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According to the US Oﬃce of Technology Assessment, healthcare technology consists of ‘the drugs, devices, and medical and surgical procedures used in medical care, and the organizational and supportive systems within which such care is provided,’ (US Congress 1982) including diagnostic, preventive, therapeutic, rehabilitative, organizational, information, educational, and supportive technologies.
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Social scientists routinely distinguish ‘advanced’ medical technologies from the more mundane healthcare technologies. The distinction between advanced and normal technology often implies that technology has become increasingly central in modern medicine. But in a broader historical perspective, technology has always been central to healthcare, indeed social life. Features of life once popularly regarded as advanced technology, such as patient records or needles, have now been absorbed into routine.
2. The Importance Of Healthcare Technology For Social Scientists
The broad deﬁnition of healthcare technology encompasses any tool from a mundane shake-down thermometer to the latest version of the computerized patient record, presenting the healthcare ﬁeld as layered with technologies. Social scientists have been mainly interested in the upper layers of the medical geology: they have written extensively about advanced life-supporting technologies, organ transplantation innovations, reproductive advances, information technologies, and genetic breakthroughs that pose profound ethical and sociological questions about equity. The introduction of new biomedical technologies not only maps medical advances but also reﬂects changes in cultural understandings of health, illness, life, death, the body, and even the family (e.g., when reproductive technologies oﬀer an alternative to sexual procreation), religion, politics, crime, nature, race, and gender.
A good example of how medical technologies inﬂuence cultural notions is the institution of brain death criteria by the Harvard Ad Hoc Committee on Death in 1968. In an archival study of the committee’s correspondence, Mita Giacomini conﬁrms the general suspicion that a signiﬁcant factor tailoring the redeﬁnition of death were the interests of the transplant community (Giacomini 1997). In 1967, after the ﬁrst heart transplant in South Africa, the general public had become sensitized to the potential conﬂict of interest of transplant surgeons to declare patients dead before their heart had stopped beating. Up until that time, physicians and lay people had been unable to come up with criteria for death beyond the century old criterium of the heartbeat cessation. The tacit consensus seemed to be to view death as a bedside physician prerogative. The transplantation community needed more ﬂexibility to receive timely access to comatose bodies and was actively involved in the creation of the new criteria. For example, clinical criteria were adapted to facilitate organ procurement. Even the term ‘brain dead’ rather than ‘irreversible coma’ ﬁt with the transplant community’s needs because only ‘dead’ people could serve as cadaver organ donors. In addition to the interests of the transplant community, the redeﬁnition of death was inﬂuenced by the emergence of the electroencephalograph and the application of resuscitative and life support technologies.
While most sociological writings have had analytical purposes, some scholars have entered the ﬁeld of health care technologies with interventionist intentions. The purpose of such socially engaged studies by feminists and other patient advocates is to inﬂuence health care policy. In their pioneering study of dying in hospitals, Barney Glaser and Anselm Strauss discussed how technological advances at the end of life created complicated lingering dying trajectories, posing special problems of information management for nurses and physicians (Glaser and Strauss 1965). Glaser and Strauss painted a poignant picture of dying patients and their relatives engaged in a painful game of extracting information from healthcare providers reluctant to reveal the terminal condition. As part of a general death awareness social movement which swept the United States in the 1960s, this study contributed to a revision of the medical school curriculum to include doctor–patient communication courses. Similar studies discussed how the rapid introduction of pharmaceutical, surgical, and technological innovations during the post-Second World War decades featured in the socialization process of individual physicians.
3. Diﬀerent Conceptualizations Of Healthcare Technology
Social scientists have viewed healthcare technology in at least three diﬀerent ways, each of which comes with a number of assumptions about the role of technology, human actors, and the social world. At stake in the diﬀerent conceptualizations is the autonomy of the technology and its power to shape social relationships. These diﬀerent approaches greatly impact the critical potential of the analysis.
