by Brent Waters
Technology is useful and beneficial. With various technologies we can accomplish a wide range of tasks with little effort. We board an airplane, for instance, and a few hours later arrive at our destination. Technologies help make our lives more comfortable. Our hand-held devices and headphones provide entertainment during our airplane trip. As late moderns—at least those living in developed economies—we enjoy an unprecedented ease of living. I have no desire whatsoever to return to a pre-technological age devoid of indoor plumbing, electric grids, reliable transportation and information networks, and accessible healthcare.
Technology is also a distraction. We sometimes use technology to avoid doing the hard work of being human in community with other persons. One such distraction is believing the fiction that technology can make us extraordinary. Many transhumanists, for instance, want to use technology to convert humans into superior beings with unimaginable physical and cognitive capabilities, perhaps even achieving personal immortality. The principal problem with this desire is that it denigrates who we are and how we spend most of our time. The transhumanists effectively loathe their status as embodied creatures because of the severe constraints that our flesh imposes on the will. For example, a body limits what one can do and how long one can live. Consequently, transhumanists resent the many mundane tasks required in meeting the needs of embodied beings as a waste of time and effort. But it is, in part, in caring bodies—our own and those of others—that we flourish as human creatures.
Recent changes in bioethics and healthcare reflect this general trend of denigrating the care for the ordinary demands of bodily existence. Over the last three decades bioethics has changed a great deal in pursuing its work, largely in response to advances in preventive, diagnostic, and therapeutic techniques. These advances have drawn especially upon developments in biotechnology, nanotechnology, genetics, information technology, and 3-D printing. The most curious change that has occurred involves the perception of the body. When I was young, the body was perceived largely as a given condition, imposing intractable limits. Humans were finite and mortal. Medicine could, at best, buy a few extra years, and ease the pain of disease and injury, but there was no serious challenge to the reality that humans naturally grow old and die. The principal task of medicine, then, was to help patients come to terms with their finitude and mortality.
Today there is a growing perception of the body as an unwanted constraint against the will, and medicine should be dedicated to overcoming the limits of being embodied. Physicians are not expected to help patients manage and come to terms with their finitude and mortality, but to wage an incessant war against these constraints with a growing arsenal of sophisticated technological weapons. The body should be an artifact of medical and technological ingenuity instead of an arbitrary given. The body, in short, is a problem to be solved.
How did we get here? I’m afraid that to answer that question I need to inflect a quick history of bioethics upon the reader. Stay with me, for I will make this as tolerably brief as possible. The birth of bioethics occurred roughly in the mid 1960s, in response, in part, to clearly immoral research conducted on unwilling or unknowing subjects. But more broadly it was a reaction to such headline catching breakthroughs as the first heart transplant and birth of a baby using in-vitro fertilization—hence the subsequent tendency of bioethicists to fixate on issues associated with the beginning and end of life.
The first phase was dominated by theologians. Their principal task was to create a person-centered practice of medicine; to see the patient as person. These theologians were troubled that the success of modern medicine was also diminishing the personhood of patients, who were treated as collections of biological parts and systems; it was the disease rather than the person that the doctor was treating. This reductionist tendency was most acute at the end of life. Increasingly, the process of dying was occurring over an extended period of time through surgical interventions, drugs, deployment of ventilators and the like. Patients were dying slowly in pieces rather than as whole persons.
Paul Ramsey was one of those earliest theologians who reacted forcefully against this state of affairs. He insisted that medical care should always be person-centered, because every patient was not a collection of failing biological parts, but always simultaneously an embodied soul and ensouled body and should be treated as such. The force of his argument is captured in the provocative titles of such essays as “On (Only) Caring for the Dying,” and “The Indignity of Dying a Death with Dignity.” For Ramsey, medicine was not a relationship between physician and patient, but between one person caring for another.
