ENCYCLOPEDIA OFENCYCLOPEDIA OF...

E N C Y C L O P E D I A O F

BIOETHICSE N C Y C L O P E D I A O F

BIOETHICS3 R D E D I T I O N

•EDITORIAL BOARD

•

EDITOR IN CHIEF

Stephen G. PostCase Western Reserve University

EDITORIAL BOARD

David BarnardUniversity of Pittsburgh

Dena S. DavisCleveland-Marshall Collegeof Law

Eric T. JuengstCase Western Reserve University

Loretta M. KopelmanEastern Carolina University

Maxwell J. MehlmanCase Western Reserve University

Kenneth F. SchaffnerGeorge Washington University

Bonnie SteinbockState University of New York,Albany

Leonard J. WeberUniversity of Detroit Mercy

Stuart J. YoungnerCase Western Reserve University

FOUNDING EDITOR

Warren T. Reich

ASSOCIATE EDITOR

Mark P. AulisioCase Western Reserve University

E N C Y C L O P E D I A O F

BIOETHICSE N C Y C L O P E D I A O F

BIOETHICS3 R D E D I T I O N

E DITE D BY

STEPHEN G. POST

VOLU M E

5T – X

APPENDICESINDEX

Encyclopedia of Bioethics, 3rd editionStephen G. Post

Editor in Chief

©2004 by Macmillan Reference USA.Macmillan Reference USA is an imprint of TheGale Group, Inc., a division of ThomsonLearning, Inc.

Macmillan Reference USA™ and ThomsonLearning™ are trademarks used herein underlicense.

For more information, contactMacmillan Reference USA300 Park Avenue South, 9th FloorNew York, NY 10010Or you can visit our Internet site at http://www.gale.com

ALL RIGHTS RESERVEDNo part of this work covered by the copyrighthereon may be reproduced or used inany form or by any means—graphic,electronic, or mechanical, includingphotocopying, recording, taping, Webdistribution, or information storage retrievalsystems—without the written permission ofthe publisher.

For permission to use material from thisproduct, submit your request via Web athttp://www.gale-edit.com/permissions, or youmay download our Permissions Request formand submit your request by fax or mail to:

Permissions DepartmentThe Gale Group, Inc.27500 Drake RoadFarmington Hills, MI 48331-3535Permissions Hotline:248-699-8006 or 800-877-4253 ext. 8006Fax: 248-699-8074 or 800-762-4058

While every effort has been made toensure the reliability of the informationpresented in this publication, The Gale Group,Inc. does not guarantee the accuracy ofthe data contained herein. The Gale Group,Inc. accepts no payment for listing; andinclusion in the publication of anyorganization, agency, institution, publication,service, or individual does not implyendorsement of the editors or publisher.Errors brought to the attention of thepublisher and verified to the satisfaction ofthe publisher will be corrected in futureeditions.

Library of Congress Cataloging-in-Publication Data

Encyclopedia of bioethics / Stephen G. Post, editor in chief.— 3rd ed.p. cm.

Includes bibliographical references and index.ISBN 0-02-865774-8 (set : hardcover : alk. paper) — ISBN

0-02-865775-6 (vol. 1) — ISBN 0-02-865776-4 (vol. 2) — ISBN0-02-865777-2 (vol. 3) — ISBN 0-02-865778-0 (vol. 4) — ISBN0-02-865779-9 (vol. 5)

1. Bioethics—Encyclopedias. 2. Medical ethics—Encyclopedias. I.Post, Stephen Garrard, 1951-QH332.E52 2003174’.957’03—dc22

2003015694

This title is also available as an e-book.ISBN 0-02-865916-3 (set)

Contact your Gale sales representative for ordering information.

Printed in the United States of America10 9 8 7 6 5 4 3 2 1

Front cover photos (from left to right): Custom Medical Stock;Photo Researchers; Photodisc; Photodisc; AP/Worldwide Photos.

•

T

•2495

TEAMS, HEALTHCARE

• • •

A healthcare team is two or more health professionals (and,when appropriate, other lay or professional people) whoapply their complementary professional skills to accomplishan agreed-upon goal. Coordinated, comprehensive patientcare is the primary goal of most teams. Other goals mayinclude education of health professionals, patients, or fami-lies; community outreach; advocacy; abuse prevention; fam-ily support; institutional planning; networking; and utiliza-tion review in hospitals. The team approach to patient carehas been viewed as a means of building and maintaining staffmorale, improving the status of a given profession (forexample, nurses and allied health professionals may becometeam collaborators with the physician rather than workingunder the physician), or improving institutional efficiency.

Some teams are ongoing, such as a psychiatric careteam, home visit team, ventilator patient care team, childdevelopment team, or rehabilitation team. Such teams maybe responsible for following the person throughout theentire process of healthcare interventions, including diagno-sis, goal setting and planning, implementation, evaluation,follow-up, and modification of goals for the patient. Otherteams form around an event (for example, a disaster planteam or organ transplant team), or focus on a single func-tion, such as discharge planning or the initiation of re-nal dialysis. Some teams are undisciplinary; others aremultidisciplinary, and may include lay people.

Though taken for granted today, a team approach tohealthcare has appeared only recently in many places whereWestern medicine is practiced. The development of teamapproaches in the United States reflects the history of that

development in North America and Europe as well. In thefirst period, between World War I and World War II, amultiprofessional approach appeared that later developedinto the team model. Major sources of impetus included theproliferation of medical specialties, an increase in expensive,complex technological interventions, and the ensuing chal-lenge of providing a coordinated and comprehensive ap-proach to patient care management. A second period ofdevelopment occurred between the 1950s and the 1980s,when teamwork became the norm: healthcare became in-creasingly hospital-based, enabling a large corps of healthprofessionals in one place to minister to the patient. Inaddition, new professional groups were generated in thebelief that healthcare should be attentive to patients’ social aswell as physical well-being. The third period, which contin-ues to the present, has focused on the appropriate goals andfunctions of the healthcare team and evaluation of the team’seffectiveness (Brown).

Ethical issues regarding teams arise in four major areas:challenges arising from the team metaphor itself; the locus ofauthority for team decisions; the role of the patient as teammember; and mechanisms for fostering morally supportableteam decisions.

The Team MetaphorIt is generally agreed that the healthcare team idea andrhetoric arose from assumptions about sports teams andmilitary teams (Nagi; Erde). This metaphor is not com-pletely fitting because the healthcare team is not in competi-tion with another team. However, it is fitting insofar asmembers experience their affiliation as entailing team loyalty,a moral obligation to other members and to the team itself.They may believe that they have voluntarily committed

TEAMS, HEALTHCARE

•

E N C Y C L O P E D I A O F B I O E T H I C S 3 r d E d i t i o n2496

themselves to a type of social contract requiring a membernot only to perform maximally but also to protect teamsecrets, thereby promoting a tendency for cover-ups orprotection of weaker members. In the military team, obedi-ence to and trust in the leader is an absolute.

A troubling ethical conflict arises when the member’smoral obligation of faithfulness to other team members or“captain” does battle with moral obligations to the patient.This may manifest itself in questions of whether to cover upnegligence or a serious mistake by some or all of the team.Overall, holding peers morally accountable for incompe-tence or unethical behavior may be made more difficult bythe team ideal. Therefore, teams must foster rules thatrequire and reward faithfulness to patient well-being, andbalance and value of team membership with that of main-taining high ethical standards.

Feminist analyses of bureaucratic structures and bioethicalissues highlight a related ethical challenge. The team meta-phor entails assumptions about relationships, rules, and“plays” that often exclude women from full participationbecause their childhood and later socialization did notprepare them for this “game” and its insiders’ rhetoric.Noteworthy is the sports or military team ethos of ignoringthe personal characteristics of fellow team members (withinlimits), provided each person is technically well suited tocarry out assigned functions. Many women find it almostimpossible to function effectively with team members whomthey judge as morally deplorable, no matter the latter’stechnical skills; for such women, the relationships amongand integrity of team members is as important as the externalgoal (Harragan).

Sometimes a further breakdown of communication andeffectiveness accrues because of the team leader’s allegianceto scientific rigor and specificity at the expense of subjectiveattentiveness to caring. Since many team leaders are physi-cians, on multidisciplinary teams the problems may becomeinterpreted as pointing to serious differences in orienta-tion between physicians and other healthcare profession-als (addressed in the next section). Whatever its cause,marginalization of some team members results in teamdysfunction.

Locus of Authority for Decision MakingRoles involve ongoing features and conduct appropriate to asituation, and create expectations in the self and othersregarding that conduct. Each role has an identity andboundaries, giving rise to the question of whose role carriesthe authority for team decision making (Rothberg). Thechallenge applies to both unidisciplinary and multidisciplinary

teams but is highlighted in multidisciplinary ones, particu-larly those involving physicians and other health profession-als. Traditionally the physician was the person in authorityby virtue of his or her office. The team metaphor reinforcesthe nonmovable locus of authority vested in one who holdssuch office (for example, captain).

At the same time, the team metaphor created expecta-tions of more equality among members based on compe-tence to provide input. Each member becomes an authorityon the basis of professional expertise instead of office, andshould be in a position to provide leadership at such time asexpertise indicates it. In ethical decisions regarding patientcare, the question of authority must be viewed in terms ofwho should have the morally authoritative voice. Technicalexpertise does not automatically entail ethical expertise. Inboth types of decision-making situations, the locus of au-thority is movable.