3.1 Social Science With Technology Perspective
In the ﬁrst conceptualization, technology is not the central focus of the analysis but more a catalyzing variable in a network of social relationships. Healthcare technology remains unproblematized, assumed in the same way that most sociologists take the physical layout of hospitals for granted. What matters is how humans (as professionals, relatives, patients) cope with the new possibilities generated by an inﬂux of instruments in technology-intensive medical settings. The primary goal of social scientists working in this approach is to analyze well-established topics of interests to observers of health and illness, that is, professionalization, social equality, social control, or medicalization, often relying upon the canon of a broad social constructivist perspective.
A good example of this approach is Renee Anspach’s study of decision-making about life and death in a neonatal intensive care unit (Anspach 1993). She situates her ethnography in a technology-intensive environment and states that most of the dilemmas about keeping premature and sick infants alive result from the availability of the technology and expectations of staﬀ and relatives. Yet, she does not name or describe what technology she is talking about, discuss its origins, or elaborate on the staﬀ’s work to keep the technology functioning and interpretive. Instead, Anspach writes about the neonatal intensive care unit as a complex social organization where diﬀerent groups of people rely on diverse sources of information and weigh varying priorities to reach a decision about the continuation of aggressive treatment. Physicians, for example, rely more on technology-derived data than nurses who depend on closer, interactive contact with infants, leading to conﬂicts in life-and-death decisions. The healthcare technology conﬁrms the power diﬀerences between an emerging and established profession.
Even scholars who make technology more central often rely on this socially determined conceptualization of medical technology. Susan Bell’s interactive diﬀusion model of the artiﬁcial hormone DES (diethylstilbestrol) applies a social constructivist social network approach to healthcare technology (Bell 1989). Bell shows how the artiﬁcal hormone originated from within scientiﬁc and health communities with distinctive ways of deﬁning problems and oﬀering solutions. A broader political-economic context (US research funding post-Second World War) structured the relationships of these communities and reﬂected the way the technology diﬀused among physicians and their women patients. In this conceptualization, the focus of the social scientist’s analysis remains with the social networks advancing the new technology. Bell explores how social communities gain or lose power because of their support for DES. Yet, how the meaning of the hormone itself changes as a result of those interactions remains unexplored.
The main assumption underlying this approach to healthcare technology is that the tools and instruments of medicine are shaped by social forces. Technology is a given (Anspach 1993), or a contingently diﬀused product following a trajectory set by social circumstances (Bell 1989). Dominant social groups invest values, power, and preferences in the healthcare technology, and it is these norms and paradigms that dominate the analysis. This approach oﬀers interesting insights into the social aspects of healthcare technology but often glosses over the technological characteristics of medical technology. In other words, what makes health-care technology such a unique case, is often left unexamined.
3.2 Humanistic Social Science Argues Against Technology
The second conceptualization of healthcare technology originates from a humanist concern about the dangers of technology and is primarily intended as a critique of the healthcare ﬁeld. In contrast with the ﬁrst approach, the spotlight of the analysis is ﬁrmly centered on healthcare technology. Healthcare technology is singled out, its eﬀects are scrutinized, compared to a technology-free past, and usually found wanting. Healthcare technology symbolizes here the power and arrogance of themedical professions, the hegemony of the medico-industrial complex, and the excesses of Western modernity. Technology becomes a modernist instrument by which some in society enforce power over others.
Authors working in this tradition emphasize how the presence of medical technology turns caregivers into technicians and leads to depersonalized and dehumanized care. Technology results in distancing and alienation in patient–care-provider interactions, a loss of dignity and integrity, and a colonization of the body. This kind of analysis receives its persuasive power from a historical or cross-cultural comparison. The technology-saturated present is compared with idealized tropes of the ‘natural’ (the natural body, birth, or death) of past epochs and of others, unpolluted by modern healthcare technology.
