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will demand that all the primary data be made The high-technology, information-rich med-
public, along with the analytical tools necessary icine of the future will provide powerful and use-
to reanalyze, test, refine, and build on them. ful tools for clinical medicine. The medicine of
Data security will have to evolve and thereby win the future will not, of course, solve all problems,
the public’s trust with new techniques that will and it cannot prevent violent or self-destructive
do what now seems impossible: guarantee pro- human behaviors. Patients will continue to rely
tection of privacy while providing detailed infor- on physicians and the medical community for
mation about each person. Societies will come the guidance, support, and help that only a
to accept that comprehensive knowledge of dis- skilled and caring heath professional can deliver.
ease, prevention, and effective treatment is an The medical community must provide direction
essential public good. to ensure that powerful new technologies are
Biomedical research, data technologies, and used to benefit the health of all. As advances in
clinical care all require resources, but the era of science and technology continue to bring disrup-
shifting more and more economic resources to- tive changes, the Journal must continue to evolve
ward health care is going to end. The medicine creatively in order to continue in its mission of
of the future will focus on more efficient use inspiring discovery and advancing care. As we
of resources to prevent disease, with the goal of head into this medicine of the future, the Journal
delivering what provides the best value for the should remain true to the principles that were
patient who needs treatment. The future of medi- set down by its founding physicians two centuries
cine also depends on reducing the enormous dis- ago: “The Journal will always be open to the accu-
parities in health, particularly those between the rate observer of nature, the useful experimenter,
richest and the poorest countries of the world. and the rational therapist.”3
A basic standard of sound medical care will be- Disclosure forms provided by the authors are available with
come an expectation of every society. Research- the full text of this article at NEJM.org.
rich countries may come to see that achieving From Boston Children’s Hospital and Harvard Medical School
basic health care throughout the world is a strat- — both in Boston (I.S.K.).
egy to promote stability and peace. The increas- 1. Committee on a Framework for Development of a New Tax-
ing power of information and communication onomy of Disease. Toward precision medicine: building a knowl-
technologies can help find ways to improve edge network for biomedical research and a new taxonomy of
disease. Washington, DC: National Academies Press, 2011.
global health. However, that goal also requires 2. Patel JP, Gönen M, Figueroa ME, et al. Prognostic relevance of
the educational and economic development that integrated genetic profiling in acute myeloid leukemia. N Engl J
are essential for societies to achieve a reason- Med 2012;366:1079-89.
3. Thomas B. Wait and Co. Proposals. Boston Patriot. Vol. 6.
able standard of health. The moral mandate No. 9. September 28, 1811:3.
here only becomes stronger as clinical progress DOI: 10.1056/NEJMe1213371
continues to accelerate in developed societies. Copyright © 2012 Massachusetts Medical Society.
Brain in a Box
Allan H. Ropper, M.D.
The brain, despite its sophistication, resides in a mendation of the Brain Trauma Foundation is to
rudimentary container. The rigid cranium re- keep intracranial pressure below 20 mm Hg in
stricts enlargement of its contents, so that intra- order to avoid poor outcome1; adherence requires
cranial pressure rises rapidly as brain volume that the pressure be measured directly. This advice
expands. When pressure becomes greatly elevat- and the assumptions that underlie it are tested
ed, cerebral blood flow is impeded, and the re- in the report by Chesnut and colleagues in the
sult is brain death. For this reason, the reduction Journal.2 They compared therapy based on the
of elevated intracranial pressure is a central measurement of intracranial pressure with a treat-
theme in the management of traumatic brain in- ment regimen that was regulated more simply with
jury, cerebral hemorrhage, and most other intra- the use of clinical observation and computed to-
cranial mass lesions. The widely adopted recom- mographic scans; the outcomes were the same.