II. PHILOSOPHY OF MEDICAL TECHNOLOGY

Philosophy of technology aspires to comprehensive reflection on the making and using of artifacts. Medicine is increasingly defined not just by the character of its human interactions (physician—patient relationships) or professional expertise (knowledge of illness and related therapies) or its end (health), but also by the type and character of its instruments (from stethoscope to high-tech imaging devices) and the construction of special human-artifact interactions (synthetic drugs, prosthetic devices). Indeed, the physician-patient relationship, medical knowledge, and the concept of health are all affected by technological change. There is even debate about whether the term artifact should include nonmaterial as well as material human constructions, in which case all of the above might well be interpreted as technologies. From either perspective, medicine and the issues of bioethics fall within the purview of the philosophy of technology.

Historical Development

Philosophy of technology as a distinct discipline originated with the publication of Ernst Kapp's Grundlinien einer Philosophie der Technik (1877), the first book to be entitled a "philosophy of technology." A left-wing Hegelian contemporary of Karl Marx, whose thought includes important analyses of human-machine systems, Kapp left Germany in the mid-1800s to become a pioneer and "hydrotherapist" on the central Texas frontier. Returning to Europe two decades later, he elaborated a general theory of technology as "organ projection"—from the hammer as extension of the fist to railway and telegraph as extensions of the circulatory and nervous systems—thereby promoting analysis of the philosophical-anthropological foundations of technology.

Another major formative figure was Friedrich Dessauer, whose Philosophie der Technik (1927) and Streit um die Technik (1956) reflect his experience as the inventor of deep penetration X-ray therapy. For Dessauer the philosophical core of technology is the act of invention, for which he sought to provide a Kantian analysis of transcendental preconditions. Dessauer's argument that the fact inventions work shows how inventors depend on insight into a supernatural realm of "pre-established solutions" to technical problems raises basic epistemological and metaphysical issues.

José Ortega y Gasset and Martin Heidegger, two major philosophers of the twentieth century, also contributed texts dedicated to the theme of technology. Ortega's "Meditación de la técnica" (1939) presents technical activity as a means for realizing some supernatural human self-conception, and modern technology as generalized knowledge of how to create such means. Ortega thus pushes anthropological reflection to new depths. Heidegger's "Die Frage nach der Technik" (1954) argues that both traditional technics or craft and modern technology are forms of truth, revealing different aspects of Being. Modern technology in particular is a "challenging" and "setting-upon" that reveals Being as "resource"—that is, the world as a reservoir of materials subject to indefinite human manipulations. In this argument Heidegger likewise carries epistemological and metaphysical reflection well beyond Kantian terms.

Lewis Mumford, Jacques Ellul, Herbert Marcuse, Jürgen Habermas, and Michel Foucault have made further contributions to the development of philosophy of technology from the perspective of social theory. Mumford (1934) focuses attention on technological materials and processes as major elements in the historical development of modern civilization. Ellul (1954) argues that the pursuit of technical efficiency is the defining characteristic of the contemporary world, which constitutes a milieu distinct from the natural and social milieus that preceded it. For Ellul, just as the Hebrew-Christian tradition once demythologized the two earlier milieus, now it called upon to demythologize technology.

Marcuse (1964) and Habermas (1968) have debated the character of technology as ideology. Foucault (1988) views all technologies and sciences as masking power manipulations, and develops a special analysis of technologies as historical transformations and determinations of the self. Such ideas exercise continuing influence in debates over the extent to which technology is properly conceived as an autonomous determinant of human affairs (see Winner, 1986) or as a social construction (see Feenberg). Such debates in turn influence fundamental orientations with regard to practical questions about the assessment and control of technology that find expression in such applied fields as medical ethics, environmental ethics, engineering ethics, and computer ethics.

Ortega and Heidegger are leading figures in the Continental or phenomenological tradition in the philosophy of technology. Further analyses of phenomenological inspiration can be found in the work of Don Ihde (1979) on human-technics interactions and of Albert Borgmann (1984) on the political-cultural implications of contemporary technological formations.

