"The medical establishment has become a major threat to health. The disabling impact of professional control over medicine has reached the proportions of an epidemic. Iatrogenesis, the name for this new epidemic, comes from iatros, the Greek word for physician, and genesis, meaning origin. Discussion of the disease of medical progress has moved up on the agendas of medical conferences, researchers concentrate on the sick-making powers of diagnosis and therapy, and reports on paradoxical damage caused by cures for sickness take (...) up increasing space in medical dope-sheets [...] The public has been alerted to the perplexity and uncertainty of the best among its hygienic caretakers [...] This book argues that panic is out of place. Thoughtful public discussion of the iatrogenic pandemic, beginning with an insistence upon demystification of all medical matters, will not be dangerous to the commonweal."-- from Introduction. (shrink)

HTA and TA institutions at national parliaments (PTA) both share the same origin and of course have objectives and some of their methods in common. Nevertheless both TA branches developed in some distance during the 1970s and 1980s. Drawing on the case of biomedicine this paper outlines the differences between HTA and PTA, highlighting the “clinical perspective” of HTA and the “societal perspective” of PTA. It is shown that biomedicine which has developed rapidly during the last decade has hardly been (...) dealt with by HTA, whereas it ranked quite prominent on the agendas of PTA institutions. Biomedical technologies became a subject of policy making beyond the boundaries of health care politics since biomedicine is perceived as an ethical challenge to society and not only as a medical innovation that has to be assessed by clinical experts. It is argued that there may however be good reasons to integrate the HTA and the PTA perspective in future TA on biomedical technologies. (shrink)

The current model of technology assessment treats ethics itself as just another problem‐solving technology. Ethics should resist this model to play a more critical role in technology assessment by better understanding the complex relationship between society, medicine, and technology—and by recasting how problems are defined.

Debates over health care have focused for so long on economics that the proper goals for medicine seem to be taken for granted; yet problems in health care stem as much from a lack of agreement about the goals and priorities of medicine as from the way systems function. This book asks basic questions about the purposes and ends of medicine and shows that the answers have practical implications for future health care delivery, medical research, and the education of medical (...) students. The Hastings Center coordinated teams of physicians, nurses, public health experts, philosophers, theologians, politicians, health care administrators, social workers, and lawyers in fourteen countries to explore these issues. In this volume, they articulate four basic goals of medicine — prevention of disease, relief of suffering, care of the ill, and avoidance of premature death — and examine them in light of the cultural, political, and economic pressures under which medicine functions. In reporting these findings, the contributors touch on a wide range of diverse issues such as genetic technology, Chinese medicine, care of the elderly, and prevention and public health. The Goals of Medicine clearly demonstrates the importance of clarifying the purposes of medicine before attempting to change the economic and organizational systems. It warns that without such examination, any reform efforts may be fruitless. (shrink)

The role of ethics in technology development has been often questioned, especially in the early days of societal reflection of technology. However, the situation has changed dramatically. Ethical consideration now is generally declared to be indispensable in shaping technology in a socially acceptable and sustainable way. The expectations of ethics are large; often even a kind of “New Ethics” is postulated. In the present paper an over-estimation of the role of ethics for technology development is rejected. It is argued that (...) ethical reflection is, indeed, indispensable in certain problem areas and situation types; but there is, on the other hand, space for technology development free from the requirement for ethical reflection. The absence of a requirement for ethical reflection, however, always has to be considered relative to some “morale provisoire” (provisional morality) as an accepted normative framework within which technology development may occur without explicit ethical reflection. If this framework, however, is doubted or is shown to be insufficient the situation changes completely. Ethical reflection in this case becomes necessary, to consider this normative framework in order to offer modifications or supplements. (shrink)

