Alternative futures for laboratory medicine in 2050: scenarios and signposts for diagnostic capability contraction

INTRODUCTION: Laboratory medicine has begun to describe its own future, and the images it produces are almost uniformly expansionary. What they rarely contain is a collapse scenario: a future in which the field delivers less than today. A profession planning for 2050 needs one. CONTENT: We summarise what structured foresight offers a clinical readership, entering through the threats quadrant of a strengths, weaknesses, opportunities and threats (SWOT) analysis, and treat the standard taxonomy of futures as a lens, not a required method. We define diagnostic capability contraction as progressive degradation rather than catastrophic disappearance, distinct from retiring tests that add nothing. Six drivers are specified: loss of laboratory-developed tests, reduced test availability, workforce attrition, supplier dependency, geographical access and payment. Evidence comes from three jurisdictions, including Japan, where one regulatory driver produced different outcomes in the same period. We set out four scenarios for 2050, one per generic image, and propose signposts as early-warning indicators, with action thresholds, for the contraction scenario. Estimates of likelihood attach to the indicators, not the futures. SUMMARY: The evidence base is uneven across drivers, and informatively so: what is not anticipated is not measured. The argument applies to our own prior work, expansionary in the same way. OUTLOOK: A set containing a contraction branch gives laboratory leadership what an expansionary set cannot: what to watch for, and when to act. A preferred future chosen without it comes from a shorter list than the field faces. Building a balanced set is work that no small group of authors can do alone.