This antitechnology analysis has been fueled by the Luddite legacy and the threat of a nuclear apocalypse, and is popular with both conservative scholars lamenting the moral, spiritual, and existential crisis in the secular West (Aries 1977) and Marxist scholars who analyze healthcare technology as an integral part of the capitalist proﬁt structure (Waitzkin 1979).These politically diverse analyses of healthcare technology have in common that they believe that technology is a powerful force shaping social relationships. This belief has been referred to as technological determinism. Technological determinism comes in diﬀerent strengths (Winner 1980): strong technological determinists believe that technology develops as the sole result of an internal dynamic and molds society to ﬁt its patterns. In his book Medical Nemesis, for example, libertarian social critic Ivan Illich views the exportation of Western medical technologies as part of an international conspiracy to spread illness across the world and establish Western medical hegemony. According to Illich, international collaboration to eradicate virus-carrying mosquitoes resulted in shortterm pyrrhic victories, in the long-term technological inference led to more virulent strains of tropical diseases and an aggravation of malnutrition (Illich 1976, Chap. 7). In a weaker version, medical technology is viewed as a political phenomenon in itself. Technology as politics occurs when a particular technological device or system becomes a way of settling an issue in a particular community or when technologies require particular kinds of political relationships. For example, physician-generated demand for expensive diagnostic technologies such as MRI scanners led to the consolidation and integration of large medical centers at the expense of many local community hospitals that did not have the patient load to justify the large capital investment. In both versions, the focus of the analysis is on what has been lost after the introduction of medical technologies. The purpose of these critiques is to warn of overtechnologization and to recapture a mystiﬁed technology impoverished past.
This conceptualization of healthcare technology often works from an analysis of extremes and is therefore limited in the analytical insights it brings in the everyday workings of healthcare technology. Yet, because of its strong rhetorical packaging, this approach to technology has often lead to more social mobilization and actual social change than the other two conceptualizations. One can detect technological determinist tenets in the hospice movement, rallying for palliative care for terminally ill people and in the ‘natural’ birth movement, pointing out the physical dangers of an overmedicalized birth. In both social movements, antitechnology sentiments united activists and led to concrete social change.
3.3 Technological Practice
A third conceptualization of healthcare technology ﬁnds a middle ground between the view that an interplay of social structure and culture shapes the use of technology and the belief that technology determines society. Drawing from the interdisciplinary ﬁeld of science and technology studies, researchers have turned to what speciﬁcally is gained and lost in medical encounters when new instruments and drugs are introduced. This approach led to a number of detailed studies of the practice of healthcare technology in which the technology takes center stage. Healthcare technology is here not an a priori established entity but both the technological elements and the social characteristics emerge during the design process and while the technology is used. Social and technological characteristics are continuously reconﬁgured in interaction, to the point that it is diﬃcult to tell where technology ends and the social begins.
As a prime example of this approach, sociologist Marc Berg addressed whether medicine has become more rational and scientiﬁc since the Second World War because of its reliance on formal tools such as standardized protocols, expert systems, clinical decision analysis, and automated decision systems (Berg 1997). Berg neither supported the Luddite camp which argues that such technologies primarily lead to deskilling nor bolstered the protechnology argument that the formal tools necessarily reduce the staﬀ’s workload, but instead showed how technologies have shifted medicine’s understanding of rationality. Rationality was not a pregiven quality but achieved in tandem with the production and implementation of formal tools. Berg analyzed how the designers of the automated clinical decision analysis systems and protocols went beyond solving technical conundrums. The designers of formal tools studied the work activities and places in which their tools needed to function and made assumptions about users, environment, input, and expected output. For example, the designers of an automated cardiac decision-making system aimed for a computer that calculated a diagnosis and suggested treatment options after a healthcare provider entered diagnostic data about chest pain. The designers prescribed medical practice with guidelines (the algorithms of the diagnostic system), prerequisites (which data is mandatory or optional), and a reshuﬄing of existing professional relationships to make their devices work (not only physicians but nurses could enter data). In the end, the automated decision-making system provided a diagnosis and the tool worked, but not in the way the designers intended it because the tool’s requirements became just one element in the management of patients’ medical conditions. For example, nurses quickly learned to enter the ‘right’ data based on the availability of beds in the intensive care unit. Medical practice and tools emerged simultaneously to constitute new forms of knowledges, new challenges, and problems to keep both the tools and the users on track, and ultimately new opportunities for diagnosing and curing.