Health technology assessment (HTA) is often biased in the sense that it neglects relevant perspectives on the technology in question. To incorporate different perspectives in HTA, we should pursue agreement about what are relevant, plausible, and feasible research questions; interactive technology assessment (iTA) might be suitable for this goal. In this way a kind of procedural ethics is established. Currently, ethics too often is focussed on the application of general principles, which leaves a lot of confusion as to what really (...) is the matter in specific cases; in an iTA clashes of values should not be approached by use of such ethics. Instead, casuistry, as a tool used within the framework of iTA, should help to articulate and clarify what is the matter, as to make room for explication and consensus building. (shrink)

Technology assessment (TA) is – for several reasons – not detachable from ethical questions. The development of institutions and concepts for TA, especially in the USA and Western Europe, has been marked by an increasing tendency to focus evaluative and normative questions. In the following paper, we point out, in as far as the common notions of TA are implicitly normative, why reflection upon conceptual options of TA inevitably leads to ethical questions, and that the key question of participation necessarily (...) comes up in the context of societal decisions made under conditions of risk or uncertainty. Arrangements of participatory and discoursive TA are referred to as possible applications of discourse ethics, but there are consequences to consider, which result from discourses in TA not being ideal discourses. Concepts and performance of TA arrangements on biotechnology and gene technology in different European countries are compared, analysing what similarities and differences can be found with respect to ethical clarification. Crucial questions of how to conceptualise participatory TA (pTA) and current topics in ethics of technology are shown to coincide. A proposal is presented of how these – theoretical normative and empirical descriptive – considerations can be used in a comprehensive conception for participatory and discoursive TA. (shrink)

The social shaping of technology (SST) approach to analysing technological development lends itself to an understanding of the relatively negotiated, heterogeneous, and local character of technologies, politicising the mediated nature of sociotechnical change. Here, conditions of actor engagement lie at the heart of analysing technology in social context—that is, the occasions, strategies, and scope of influence that are afforded different actors, by way of how particular problems come to be defined and resolved. In this paper we examine the framing of (...) a number of concrete technology assessments (TAs) from Denmark, from the realms of general TA and health technology assessment (HTA). Our examination of the TA initiatives is directed towards the relatively open-ended and consequently explorative and qualitative stance that SST takes in characterising the boundaries between the technical and the social. The paper goes on to discuss a possible place of ethical inquiry in TA, based on the understanding of technological development that SST affords. In the reflexive approach to addressing technology's relation to society, technology no longer maintains a universally reducible character in time or in social space. Through the possibility of analytically and practically opening up for otherwise seemingly locked actor-positions SST gives room for a more differentiated questioning and treatment of ethical issues in which technology may be implicated. (shrink)

Like the broom in “The Sorcerer's Apprentice,” technologies take on a life of their own. To bring them under control, doctors must learn to tolerate ambiguity, resist the lure of the immediate, cease fearing uncertainty, and rechannel their response to wonder.

Resource allocation is a central part of the decision-making process in any health care system. Resources have always been finite, thus the ethical issues raised are not new. The debate is now more open, and there is greater public awareness of the issues. It is increasingly recognised that it is the technology which determines resources. The ethical issues involved are often conflicting and relate to issues of individual rights and community benefits. One central feature of resource allocation is the basing (...) of decisions on the outcomes of health care and on their subsequent economic evaluation. The knowledge base is therefore of great importance as is the audit of results of clinical treatment. Public involvement is seen as an integral part of this process. For all parts of the process, better methodologies are required. (shrink)

Alarmed by Three Mile Island, Love Canal, and other disastrous deployments of new technologies, the public is demanding more voice in the decision-making on technology. To make this possible, it is proposed that metatechnology be evolved that will provide a practical technology for the safe, effective, and economical use of technology. A case history of a specific metatechnology is presented. Here the metatechnology enabled a realistic balancing of the benefits of mass screening of women by mammography against the hazards from (...) the X-rays. By showing that the screening of women under 50 was counterproductive, this metatechnology helped to ban such screening in a program involving a quarter of a million women. The strategic mistake in setting up this and other technological programs was that the decisions were made by the technologists. They benefited the technologists but were not beneficial to the women. One of the potentials of metatechnology is that in its fully computerized versions it could be used directly by the public for decision-making on the deployment of technologies. (shrink)

