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Medical Technology and the Concept of Health Care

BY ERIC MATTHEWS, UNIVERSITY of ABERDEEN

It is a commonplace that medicine in the last fifty years or so has enormously increased its capacity to help patients, and that this is largely due to its technological development. In his book The Youngest Science, the distinguished American doctor, Lewis Thomas, well describes the transformation in what medicine could offer from the days when his father was practising medicine in the early years of the century, through his own training in the thirties, to the present day. His father, he says, could do little more in most cases than identify the patient's condition, offer a prognosis of its future course, and, if necessary, provide comfort while the disease ran its course. In Thomas's own student days, it was already possible to do more, with the discovery of new drugs and other forms of treatment: but by now medicine can achieve what would earlier have seemed miracles in prolonging life and easing pain. Thomas may be a little inclined to exaggerate the extent of the change, but there is little doubt that what he says is broadly correct.

In this paper, I want to argue that this change is not merely quantitative, an increase in the number of things doctors can do for patients, but qualitative, a change in the kinds of things they can do. The increasing use of technology in medicine, I shall argue, changes our whole concept of health, and so what we mean by caring for health. My argument will be based on general philosophical considerations about technology, which, because of their generality, should have application to the use of technology in other areas of human life as well as medicine.

'Technology' is an expression of ordinary language, and is not precisely definable. We seem to use it quite widely to refer to any conscious human intervention in natural processes to achieve human ends. As active creatures, human beings cannot help but intervene in nature: every time a human being, say, plucks fruit from a tree to eat it, he or she is changing the state of nature from what it was before. But the same is true of interventions by other animals - birds building nests, beavers constructing dams, and so on. When human beings intervene consciously, however, their intervention is based on some kind of knowledge of the natural processes involved, which enables the human beings to make use of those processes to achieve their own ends. When human beings engage in agriculture, for example, they make use of their knowledge of the connection between planting seeds in certain environments and the eventual appearance of full-grown plants in order to ensure themselves a supply of the relevant kind of food.

This knowledge may, however, be either what is often called 'purely empirical' or what might be called 'fully scientific'. It is purely empirical if it is knowledge simply of observable regularities in nature (e.g. when seeds of a certain kind are planted in a certain kind of soil, wheat grows); it is fully scientific when it is knowledge of the underlying causal processes which are responsible for the observable regularities (e.g. knowledge of the processes by which seeds are transformed in appropriate conditions into full-grown plants). There is a narrower sense of 'technology' in which it is only conscious human interventions guided by fully scientific knowledge which qualify for the application of the term, and there is a strong tendency to use the term preferentially in this narrower sense, as when we associate the development of technology with the growth of modern science. Certainly, when we speak of medical technology, we seem to be using the narrower sense.

In order to explain why it is important from our present point of view to make this distinction, I want to introduce the concept of a 'natural order'. By this I mean that state of things which exists prior to any conscious intervention by human beings (or indeed by any other beings capable of conscious intervention). It is intended as a purely descriptive term, without any evaluative overtones: the use of the word 'order', for instance, is not meant to carry any implication that this state of things is better than any alternative. Now, it is reasonably clear that some conscious human interventions ('technology' in the wider sense) do not disturb this natural order, any more than the unconscious interventions of non-human creatures. If, for example, I notice that water poured on to a fire puts it out, but do not understand the mechanism by which this works, I may put my observation to use when there is an unwelcome fire in my vicinity by pouring water on to the flames. Although the resulting state of affairs will be different from what would have happened if I had not intervened, the natural order will not be disturbed. In that natural order, water poured on to a fire would in these circumstances have put it out even if human beings had never existed, or had never taken any conscious steps to intervene. The fact that it was a human being who poured the water in this case, rather than, say, a shower of rain or a waterfall, is purely incidental.

Technology in the narrow sense, however, can disturb the natural order. For knowledge of underlying causes enables human beings to bring about results which would never have happened if human beings with that knowledge had not existed. For example, someone situated two hundred miles away from me could never have heard my utterances at (to all intents and purposes) the same time that I made them unless human beings had gained knowledge of the processes underlying telephony. (Compare the invention of the telephone - 'technology' in the narrower sense - with the use of a metal cone to amplify someone's voice so that it can heard at a shorter distance - 'technology' in the broader sense). When we say that technology is contrary to nature, this is the kind of thing we have in mind.

If this is so, then the more technology in the narrow sense (which I shall henceforth call simply 'technology', for short) becomes part of human life, the more human beings become independent of the natural order. In a society without telephones, human oral communication is restricted to what the natural order allows: that is, people can talk to other people only if those others are within reach of the sound waves issuing from the speaker's mouth. Being able to use the telephone clearly frees one from that restriction, and to that extent from the natural order.