A different, equally strong tradition in the philosophy of technology is constituted by Anglo-American analytic reflection on artificial intelligence (AI). Here questions center on the extent to which brains are computers and thinking processes can be modeled (see, e.g., Simon; Dreyfus). In contrast to the phenomenological tradition, the Anglo-American analysis of AI exhibits considerable interactions with biomedical theory of neurological processes and, to a lesser extent, with biomedical practice.

Theoretical Perspectives

Throughout its diverse strands, philosophy of technology, like philosophy generally, includes theoretical and practical issues, from epistemology and metaphysics to ethics and politics, all of which can helpfully inform bioethics. Comprehensive understanding nevertheless grows out of partial understandings. The making and using of artifacts involve not only the artifacts themselves but also technological knowledge, technological activity, and technological volition. Theoretical analyses can thus conveniently be described by referencing tendencies to interpret technology in one of four primary forms.

TECHNOLOGY AS OBJECT. The theory that identifies technology with particular artifacts, such as tools, machines, electronic devices, or consumer products, is the commonsense view. Initially it involves a classification of artifacts into different types, according to their own internal structures, different kinds of human engagement, impacts on the environment, or other factors. Mumford, for instance, distinguishes utilities (roads, electric power networks), tools (artifacts under immediate human power and guidance), machines (nonhuman power with immediate human guidance), and automatons (nonhuman power and no immediate human guidance).

Taking a different tack, Borgmann argues a distinction between things and devices. An example of a thing, in Borgmann's special sense, is a traditional fireplace, which engages a variety of human activities ranging from cutting wood to cooking food, functions in a clearly understandable manner, and is an explicit center of daily life. By contrast, a device, such as a heat pump, simply makes available some commodity (hot and cold air) by nonobvious processes and disappears into a background of quotidian activities. The device is a special instance of what Heidegger called a "resource."

Ihde, in a different but equally provocative manner, distinguishes embodiment and hermeneutic relations between humans and their instruments. Embodiment relations experience the world through instruments, as exemplified by eyeglasses, which disappear into and become an unconscious part of the experience of seeing. In hermeneutic relations, by contrast, the instrument itself—for instance, a camera—becomes part of the world with which one engages; a user consciously focuses on the operation and interpretation of this instrument. Both Borgmann's and Ihde's distinctions obviously provide frameworks within which to interpret the myriad tools and instruments of high-technology medicine.

TECHNOLOGY AS KNOWLEDGE. Etymologically, however, the word technology implies not objects but "knowledge of techne," or craft skill. Epistemological analyses of such knowledge distinguish between knowing how (intuitive skill) and knowing that (propositional knowledge). The transition from premodern technics to modern technology can thus be argued as defined by the development of propositional knowledge about techne through the unification of technics and science.

This theory of modern technology as applied science is particularly influential among scientists and engineers, and has been given detailed philosophical exposition by Mario Bunge (1967). For Bunge, modern technology develops when the rules of prescientific crafts, originally discovered by trial-and-error methods, are replaced by the "grounded rules" or technological theories. Technological theories can be formulated by applying either the content or the method of science to technical practices. The former application takes preexisting scientific knowledge (e.g., fluid dynamics) and adapts it under certain boundary conditions to formulate an engineering science (aerodynamics). The latter uses the methods of science to formulate distinctive engineering analyses of human-machine interactions, such as operations research and decision theory.

Medicine can readily be incorporated within such an epistemological analysis. Prior to the nineteenth century, most medical practice relied on rule-of-thumb experience. But twentieth-century medicine has involved the progressive grounding of medical practice in the sciences of anatomy and physiology as well as the development of such distinctive fields as epidemiology and biomedical engineering. Indeed, José Sanmartín (1987), for instance, analyzes genetic engineering exactly as an embedding of techniques in scientific theory.