Clarification of role identity and boundaries helps tocreate reasonable expectations and mitigate this type ofconflict regarding locus of authority (and concomitant locusof accountability) regarding team decisions (Green). A fur-ther complication arises, however, because teams usuallyhave several members. A critical question regarding suchcollective decision making is whether team decisions are thesum of individual members, with accountability allocatedonly to the individuals, or whether a team itself can beregarded as a moral agent (Pellegrino). Lively debate contin-ues regarding this topic (Abramson; Newton; Green).

Sometimes teams have difficulty coming to consensusabout the appropriate course of action. The moral responsi-bility of the team members is to assure that further roleclarification, further attempts at consensus building, andother collective decision-making mechanisms are instru-mental only to maximizing patient well-being (or any otherappropriate goal of teamwork). Negotiation strategies mustbe built into the team process so that the authority of anyone or several members, or even the team as a whole, doesnot govern at the cost of the competent, compassionatedecision geared to the appropriate ends of that team’sactivities.

The Patient as Team MemberThere is much discussion about whether and in what respectpatients/clients and their families are members of healthcareteams. The doctrine of informed consent and its underlyinglegal and ethical underpinnings dictate that patients andfamilies should have input into decisions affecting them-selves and their loved ones. At the same time, much of theteam’s work proceeds without direct involvement of patients

TECHNOLOGY

•

E N C Y C L O P E D I A O F B I O E T H I C S 3 r d E d i t i o n 2497

and families. Some have argued that a primary care orienta-tion places the patient as focus and arbiter of the care, andthat present team practices fall short of that essential condi-tion (Smith and Churchill). Others argue that conceptuallya primary care approach is consistent with the goals of goodteamwork (Barnard).

Moral Education for TeamsThe team ideal provides a widely used model for effectiveand efficient patient care. Ethical issues are an inherent partof clinical decision making. In preparation for facing ethicalissues the team can (1) develop a common moral languagefor discussion of the issues; (2) engage in cognitive andpractical training in how to articulate feelings about perti-nent ethical issues; (3) clarify values to uncover key interestsamong team members; (4) participate in common experi-ences upon which to base workable policies; and (5) refine adecision-making method for the team to use (Thomasma).

It appears that team approaches to a wide variety ofhealthcare issues and events will continue to develop andgrow. The emergence of ethics committees as a type of teamapproach focusing explicitly on ethical decisions should helpfurther in these deliberations.

RUTH B. PURTILO (1995)

BIBLIOGRAPHY REVISED

SEE ALSO: Consensus, Role and Authority of; Long-TermCare; Medicine, Profession of; Nursing, Profession of; Pallia-tive Care and Hospice; Trust; Women as Health Pro-fessionals

BIBLIOGRAPHY

Abramson, Marcia. 1984. “Collective Responsibility in Interdis-ciplinary Collaboration: An Ethical Perspective for SocialWorkers.” Social Work in Health Care 10(11): 35–43.

Barnard, David. 1987. “The Viability of the Concept of aPrimary Health Care Team: A View from the Medical Humani-ties.” Social Science and Medicine 25(6): 741–746.

Becker-Reems, Elizabeth D., and Garrett, Daniel G. 1998.Testing the Limits of Teams: How to Implement Self-Managementin Health Care. Chicago: American Hospital Association.

Brown, Theodore. 1982. “An Historical View of Health CareTeams.” In Responsibility in Health Care, ed. George J. Agich.Philosophy and Medicine, vol. 12. Boston: D. Reidel.

Doucet, Hubert; Larouche, Jean-Marc; Melchin, Kenneth R.;Larouche, Jean-Claude. 2000. Ethical Deliberation inMultiprofessional Health Care Teams. Ottawa, Ontario: Uni-versity of Ottawa Press.

Erde, Edmund. 1982. “Logical Confusions and Moral Dilemmasin Health Care Teams and Team Talk.” In Responsibility in

Health Care, ed. George J. Agich. Philosophy and Medicine, vol.12. Boston: D. Reidel.

Gilligan, Carol. 1982. In a Different Voice: Psychological Theoryand Women’s Development. Cambridge, MA: Harvard Univer-sity Press.

Green, Willard. 1988. “Accountability and Team Care.” Theo-retical Medicine 9:33–44.

Harragan, Betty L. 1977. Games Mother Never Taught You:Corporate Gamesmanship for Women. New York: Warner.

Heinemann, Gloria D., and Zeiss, Antonette M., eds. 2002.Team Performance in Health Care: Assessment and Development(Issues in the Practice of Psychology). New York: PlenumPublishers.

Nagi, Saad Z. 1975. “Teamwork in Health Care in the UnitedStates: A Sociological Perspective.” Milbank Memorial FundQuarterly 53:75–81.

Newton, Lisa H. 1982. “Collective Responsibility in HealthCare.” Journal of Medicine and Philosophy 7(1): 11–21.

Pellegrino, Edmund D. 1982. “The Ethics of Collective Judg-ments in Medicine and Health Care.” Journal of Medicine andPhilosophy 7(1): 3–10.

Purtilo, Ruth B. 1988. “Ethical Issues and Teamwork: TheContext of Rehabilitation.” Archives of Physical Medicine andRehabilitation 69(5): 318–326.

Purtilo, Ruth B. 1998. “Rethinking the Ethics of Confidentialityand Health Care Teams.” Bioethics Forum 14(3–4): 23–27.

Rothberg, June. 1985. “Rehabilitation Team Practice.” In Inter-disciplinary Team Practice: Issues and Trends, ed. Pedro J. Leccaand John S. McNeil. New York: Praeger.

Siegler, Eugenia L.; Myer, Kathryn; Fulmer, Terry., eds. 1998.Geriatric Interdisciplinary Team Training. New York: Springer.

Smith, Harmon L., and Churchill, Larry R. 1986. ProfessionalEthics and Primary Care Medicine: Beyond Dilemmas andDecorum. Durham, NC: Duke University Press.

Thomasma, David. 1981. “Moral Education in InterdisciplinaryTeams.” Prospectus for Change 6(5): 1–4.

Wagner, Joan; Rafter, Roseanne Hanlon; and Saveriano, Juliana.1999. Interdisciplinary Team in the Long Term Continuum: ACollaborative Approach. New York: Springer.

TECHNOLOGY

• • •I. History of Medical Technology

II. Philosophy of Medical Technology

I . HISTORY OF MEDICAL TECHNOLOGY

Medical technologies are objects, directed by procedures,that are applied against the hazards of illness. The object is

TECHNOLOGY

•


the tangible dimension of technology. The procedure is thefocused and standardized plan that guides the use of theobject according to defined purposes.

Some medical technologies are more object-embedded.In them the tangible portion is the principal functionalcomponent. The X ray, artificial kidney, and penicillin areexamples. Others technologies are more procedure-embedded.Their main function is to organize facts, individuals, and/orother technologies. Examples are the medical record, hospi-tal, and surgical procedures. Indeed, the common synonymfor the surgical procedure, the operation, connotes actionsthat are related as parts in a series.

It is important to distinguish technologies from anothermedium through which actions are taken in medicine—techniques. Medical techniques are procedures mediatedthrough the human senses rather than through objects.Examples are percussion, pulse-feeling, and psychoanalysis.This perspective on medical technology will be used inthis entry.

Technology, Nature, and EthicsThe works of the Hippocratic corpus, a group of essays onmedical theory and therapy written between the fifth andthird centuries B.C.E., analyze the relation between natureand the agents of the medical art, from the viewpoints ofeffectiveness and ethics.

The ancient Greek concepts of health and illness werebased on a theory postulating four humors or basic elementsof the body: blood, phlegm, yellow bile, and black bile. Inhealth, these were in a stable equilibrium. Illness occurredwhen one or more of these humors increased or decreasedand thus changed their proportional relation. This changecaused an instability of the equilibrium state synonymouswith health, and the breakdown produced illness. Nature—the force that inclined the humors toward remaining in orreturning to the proportional relations of the healthfulstate—was viewed as the most powerful agent of healing.The purpose of the medical art was to assist nature toreestablish the proportional relationship of health amongthe humors.

Works in the Hippocratic corpus cautioned physiciansagainst misapplying medical means. Such behavior consti-tuted an offense that could harm both the patient and thereputation of medicine. In the essay “The Art,” the followingobservation is made:

For in cases where we may have the masterythrough the means afforded by a natural constitu-tion or by an art, there we may be craftsmen, butnowhere else. Whenever therefore a man suffers

from an ill which is too strong for the means at thedisposal of medicine, he surely must not evenexpect that it can be overcome by medicine.(Hippocrates, 1923a, p. 203)

To exceed the rational limits of the means of medicine was tocommit the sin of hubris.

The technology of Greek doctors was relatively simple.They used ointments, compresses, bandages, surgical instru-ments, simple and compound drugs, and bloodletting inmoderation. They used the techniques of history taking,visual observation, and palpation to learn the circumstancesof illness, and prescribed diets, bathing, and exercise tomaintain health and combat illness.

The Greeks also recognized that the manner in whichphysicians dressed, approached the bedside, and discussedillness with a patient could influence their success at healingby producing help and avoiding harm, and thus had anethical meaning. Accordingly, attention to the effects of thephysician as a person on the patient as a person became asignificant aspect of Greek medical practice. The physicianis told “to have at his command a certain ready wit, asdourness is repulsive both to the healthy and the sick.”When coming into the sickroom, doctors should considertheir “manner of sitting, reserve, arrangement of dress,decisive utterance, brevity of speech.” The doctor was toperform all duties “calmly and adroitly, concealing mostthings from the patient while you are attending him,” lestsuch revelations cause the patient to take “a turn for theworse” (Hippocrates, 1923b, pp. 291–299).

