sex and single parents and older women who want to have genetically related children.

There is considerable research underway and commercial interest in this area. It raises significant questions about the status and significance of genetic relatedness and parenthood.

Longevity research and treatments

Ageing is associated with many long-term conditions, such as heart disease, stroke and dementia. Researchers are working to understand biological ageing and potential interventions to improve longevity including drugs and dietary restriction, boosting mitochondria, stem cell therapy and blood transfusions from younger donors.

Treatments for biological ageing could reduce the burden of age-related disease on health and social care. However, ethical questions arise around the (over)medicalisation of ageing and impacts on population demographics and the environment.

Neural organoids

Neural organoids are small, lab-grown structures made from stem cells. They offer researchers the opportunity to study human brain development, though it is uncertain exactly how well organoids can model human brain function.

As neural organoids become increasingly complex, ethical considerations relate to their ability to develop consciousness and sentience, their moral and legal status, their potential to replace animals in research, and informed consent for donors.

Polygenic scores and indexes

Researchers have developed genomic predictors, called polygenic scores (for health conditions) and polygenic indexes (for social and behavioral traits), that estimate a person’s likelihood of developing a certain trait compared to others in the population. Although these predictors aren’t accurate, they continue to improve and hold potential for improving some outcomes. However, they don’t work equally well for everyone, which could worsen inequalities and embed discrimination.

Precision medicine

Precision medicine, also referred to as personalised medicine, uses information about an individual’s genome, proteins and environment to optimise diagnosis, prevention and treatment. For example, the NHS is trialling personalised mRNA cancer vaccines based on the specific mutations of an individual’s cancer.

Although most established in oncology, precision medicine has applications across healthcare. Some concerns have been raised about fairness in precision medicine, particularly highlighting bias in the datasets used and unequal outcomes and access.

a) Pharmacogenomics

Preconception screening

Prospective parents with a family history of conditions like cystic fibrosis, sickle cell anaemia or thalassaemia can have genetic testing before they conceive to assess if they are carriers.

Preconception screening tests for a broader range of conditions are targeted at ‘healthy’ individuals. Ethical questions include whether there should be limits on what is tested for, how screening is regulated, and whether screening could become a requirement for gamete donors.

Quantum technologies

Quantum technologies utilise quantum mechanics to achieve capabilities beyond classical machines.

The UK Government’s National Quantum Strategy includes for every NHS Trust to benefit from quantum sensing solutions by 2030, enhancing early diagnosis and treatment for chronic illnesses. The Royal Academy of Engineering have emphasised the need for Government support in skills development, standards, and regulation to ensure responsible, ethical innovation and address environmental impacts.

The wellness agenda

Wellness describes the pursuit of one’s holistic health through lifestyle choices. This is a rapidly growing industry, encompassing a range of activities and technologies, such as mindfulness apps, smart watches and direct-to-consumer (DTC) microbiome tests.

Wellness products fall outside of regulation for medical devices, and concerns have been raised about data collection and privacy, lack of robust evidence and risks of widening health inequalities. The wellness agenda also has implications for societal views towards individual responsibility for health.

Xenotransplantation

Xenotransplantation could alleviate organ shortages, especially for ethnic minority patients who are less likely to find donors. Key ethical questions arise over who participates in research trials, and the vulnerability of patients.

Ethical objections include concerns about animal welfare, opposition to genetic engineering, public perception and environmental impact. Whether religious objections to animal-derived organs should affect eligibility for a human transplant is also in question.

Cryopreservation

Reproductive cells – eggs, sperm and embryos – can be frozen to potentially preserve and extend fertility in combination with IVF treatment.

Ovarian tissue can be removed and frozen. Transplantation after ovarian tissue cryopreservation is being offered as an elective procedure to postpone menopause symptoms and potentially extend fertility. There is a lack of research into the efficacy and safety of evidence of this intervention.

Ectogestation

Ectogenesis is a process enabling the partial or full development of an organism outside of the womb, in conditions that mimic the womb.

Current research explores how this could occur. Greater understanding could lead to improvements in treatment outcomes for very premature babies. There is speculation that ‘artificial’ wombs might negate the need for a human womb, bringing significant ethical and social implications for the future of reproduction.

Emerging treatments in mental health

New approaches to treating mental health issues include identifying genetic factors, AI-powered brain scans to identify abnormalities, and brain stimulation techniques using electricity to stimulate parts of the brain. The use of psychedelic drugs to treat conditions including depression, eating disorders and PTSD is being explored.

Ethical questions arise over efficacy and evidence base, and the extent to which we are taking an overly medicalised approach to mental health.

Epigenetics

Epigenetics involves changes in gene expression, influenced by environmental factors like diet and stress. These modifications affect how genes are accessed and utilised.

Ethical concerns arise regarding epigenetic data handling and storage and possible discrimination based on lifestyle. Research into epigenetic editing raises questions about targeting specific traits, potentially reinforcing stereotypes related to disability, sex, gender, and sexuality.

Gene drive technology

Gene drives alter or suppress animal populations through the introduction of a mutation or foreign gene. Potential applications include controlling disease vectors such as mosquitos, rodents, and invasive species.

Ethical questions arise in balancing potential benefits to human health against ecological risks. For example, species could evolve resistance to the gene drive sequence. Any future legislative changes to gene drives would likely involve public consultation and international alignment. 

Geoengineering

Geoengineering refers to large-scale interventions in the Earth’s climate system, aimed at mitigating the effect of climate change. Examples include the removal of CO₂ from the atmosphere using carbon capture technologies and solar radiation management, which involves techniques to reflect a small percentage of the Sun’s light and heat back into space to cool the planet. These methods are expensive and the long-term impacts and risks of interfering with natural processes and environments are, as yet, unknown.

Sports performance and competitive advantage

Sports performance is influenced by physiological, medical and genetic factors. The impact of genomic variants linked to athletic performance remains uncertain, but the World Anti-Doping Agency has developed research into detecting ‘gene doping’.

Access to new technologies, resources and funding raise fairness questions. AI tools for talent identification can present ethical challenges. Concerns persist regarding impacts of sex testing / regulations for transgender athletes and people with sexual development differences.