TECHNOLOGY AS ACTIVITY. The transformation of some technics (such as medicine) into an applied science is not, however, simply an epistemic event. As Foucault (1963) argues, for example, modern medicine "is made possible as a form of knowledge" by the reorganization of hospitals and new kinds of medical practices. This emphasis on technology as activity or a complex of activities is characteristic of social theory. Ellul's "characterology of technique" and analysis of the central role played by the rational pursuit of technical efficiency in the economy, the state, and what he terms "human techniques" (ranging from education to medicine) is another case in point, as are the Marxist and neo-Marxist analyses of Marcuse, Habermas, and Andrew Feenberg.

The emphasis on technology as activity has roots in Max Weber's observation that there are techniques of every conceivable human activity—from artistic production and performance to mass manufacturing and bureaucratic organization—even education, politics, and religion. One classic problem for social theorists is to explain the character and limits of technicalization—that is, the movement from traditional societies, in which techniques are situated within and delimited by nontechnical values, to modern societies, in which techniques are increasingly evaluated solely in technical terms. In traditional societies, for example, animals can be eaten only if butchered in a ritually prescribed manner; in modern societies animal slaughter is largely subject to calculations of efficiency.

Efficiency can also be conceived in economic terms and applied at micro or macro levels. The former is typical of analyses internal to business corporations (including hospitals and clinics); the latter, of social assessments of technology. In regard to technology assessments especially, there arise questions of the limits of technicalization and possible alternative forms of technical institutions (see Feenberg), as well as of responsible agency and risk.

TECHNOLOGY AS VOLITION. A fourth element in the interrelationship of knowledge, object, and activity is that of volition. The human activity of making and using artifacts depends not only on knowledge but also on volition. Indeed, it can be argued that volition is even more important in this respect than knowledge, that is, that human action can be ignorant but not unwilled.

The philosophical analysis of volition distinguishes between volition in the weaker senses of wishing, hoping, longing, and desiring, and the stronger or more decisive intending and affirming. Volition in the second or stronger senses is constituted by self-reflective identification with some particular wish, hope, or desire that takes on the character of a project. Ortega, Mumford, and Frederick Ferré (1988) argue that technology is essentially a matter of volition in one or more of these senses. According to Ferré, for instance, technology is grounded in "the urge to live and to thrive." For Ortega, technology is based in the willed attempt at a worldly realization of some specific selfimage. For Mumford, technology in a distinctive sense emerges when human beings subordinate their traditional polytechnical activities of craft, religious ritual, and poetry to the monotechnical pursuit of physical power— something that first happened about five thousand years ago in Egypt, with the construction of the pyramids by means of large, rigid, hierarchical social organizations that he terms "megamachines."

Defining technology in terms of volition makes possible the perception of broad historical continuities more than does a focus on the elements of knowledge or object or even activity. It is inherently more believable that the will to fly was coeval with human existence than that technical knowledge of how to fly, flying machines, or the human performance of flying or flying-like actions have existed from time immemorial. Such an approach once again has immediate implications for the interpretation of medicine. If medicine is interpreted primarily as grounded in volition, then it is inherently more believable that there exists a fundamental continuity between premodern and modern medicines.

Nevertheless, one of the most sustained critiques of modern medicine is precisely that as volition, it is fundamentally different from all previous kinds of medicine. Ivan Illich's Medical Nemesis (1976) argues that modern medicine arises from a basic "social commitment to provide all citizens with almost unlimited outputs." Indeed, the nemesis of rising iatrogenic disease is a direct result of "our contemporary hygienic hubris," which can be reversed only "through a recovery of the will to self-care." In the 1990s, however, Illich becomes critical of the idea of self-care when it serves as an ideological support for what has been termed "health fascism."

Practical Perspectives

Not theoretical analysis, however, but ethical and political concerns predominate in philosophy of technology. Ethics has from its beginnings in the West involved at least marginal considerations of technology. Aristotle's Nicomachean Ethics, for instance, in passing identifies techne as an intellectual virtue. More than two thousand years later Immanuel Kant distinguished moral and technical imperatives. But in line with such marginal attention, from Plato and Aristotle to the Renaissance, technology was widely accepted as properly subject to ethical constraints. From the Renaissance to the Enlightenment, by contrast, traditional restraints were effectively replaced with an ethical commitment to the unfettered pursuit of technology for what Francis Bacon called "the relief of man's estate." It is precisely this modern commitment, along with its subsequent questioning in response to a series of increasingly prominent problems, that frames the contemporary prominence of ethical issues in the philosophy of technology.