The Hippocratic Greek physicians recognized that ap-propriate applications of technology required a searchinganalysis of its capabilities, of the ethical canons that shouldguide its use, and of the relation between technology andnature in treating patients. Consideration of these threefactors was the significant contribution of Greek civilizationto the use of medical technology.

Anatomy and SpecializationThe content of the technologies used in medical practice didnot change appreciably for two thousand years. Indeed, theHippocratic works and other Greek texts, in Latin transla-tions, formed the core of medical learning in Europe throughthe Middle Ages.

As the sixteenth century began, however, a growinginterest in firsthand exploration of nature, and learning andquestioning the authority of tradition, created what we callthe Renaissance, generating a perspective that would eventu-ally exert a profound influence on the development and use

TECHNOLOGY

•


of technology in medicine. Although the study of thestructural composition of the body through anatomic dissec-tion was thwarted by cultural, social, and religious constraintsagainst dismemberment, Renaissance scientific and artisticinterest in the body’s physical makeup overcame theserestrictions and encouraged its exploration.

The leading figure in this movement was AndreasVesalius, a physician and professor at Padua, who in 1543published De humani corporis fabrica. In it the structure ofthe body was analyzed in detail and portrayed throughillustrations that were far in advance of any previous work.Its illustrations, the work of a still unknown Renaissanceartist, were startling in their beauty and detail. In contrast,the typical anatomical illustrations of the day were inaccu-rate and crude outlines, with organs drawn in more assymbols than as representations. Vesalius corrected over twohundred errors in the work that had been the standard,authoritative text in use for almost fifteen hundred years.Written by the Greek doctor Galen in the second century, itreflected typical restrictions on human dissection, for itscontent was based on animal dissection (mainly pigs andapes) extrapolated to human structure.

Vesalius’ book, devoted to the normal anatomy of thebody, fostered within medicine an interest in bodily struc-ture, particularly in the changes it underwent when attackedby illness. During the next two hundred years, physiciansexamined bodies and wrote texts commenting on the patho-logical transformation of anatomic structure. These effortswere brought together in a 1761 text by the Italian physicianGiovanni Battista Morgagni, The Seats and Causes of DiseasesInvestigated by Anatomy. The work’s principal objective wasto demonstrate that the symptoms of illness in the livingwere determined by the structural changes produced withinthe body by disease. Morgagni demonstrated this relationthrough a tripartite analysis of cases. Typically, he began byreporting on the clinical course of an illness experienced by apatient who eventually died. This was followed by theautopsy findings. Then came a synthetic commentary inwhich he connected clinical and autopsy results.

Morgagni asserted that through anatomic examination,particular diseases could be recognized by their telltalefootprints on the landscape of the body. As the title ofMorgagni’s work suggests, the author believed that diseaseshad “seats” in the body, and that they were expressedthrough characteristic disruptions of the body’s fabric indiscernible sites. This perspective ran directly counter to thatprevailing under the humoral theory of illness, dominantsince Hippocratic times.

Anatomy, beginning in the sixteenth century, when itdeparted from this whole-body perspective, focused the

doctor’s vision on the search for sites in the body where achange in structure had occurred. The leading question foranatomists and the physicians who adopted their outlookwas Where is the disease? This question and viewpoint pavedthe way for the modern specialization of medicine, begin-ning in the nineteenth century and undergirded by a newtechnology. It justified a retreat by the doctor from patientsas individuals to aspects of their anatomy, giving rise to thepractice of having different physicians for the eyes, heart,kidneys, and other organs and organ systems.

Technology and the Nineteenth CenturyWith the anatomic ideology firmly established, the nine-teenth century became one of the great centuries for medi-cine, a time of significant advance and change fueled largelyby technologic innovation.

The transformation of diagnosis by technology was oneof the century’s most important features. The symbol andinitiator of this change was a simple instrument used toenhance the conduction of sound, the stethoscope. Itstransforming effect was as much caused by the new relation-ship it generated between physicians and patients as by thenew information it provided. Before the stethoscope, theevidence that physicians acquired about illness came mostlyfrom two sources: the visual inspection of the motions andsurface of the body, and the story told by the patient of theevents, sensations, and feelings that accompanied the illness.It was this encounter with the life of the patient that was atonce enlightening, troubling, and engaging for physicians.

The patient’s story provided significant diagnostic evi-dence that often determined the doctor’s judgment. Butphysicians expressed concern about the authenticity of thisevidence, which usually could not be confirmed. Who couldknow if a patient really heard a buzzing in the ears? Diagno-sis was prone to the distortions of memory and whim. For allof its evidentiary faults, however, the narrative of the pa-tient’s journey through illness connected the doctor with thelife of the patient.

The stethoscope challenged the place of the narrative ofillness. It was introduced into practice through 1819 treatise(De l’auscultation médiate), written by the inventor of thestethoscope, the French physician René Laennec. Laennecclaimed that physicians who placed their ear to one end ofthe foot-long wooden tube that was the first stethoscope andthe other end to the chest of a patient, would hear soundsgenerated by the heart and lungs indicative of health ordisease within them. He demonstrated through autopsyevidence that a particular sound perceived in the chest

TECHNOLOGY

•


corresponded to a particular lesion within its anatomicstructure. He asserted that his technology enabled physi-cians to diagnose illness not only precisely but often withoutthe help of other symptoms. Doctors need depend on no oneelse. They could be scientifically self-reliant. The findings oftheir own senses, extended by a simple instrument, wereadequate to reach diagnostic judgments.

This technological advance reduced the significance ofthe patient’s narrative. Why should physicians painstakinglyacquire this story and its subjective and unverifiable verbalevidence, if they could use more objective sonic evidencethey gathered themselves? With the stethoscope, physiciansstepped back from the lives of patients. They began toengage patients through the anatomic and physiologic signsdetected by their instruments.

Other simple technologies to extend the doctor’s sensesinto the body, such as the ophthalmoscope (1850), theclinical thermometer (1867), and the sphygmomanometer(1896), were introduced during the nineteenth century. Bythe century’s end physicians had become skillful diagnosti-cians, seekers of physical clues they used to deduce the sourceof their patients’ troubles. The doctor’s black bag containedthe technologies to explore the body physically and to obtainevidence that greatly improved diagnostic accuracy. It was,in fact, through witnessing great skill in the analysis ofphysical evidence by one of his instructors, Joseph Bell, thata physician-in-training, Arthur Conan Doyle, was led tocreate the fictional character Sherlock Holmes.

Still, therapy remained limited. In the 1860 address tothe Massachusetts Medical Society, Oliver Wendell Holmes,Harvard professor of anatomy, proclaimed: “I firmly believethat if the whole materia medica, as now used, could be sunkto the bottom of the sea, it would be all the better formankind,—and all the worse for the fishes” (Holmes, p. 203).

The only major bright spot to emerge in the nineteenthcentury on the therapeutic side of medicine was in surgery.Radical change in the ability of surgeons to perform thedangerous and delicate work of cutting into the bodyoccurred through two separate innovations, one introducedin 1846 and the other in 1867. At the beginning of thenineteenth century, pain had become so inseparably linkedwith surgical incision that several reports of an anestheticeffect produced by nitrous oxide and ether were disregardedby practitioners. Surgical pain was dealt with by efforts toshorten its presence. Techniques of rapid surgery weredeveloped, with some surgeons capable of detaching a limbin minutes. The conclusive demonstration (in a surgicalprocedure for a tumor of the neck) at the MassachusettsGeneral Hospital in 1846 of the ability to control operative

pain through use of ether, was made by the AmericanDentist William Morton, who administered the ether. Itameliorated the trauma of surgery for patient and surgeonalike, but cutting into the cavity of the body still was limitedby infection.

To control infection, insight was needed into the causalrole of bacteria. Joseph Lister, a British surgeon, wrote apaper in 1867 in which he described eleven operations oncompound fractures of the limbs in which nine patientsrecovered without amputation, one required it, and onedied. These startling results were made possible by treatingthe operating space—wound, instruments, surgeon’s hands,and air—with the antiseptic carbolic acid. In 1882, theGerman scientist Robert Koch published a paper that provedthrough rigorous experiments the causal link between thetubercle bacillus and tuberculosis—a disease that at the timewas responsible for about one out of seven deaths in Europe.This essay established the pivotal role played by bacteria ininfection. It not only gave further impetus to the practice ofantiseptic surgery and liberated surgeons, no longer thwartedby pain or infection, to perform extensive operations withinthe body cavity. It also produced a new workshop for surgeryand all of medicine—the hospital.

The Technologies of Twentieth-Century MedicineThe origins of the hospital reside in military hospitals put upby Roman soldiers on their routes of march, and hospicesestablished early in the history of Christianity to care for thehomeless, travelers, orphans, the hungry, and the sick. Thesemultiple activities gradually became divided among separateinstitutions, one of which was the hospital. It flourishedgreatly through the medieval period but began a declineafterward, due to diminished church support of its activities.

By the nineteenth century the hospital’s medical rolewas restricted. It was a place for those who could not affordeither to call a physician or surgeon to the house fortreatment or to employ servants to administer needed bed-side care at home. There were two kinds of medicine: homecare for the well-to-do and hospital care for the indigent.Hospitals were dangerous places. Infections could ragethrough them, killing large numbers of patients and makingwork there dangerous for staff. Hospitals were also feared forthe moral dangers said to be posed to women and childrenby the rough patients they housed.