This manifestly applies to the case of health care, too. For most of its history, medicine has been pre-technological: it has been 'scientific' only to the extent that it has been based on careful observation of such things as the course of diseases, the sorts of diet and regimen which tend to keep people healthy, the ways in which certain herbs or other forms of treatment seem to offer relief in some cases, and so on. Such empirical observation has enabled doctors to make reasonably accurate predictions of what will happen to a patient, and to offer treatment in a limited number of cases which works, if it does at all, because it fits in with the natural order, not because it defies nature. A patient's fever can be relieved by administering cold water to the patient's body. That may hopefully speed up the patient's recovery, if he or she is going to recover in the natural course of events, but it will not in itself cure the fever.

Once medicine becomes technological, the situation changes radically. If we know the underlying causal mechanisms of the fever, and have other relevant scientific (e.g. chemical) knowledge, then we can devise drugs, not just to alleviate the symptoms of fever, but to cure it. Thus, someone who in the natural order would have died from the fever need do so no longer. Technological medicine takes human beings out of the natural order, and does so increasingly as new technologies develop. To save lives which would in the course of nature have ended by means of drugs is one thing; it is a much greater thing still to save lives by assisting the function of failing organs by mechanical means, as in renal dialysis or the use of heart pace-makers; it is going yet further to save lives by replacing the organs altogether by other organs, taken from other human beings or even from animals of other species. Each of these marks a step further from the natural order, from the governance of processes by impersonal laws of nature, with which human beings can only cooperate, to an order constructed by human beings.

The contention of this paper, as I said at the beginning, is that this increasingly tends to change what we mean by health. Our understanding of 'health' cannot ultimately be separated from our understanding of medicine, of the ways in which we care for health. When doctors could do little for us except to diagnose what was wrong with us, to give advice about diet and exercise and offer comfort to us in our suffering, caring for health was largely the individual's responsibility, and this necessarily determined the concept of health itself. In that situation, to be 'healthy' meant to be functioning in accordance with the normal standards of our species - to be able, for instance, to be as physically active as most members of the human species can expect to be, to be able to eat a normal meal without suffering indigestion, not to suffer unusual and persistent pain, and to live a normal human lifespan. Whether one was healthy in this sense largely depended on luck (in having a good constitution and in living in one of the better-off sections of society), partly on good management on one's own part - living moderately, taking exercise, having a healthy diet - and hardly at all on doctors. The doctor's role was largely educational and prescriptive: it is significant that people used to talk about 'doctor's orders', implying that the doctor was in the superior relationship of teacher to pupil, rather than in the more egalitarian position of carer to person cared for.

One must not exaggerate: much of medical care, even in advanced Western countries, is still like this. But the general culture of Western medicine has become increasingly technological. It is now possible to extend life in circumstances in which patients in the past would certainly have died - even in cases where an unwise diet or lifestyle would have condemned the patient to an early grave. Doctors can offer naturally infertile couples, or even to homosexual couples, at least the chance to have children of their own, genetically related to at least one of them: even single women can have children (without any messy involvement in sexual relations with a man). The possibility of correcting genetically determined diseases and handicaps, and so of determining the kinds of people who will be in the population is likely to realised in the foreseeable future. Drugs may make it possible to avoid even the normal feelings of being 'low' that most human beings naturally experience. And so on.

In these circumstances, 'health' comes more and more to mean, not just the normal, species-specific functioning of the human organism (within the constraints of the 'natural order'), but the state which medical care ought to achieve for us (which breaks those constraints). For instance, a 'normal' human lifespan subject to the constraints of the natural order (governed by the ordinary laws of nature) would be that which one could expect if one was blessed with a good constitution, managed to avoid life-threatening accidents and diseases, was well-nourished and took a reasonable amount of exercise. But medical technology, now or in the nearish future, can make a good constitution not just a matter of luck but everyone's birthright, can remove the threat from accidents and disease and can compensate for bad diet and lack of exercise. Health becomes, not the best one can expect given the limitations of human life, but freedom from those limitations themselves. And it becomes something which is not a mixture of luck and personal responsibility but something which one depends on medical expertise to provide.

I said earlier that there are no evaluative overtones inherent in the concept of a 'natural order'. Whether one thinks it is a good or a bad thing for human beings to find the means of escaping from its constraints is a matter for argument. My contention in this paper is that medical technology does increasingly lead to a situation where human beings do so escape, and that this is something which we must therefore take into account when we think about health, health care and the just allocation of health care resources.

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