Technopoly (13 page)

To add substance to this claim, Ms. Payer quotes Oliver Wendell Holmes as saying, with his customary sarcasm:

The spirit of attack mocked here by Holmes was given impetus even before the American Revolution by Dr. Benjamin Rush, perhaps the most influential medical man of his age. Rush believed that medicine had been hindered by doctors placing “undue reliance upon the powers of nature in curing disease,” and specifically blamed Hippocrates and his tradition for this lapse. Rush had considerable success in curing patients of yellow fever by prescribing large quantities of mercury and performing purges and bloodletting. (His success was probably due to the fact that the patients either had mild cases of yellow fever or didn’t have it at all.) In any event, Rush was particularly enthusiastic about bleeding patients, perhaps because he believed that the body contained about twenty-five pints of blood, which is more than twice the average actual amount. He advised other doctors to continue bleeding a patient until four-fifths
of the body’s blood was removed. Although Rush was not in attendance during George Washington’s final days, Washington was bled seven times on the night he died, which, no doubt, had something to do with why he died. All of this occurred, mind you, 153 years after Harvey discovered that blood circulates throughout the body.

Putting aside the question of the available medical knowledge of the day, Rush was a powerful advocate of action—indeed, gave additional evidence of his aggressive nature by being one of the signers of the Declaration of Independence. He persuaded both doctors and patients that American diseases were tougher than European diseases and required tougher treatment. “Desperate diseases require desperate remedies” was a phrase repeated many times in American medical journals in the nineteenth century. The Americans, who considered European methods to be mild and passive—one might even say effeminate—met the challenge by eagerly succumbing to the influence of Rush: they accepted the imperatives to intervene, to mistrust nature, to use the most aggressive therapies available. The idea, as Ms. Payer suggests, was to conquer both a continent and the diseases its weather and poisonous flora and fauna inflicted.

So, from the outset, American medicine was attracted to new technologies. Far from being “neutral,” technology was to be the weapon with which disease and illness would be vanquished. The weapons were not long in coming. The most significant of the early medical technologies was the stethoscope, invented (one might almost say discovered) by the French physician René-Théophile-Hyacinthe Laënnec in 1816. The circumstances surrounding the invention are worth mentioning.

Working at the Necker Hospital in Paris, Laënnec was examining a young woman with a puzzling heart disorder. He tried to use percussion and palpation (pressing the hand upon the
body in hope of detecting internal abnormalities), but the patient’s obesity made this ineffective. He next considered auscultation (placing his ear on the patient’s chest to hear the heart beat), but the patient’s youth and sex discouraged him. Laënnec then remembered that sound traveling through solid bodies is amplified. He rolled some sheets of paper into a cylinder, placed one end on the patient’s chest and the other to his ear.
Voilà!
The sounds he heard were clear and distinct. “From this moment,” he later wrote, “I imagined that the circumstance might furnish means for enabling us to ascertain the character, not only of the action of the heart, but of every species of sound produced by the motion of all the thoracic viscera.” Laënnec worked to improve the instrument, eventually using a rounded piece of wood, and called it a “stethoscope,” from the Greek words for “chest” and “I view.”
⁷

For all its simplicity, Laënnec’s invention proved extraordinarily useful, particularly in the accuracy with which it helped to diagnose lung diseases like tuberculosis. Chest diseases of many kinds were no longer concealed: the physician with a stethoscope could, as it were, conduct an autopsy on the patient while the patient was still alive.

But it should not be supposed that all doctors or patients were enthusiastic about the instrument. Patients were often frightened at the sight of a stethoscope, assuming that its presence implied imminent surgery, since, at the time, only surgeons used instruments, not physicians. Doctors had several objections, ranging from the trivial to the significant. Among the trivial was the inconvenience of carrying the stethoscope, a problem some doctors solved by carrying it, crosswise, inside their top hats. This was not without its occasional embarrassments—an Edinburgh medical student was accused of possessing a dangerous weapon when his stethoscope fell out of his hat during a snowball fight. A somewhat less trivial objection raised
by doctors was that if they used an instrument they would be mistaken for surgeons, who were then considered mere craftsmen. The distinction between physicians and surgeons was unmistakable then, and entirely favorable to physicians, whose intellect, knowledge, and insight were profoundly admired. It is perhaps to be expected that Oliver Wendell Holmes, professor of anatomy at Harvard and always a skeptic about aggressiveness in medicine, raised objections about the overzealous use of the stethoscope; he did so, in characteristic fashion, by writing a comic ballad, “The Stethoscope Song,” in which a physician makes several false diagnoses because insects have nested in his stethoscope.

But a serious objection raised by physicians, and one which has resonated throughout the centuries of technological development in medicine, is that interposing an instrument between patient and doctor would transform the practice of medicine; the traditional methods of questioning patients, taking their reports seriously, and making careful observations of exterior symptoms would become increasingly irrelevant. Doctors would lose their ability to conduct skillful examinations and rely more on machinery than on their own experience and insight. In his detailed book
Medicine and the Reign of Technology
, Stanley Joel Reiser compares the effects of the stethoscope to the effects of the printing press on Western culture. The printed book, he argues, helped to create the detached and objective thinker. Similarly, the stethoscope

Here we have expressed two of the key
ideas
promoted by the stethoscope: Medicine is about disease, not the patient. And, what the patient knows is untrustworthy; what the machine knows is reliable.