New technologies transformed the hospital medicallyand socially. Surgery could no longer be done on kitchentables at home: it required an antiseptic environment,

TECHNOLOGY

•


sterilized instruments, and a staff of skilled nurses for theaftercare of patients undergoing more extensive proceduresthan were possible in the past.

As the twentieth century dawned, diagnosis and ther-apy of nonsurgical disease could not be readily done in thehome with technology carried in a doctor’s bag. diagnostictechnology now entered a new phase of development. Thesimple instruments to extend the senses of the physicianswere being replaced by sensing machines too large andexpensive to be housed anywhere but in hospitals.

This new technology automatically recorded the data ofillness, leaving the reading of its results to the doctor. The Xray, discovered in 1895; the ward laboratory, with itsmicroscopes and chemical tests of the body fluids, whichcame together as a hospital space in the early 1900s; and theelectrocardiograph, introduced in 1906, all converted medi-cal diagnosis from a personal act to a scientific event. Thephysician leaning over the bedside, at least physically con-nected to the patient through the stethoscope and similartechnologies, became an increasingly anachronistic image asthe twentieth century wore on. The physician holding an Xray up to light, studying it, was more in keeping withphysicians’ growing self-image as scientists. Where was thepatient? There was less need for personal medical encoun-ters; the best evidence available to medicine was increasinglynot what the patient said, nor what the physician sensed, butwhat the pictorial or graphic image reported.

As it entered this new technologic phase, medicinerequired a location within which patients, the increasinglyspecialized medical staff, and technology could be broughttogether. The hospital became that place. Its success wasdramatic. While there were about four hundred hospitals inthe United States in 1875, by 1909 the number grew to overfour thousand, and by 1929 surpassed six thousand. Nolonger shunned but sought by communities, the hospitalbecame the workshop of medicine. By the mid-twentiethcentury not only patients and technology but also doctors’offices were placed in hospitals. Home care and the housecall, no longer adequate as means to apply new medicalknowledge, were disappearing as the hospital, perhaps thequintessential technology of the twentieth century to organ-ize medical care, enfolded medicine.

Several other innovations critical to the functions ofhospitals and medicine were in place by the mid-twentiethcentury. One—having integrative influence like the hospital—was the technology of organizing the data of medicine—themedical record. It was fundamentally reformed in the 1920sby the work of the American College of Surgeons (Reiser,1991). In an era of growing specialization, not only among

physicians but also among nurses and the technical expertsneeded to run the hospital and its machines (there were overtwo hundred separate healthcare specializations by the mid1970s), communication was of great importance. How tolearn what each had done? Through the record, which wasthe main agent of synthesis in medicine. In its pages thethoughts and actions of a diverse staff were recorded.

But for all its integrative significance, the medicalrecord remains a problem. It shows the results of theinformation explosion. These data literally burst the con-fines of the chart. Hundred-page records abound. Theycontain the details of medical care, but their order oftenmakes following the course of an illness, or locating aparticular bit of information, difficult and frustrating. Inno-vations such as the unit record (having all hospital encoun-ters of a patient recorded in a single place rather thandispersed through separate charts in each clinic); the problem-oriented record (ordering medical data problems—physical,psychologic, or social—rather than by data source, such asputting laboratory data in one place, X-ray data in another);and the computerized record have yet to solve the problemof what to do with the avalanche of technologic evidence.

Another critical innovation available by mid-centurywas antibiotics. The mass production of penicillin in 1944(it had been discovered by Alexander Fleming in 1928)inaugurated the antibiotic era in medicine. Antibiotic drugsflowed from the laboratories of the pharmaceutical industry,finally breaking the hold of bacterial illness. Penicillin wascalled a wonder drug when it was introduced. Given thedrug, a patient gravely ill with meningitis or pneumoniawould be up and about and home in a week. Not only was itfast-acting and fully curative, but it was safe and cheap. Itwas commonly thought that penicillin would be the firstinnovation of a pharmaceutical revolution to produce notonly antibacterial drugs but also drugs to deal as effectivelywith other human ailments. However, the symbol of medi-cine in the second half of the twentieth century would not bepenicillin but a machine that made its debut in the mid-1950s.

The artificial respirator had a long history, dating backto the mid-nineteenth century, when rudimentary forerun-ners were fashioned to deal mainly with the respiratory crisisof drowning. A tank respirator introduced by Philip Drinkerand Charles McKhann in 1929, which used negative-pressure techniques to secure respiration, became the “ironlung” that sustained victims of poliomyelitis. Its effective-ness was variable, and its use was complicated. But by themid-1950s, using new machines based on positive-pressuretechnology, clinicians had a far better means of dealing withdiseases and accidents that threatened lives through respira-tory failure.

TECHNOLOGY

•


Initially, this machine was intended to assist critically illpersons by temporarily sustaining a vital physiologic func-tion and giving them time to recover. For the first time inmedical history, physicians acquired a technology that, alliedto other advances in nursing, monitoring, and drug therapy,and all brought together by an integrative technique of careembodied in the intensive care unit (ICU), permitted thelong-term sustenance of desperately ill people who had nochance of recovery. Now families and medical staff waited byICU beds, where the main signs of life were not manifest inthe expressions or movements of the patient but in themechanical sounds, motions, and readouts of the newmachinery of rescue.

Ethical Issues in ApplyingMedical TechnologiesAs families and medical staff assimilated the consequences ofthe life-support technology represented by the artificialrespirator that could prolong dying or life without cogni-tion, they reached out to the ethical traditions of religion,medicine, and society for help (Pius XII, pp. 501–504).Physicians particularly began to see that the ethical problemsto be solved in these crises were as great as or greater than thetechnical problems of treatment. How to decide whether ina hopeless case to remove the technology that maintainedthe person’s life? On what values should this judgment bebased, and who should decide?

Other machines developed in this period posed asimilar mix of ethical and technical issues. The artificialkidney was created as a device for acute, intermittent dialysisby Willem Kolff in The Netherlands in 1944. However, itwas introduced as a clinically usable machine in the early1960s in Seattle, Washington, by Belding Schribner. Headded an arteriovenous shunt that allowed long-term accessto it and made continuing hemodialysis possible. Thelimited number of machines and personnel to run them ledto moral agonizing over developing criteria for selection.Someone had to choose which of the thousands of individu-als in the United States having chronic renal failure and ableto benefit from dialysis would gain access to a technologythat could save their lives. Thirteen years after the machine’sintroduction, American society decided how to resolve thiscrisis. In 1973, U.S. congressional legislation provided fundsto provide dialysis to all who required it.

Technologies such as the artificial kidney and therespirator have been criticized as offering expensive butpartial solutions to fundamental problems of biologic break-down. The American physician Lewis Thomas calls them

“halfway technologies,” because they represent only a partial(halfway) understanding of a biologic puzzle that, oncesolved, will do away with the expense and the disadvantagesof such therapies (Thomas, p. 37).

The extraordinary and growing expense of the healthcaresystem that followed the development of such technologiesmay be reduced when biomedical research produces com-prehensive biologic answers to problems such as organfailure. But in the twentieth century, we have acquired fewsuch complete technologies. One group, already mentioned,is penicillin and other antibiotics, which offer total solu-tions, that also are inexpensive and rapidly acting, to theproblems of bacterial infection. A second generic completetechnology is the vaccine. Those invented to prevent small-pox (first introduced in the eighteenth century) and polio-myelitis (developed in the mid-1950s) have in the twentiethcentury eradicated the first disease and almost wholly con-tained the second.

The emerging field of genetic research promises funda-mental solutions to a host of disorders, with the prospect oftheir early detection and correction. Finally, the growingability to visualize the basic structures of the body throughendoscopes and computer-driven imaging machines such asthe MRI and PET scans provides diagnostic knowledgefacilitating the use of therapeutic technologies that promisecomplete cures. Indeed, genetic and imaging technologieshave taken the anatomic concept of illness to its ultimateterminus. To the question “Where is the disease?” theanswer now can be “In this particular gene!”

ConclusionTechnologies, history shows, can be imperative: We may beimpelled to use the capacities they provide us withoutadequate reflection on whether they will lead to the humanegoals of medical care. The ancient Greeks understood thisissue. They recognized that technologic means must be usedin consonance with articulated, ethically informed ends.Their example remains worth following.

STANLEY JOEL REISER (1995)


SEE ALSO: Artificial Hearts and Cardiac Assist Devices;Artificial Nutrition and Hydration; Cybernetics; Dialysis,Kidney; Deep Brain Stimulation; DNR; ElectroconvulsiveTherapy; Enhancement Uses of Medical Technology; Fertil-ity Control: Medical Aspects; Genetic Testing and Screening;Life Sustaining Treatment and Euthanasia; Organ Trans-plants, Medical Overview; Pediatrics, Intensive Care in;

TECHNOLOGY

•


Psychosurgery, Medical and Historical Aspects of; Reproduc-tive Technologies; Tissue Banking and Transplantation,Ethical Issues in; Transhumanism and Posthumanism; Vir-tue and Character; and other Technology subentries

BIBLIOGRAPHY

Grace, P A. 1997. “Men, Medicine and Machines.” Irish Journalof Medical Sciences 166(3): 152–156.

Hippocrates. 1923a. “The Art.” In Vol. 2 of Hippocrates, 4 vols.,tr. William H. S. Jones. Cambridge, MA: Harvard UniversityPress.