The most radical conceptual innovation of the science and technology scholars was to extend agency from humans to things. According to the French sociologist Bruno Latour, this ontological extension of human agency occurs through the delegation of agency from humans to nonhumans (Latour 1987). Machines and instruments, such as thermostats and tape recorders, perform as agents because they substitute for the actions of people. As Stefan Hirschauer has shown, during surgery, pumps and monitors become a patient’s ‘externalized organs,’ taking over vital functions (Hirschauer 1991). Because a malfunctioning ventilator might mean the end of life, there is no easy distinction between the human and the technical realm. Technology acts similarly to people. This does not mean that humans and nonhumans are equal. Andrew Pickering, for example, draws the line at intentionality; intentions cannot be attributed to nonhumans (Pickering 1995). Some critics have charged that analyzing technology as actors is disempowering, because ultimately humans need to be held accountable. But other researchers have linked the premise of technological practice to a more critical and interventionist agenda (Timmermans 1999).
The key characteristic of this approach is that changes in the social and the technical realm are investigated symmetrically as they enfold over time. Instead of assuming the predominance of social or technological forces in advance, the social scientist studies how technological innovations advance new medical practices and understandings about health and illness.
4. A Selection Of Research Topics In Healthcare Technology
4.1 Organ Transplantation Technology
Like ethicists and physicians, social scientists have been particularly puzzled by the Janus face of biomedical technology: the instruments of medicine have the potential to postpone mortality and enhance the quality of life, yet, also possess the possibility of destroying the world as we know it. Nowhere is the Janus face of biotechnology better researched than in the area of the biomedical organ transplant technologies. The transplant of kidneys, hearts, lungs, heart and lungs, liver, and pancreas beneﬁtted from the development of immunosuppressive drugs that counteracted the body’s tendency to attack the foreign organ and, in the case of US kidney transplants, from Medicare funding in 1972. Since the technology moved down a continuum from experimental to therapeutic, its utilization has prolonged and saved lives that would otherwise almost deﬁnitely be lost, but it also spawned many unintended, complex ethical, ﬁnancial, legal, and social problems.
Renee Fox and Judith Swazey point out in a classic study that more than just organs are exchanged during organ transplantation (Fox and Swazey 1978). The technological procedure poses important questions about the corporeality of personal identity, the relationship of a body to its parts, and the boundaries that deﬁne social ties. Organ procurers present the donation of cadaver organs or, in the case of kidneys, live organs as the ultimate ‘gift of life,’ invoking Judeo-Christian values of altruism, generosity, humanitarianism, and freedom of choice. For the recipient, the donated organ might not only be under continuous threat of immunological rejection but might also carry a heavy symbolic load. Because a donated organ can not be reciprocated with another gift, the organ exchange locks two people and their relatives in an unequal relationship, creating what Fox and Swazey term ‘the tyranny of the gift’ (Fox and Swazey 1978, pp. 20–32). Relatives of donors might insist on developing kin relationships with recipients because a piece of their loved one ‘lives on’ in another person. For recipients, the reconstruction of the body requires an active reshaping of the self (Sharp 1995). These social complications of organ donation are exacerbated by the ‘scarcity of organs.’ In the US, organ donation seems to have leveled oﬀ at 5,000 while the demand for organs has topped more than 33,000 and keeps rising (Sharp 1995).
With a much higher demand than supply, who is more likely to receive organs? According to the American Medical Association, medical need should prevail. But does medical need mean that the person who is the sickest should get priority or the person who has the best chance of long-term survival? According to social scientists, the chance to receive an organ is positively correlated with socioeconomic status and patient’s race (Kutner 1987). African Americans are less likely to be donors, organ procurers, or recipients of organs. In addition, people with history of mental, emotional, or family problems are less likely to receive organs, raising ethical questions about disability when patients with Down’s Syndrome were initially refused a position on the organ donation waiting list. Economists have tried to move away from the gift giving ideology towards a market ideology that considers organs as any other commodity to be bought and sold. Several proposals circulating in medical circles propose to pay a ﬁnancial beneﬁt to the estate of the donor to motivate donation. In other countries and some US states, the governments have tried to enhance organ donation with a system of presumed consent: everyone is presumed to be an organ donor unless documented otherwise.