ALIENATION. Historically, the first problem of modern technology involved the industrial revolution and alienation. At the basis of modern technological making lies a belief that the world as it is given does not provide a suitable home for human beings; humanity must construct a home for itself. The problem is that human beings do not immediately find themselves at home in the worlds they technologically create. The resulting alienation is especially problematic to the extent that it is grounded in attempts to overcome alienation.

The two most extensive critiques of technological alienation are Romanticism and socialism. The Romantic critique, an early version of which appears in Jean-Jacques Rousseau's Discourse on the Sciences and the Arts (1750), focuses on how technology alienates the individual from feelings and sentiments, as manifested in relationships with nature, the past, or other human beings. This is caused, according to the Romantic argument, by a one-sided development of rationality. Romanticism thus perceives technology as an extension of reason and proposes to enclose it within a larger affective life.

By contrast, in the socialist critique of alienation, Marx, like Kapp, explicitly conceives technology as a human organ projection. Marx thus focuses on the separation of human beings from control over the tools and products of their labor, as manifested in an economy based on money and the "fetishism of commodities." In response, socialism argues for a comprehensive restructuring of society to promote worker control of the means of production.

In biomedical practice the use of technological instruments and rationalized systems of diagnosis raises the issue of alienation in the form of questions about the depersonalization of healthcare techniques and organizations. Responses can exhibit characteristically Romantic or socialist features. Exemplifying Romanticism are proposals to situate diagnostic techniques within a more humanistic framework, perhaps one of beautiful buildings and a pleasant environment. Exemplifying a socialist response might be arguments for the promotion of patient autonomy by granting patients more direct control over their own healthcare institutions.

WARFARE. A second ethical problem has centered on technology and war. There are two basic theories about the relationship between war and technology: First, technological weapons make war so horrible that it becomes unthinkable; rational self-interest leads to deterrence of their use. Second, human beings will always tend to miscalculate their self-interests and go to war; weapons production must therefore be limited, and a higher ideal of global human unity promoted.

Prior to World War I, naive versions of the first theory largely supported the pursuit of technology. The trauma of the war contributed to pessimistic criticisms of technological civilization and led to emphasis on the second theory. This pessimistic critique, coupled with idealist attempts at world government, failed to avoid World War II and a technological practice of genocide, the invention and use of the atomic bomb, and a subsequent Cold War spread of nuclear weapons. As a result, much more sophisticated versions of deterrence policy were developed in alliance with management and decision theories. Advanced technological weapons development projects also stimulated science and technology policy and management studies, while the practice of nuclear deterrence was subject to extended moral criticism. One of the more idealistic criticisms argues that human unity and peace, which in the past could remain as moral exhortations, have now become necessities, lest human beings obliterate themselves from the face of the planet. In this argument the rational self-interest of the first theory appears to merge with the idealism of the second.

Prospects for social and genetic engineering call forth similar arguments between pragmatic deterrence management and idealistic delimination. The progressive refinements of conditioning techniques and sophisticated drug therapies create behavior-control technologies of immense potential power. Developments in recombinant DNA technology and the Human Genome Project offer opportunities to extend this power to the biological creation of human life. As Sanmartín has pointed out, this attack on the vagaries of human nature can be seen as developing new technologies for the prevention of "social diseases" such as war.

TECHNOLOGY AND SOCIAL CHANGE. Concerns about the relatively specific issues of alienation and warfare have been complemented by more general analyses of the causal relations and patterns of interaction that obtain between technology and social change. Such analyses include bottom-up case studies of changes related to bureaucracy, urbanization, work (from mass production to automation to customized production), leisure and mobility, secularization, communications (from telephone and radio to television and computer), and medical technologies, as well as top-down theoretical reflections on the same dimensions of social life and on the social order as a whole. Within both approaches it is common to find descriptions of disorder between technology and society brought about by technological change along with arguments for addressing such disorder by means of some intellectual and/or volitional adaptations.