Hippocrates. 1923b. “Decorum.” In Vol. 2 of Hippocrates, 4vols., tr. William H. S. Jones. Cambridge, MA: HarvardUniversity Press.

Holmes, Oliver Wendell. 1883. “Currents and Counter Currentsin Medical Science.” In his Medical Essays, 2nd edition.Boston: Houghton Mifflin.

Jeffrey, Kirk. 2001. Machines in Our Hearts: The Cardiac Pace-maker, the Implantable Defibrillator, and American HealthCare. Baltimore: John Hopkins University Press.

Koch, Robert. 1886. “The Etiology of Tuberculosis.” In RecentEssays by Various Authors on Bacteria in Relation to Disease, ed.W. Watson Cheyne. London: New Sydenham Society.

Laennec, René. 1821. A Treatise on Diseases of the Chest, tr. JohnForbes. London: T. & G. Underwood.

Lister, Joseph. 1867. “On the Antiseptic Principle in the Practiceof Surgery.” Lancet 2: 353–356.

Morgagni, Giovanni Battista. 1960. The Seats and Causes ofDiseases Investigated by Anatomy, tr. Benjamin Alexander. NewYork: Hafner.

Nightingale, Florence. 1863. Notes on Hospitals, 3rd edition, rev.London: Longman, Green, Longman, Roberts, & Green.

Pius XII. 1977 (1958). “The Prolongation of Life.” In Ethics inMedicine: Historical Perspectives and Contemporary Concerns,eds. Stanley Joel Reiser, Arthur J. Dyck, and William J.Curran. Cambridge, MA: MIT Press.

Reiser, Stanley Joel. 1978. Medicine and the Reign of Technol-ogy. New York: Cambridge University Press.

Reiser, Stanley Joel. 1991a. “The Clinical Record in Medicine.Part I: Learning from Cases.” Annals of Internal Medicine114(10): 902–907.

Reiser, Stanley Joel. 1991b. “The Clinical Record in Medicine:Part II: Reforming Content and Purpose.” Annals of InternalMedicine 114(11): 980–985.

Sandelowski, Margarete. 2000. Devices & Desires: Gender, Tech-nology, and American Nursing (Studies in Social Medicine).Raleigh: University of North Carolina Press.

Stanton, Jennifer, ed. 2002. Innovations in Medicine and Health:Diffusion and Resistance in the Twentieth Century (Studies in theSocial History of Medicine). London: Routledge.

Thomas, Lewis. 1977. “On the Science and Technology ofMedicine.” In Doing Better and Feeling Worse: Health in theUnited States, ed. John H. Knowles. New York: Norton.

Vesalius, Andreas. 1980 (1543). De humani corporis fabrica.Stuttgart: Medicina Rara.

I I . PHILOSOPHY OF MEDICALTECHNOLOGY

Philosophy of technology aspires to comprehensive reflec-tion on the making and using of artifacts. Medicine isincreasingly defined not just by the character of its humaninteractions (physician—patient relationships) or profes-sional expertise (knowledge of illness and related therapies)or its end (health), but also by the type and character of itsinstruments (from stethoscope to high-tech imaging de-vices) and the construction of special human-artifact inter-actions (synthetic drugs, prosthetic devices). Indeed, thephysician-patient relationship, medical knowledge, and theconcept of health are all affected by technological change.There is even debate about whether the term artifact shouldinclude nonmaterial as well as material human construc-tions, in which case all of the above might well be interpretedas technologies. From either perspective, medicine and theissues of bioethics fall within the purview of the philosophyof technology.

Historical DevelopmentPhilosophy of technology as a distinct discipline originatedwith the publication of Ernst Kapp’s Grundlinien einerPhilosophie der Technik (1877), the first book to be entitled a“philosophy of technology.” A left-wing Hegelian contem-porary of Karl Marx, whose thought includes importantanalyses of human-machine systems, Kapp left Germany inthe mid-1800s to become a pioneer and “hydrotherapist” onthe central Texas frontier. Returning to Europe two decadeslater, he elaborated a general theory of technology as “organprojection”—from the hammer as extension of the fistto railway and telegraph as extensions of the circulatoryand nervous systems—thereby promoting analysis of thephilosophical-anthropological foundations of technology.

Another major formative figure was Friedrich Dessauer,whose Philosophie der Technik (1927) and Streit um dieTechnik (1956) reflect his experience as the inventor of deeppenetration X-ray therapy. For Dessauer the philosophicalcore of technology is the act of invention, for which hesought to provide a Kantian analysis of transcendentalpreconditions. Dessauer’s argument that the fact inventionswork shows how inventors depend on insight into a super-natural realm of “pre-established solutions” to technicalproblems raises basic epistemological and metaphysical issues.

José Ortega y Gasset and Martin Heidegger, two majorphilosophers of the twentieth century, also contributed texts

TECHNOLOGY

•


dedicated to the theme of technology. Ortega’s “Meditaciónde la técnica” (1939) presents technical activity as a meansfor realizing some supernatural human self-conception, andmodern technology as generalized knowledge of how tocreate such means. Ortega thus pushes anthropologicalreflection to new depths. Heidegger’s “Die Frage nach derTechnik” (1954) argues that both traditional technics orcraft and modern technology are forms of truth, revealingdifferent aspects of Being. Modern technology in particularis a “challenging” and “setting-upon” that reveals Being as“resource”—that is, the world as a reservoir of materialssubject to indefinite human manipulations. In this argu-ment Heidegger likewise carries epistemological and meta-physical reflection well beyond Kantian terms.

Lewis Mumford, Jacques Ellul, Herbert Marcuse, JürgenHabermas, and Michel Foucault have made further contri-butions to the development of philosophy of technologyfrom the perspective of social theory. Mumford (1934)focuses attention on technological materials and processes asmajor elements in the historical development of moderncivilization. Ellul (1954) argues that the pursuit of technicalefficiency is the defining characteristic of the contemporaryworld, which constitutes a milieu distinct from the naturaland social milieus that preceded it. For Ellul, just as theHebrew-Christian tradition once demythologized the twoearlier milieus, now it called upon to demythologizetechnology.

Marcuse (1964) and Habermas (1968) have debatedthe character of technology as ideology. Foucault (1988)views all technologies and sciences as masking power ma-nipulations, and develops a special analysis of technologiesas historical transformations and determinations of the self.Such ideas exercise continuing influence in debates over theextent to which technology is properly conceived as anautonomous determinant of human affairs (see Winner,1986) or as a social construction (see Feenberg). Suchdebates in turn influence fundamental orientations withregard to practical questions about the assessment andcontrol of technology that find expression in such appliedfields as medical ethics, environmental ethics, engineeringethics, and computer ethics.

Ortega and Heidegger are leading figures in the Conti-nental or phenomenological tradition in the philosophy oftechnology. Further analyses of phenomenological inspira-tion can be found in the work of Don Ihde (1979) onhuman-technics interactions and of Albert Borgmann (1984)on the political-cultural implications of contemporary tech-nological formations.

A different, equally strong tradition in the philosophyof technology is constituted by Anglo-American analytic

reflection on artificial intelligence (AI). Here questionscenter on the extent to which brains are computers andthinking processes can be modeled (see, e.g., Simon; Dreyfus).In contrast to the phenomenological tradition, the Anglo-American analysis of AI exhibits considerable interactionswith biomedical theory of neurological processes and, to alesser extent, with biomedical practice.

Theoretical PerspectivesThroughout its diverse strands, philosophy of technology,like philosophy generally, includes theoretical and practicalissues, from epistemology and metaphysics to ethics andpolitics, all of which can helpfully inform bioethics. Com-prehensive understanding nevertheless grows out of partialunderstandings. The making and using of artifacts involvenot only the artifacts themselves but also technologicalknowledge, technological activity, and technological voli-tion. Theoretical analyses can thus conveniently be de-scribed by referencing tendencies to interpret technology inone of four primary forms.

TECHNOLOGY AS OBJECT. The theory that identifies tech-nology with particular artifacts, such as tools, machines,electronic devices, or consumer products, is the commonsenseview. Initially it involves a classification of artifacts intodifferent types, according to their own internal structures,different kinds of human engagement, impacts on theenvironment, or other factors. Mumford, for instance, dis-tinguishes utilities (roads, electric power networks), tools(artifacts under immediate human power and guidance),machines (nonhuman power with immediate human guid-ance), and automatons (nonhuman power and no immedi-ate human guidance).

Taking a different tack, Borgmann argues a distinctionbetween things and devices. An example of a thing, inBorgmann’s special sense, is a traditional fireplace, whichengages a variety of human activities ranging from cuttingwood to cooking food, functions in a clearly understandablemanner, and is an explicit center of daily life. By contrast, adevice, such as a heat pump, simply makes available somecommodity (hot and cold air) by nonobvious processes anddisappears into a background of quotidian activities. Thedevice is a special instance of what Heidegger called a“resource.”

Ihde, in a different but equally provocative manner,distinguishes embodiment and hermeneutic relations be-tween humans and their instruments. Embodiment rela-tions experience the world through instruments, as exempli-fied by eyeglasses, which disappear into and become anunconscious part of the experience of seeing. In hermeneutic

TECHNOLOGY

•


relations, by contrast, the instrument itself—for instance, acamera—becomes part of the world with which one engages;a user consciously focuses on the operation and interpreta-tion of this instrument. Both Borgmann’s and Ihde’s dis-tinctions obviously provide frameworks within which tointerpret the myriad tools and instruments of high-technologymedicine.