The reign of the theologians, however, was short-lived. The primary reason for their demise was that although they shared a dedication to a person-centered medical care, there was no agreement on who or what is a person. At one extreme, some bioethicists insisted that being alive is the sole criterion of personhood. Consequently, patients should always be treated as persons from the moment of conception until the last breath. At the other extreme, others maintained that multiple criteria, such as consciousness, brain function, or minimal IQ, could be used to determine the presence or absence of personhood. Consequently, some patients could be treated as nonpersons at various stages of life such as being in the womb or in a persistent vegetative state.
This lack of consensus was not very helpful in guiding the actual practice of medicine. So, in the second stage of bioethics, philosophers filled the void. They too lacked a consensus regarding personhood, but they devised a useful rule of thumb. To oversimplify: a person is someone who is capable of making decisions that she believes to be in her self-interest. If someone is not capable, then a conscientious person should be assigned to make those decisions on her behalf. This rule of thumb informed four ethical principles that have come to dominate both bioethics and medical practice: 1) Nonmalficence: do not intentionally harm a patient; 2) Beneficence: treat patients in ways that are judged to benefit them; 3) Justice: do not treat patients unfairly so that some benefit while others are exploited or discriminated against; 4) Autonomy: patients (or their surrogates) must give their informed consent to treatment. Respecting a person’s autonomy bears the heaviest weight among these principles, because this principle preserves a patient-centered practice of medicine. Healthcare professionals can only do what I allow them to do to me, except in emergencies. Bioethics moved away from the patient as person to the patient as autonomous person.
I believe we are now entering a third phase, a transition from the patient as autonomous person to the patient as consumer. In this transition, the philosophers are being replaced by managers and lawyers. This consumerist stance is a logical consequence of defining personhood as autonomy. If patients should determine their courses of treatment, why should they settle for a limited range of options that healthcare providers offer? They should demand more, and they are. What are we, as autonomous consumers of healthcare demanding? Increasingly we are demanding that medicine help us overcome unwanted constraints imposed by the body, especially as we grow older. And so, enhancing physical and cognitive performance is complementing and supplementing the more traditional medical practices of prevention, diagnosis, and therapy. Consumers want their healthcare providers to help them live long, physically vigorous, and mentally alert lives. Hence, the image of pensioners is no longer oldsters dozing off in rocking chairs, but enthusiastic pensioners, blissfully playing endless rounds of golf, day-after-day. And if we take autonomy seriously as the ability of persons to take action in behalf of their respective self-interests, then no compelling moral objection can be raised against healthcare providers satisfying this demand, so long as the medical products that are consumed are relatively safe and reliable.These three phases of bioethics—the patient as person, the patient as autonomous person, and the patient as consumer—are accompanied by two roughly corresponding transitions in medical practice.
The first transition is from a paternalistic practice of medicine to one that is contractual. In the paternalistic practice of medicine, the physician, in virtue of his or her specialized training, expertise, and experience knew what was best for the patient. When I was young, for example, a visit to the doctor went something like this: I would state my complaint. The doctor would poke and probe me with various instruments, and then tell me to do this and that. That was the end of the conversation, and if on the next visit I confessed that I failed to do what I was told, I could expect a severe scolding. I’m not suggesting that these physicians were tyrants. To the contrary they were often wise, kind, and benevolent. But they were clearly in charge, and my role, if I wanted to get better, was to obey their commands.
A visit to the doctor’s office is no longer like this. After stating my complaint, the doctor authorizes a battery of tests and may refer me to a specialist or two. Once all the data has been collected, my doctor or a specialist describes a range of treatment options, and I decide which, if any, I will undertake. In this contractual relationship between physician and autonomous patient, a number of safeguards are needed to protect both parties, a necessity reflected in the proliferation of informed consent documents authorizing who the doctor may confer with, advanced care directives and durable power of attorney forms that are kept on file.
The second, current transition is from a contractual practice of medicine to consumerist healthcare. In this transition, healthcare providers are effectively asking consumers what they think of their products: are you happy with what we provided? The signs of this transition are subtle, but nonetheless telling. For example, within a day or two following a visit to the doctor’s office, my healthcare provider emails a link to an evaluation form. On scale of one to ten I am asked how satisfying my visit was. Most of the questions involve ease in making the appointment, the friendliness and communication skills of the staff, the attractiveness of the waiting room, how long I waited, and so on. The final question is always how likely I might be to recommend this office to a friend or family member. My healthcare provider is always gauging my satisfaction with the services it provides.
