Notes from Chapter 7: Society and Technological Change

The ideas and examples referenced below are notes compiled by Robert Keel from his reading of Volti, Rudi. 2014. Society and Technological Change. 7th edition. New York, NY: Worth Publishers. They are intended for classroom use.

Medical Technologies

• Despite problems, most agree technology has improved medicine and longevity for human beings.
• Technology has also reduced agony associated with illness.
  1. Dialysis for kidneys.
  2. Artificial Hearts and transplants.
• Material technology is not solely responsible for improvement in health.
  • Nutrition, sanitation, and personal hygiene have made a significant impact: Public Health (see also)
  • Public health timeline, 20th century achievements in USA, historical highlights, a history (another history).
  • 19th century medicine.
• As long as we live, experience illness, and die there will be a demand for medical (technological) intervention (sociology of health and health care).
• A bit about demography.

Expenditures for medical attention are Not weighed against other expenditures:

• We may forgo a car for a down payment on a new house.
• But we will not forgo heart surgery for some other good or service.

BUT, nonetheless, technology has created new health problems.

• Despite rising cost of medical technology, the individual is largely unaffected.
• 1950: private insurance paid less than half of medical expense.
• 2004: Private insurance along with Medicare/Medicaid pays over 87%.
• Given spiraling costs, medical technology may not always be a solution.
• Medical technology inappropriate when:
  1. Unnecessary: Patient has condition too advanced to respond to treatment.
  2. Unsafe: Complications outweigh possible benefits.
  3. Unkind: After treatment, quality of life no better or worse than before.
  4. Unwise: Resources could be better used on other patients.

We tend to minimize or ignore costs when someone we love may improve by the use of medical technology.

Kidney Dialysis

• Kidney Failure (end-state renal disease) significantly improved by medical technology.
• U.S. fourth largest killer.
• Development of Dialysis Machine: Willem Kolff--Dutch doctor (1940’s), salvaged bathtub and parts to create dialysis machine.
• Machine cleanses blood.
• Artificial kidney became possible because of machine.
• Demand for dialysis greatly outnumbered machines available, some patients had to be rejected.
• Seattle Artificial Kidney Center (leading institution in field) decided who would get kidney treatment.
  • Making this "life or death" decision based on certain criteria aroused much consternation.
  • Children and adults over 45 excluded.
  • People chosen on the basis of gender, marital status dependants, emotional stability, income, net worth, educational level, past performance and future potential. (Bourgeoisie saving the bourgeoisie)(page 129)
• Treatment very expensive--1970 2X/week $3,000-$5,000
• Start up expenses around $9,000-$13,000.
• 2005--U.S. government spends $17 billion/year.
• As population ages, demand for dialysis will increase.
• Current: 1/3 of dialysis patients > 65 yrs.
• Britain: increasing number of people over 65 receiving dialysis (once limited to those 55 and younger).
• U.S.: much more liberal distribution of treatment.
• Which system is better???
• 2016: "New Procedure Allows Kidney Transplants From Any Donor" (Gina Kolata, New York Times, Health, March 9, 2016)

• Bypass Surgery – segment of vein is removed from leg or chest and is spliced into one or more of the five coronary arteries that transport blood to the heart.
• Treatment has become routine, but expense not equal to population treatment serves:
  • Bypass: 1% of national medical expenditure but serves only .04% of population
  • Often bypass is not helpful because heart is already too weak from disease.
• Same is true for angioplasty--(less expensive) procedure often ineffective, and although supposed to be in lieu of bypass surgery, has led to higher rates of bypass surgery in those over 65.
• Heart transplant is a possibility but not a viable solution
• 75,000 need heart transplant but only around 2,000 donors available
• Artificial hearts (Jarvik-7 – 1970’s U. of Utah) not effective--caused seizures and host of problems. Banned in 1990.
  Robert Jarvik and his creation, the Jarvik-7 (c) William Coupon / CORBIS.
• The Source: The artificial heart.
  