TECHNOLOGY AS KNOWLEDGE. Etymologically, however,the word technology implies not objects but “knowledge oftechne,” or craft skill. Epistemological analyses of suchknowledge distinguish between knowing how (intuitiveskill) and knowing that (propositional knowledge). Thetransition from premodern technics to modern technologycan thus be argued as defined by the development ofpropositional knowledge about techne through the unifica-tion of technics and science.

This theory of modern technology as applied science isparticularly influential among scientists and engineers, andhas been given detailed philosophical exposition by MarioBunge (1967). For Bunge, modern technology developswhen the rules of prescientific crafts, originally discovered bytrial-and-error methods, are replaced by the “groundedrules” or technological theories. Technological theories canbe formulated by applying either the content or the methodof science to technical practices. The former applicationtakes preexisting scientific knowledge (e.g., fluid dynamics)and adapts it under certain boundary conditions to formu-late an engineering science (aerodynamics). The latter usesthe methods of science to formulate distinctive engineeringanalyses of human-machine interactions, such as operationsresearch and decision theory.

Medicine can readily be incorporated within such anepistemological analysis. Prior to the nineteenth century,most medical practice relied on rule-of-thumb experience.But twentieth-century medicine has involved the progres-sive grounding of medical practice in the sciences of anat-omy and physiology as well as the development of suchdistinctive fields as epidemiology and biomedical engineer-ing. Indeed, José Sanmartín (1987), for instance, analyzesgenetic engineering exactly as an embedding of techniquesin scientific theory.

TECHNOLOGY AS ACTIVITY. The transformation of sometechnics (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 aform of knowledge” by the reorganization of hospitals andnew kinds of medical practices. This emphasis on technol-ogy as activity or a complex of activities is characteristic ofsocial theory. Ellul’s “characterology of technique” and

analysis of the central role played by the rational pursuit oftechnical efficiency in the economy, the state, and what heterms “human techniques” (ranging from education tomedicine) is another case in point, as are the Marxist andneo-Marxist analyses of Marcuse, Habermas, and AndrewFeenberg.

The emphasis on technology as activity has roots inMax Weber’s observation that there are techniques of everyconceivable human activity—from artistic production andperformance to mass manufacturing and bureaucratic or-ganization—even education, politics, and religion. Oneclassic problem for social theorists is to explain the characterand limits of technicalization—that is, the movement fromtraditional societies, in which techniques are situated withinand delimited by nontechnical values, to modern societies,in which techniques are increasingly evaluated solely intechnical terms. In traditional societies, for example, animalscan be eaten only if butchered in a ritually prescribedmanner; in modern societies animal slaughter is largelysubject to calculations of efficiency.

Efficiency can also be conceived in economic terms andapplied at micro or macro levels. The former is typical ofanalyses internal to business corporations (including hospi-tals and clinics); the latter, of social assessments of technol-ogy. In regard to technology assessments especially, therearise questions of the limits of technicalization and possiblealternative forms of technical institutions (see Feenberg), aswell as of responsible agency and risk.

TECHNOLOGY AS VOLITION. A fourth element in theinterrelationship of knowledge, object, and activity is that ofvolition. The human activity of making and using artifactsdepends not only on knowledge but also on volition.Indeed, it can be argued that volition is even more importantin this respect than knowledge, that is, that human actioncan be ignorant but not unwilled.

The philosophical analysis of volition distinguishesbetween volition in the weaker senses of wishing, hoping,longing, and desiring, and the stronger or more decisiveintending and affirming. Volition in the second or strongersenses is constituted by self-reflective identification withsome particular wish, hope, or desire that takes on thecharacter of a project. Ortega, Mumford, and FrederickFerré (1988) argue that technology is essentially a matter ofvolition in one or more of these senses. According to Ferré,for instance, technology is grounded in “the urge to liveand to thrive.” For Ortega, technology is based in thewilled attempt at a worldly realization of some specific self-image. For Mumford, technology in a distinctive senseemerges when human beings subordinate their traditional

TECHNOLOGY

•


polytechnical activities of craft, religious ritual, and po-etry to the monotechnical pursuit of physical power—something that first happened about five thousand years agoin Egypt, with the construction of the pyramids by means oflarge, rigid, hierarchical social organizations that he terms“megamachines.”

Defining technology in terms of volition makes possi-ble the perception of broad historical continuities more thandoes a focus on the elements of knowledge or object or evenactivity. It is inherently more believable that the will to flywas coeval with human existence than that technical knowl-edge of how to fly, flying machines, or the human perform-ance of flying or flying-like actions have existed from timeimmemorial. Such an approach once again has immediateimplications for the interpretation of medicine. If medicineis interpreted primarily as grounded in volition, then it isinherently more believable that there exists a fundamentalcontinuity between premodern and modern medicines.

Nevertheless, one of the most sustained critiques ofmodern medicine is precisely that as volition, it is funda-mentally different from all previous kinds of medicine. IvanIllich’s Medical Nemesis (1976) argues that modern medi-cine arises from a basic “social commitment to provide allcitizens with almost unlimited outputs.” Indeed, the neme-sis of rising iatrogenic disease is a direct result of “ourcontemporary 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 whenit serves as an ideological support for what has been termed“health fascism.”

Practical PerspectivesNot theoretical analysis, however, but ethical and politi-cal concerns predominate in philosophy of technology.Ethics has from its beginnings in the West involved atleast marginal considerations of technology. Aristotle’sNicomachean Ethics, for instance, in passing identifies techneas an intellectual virtue. More than two thousand yearslater Immanuel Kant distinguished moral and technicalimperatives. But in line with such marginal attention, fromPlato and Aristotle to the Renaissance, technology waswidely accepted as properly subject to ethical constraints.From the Renaissance to the Enlightenment, by contrast,traditional restraints were effectively replaced with an ethicalcommitment to the unfettered pursuit of technology forwhat Francis Bacon called “the relief of man’s estate.” It isprecisely this modern commitment, along with its subse-quent questioning in response to a series of increasinglyprominent problems, that frames the contemporary promi-nence of ethical issues in the philosophy of technology.

ALIENATION. Historically, the first problem of moderntechnology involved the industrial revolution and aliena-tion. At the basis of modern technological making lies abelief that the world as it is given does not provide a suitablehome for human beings; humanity must construct a homefor itself. The problem is that human beings do not immedi-ately find themselves at home in the worlds they technologi-cally create. The resulting alienation is especially problem-atic to the extent that it is grounded in attempts to overcomealienation.

The two most extensive critiques of technological al-ienation are Romanticism and socialism. The Romanticcritique, an early version of which appears in Jean-JacquesRousseau’s Discourse on the Sciences and the Arts (1750),focuses on how technology alienates the individual fromfeelings and sentiments, as manifested in relationships withnature, the past, or other human beings. This is caused,according to the Romantic argument, by a one-sided devel-opment of rationality. Romanticism thus perceives technol-ogy as an extension of reason and proposes to enclose itwithin a larger affective life.

By contrast, in the socialist critique of alienation, Marx,like Kapp, explicitly conceives technology as a human organprojection. Marx thus focuses on the separation of humanbeings from control over the tools and products of theirlabor, as manifested in an economy based on money and the“fetishism of commodities.” In response, socialism arguesfor a comprehensive restructuring of society to promoteworker control of the means of production.

In biomedical practice the use of technological instru-ments and rationalized systems of diagnosis raises the issue ofalienation in the form of questions about the depersonaliza-tion of healthcare techniques and organizations. Responsescan exhibit characteristically Romantic or socialist features.Exemplifying Romanticism are proposals to situate diagnos-tic techniques within a more humanistic framework, per-haps one of beautiful buildings and a pleasant environment.Exemplifying a socialist response might be arguments for thepromotion of patient autonomy by granting patients moredirect control over their own healthcare institutions.

WARFARE. A second ethical problem has centered on tech-nology and war. There are two basic theories about therelationship between war and technology: First, technologi-cal weapons make war so horrible that it becomes unthink-able; rational self-interest leads to deterrence of their use.Second, human beings will always tend to miscalculate theirself-interests and go to war; weapons production musttherefore be limited, and a higher ideal of global humanunity promoted.

TECHNOLOGY

•


Prior to World War I, naive versions of the first theorylargely supported the pursuit of technology. The trauma ofthe war contributed to pessimistic criticisms of technologicalcivilization and led to emphasis on the second theory. Thispessimistic critique, coupled with idealist attempts at worldgovernment, failed to avoid World War II and a technologi-cal practice of genocide, the invention and use of the atomicbomb, and a subsequent Cold War spread of nuclear weap-ons. As a result, much more sophisticated versions ofdeterrence policy were developed in alliance with manage-ment and decision theories. Advanced technological weap-ons development projects also stimulated science and tech-nology policy and management studies, while the practice ofnuclear deterrence was subject to extended moral criticism.One of the more idealistic criticisms argues that humanunity and peace, which in the past could remain as moralexhortations, have now become necessities, lest humanbeings obliterate themselves from the face of the planet. Inthis argument the rational self-interest of the first theoryappears to merge with the idealism of the second.

Prospects for social and genetic engineering call forthsimilar arguments between pragmatic deterrence manage-ment and idealistic delimination. The progressive refine-ments of conditioning techniques and sophisticated drugtherapies create behavior-control technologies of immensepotential power. Developments in recombinant DNA tech-nology and the Human Genome Project offer opportunitiesto extend this power to the biological creation of human life.As Sanmartín has pointed out, this attack on the vagaries ofhuman nature can be seen as developing new technologiesfor the prevention of “social diseases” such as war.