In the period between the two world wars, for instance, William F. Ogburn's Social Change (1922) described a "cultural lag" between technological development and social adaptation across a variety of indicators, and argued for a more intelligent appropriation of technology. A decade later Henri Bergson's Two Sources of Morality and Religion (1932) argued that the vices of industrial civilization as a whole could be corrected only by what he termed a "supplement of soul" that is at once ascetic (against luxuries) and charitable (for eliminating inequalities).

To stress the need for intellectual or rational adaptations is no doubt more characteristic of advanced industrial society, with its concomitant large-scale educational institutions and activities. The kind of piecemeal social engineering advocated by John Dewey and Karl Popper, and the many theories of economic rationality from Pareto efficiency to risk-benefit analysis, and of postindustrial organization from Daniel Bell to Habermas, likewise advocate effective increases in the rational control of modern technology. By contrast, a follower of Bergson such as Ellul argues that technology has become a kind of totalitarian milieu that requires comprehensive demythologizing. Others suggest the need for expansions of affective sensibility. Some theories of postmodern culture exhibit certain affinities with this approach.

With regard to increasing rationality, Kristin Shrader-Frechette (1991) has drawn an explicit parallel between the requirements of informed consent in the practice of medically risky procedures and the general societal adaptation to technological change. With regard to affective responses to technological change, the work of Illich is illustrative.

POLLUTION AND THE ENVIRONMENTAL CRISIS. Perhaps even more demanding of attention than warfare, and adding a new dimension to analyses of technological change, are problems associated with environmental pollution and global climate transformation. The environmental crisis has obvious and fundamental impacts on human health and safety, and thereby on biomedicine. Indeed, outside medical ethics, perhaps the single most intensively explored area of applied philosophy is that of environmental ethics.

Beyond intensified self-interest, environmental change has engendered the new science of ecology and extended ethical concern both temporally (for future generations) and ontologically (for nonhuman entities). As analyzed by Hans Jonas (1979), this extension is grounded in "the altered nature of human action" brought about by the "novel powers" of modern technology. Although all human life requires some technical activity, not until the advent of modern scientific technology did the technical power to create become so explosive as to be capable of fundamentally transforming nature and the future of the human condition. On the basis of this power there arises what Jonas terms an "imperative of responsibility" to "ensure a future."

Jonas explicitly argues the application of this principle of responsibility in the field of bioethics. Applications might also be adumbrated for other discussions in environmental ethics, such as those that distinguish shallow versus deep ecology movements and argue the rights of nature understood as wilderness. Could one not, for instance, distinguish a shallow versus a deep bioethics? Would it not be possible to argue, against excessive medical intervention, a defense of wildness in biology?

ENGINEERING ETHICS. A second well-developed field of applied ethics with potential implications for the medical dimensions of bioethics is that of engineering ethics (see Martin and Schinzinger). Here a basic shift has taken place in the interpretation of the primary responsibility of the professional engineer—from loyalty to a company or client (patterned after the ethics of the medical and legal professions) to responsibility to public health, safety, and welfare. Could this shift, resting on a recognition of engineering as social experimentation, have implications for new understandings of professional medical obligation? Is it not the case that technological medicine is, as much as the treatment of individual patients, to some extent a social experiment? If so, then the engineering ethics defense of the rights and role of the whistle-blower might well have analogous applications in the biomedical field.

COMPUTERS AND INFORMATION TECHNOLOGY. A third well-developed area of applied ethics deals with computers. One defining book in this field was written by a computer scientist (see Weizenbaum) and based on Mumford's philosophical anthropology of the human as a polyvalent being for whom calculating is only a very small part of thinking and a limited dimension of technics. Key issues in the philosophical analysis of computers concern the degree to which human thinking can be modeled by computers and the extent to which human beings should properly rely on computer programs, especially in areas such as weapons. Subsequent development, as summarized by Deborah Johnson (1985), has emphasized issues of individual privacy and corporate security, the formulation of ethical codes for computer professionals, and liabilities for the malfunctioning of computer programs. The computerization of medical practice calls for the application of such reflection to many aspects of high-tech medical diagnosis and treatment.