The process of technological change in obstetrics must be understood as contingent on the exigencies of the professional project, rather than in terms simply of improvement or dehumanization of care. Transformation in the procedures by which the female pelvis and the fetal head have been measured illustrate this point. The development of new measurement techniques was profoundly influenced by the shifting locus of obstetric care and by changing professional concerns, including the initial demarcation of a professional practice and subsequent debates (...) about preferred modes of intervention. (shrink)

Is technology value-free or is it value-laden? How does technology affect human autonomy? These questions, viewed within the context of medicine, are the focus of attention in this article. The central argument is that we need neither to subscribe to the value-neutrality dictum nor to the all-encompassing value-ladenness thesis to explain the pertinent position of technology in medicine. Technology is constitutive of and strongly implicated in difficult questions of value. This, however, does not mean that technology is identical to (or (...) neutral to) these value-laden questions. Technology poses issues of value, but only some of these relate to technology qua technology. Hence, it makes a difference whether we discuss general questions of value posed by technology or whether we discuss the value-ladenness of technology. Admitting technological value-ladenness does not imply that we are subject to a technological imperative that reduces our autonomy, on the contrary, it explains how technology increases our responsibility. This is particularly prominent in medicine. (shrink)

The objective of this article is to analyse the value-ladenness of technology in the context of medicine. To address this issue several characteristics of technology are investigated: i) its interventive capacity, ii) its expansiveness and iii) its influence on the concept of disease, iv) its generalising character, v) its independence of the subjective experience of the patient. By this analysis I hope to unveil the double face of technology: Technology has a Janus-face in modern medicine, and the opposite of its (...) factual face is evaluative. (shrink)

Evidence based medicine has much to offer, but a great deal remains to be done to create a better understanding of what it can and cannot do.The term EBM , as we use it nowadays, was introduced in 1992 by the same group of people who, years before, founded the discipline called “Clinical epidemiology” .1 CE stemmed essentially from the idea of adapting and expanding epidemiological methods to medical and health care decision making; CE was in fact defined as “ (...) the discipline dealing with the study of the occurrence of medical decisions in relation to their determinants”.1CE has been very successful in illustrating new ways of teaching medicine and training health professionals, and has positioned itself around the notion that “critical appraisal skills” are yet another set of essential abilities which—in addition to the interpersonal, diagnostic, and prognostic skills—a good doctor should master. An important by product of CE was documentation which showed that much of the available evidence on diagnosis, prognosis, and treatment of diseases was of poor methodological quality and quite often of dubious transferability to everyday clinical practice.This led to a strong call for improving the scientific basis of clinical practice, which was seen as too often dominated by practices of unproven effectiveness. This was the background for the 1992 Journal of the American Medical Association article that first used the term “evidence based medicine”.2In essence, proponents of EBM said that “all medical action of diagnosis, prognosis, and therapy should rely on solid quantitative evidence based on the best of …. (shrink)

Value-freedom or value-neutrality is a well-known topic in the philosophy of science. But what about the value-neutrality of technology, medical or other? Is it too far-fetched to imagine technology as in some sense value-neutral — in view of its intimate connection with purposeful human action? No; unexpected perhaps, but less far-fetched than expected. If we try to conceive of technology as a cognitive possibility abstracted from each and every specific social context, we shall find three senses in which it may (...) be regarded as value-neutral: neutral vis-à-vis different possible uses and ends; neutral before action; neutral qua cognitive object, analogous to the cognitive core of science. The further meanings and implications of these three senses of value-neutrality are discussed.What is this exercise good for? The nature of technology is indeed worth pondering in its own right, not least from this rather unusual angle. But beyond that: as the possible meanings of value-neutrality are tried out, the radical nature of human responsibility for the social implementation of technology will be highlighted. (shrink)