The healthcare industry has tapped into a strong consumerist desire to live long and healthy lives. To a remarkable extent this demand is being met through improved diet and exercise regimes, drugs, joint replacements and other surgical interventions. Those having access to excellent healthcare are tending to live longer and healthier lives. The healthcare industry is also promising its customers that it can help them live better lives over a more extended period of time. There is nothing inherently wrong in striving to become better; nothing wrong in trying make better human beings, or to become better at being human. But in offering the promise of long and healthy lives, can healthcare ever satisfy this demand fully? If one is healthy, can a life ever be too long? Have you ever met a person complaining about being too healthy? Is there a point when we reach the perfect age and state of health that satisfies our hearts’ desires?
This dilemma of an unsatiated demand for healthcare is compounded by an unfortunate phrase coined in the bioethics literature around a decade ago, namely that “aging is a disease.” I think this phrase was meant as a shorthand reference to a list of maladies associated with aging, such as loss of physical strength and dexterity, memory loss, slower cognition, susceptibility to illness and the like. And indeed, as I mentioned previously, we are making notable advances in treating an aging population. But if aging is a disease that can be treated, doesn’t this imply that someday technologies can be developed to cure it? What would it mean to cure aging?
To be clear, I am not suggesting that medicine should not develop and use sophisticated technologies that more effectively treat its patients. But when healthcare is used to treat the body as a problem to be solved, then we are distracted away from the more important task of flourishing as embodied, and thereby necessarily finite and mortal, creatures. How might we redirect our attention? By turning to the commonplace, mundane activities of being embodied human creatures. These mundane are boring, mind-numbing, and repetitious. Clothes must be washed, homes cleaned, and meals prepared day in and day out. And yet in their very repetition, these mundane tasks are formative, helping to shape us as people who do those things that are required in taking care of one another. The mundane can also be iconic, providing moments when we catch of glimpse of what is most important, such as the love that created us and the love we share with one another. In short, it is the ordinary, not the extraordinary, that enables us to flourish as human beings.
I’ll conclude my plea for the importance of the ordinary in assessing the impact of technology on healthcare with a literary illustration. The novel, The Sea by John Banville, is a story about a man who must deal with his terminally-ill wife, and later come to terms with his loss and grief. On the day he hears the terrible news that his wife is dying he makes the following observation: “The kettle came to the boil and switched itself off and the seething water inside it settled down grumpily. I marveled, not for the first time, at the cruel complacency of ordinary things. But no, not cruel, not complacent, only indifferent, as how could they be otherwise?” This seeming indifference, however, provides an important backdrop to the story. It is in and through the mundane things he does in caring for his wife, sometimes well and sometimes badly, and later the ordinary things he does in coming to terms with his loss and grief, sometimes well and sometimes badly, that the husband discovers the intrinsic, meaningful rhythm life takes on over time, subtly disclosing the fact that we are not really alone. Again, in coming to grips with the impending reality of his wife’s death, his life has become unalterably redirected. But he observes: “But then, at what moment, of all our moments, is life not utterly changed, until the final, most momentous change of all?” Cumulatively, these changes against the apparent indifference of the ordinary produce a profound insight in reference to his daughter, Chloe: “In her I had my first experience of the absolute otherness of other people. It is not too much to say—well, it is, but I shall say it anyway—that in Chloe the world was first manifest for me as an objective entity.” As a husband, parent, and widower he learns that he is not the center of the universe. And it is in such decentering that we are prepared to receive the gift of flourishing, also known as happiness; the genuinely good life.
 John Banville, The Sea (New York: Knopf, 2005), p. 15.
 Banville, The Sea, p. 25.
 Banville, The Sea, pp. 124-125.