Anthropologist Margaret Lock’s study of organ transplants and brain-death in Japan and the US (Lock 1989) oﬀers an important counterargument against the idea of the ‘technological imperative.’ The technological imperative implies an inherent force in healthcare technology; once a medical technique is available there is virtually no objection possible for not using it. The concept, introduced by economist Victor Fuchs, has caught on in other studies to explain the quest for more and better technologies and the quick adoption of questionable technologies (Rothman 1997). Lock explained that any technological imperative is not inherent to technology but to the broader culture. Although Japanese physicians and scientists possess all the technical know-how and skills to implement organ transplants, Japanese people have until recently chosen not to take the cadaver organ transplant route but instead focus on the development of artiﬁcial organs. The reason for Japan’s reluctance to jump the organ transplant bandwagon is that brain death is not accepted as a suﬃcient criterion of death for religious reasons and because Japanese families nurse their terminally ill and would be reluctant to accept that a breathing body with a heartbeat is ‘dead.’ In addition, Japanese have a diﬀerent concept of the self and feel reluctant to just emulate every technological innovation from the West.
4.2 Reproductive Technologies
Another area ﬂush with research attention is the ﬁeld of reproductive technologies. Diﬀerent infertility treatments, biotechnologies, and fetal surgeries have opened the categories of parent, child, fetus, human, family, and even population to some renegotiation. Key questions include control over the human body, the manipulation of eggs, sperm, and embryos, and the threat these technologies pose for the identity and legal status of the ‘products’ created. Reproductive technologies have been largely analyzed from feminist inspired perspectives but the emphasis of the analysis has shifted over time. Initially, feminist scholars looked at reproductive technology as a tool to liberate women because it could sever the link between sexuality and reproduction. A technological ﬁx would erase some of the diﬀerences between men and women and create equal sexuality (Firestone 1970).
While reproductive possibilities seem to be more about fulﬁlling than rejecting the traditional female role, some feminist scholars gaze at new technologies as the next installment of patriarchal exploitation of women’s bodies and reproductive processes. Reproductive technologies are viewed as attacking women, a modern incarnation of eugenics. The technologies become ‘technical delegates,’ tools used to compensate for the perceived deﬁciencies of its users. Women’s bodies are opened up, manipulated, and controlled to be ultimately bypassed. The consequence is an alienation, commodiﬁcation, and depersonalization of women’s bodies (Corea et al. 1985).
More recently, feminists have looked at the same reproductive technologies from a postmodern perspective (Casper and Clarke 1998), giving more agency to women themselves. The postmodern strategies concentrate upon the design and transformation of reproductive bodes. Poststructuralist feminists have rejected the notion that the ‘real female body’ is passively ‘acted upon,’ instead preferring to view it as being both inscribed and constituted through reproductive discursive practices and processes. Reproductive technologies generate diﬀerent kinds of subjectivity. For example, Charis Cussins analyzed how undergoing infertility treatments ﬁgures in women’s self making and at the same time transforming their body conceptions (Cussins 1998). She located the fertility treatment in women’s biography. Before entering the infertility clinic, many women have already a history of trying not to get pregnant using anticonceptiva, followed by a period of increased awareness of what could have gone wrong while trying to conceive. Cussins showed that the objectiﬁcation, naturalization, and bureaucratization of the women’s bodies during pelvic exams, ultrasound, explanatory surgery, and embryology laboratory is associated with particular forms of agency. If the activities in the infertility clinic lead to pregnancy, the patient exercises agency in her active participation of the diﬀerent forms of objectiﬁcation. If the treatment cycle has been unsuccessful, women reported their lack of agency or insuﬃcient attention to the speciﬁcity of the patient. The consequence of the process in which women render themselves compatible with instruments, drugs, and material surroundings is what Cussins called an ‘ontological choreography’ with the potential of transforming the women’s long-term self-perceptions as potential mothers.
Most feminist writing, both past and recent work, is ultimately aimed at creating awareness of the reproductive technologies cost and beneﬁts for women, a women centered reappropriation of the technologies, or to oﬀer alternatives for social change (see the book The New Our Bodies, Ourselves (Boston Women’s Health Book Collective 1992).