TECHNOLOGY AND SOCIAL CHANGE. Concerns about therelatively specific issues of alienation and warfare have beencomplemented by more general analyses of the causal rela-tions and patterns of interaction that obtain between tech-nology and social change. Such analyses include bottom-upcase studies of changes related to bureaucracy, urbanization,work (from mass production to automation to customizedproduction), leisure and mobility, secularization, communi-cations (from telephone and radio to television and com-puter), and medical technologies, as well as top-down theo-retical reflections on the same dimensions of social life andon the social order as a whole. Within both approaches it iscommon to find descriptions of disorder between technol-ogy and society brought about by technological changealong with arguments for addressing such disorder by meansof 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 amore intelligent appropriation of technology. A decade laterHenri Bergson’s Two Sources of Morality and Religion (1932)argued that the vices of industrial civilization as a wholecould be corrected only by what he termed a “supplement ofsoul” that is at once ascetic (against luxuries) and charitable(for eliminating inequalities).

To stress the need for intellectual or rational adapta-tions is no doubt more characteristic of advanced industrialsociety, with its concomitant large-scale educational institu-tions and activities. The kind of piecemeal social engineeringadvocated by John Dewey and Karl Popper, and the manytheories of economic rationality from Pareto efficiency torisk-benefit analysis, and of postindustrial organization fromDaniel Bell to Habermas, likewise advocate effective in-creases in the rational control of modern technology. Bycontrast, a follower of Bergson such as Ellul argues thattechnology has become a kind of totalitarian milieu thatrequires comprehensive demythologizing. Others suggestthe need for expansions of affective sensibility. Some theo-ries of postmodern culture exhibit certain affinities with thisapproach.

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

POLLUTION AND THE ENVIRONMENTAL CRISIS. Perhapseven more demanding of attention than warfare, and addinga new dimension to analyses of technological change, areproblems associated with environmental pollution and glo-bal climate transformation. The environmental crisis hasobvious and fundamental impacts on human health andsafety, and thereby on biomedicine. Indeed, outside medicalethics, perhaps the single most intensively explored area ofapplied philosophy is that of environmental ethics.

Beyond intensified self-interest, environmental changehas engendered the new science of ecology and extendedethical concern both temporally (for future generations) andontologically (for nonhuman entities). As analyzed by HansJonas (1979), this extension is grounded in “the alterednature of human action” brought about by the “novelpowers” of modern technology. Although all human liferequires some technical activity, not until the advent ofmodern scientific technology did the technical power tocreate become so explosive as to be capable of fundamentallytransforming 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.”

TECHNOLOGY

•


Jonas explicitly argues the application of this principleof responsibility in the field of bioethics. Applications mightalso be adumbrated for other discussions in environmentalethics, such as those that distinguish shallow versus deepecology movements and argue the rights of nature under-stood as wilderness. Could one not, for instance, distinguisha shallow versus a deep bioethics? Would it not be possible toargue, against excessive medical intervention, a defense ofwildness in biology?

ENGINEERING ETHICS. A second well-developed field ofapplied ethics with potential implications for the medicaldimensions of bioethics is that of engineering ethics (seeMartin and Schinzinger). Here a basic shift has taken placein the interpretation of the primary responsibility of theprofessional engineer—from loyalty to a company or client(patterned after the ethics of the medical and legal profes-sions) to responsibility to public health, safety, and welfare.Could this shift, resting on a recognition of engineering associal experimentation, have implications for new under-standings of professional medical obligation? Is it not thecase that technological medicine is, as much as the treatmentof individual patients, to some extent a social experiment? Ifso, then the engineering ethics defense of the rights and roleof the whistle-blower might well have analogous applica-tions in the biomedical field.

COMPUTERS AND INFORMATION TECHNOLOGY. A thirdwell-developed area of applied ethics deals with computers.One defining book in this field was written by a computerscientist (see Weizenbaum) and based on Mumford’s philo-sophical anthropology of the human as a polyvalent beingfor whom calculating is only a very small part of thinkingand a limited dimension of technics. Key issues in thephilosophical analysis of computers concern the degree towhich human thinking can be modeled by computers andthe extent to which human beings should properly rely oncomputer programs, especially in areas such as weapons.Subsequent development, as summarized by Deborah John-son (1985), has emphasized issues of individual privacy andcorporate security, the formulation of ethical codes forcomputer professionals, and liabilities for the malfunction-ing of computer programs. The computerization of medicalpractice calls for the application of such reflection to manyaspects of high-tech medical diagnosis and treatment.

DEVELOPMENT AND DIVERSITY. The ambiguities of tech-nology in developing countries, together with reassessmentsof the impacts of advanced technological transformations inrelation to women and ethnic minorities, especially in theUnited States and Europe, raise new issues regarding the

abilities of scientific technology to accommodate true diver-sity. On the one side, there are questions of equity. Inadvanced technological countries, technological power andaffluence are not equally shared between men and womenand among different ethnic communities. Nor does thereappear to be equality of opportunity among advanced anddeveloping countries. On the other side, technological de-velopment tends to set up national and international eco-nomic orders that homogenize personal and world cultures.Distinctions among markets and ways of life are subsumedwithin the financial structures of transnational corporationsand global communications systems. This paradox of ineq-uity and homogenization poses a fundamental challenge toboth reflection and action.

Attempts to address this challenge can be found in thealternative technology movement, arguments regarding theethics and politics of development, and in diverse feministcontributions to the philosophy of technology (as collected,for instance, in Rothschild). Feminist critiques of technol-ogy, for instance, emphasize both the need for equity and thethreats of homogenization. Technologies of the workplaceare to a large extent sexually differentiated; those of thehome are designed and used in ways that confirm masculineand feminine roles. But technological culture creates imagesof androgynous liberation while medical procedures dimin-ish the experiences of gendered bodies. In the face of thisparadox, what some feminists argue is the need for a newtheory and practice of technology itself, a truly alternativetechnology, one that transforms both its masculine biasesand its characteristically modern commitments. The idealsand pursuit of alternative medicines can be interpreted asconcrete attempts to achieve such a goal.

ConclusionSuccessive technological problems have provoked a series ofethical analyses and moral responses. Reflections on theseproblems and their emerging responses, because they havebeen focused on a particular technology, have tended toremain isolated from each other and untested by generaliza-tion. Philosophies of technology that have attempted tobridge such particularities, and that include a substantialrole for bioethics, can be found in the work of Jonas,Sanmartín, Gilbert Hottois (1990), and Friedrich Rapp(1990).

Complementing such work, problems addressed by thevaried discussions of practice have been approached fromwithin a variety of ethical frameworks, among which arenatural-law theory, deontologism, and consequentialism.With natural-law theory, one tends to assess technological

TECHNOLOGY

•


change in terms of its harmony with some given lawful orderperceived in nature. With deontological theory the emphasisis on evaluating the rightfulness and wrongfulness of techno-logical change in accord with some inner criteria of theaction. With consequentialism there is an effort to look tothe goodness or badness of future results that flow fromsome particular technology. Each such ethical frameworkcan exhibit selective affinities with different basic theoreticalconceptions of technology.

Environmental ethics, for instance, tends to be distin-guished by criticisms of technologies that do not harmonizewith preexisting natural order. The emphasis here is easilyplaced on human activity, with nonhuman realities takingon special moral significance. Computer ethics, by contrast,tends to put forth deontological principles about thewrongness, for instance, of the invasion of privacy. Such anethics emphasizes human intention or volition with respectto technology. Finally, technology policy studies are likely tostress the evaluation of technologies in terms of results, andthus to call attention to the physical consequences of techno-logical decisions. Here the issue of risk becomes a specialchallenge to the accepted cost-benefit calculus typical ofconsequentialist analysis.

The suggestive character of such relationships pointstoward the need for a more systematic pursuit of thephilosophy of technology in ways that integrate epistemo-logical, metaphysical, ethical, and political analyses. Theyalso indicate the opportunities for more extended interac-tions between general philosophies of technology and theissues of biomedical ethics, interactions that have the poten-tial for deepening and increasing the fruitfulness of both.

CARL MITCHAM (1995)


SEE ALSO: Human Dignity; Human Nature; Medicine,Philosophy of; Natural Law; Posthumanism andTranshumanism; Virtue and Character; and other Technol-ogy subentries

BIBLIOGRAPHY

For more extensive introductions to philosophy of technology,see Friedrich Rapp (1978), Carl Mitcham (1980), and Freder-ick Ferré (1988), which can be complemented with thecollections of readings by Carl Mitcham and Robert Mackey(1972) and Friedrich Rapp (1974). The most important serialsare Research in Philosophy and Technology (1978–present) andPhilosophy and Technology (1981–present). There is also a“Philosophy of Technology” monograph series from Indiana

University Press (1990–present). For bibliography, consultCarl Mitcham and Robert Mackey, Bibliography of the Philoso-phy of Technology (Chicago: University of Chicago Press, 1973;paperback reprint with author index, Ann Arbor: Books onDemand, 1985), and supplements that have appeared inResearch in Philosophy and Technology.

Achterhuis, Hans, ed. 2001. American Philosophy of Technology:The Empirical Turn, tr. Robert P. Crease. Bloomington:Indiana University Press.