  
• Means hardly justified by end result.
• Artificial hearts can be "bridge" for those awaiting human heart, but no permanent solution.
• AbioCor Implantable Replacement Heart approved in 2006--still a temporary solution.
• Currently (2013), Left Ventricular Assist Device (LVAD)--still temporary. Treating thousands--maybe as many as 50,000 could benefit
• Costs of artifical hearts--12,000 patients: $1.3 billion (for 5 years). If all with end-stage heart disease treated: $3.8 billion.
• Widespread use of LVAD: $10 billion per year.
• Transplant operations are very costly-- $200,000-$1 million/transplant.
• 2016: Update on the artificial heart.

How should funds for costly medical procedures be allocated?

• Artificial heart program – or – anti-tobacco education program?
• Sustain life of premature infants – or – invest in prenatal education programs?
• Who decides? The Health Care Industry?

Diagnostic Technologies

• Stethoscope, X-ray machine, ophthalmoscope, laryngoscope, EKG, MRI, and CT scan have taken mystery and "guess work" out of medical diagnosis.
• No longer do we rely on 4 humors.
• 
  http://www.calvin.edu/academic/medieval/medicine/overview/overview.htm
• These new technologies have often created their own need.
• Fetal heart monitors have no evident benefit, but number of Cesarean section deliveries increased.
• Doctors often over-prescribe technology for fear of mal-practice lawsuits (MRI and CAT scans).
• Tests can make patient worse than when they initially were--this is especially true for the elderly.
• Sociologically, diagnostic tests and technologies helped to create an "objective disease."
• Physician: no longer is it necessary to talk with the patient and obtain their account of their illness.
• 10 Tests to Question. Choosing Wisely.
• Technology has objectified and legitimated the medical profession.
• Technology doesn’t account for the psychological component to illness.

Medical Technologies and Medical Ethics

Medical technologies and the questions surrounding creating and preserving life.

New ways of making and sustaining babies

1. 1978, first baby born that was conceived by in-vitro fertalization.
   1. Involves fertalizing multiple eggs--ethical questions, what to do with un-used embryos?
   2. Used when female's fallopian tubes block or male's sperm count is low
2. In other cases, surrogate mothers implanted with embryo (may be from an egg donor) or artificially inseminated (issue of legal status of surrogate)
3. What is a family? What roles do the multiple people involved play?
4. Premature births: many do quite well
   1. Many suffer from major medical problems
   2. How long should life be preserved? At what cost?
   3. What about a focus on pre-natal care?
5. Pre-natal tests: some conditions (PKU) can be treated, others cannot.
   1. Preimplantation genetic diagnosis (in-vitro): What to do if embryo has probability of major disease?

When does life end? When should it?

1. Historically, major organ failure meant death. Today, not so true.
2. At what point is preserving life pointless? When does death occur?
   1. Terry Schiavo case.
3. What technologies should be used (feeding tube) and at what cost?

Halfway Technologies

• Medical technologies often palliative--treats kidney disease but not the causes of disease.
• Technology has extended life and made it more comfortable but has not addressed causes and conditions.

Questions (page 141):

1. As noted in this chapter, about a quarter of Medicare and Medicaid expenditures are incurred during the last year of life. Given the increasing financial burdens of both programs, should anything be done about this situation? If so, what? When the demand for a new medical technology exceeds the supply, what should he used to determine who gets it? A lottery? The ability to pay? The "merit" of the recipient? Might it be better to limit the development of new technologies in order to forestall the need to make these choices?
2. Attempts at developing devices to completely replace human hearts have not been successful, but many technologies require a long development period before they are successfully employed. Should R&D for artificial heart technologies continue? If so, how should it be financed? Are there some ongoing medical programs that are less deserving of financial surport than the development of an artificial heart?
3. Who should make the decision to terminate life support when a person is a permanent vegetative state, and has left no instructions concerning the indefinite prolongation of his or her life? Should government officials, elected or otherwise, have a role in making this decision?
4. Some medical procedures can be characterized as "halfway technologies," while others are at least close to being completely effective. What accounts for the difference? What "halfway technologies" of the past have become much more effective today? Why has this advance occurred?