4.3 Technology And Healthcare Costs
With the explosion of healthcare costs worldwide, social scientists have also investigated the ﬁnancial role of medical technologies in the healthcare system. Although there seems to be a general consensus that technology has contributed to rising healthcare raised costs, exact ﬁgures of how much cost has increased or mechanisms of cost raising are not well documented. Researchers at the US Oﬃce of Technology Assessment, for example, estimated that new technologies accounts for anywhere between one-third to three quarters of the cost of hospital care—a range of several billions of dollars (Banta et al. 1981). Others have estimated that healthcare technology takes up 10 to 40 percent of the increase in healthcare expenditures over time, again a very wide range (Neumann and Weinstein 1991).
Problems with calculating the cost of technology include the broad deﬁnition of healthcare technology and the scope of health expenditures. Should medical technology be limited to ‘big ticket’ items or include the entire technical geology? When calculating health expenditures, some researchers take only the capital cost, while other scholars combine the capital cost with more expensive operating costs and increased use of auxiliary services. Other problems include measuring cost saving and balancing health outcomes of lifesaving technologies against long-term institutional expenditures. In some studies, all increases not explained by other factors are attributed to technology, while others focus on the cost of treating certain illnesses or the cost of particular technologies (Neumann and Weinstein 1991).
Relying on total healthcare costs, Frans Rutten and Gouke Bonsel note that labor intensive, low-technological interventions such as mental healthcare are two to four times as expensive as the cost of high cost technology, such as kidney dialysis and transplantation, megavolt therapy, CT tomography, cardiac surgery, in vitro fertilization, and picture archiving. They also found that even when one isolates technology, it is often the specialized and highly salaried personnel that take up the major part of the total cost. They conclude that ‘high cost technology is expensive per item, but that its contribution to total healthcare expenditure is limited’ (Rutten and Bonsel 1992). Economist Victor Fuchs calculated that technology contributed 0.6 percentage points of the 8 percent annual rate of increase in health expenditures from 1937 to 1967 (Fuchs 1972).
Pulitzer-prize winner sociologist Paul Starr has also oﬀered a caveat to the reasoning that technology is to blame for ﬁnancial healthcare woes. Big-ticket technologies such as new imaging machines, organ trans- plantation, intensive care units, and renal dialysis have undoubtedly brought higher costs ‘But, only about a third of the higher levels of spending (in the United States), compared with Canada, reﬂects the expense of hospital care—and of that, only a portion is due to greater use of technology’ (Starr 1994, p. 22). Starr instead suggested that we adopt a systemic view to explain the rising healthcare costs in the US. He located expanding costs in the historical development of a number of incentives for private decision makers to expand and intensify medical services.
The factors singled out to explain the importance of technology in the healthcare ﬁeld relate to technological characteristics and the wider healthcare ﬁeld. In the innovation literature, healthcare technologies are considered ‘dynamic,’ that is, they develop as they are diﬀused. This means that technological innovations are regularly introduced before information about eﬀectiveness and cost is established. Social observers also point to the billion-dollar medical industry, the public’s seemingly unsatiable appetite for more technology, and varying incentive structures. Countries with stronger centralized government regulation have been able to curtail costs via planning and technology allocation. Countries following more of a market model create a situation where hospitals invest in technologies to remain competitive. The consequence of these incentives is, paradoxically, an underuse of services.
Consider the case of early detection of breast cancer through the use of mammography [in the US]. With fully utilized mammography machines, a screening mammography examination should cost no more than $55 … But because machines are typically used far beneath capacity, prices run double that amount. With prices so high, many women cannot aﬀord a mammogram … In other words, because we ha e too many mammography machines, we ha e too little breast cancer screening (Starr 1994, p. 25, emphasis in original)
5. Future Trends
The electronic patient record, telemedicine, artiﬁcial organs, and genetics will continue to raise the specter of healthcare technologies in the coming decades. The challenge for social scientists remains to keep up with the multitude of micro and macro changes healthcare technology poses for societies without falling into simplistic forms of technological determinism or social essentialism.
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