Bergson, Henri. 1932. Les deux sources de la morale et de lareligion. Paris: F. Alcan. Translated by Ruth Ashley Audra,Cloudesley S. H. Brenton, and William H. Carter under thetitle The Two Sources of Morality and Religion. London:Macmillan, 1935.

Bilsker, Richard. 2002. On the Philosophy of Technology. Bel-mont, CA: Wadsworth.

Borgmann, Albert. 1984. Technology and the Character of Con-temporary Life: A Philosophical Inquiry. Chicago: University ofChicago Press.

Bunge, Mario. 1967. “Action.” In The Search for Truth, vol. 2 ofhis Scientific Research. Berlin: Springer-Verlag.

Bunge, Mario. 1985. “Technology: From Engineering to Deci-sion Theory.” In Life Science, Social Science, and Technology,part 2 of Philosophy of Science and Technology, vol. 7 of hisTreatise on Basic Philosophy. Boston: D. Reidel.

Edelbach, Ralph; Wainwright, Steve; Hawes, Worth; and Winston,Morton Emanuel, eds. 2002. Society, Ethics, and Technology.Belmont, CA: Wadsworth.

Dessauer, Friedrich. 1927. Philosophie der Technik: Das Problemder Realisierung. Bonn: Friedrich Cohen. 2nd enl. edition,Streit um die Technik. Frankfurt am Main: J. Knecht, 1956.

Dreyfus, Hubert L. 1972. What Computers Can’t Do: A Critiqueof Artificial Reason. New York: Harper and Row. Rev. ed.,What Computers Can’t Do: The Limits of Artificial Intelligence.New York: Harper and Row, 1979. 2nd rev. edition. WhatComputers Still Can’t Do: A Critique of Artificial Reason.Cambridge, MA: MIT Press, 1992.

Ellul, Jacques. 1954. La technique; ou, l’enjeu du siècle. Paris:Armand Colin. 2nd rev. edition. Paris: Economica, 1990.Translated by John Wilkinson under the title The Technologi-cal Society. New York: Alfred A. Knopf, 1964.

Ellul, Jacques. 1977. Le système technicien. Paris: Calmann-Lévy.Translated by Joachim Neugroschel under the title The Tech-nological System. New York: Continuum, 1980.

Ellul, Jacques. 1988. Le bluff technologique. Paris: Hachette.Translated by Geoffrey W. Bromiley as The TechnologicalBluff. Grand Rapids, MI: W. B. Eerdmans, 1990.

Feenberg, Andrew. 1991. Critical Theory of Technology. NewYork: Oxford University Press. Carries forward the ideas ofMarx, Marcuse, and Habermas.

Fellows, Roger, ed. 1995. Philosophy and Technology. New York:Cambridge University Press.

Ferré, Frederick. 1988. Philosophy of Technology. EnglewoodCliffs, NJ: Prentice-Hall.

TECHNOLOGY

•


Foucault, Michel. 1963. Naissance de la clinique: une archéologiedu regard médical. Paris: Presses Universitaires de France.Translated by A. M. Sheridan Smith under the title The Birthof the Clinic: An Archeology of Medical Perception. New York:Pantheon, 1973.

Foucalt, Michel. 1988. Technologies of the Self: A Seminar withMichel Foucault, eds. Luther H. Martin, Huck Gutman, andPatrick H. Hutton. Amherst: University of MassachusettsPress.

Habermas, Jürgen. 1968. Technik und Wissenschaft als “Ideologie.”Frankfurt am Main: Suhrkamp. Translated by Jeremy J.Shapiro as the last three essays in Toward a Rational Society:Student Protest, Science, and Politics. Boston: Beacon Press,1970.

Harding, Sandra and Figueroa, Robert, ed. 2003. Science andOther Cultures: Diversity in the Philosophy of Science andTechnology. New York: Routledge.

Heidegger, Martin. 1954. “Die Frage nach der Technik.” In hisVorträge und Aufsätze, pp. 13–44. Pfullingen: Günther Neske.Translated by William Lovitt under the title “The QuestionConcerning Technology.” In The Question Concerning Tech-nology and Other Essays. San Francisco: Harper & Row,1977.

Hottois, Gilbert. 1984. Le signe et la technique: La philosophie àl’épreuve de la technique. Paris: Aubier.

Hottois, Gilbert. 1990. Le paradigme bioéthique: Une éthiquepour la technoscience. Brussels: De Boeck.

Ihde, Don. 1979. Technics and Praxis. Boston: D. Reidel.

Ihde, Don. 1990. Technology and the Lifeworld: From Garden toEarth. Bloomington: Indiana University Press.

Illich, Ivan. 1973. Tools for Conviviality. New York: Harper andRow.

Illich, Ivan. 1976. Medical Nemesis: The Expropriation of Health.New York: Pantheon.

Johnson, Deborah G. 1985. Computer Ethics. Englewood Cliffs,NJ: Prentice-Hall.

Johnson, Deborah G., ed. 1991. Ethical Issues in Engineering.Englewood Cliffs, NJ: Prentice-Hall.

Johnson, Deborah G., and Snapper, John W., eds. 1985. EthicalIssues in the Use of Computers. Belmont, CA: Wadsworth.

Jonas, Hans. 1979. Das Prinzip Verantwortung: Versuch einerEthik für die technologische Zivilisation. Frankfurt am Main:Suhrkamp. Translated by Hans Jonas and David Herr underthe title The Imperative of Responsibility: In Search of an Ethicsfor the Technological Age. Chicago: University of ChicagoPress, 1984.

Jonas, Hans. 1985. Technik, Medizin und Ethik: Zur Praxis desPrinzips Verantwortung. Frankfurt am Main: Insel.

Kapp, Ernst. 1877. Grundlinien einer Philosophie der Technik:Zur Entstehungsgeschichte der Kultur aus neuen Gesichtspunkten.Braunschweig: G. Westermann.

Marcuse, Herbert. 1964. One-Dimensional Man: Studies in theIdeology of Advanced Industrial Society. Boston: Beacon Press.

Martin, Mike W., and Schinzinger, Roland. 1989. Ethics inEngineering. 2nd edition. New York: McGraw-Hill.

Mitcham, Carl. 1980. “Philosophy of Technology.” In A Guideto the Culture of Science, Technology, and Medicine, ed. Paul T.Durbin. New York: Free Press.

Mitcham, Carl. 1996. “The Philosophical Challenge of Technol-ogy.” American Catholic Quarterly 70(Supp): 45–58.

Mitcham, Carl, and Mackey, Robert, eds. 1972. Philosophy andTechnology: Readings in the Philosophical Problems of Technol-ogy. New York: Free Press. Paperback reprint, 1983.

Mumford, Lewis. 1934. Technics and Civilization. New York:Harcourt Brace.

Mumford, Lewis. 1967. Technics and Human Development. Vol.1 of The Myth of the Machine. New York: Harcourt BraceJovanovich.

Mumford, Lewis. 1970. The Pentagon of Power. Vol. 2 of TheMyth of the Machine. New York: Harcourt Brace Jovanovich.

Ogburn, William F. 1922. Social Change with Respect to Cultureand Original Nature. New York: Viking.

Ortega y Gasset, José. 1939. “Meditación de la técnica.” In hisEnsimismamiento y alteración. Buenos Aires: Espasa-Calpe.Collected in vol. 5 of Obras completas. Madrid: Alianza, 1946.

Rapp, Friedrich J. 1978. Analytische Technikphilosophie. Freiburg:Karl Alber. Translated as Analytical Philosophy of Technology.Boston Studies in the Philosophy of Science, vol. 63. Boston:D. Reidel, 1981.

Rapp, Friedrich J. 1982. “Philosophy of Technology.” In vol. 2of Contemporary Philosophy: A New Survey, ed. GuttormFloistad. The Hague: Martinus Nijhoff.

Rapp, Friedrich J., ed. 1974. Contributions to the Philosophy ofTechnology: Studies in the Structure of Thinking in the Techno-logical Sciences. Boston: D. Reidel.

Rapp, Friedrich J., ed. 1990. Technik und Philosophie. Düsseldorf:VDI Verlag. A cooperative overview with contributions byRapp, Alois Huning, Ernst Oldemeyer, Hans Lenk, andWalther Ch. Zimmerli.

Rothschild, Joan, ed. 1983. Machina ex Dea: Feminist Perspec-tives on Technology. New York: Pergamon.

Sanmartín, José. 1987. Los nuevos redentores: Reflexiones sobrela ingeniería genética, la sociobiología y el mundo feliz que nosprometen. Barcelona: Anthropos.

Scharff, Robert C., and Duske, Val, eds. 2002. Philosophy ofTechnology, the Technological Condition: The TechnologicalCondition: An Anthology (Blackwell Philosophy Anthologies).Malden, MA: Blackwell.

Shrader-Frechette, Kristin S. 1991. Risk and Rationality: Philo-sophical Foundations for Populist Reforms. Berkeley: Universityof California Press.

Simon, Herbert A. 1969. The Sciences of the Artificial. Cam-bridge, MA: MIT Press. 2nd enl. edition, Cambridge, MA:MIT Press, 1991.

Tiles, Mary, and Oberdiek, Hans. 1995. Living in a TechnologicalCulture: Human Tools and Human Values. New York: Routledge.

TISSUE BANKING AND TRANSPLANTATION, ETHICAL ISSUES IN

•

E N C Y C L O P E D I A O F B I O E T H

ENCYCLOPEDIA OFENCYCLOPEDIA OF...

Documents

Transcript of ENCYCLOPEDIA OFENCYCLOPEDIA OF...