The stethoscope could not by itself have made such ideas stick, especially because of the resistance to them, even in America, by doctors whose training and relationship to their patients led them to oppose mechanical interpositions. But the ideas were amplified with each new instrument added to the doctor’s arsenal: the ophthalmoscope (invented by Hermann von Helmholtz in 1850), which allowed doctors to see into the eye; the laryngoscope (designed by Johann Czermak, a Polish professor of physiology, in 1857), which allowed doctors to inspect the larynx and other parts of the throat, as well as the nose; and, of course, the X-ray (developed by Wilhelm Roentgen in 1895), which could penetrate most substances but not bones. “If the hand be held before the fluorescent screen,” Roentgen wrote, “the shadow shows the bones darkly with only faint outlines of the surrounding tissues.” Roentgen was able to reproduce this effect on photographic plates and make the first X-ray of a human being, his wife’s hand.

By the turn of the century, medicine was well on its way to almost total reliance on technology, especially after the development of diagnostic laboratories and the discovery and use of antibiotics in the 1940s. Medical practice had entered a new stage. The first had been characterized by direct communication with the patient’s experiences based on the patient’s reports, and the doctor’s questions and observations. The second was characterized by direct communication with patients’ bodies through physical examination, including the use of carefully
selected technologies. The stage we are now in is characterized by indirect communication with the patient’s experience and body through technical machinery. In this stage, we see the emergence of specialists—for example, pathologists and radiologists—who interpret the meaning of technical information and have no connection whatsoever with the patient, only with tissue and photographs. It is to be expected that, as medical practice moved from one stage to another, doctors tended to lose the skills and insights that predominated in the previous stage. Reiser sums up what this means:

There is still another reason why the modern physician is estranged from his own judgment. To put it in the words of a doctor who remains skilled in examining his patients and in evaluating their histories: “Everyone who has a headache wants and expects a CAT scan.” He went on to say that roughly six out of every ten CAT scans he orders are unnecessary, with no basis in the clinical evidence and the patient’s reported experience and sensations. Why are they done? As a protection against malpractice suits. Which is to say, as medical practice has moved into the stage of total reliance on machine-generated
information, so have the patients. Put simply, if a patient does not obtain relief from a doctor who has failed to use all the available technological resources, including drugs, the doctor is deemed vulnerable to the charge of incompetence. The situation is compounded by the fact that the personal relationship between doctor and patient now, in contrast to a century ago, has become so arid that the patient is not restrained by intimacy or empathy from appealing to the courts. Moreover, doctors are reimbursed by medical-insurance agencies on the basis of what they
do
, not on the amount of time they spend with patients. Nontechnological medicine is time-consuming. It is more profitable to do a CAT scan on a patient with a headache than to spend time getting information about his or her experiences and sensations.

What all this means is that even restrained and selective technological medicine becomes very difficult to do, economically undesirable, and possibly professionally catastrophic. The culture itself—its courts, its bureaucracies, its insurance system, the training of doctors, patients’ expectations—is organized to support technological treatments. There are no longer methods of treating illness; there is only one method—the technological one. Medical competence is now defined by the quantity and variety of machinery brought to bear on disease.

As I remarked, three interrelated reasons converged to create this situation. The American character was biased toward an aggressive approach and was well prepared to accommodate medical technology; the nineteenth-century technocracies, obsessed with invention and imbued with the idea of progress, initiated a series of remarkable and wondrous inventions; and the culture reoriented itself to ensure that technological aggressiveness became the basis of medical practice. The ideas promoted by this domination of technology can be summed up as follows: Nature is an implacable enemy that can be subdued only by technical means; the problems created by technological
solutions (doctors call these “side effects”) can be solved only by the further application of technology (we all know the joke about an amazing new drug that cures nothing but has interesting side effects); medical practice must focus on disease, not on the patient (which is why it is possible to say that the operation or therapy was successful but the patient died); and information coming from the patient cannot be taken as seriously as information coming from a machine, from which it follows that a doctor’s judgment, based on insight and experience, is less worthwhile than the calculations of his machinery.

Do these ideas lead to better medicine? In some respects, yes; in some respects, no. The answer tends to be “yes” when one considers how doctors now use lasers to remove cataracts quickly, painlessly, and safely; or how they can remove a gallbladder by using a small television camera (a laparoscope) inserted through an equally small puncture in the abdomen to guide the surgeon’s instruments to the diseased organ through still another small puncture, thus making it unnecessary to cut open the abdomen. Of course, those who are inclined to answer “no” to the question will ask how many laparoscopie cholecystectomies are performed
because
of the existence of the technology. This is a crucial point.