DEVELOPMENT AND DIVERSITY. The ambiguities of technology in developing countries, together with reassessments of the impacts of advanced technological transformations in relation to women and ethnic minorities, especially in the United States and Europe, raise new issues regarding the abilities of scientific technology to accommodate true diversity. On the one side, there are questions of equity. In advanced technological countries, technological power and affluence are not equally shared between men and women and among different ethnic communities. Nor does there appear to be equality of opportunity among advanced and developing countries. On the other side, technological development tends to set up national and international economic orders that homogenize personal and world cultures. Distinctions among markets and ways of life are subsumed within the financial structures of transnational corporations and global communications systems. This paradox of inequity and homogenization poses a fundamental challenge to both reflection and action.

Attempts to address this challenge can be found in the alternative technology movement, arguments regarding the ethics and politics of development, and in diverse feminist contributions to the philosophy of technology (as collected, for instance, in Rothschild). Feminist critiques of technology, for instance, emphasize both the need for equity and the threats of homogenization. Technologies of the workplace are to a large extent sexually differentiated; those of the home are designed and used in ways that confirm masculine and feminine roles. But technological culture creates images of androgynous liberation while medical procedures diminish the experiences of gendered bodies. In the face of this paradox, what some feminists argue is the need for a new theory and practice of technology itself, a truly alternative technology, one that transforms both its masculine biases and its characteristically modern commitments. The ideals and pursuit of alternative medicines can be interpreted as concrete attempts to achieve such a goal.

Conclusion

Successive technological problems have provoked a series of ethical analyses and moral responses. Reflections on these problems and their emerging responses, because they have been focused on a particular technology, have tended to remain isolated from each other and untested by generalization. Philosophies of technology that have attempted to bridge such particularities, and that include a substantial role for bioethics, can be found in the work of Jonas, Sanmartín, Gilbert Hottois (1990), and Friedrich Rapp(1990).

Complementing such work, problems addressed by the varied discussions of practice have been approached from within a variety of ethical frameworks, among which are natural-law theory, deontologism, and consequentialism. With natural-law theory, one tends to assess technological change in terms of its harmony with some given lawful order perceived in nature. With deontological theory the emphasis is on evaluating the rightfulness and wrongfulness of technological change in accord with some inner criteria of the action. With consequentialism there is an effort to look to the goodness or badness of future results that flow from some particular technology. Each such ethical framework can exhibit selective affinities with different basic theoretical conceptions of technology.

Environmental ethics, for instance, tends to be distinguished by criticisms of technologies that do not harmonize with preexisting natural order. The emphasis here is easily placed on human activity, with nonhuman realities taking on special moral significance. Computer ethics, by contrast, tends to put forth deontological principles about the wrongness, for instance, of the invasion of privacy. Such an ethics emphasizes human intention or volition with respect to technology. Finally, technology policy studies are likely to stress the evaluation of technologies in terms of results, and thus to call attention to the physical consequences of technological decisions. Here the issue of risk becomes a special challenge to the accepted cost-benefit calculus typical of consequentialist analysis.

The suggestive character of such relationships points toward the need for a more systematic pursuit of the philosophy of technology in ways that integrate epistemological, metaphysical, ethical, and political analyses. They also indicate the opportunities for more extended interactions between general philosophies of technology and the issues of biomedical ethics, interactions that have the potential for deepening and increasing the fruitfulness of both.

carl mitcham (1995)

bibliography revised

SEE ALSO: Human Dignity; Human Nature; Medicine, Philosophy of; Natural Law; Posthumanism and Transhumanism;Virtue and Character; and other Technology subentries

BIBLIOGRAPHY

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