Technology in Pain Medicine
Recently, Valentinuzzi reported on the widespread use of alternative devices and medicines to treat pain, despite the apparent absence of evidence to validly compel, support and/or sustain the clinical utility (if not safety) of these approaches.2 This prompts the question of why these devices and techniques are being used with what appears to be a relative disregard for any substantive validation of safety or clinical value. One possibility is the influence of what Hans Lenk has called “the technological imperative” that is, the perceived need to put into use any and all technologies (and techniques) simply because “we can.”3 This may be the case, at least in part. However, in this essay, I argue that the underlying cause is not simply the urge to use what has been created, but rather the effect(s) of market forces upon the conduct of research that shapes how any new or novel technology is used in medicine (and society, at large). This raises further questions of whether market-dictated forces can be consistent with a regard for patients’ wellbeing and the activities of medicine as an individual and social good.
In citing Hippocratic maxims, Valentinuzzi rightly notes the primacy of patients’ best interest(s) in dictating the ends and goals of medicine. Consistently, both the Hippocratic Corpus and the Oath itself call for the clinician to be prudent regarding using any and all treatments, so as to adhere to, and maximize the ends of the practice.4,5 As classically defined, those ends (i.e., the telos of medicine) are the technically right and ethically good care of persons rendered vulnerable by disease, illness, and injury.6,7 Clearly such ends establish medicine as a therapeutic and moral endeavor, and the co-actualization of these domains are inextricably interwoven. Moreover, the classical definition does not simply describe the medical condition of the patient, but refers to the existential condition of being a patient as one of vulnerability. It is this vulnerability that drives the patient to both seek the clinician for both her expert knowledge, and trust that her knowledge will be fully and authentically used to lessen and/or prevent (further) suffering or harm(s).8
The Role of Research
Research fuels and sustains this knowledge, and should provide the physician with an understanding of which techniques and/or technologies work, which don’t, and why.9,10 Research can take time and, while there has been some debate about whether the relative slowness of the research process incurs a negative effect on healthcare (e.g., by delaying the availability of new techniques, technologies, drugs, etc.),11 these concerns are countered by the argument that 1) research is aimed at advancing the “good” of knowledge that can prevent against particular harms (of omission and commission), 2) the research process seeks to evaluate as many variables as possible in this goal, so as to maximize benefit(s) and reduce potential risk(s), and 3) this cannot be rushed or compromised.
Obviously, neither research nor medicine occurs in a social vacuum and so the direction and conduct of both are susceptible to particular socio-cultural and temporal values and biases.12 Given that science can never be truly “value-free,” it is incumbent upon scientists and physicians (as users and enactors of scientific knowledge) to recognize this potential for value-ladeness, and respond with self-criticism, self-revision, and self-control.
Determining which technologies to use and which to avoid can be a problem of excessive choice—especially since much of the intellectual landscape of modern medicine has been shaped by technological advances, and this has generally yielded a positive net effect. This tends to reinforce Jurgen Habermas’ claim that the use of technology can be seen as progress.13 The Industrial Revolution(s) gave rise to incentives to develop machines to ease and improve the quality of life and, by the end of the 20th century, this had led to considerable social technophilism and technocentricism.14 To be sure, we must acknowledge 1) the pervasiveness of technology in virtually all facets of modern life, 2) that analysis of health trends in third-world countries that has irrefutably demonstrated that the absence or unavailability of medical technology incurs significantly negative impact on broad aspects of the public health, and 3) the potential and actual cost-savings afforded through the prudent use of medical technology.15 Given these facts, it would be counter-intuitive, if not pragmatically and ethically unsound to ignore or refute the benefits of technology in and to medicine. But, to balance that reality, one needs only to consider the philosopher Hans Jonas’ reckoning that in modern society, technology has become “…a process” and worldview.16
Considering Another “Technological Imperative”
The rise of technology concomitantly advanced (and was fortified by) the industrial market-model, as well as the needs and desires for speed and efficiency. While incentives for time-efficiency were initially intended to ease the human condition, the pervasiveness of the market-effect wedded time- and cost-efficiency to end-goals of increasing economic gain(s) with minimal loss (of fiscal, physical, and temporal resources).17 Therefore, I opine that many of the problems of modern medicine are not due to technology, per se, but to the commodification of medicine, and the use of technology as a leveraging factor in this market ethos.
To be sure, technology has become an important, if not frankly necessary, tool in the contemporary practice of medicine. But given Alasdair MacIntyre’s definition of a practice as “…an exchange of the good between individuals … in relationship,”18 it becomes clear that the use of technology is not sufficient for the full enactment of medicine as a practice.19 In fact, the essential, telic “good” of medicine (i.e., a right and morally sound healing) is wholly dependent upon the physician’s ability to understand inherent strengths and limitations of any therapeutic(s) in various applications, evaluate the safety, risks, and burdens of use or non-use, and determine the relative benefits that such treatments can provide for specific patients.20 In light of this, I believe that the real “imperative” is not merely to develop and use technology, but to understand how such technology works, and how it could (best) be used to achieve the good ends of medicine. The decisional process that directs this use in the treatment of individual patients is reliant both upon research to determine the practical good of a given technique or technology, and the physician’s ability to sift through this available research to direct evidence-based, patient-centered care.
In this latter regard, medicine is both art and skill—what is referred to in classical Greek as tekne.21 As a matter of fact, the effective use of research and technology comprises much of the tekne of modern medicine.22 But technology—like any tool—is inert; it must be employed by individuals within a system that establishes paradigms and protocols that define and describe its utility and use(s).