Evidence based medicine has been a topic of considerable controversy in medical and health care circles over its short lifetime, because of the claims made by its exponents about the criteria used to assess the evidence for or against the effectiveness of medical interventions. The central epistemological debates underpinning the debates about evidence based medicine are reviewed by this paper, and some areas are suggested where further work remains to be done. In particular, further work is needed on the theory (...) of evidence and inference; causation and correlation; clinical judgment and collective knowledge; the structure of medical theory; and the nature of clinical effectiveness. (shrink)

Health technology assessment (HTA) is often biased in the sense that it neglects relevant perspectives on the technology in question. To incorporate different perspectives in HTA, we should pursue agreement about what are relevant, plausible, and feasible research questions; interactive technology assessment (iTA) might be suitable for this goal. In this way a kind of procedural ethics is established. Currently, ethics too often is focussed on the application of general principles, which leaves a lot of confusion as to what really (...) is the matter in specific cases; in an iTA clashes of values should not be approached by use of such ethics. Instead, casuistry, as a tool used within the framework of iTA, should help to articulate and clarify what is the matter, as to make room for explication and consensus building. (shrink)

Health technology assessment consists of thesystematic study of the consequences of theintroduction or continued use of the technology in aparticular context, with the explicit objective toarrive at a judgment of the value or merit of thetechnology. Ideally, it is aimed at assessing allaspects of a given technology or group oftechnologies, including non-technical, e.g.socio-ethical, aspects. However, methods for assessingsocio-ethical implications of health technology arerelatively undeveloped and few mechanisms exist totake action based on the results of such evaluations.Still, the examples of cochlear (...) inplants and other cases illustratethat HTA is not a matter of merely collecting thefacts about a technology. The facts must beplausible and relevant from a particular framework,which is not always shared by different groups. It ishere that socio-ethical aspects are encountered. Ifhealth technology assessment aims to enhance theaccountability of the decision making processregarding funding and use of health technology, it isa major challenge to assessors of health technologiesto deal adequately with existing value pluralism. Inthis respect interactive evaluation may have somethingto offer. (shrink)

Value-freedom or value-neutrality is a well-known topic in the philosophy of science. But what about the value-neutrality of technology, medical or other? Is it too far-fetched to imagine technology as in some sense value-neutral — in view of its intimate connection with purposeful human action? No; unexpected perhaps, but less far-fetched than expected. If we try to conceive of technology as a cognitive possibility abstracted from each and every specific social context, we shall find (at least) three senses in which (...) it may be regarded as value-neutral: (1) neutral vis-à-vis different possible uses and ends; (2) neutral before action; (3) neutral qua cognitive object, analogous to the cognitive core of science. The further meanings and implications of these three senses of value-neutrality are discussed.What is this exercise good for? The nature of technology is indeed worth pondering in its own right, not least from this rather unusual angle. But beyond that: as the possible meanings of value-neutrality are tried out, the radical nature of human responsibility for the social implementation of technology will be highlighted. (shrink)

Medical technology assessment deals with the evaluation of novel or existing health care procedures. This paper addresses the interdependence between factual and normative issues, using the controversies about acceptability and desirability of reduced-size liver transplantations with living donors as example.

The editors of the symposium hope it will provide a balanced appraisal of evidence based medicine.This symposium is devoted to evidence based medicine and the ethical issues it raises. Since Sir Archie Cochrane’s seminal Nuffield Provincial Hospitals Trust lectures in 1972 and their publication as the Rock Carling monograph for that year, Effectiveness and Efficiency: Random Reflections on Health Services, the idea that medical interventions and health services should be evaluated and selected on the basis of the most reliable evidence (...) available for their effectiveness and cost effectiveness has become very widely accepted.1,2 This widespread acceptance has not been complete, and it sometimes seems that there are as many critics of EBM as advocates. Whereas the importance of randomised trial evidence, critical appraisal, meta-analysis, and systematic review …. (shrink)

The current model of technology assessment treats ethics itself as just another problem‐solving technology. Ethics should resist this model to play a more critical role in technology assessment by better understanding the complex relationship between society, medicine, and technology—and by recasting how problems are defined.