The Technological Enframing of Medicine

The physician-philosopher Edmund Pellegrino believed that there was a fundamental continuity in Western medicine that linked physicians today to their forebears, as far back as the ancient Greeks and Romans. For example, he argued that the ends of medicine today are humanitas—love of humanity—and misericordia—the practice of mercy—and he cited the works of Scribonius Largus, physician to the Roman emperor Claudius in the first century AD.[1] Although he recognized historical changes in medicine, he nevertheless thought that the “fact of illness,” the existence throughout history of maladies that have led humans to seek the assistance of physicians, creates sufficient continuity to allow ancient medicine to inform our own.[2]

There is a tendency related to this line of thinking in which physicians and other commentators posit a kind of Edenic narrative, according to which a morally pure medicine comes to be corrupted by a malign external influence. Various forces have played the role of the serpent in these narratives, but one genre focuses on technology. In such stories, medicine’s golden age ended once some new device—such as radiological imaging techniques, computers, electronic medical records (EMRs), telemedicine, or the current target of many a journal article, artificial intelligence—encroached on health care. Yet the introduction of these technologies into contemporary medicine continues unimpeded. Multiple companies are racing to develop AI devices that not only function well in medical spaces but raise revenue, and I expect we will see them used widely by the end of this decade. This trend raises a question for medical critics of technology: why, if technologies are non-essential to medicine, do physicians seem so eager to use them? If technology is a malign external force, why is medicine so powerless to resist it? I argue that technology is not in fact external to contemporary medicine. Rather, contemporary medicine has become essentially technological in the way that it treats both sides of the doctor-patient relationship.

In asserting that medicine has become technological, I am not making the banal observation that technological devices are ubiquitous in health care. Rather, I claim that medicine is technological in the sense that Martin Heidegger described in his essay, “The Question Concerning Technology.” Heidegger argues that the essence of technology is not a device but rather “enframing,” a kind of instrumental reason that conceives of the world, including other persons, as “standing reserve,” intrinsically meaningless raw material awaiting the imposition of the human will to optimize it.[3] In this paradigm, technology “challenges-forth”: it foregrounds those aspects of the world that are available for efficient manipulation and obscures all else, concealing the true natures of things. This imperative of technological mastery, which had historically been intertwined with Christian beliefs about human nature and purpose, eventually becomes an end in itself. Ultimately technology forms a “double hermeneutic loop”: what purports to be a neutral way of understanding the world shapes human self-understanding, so humans themselves become “objects whose energies can be scientifically controlled and released,” to the neglect of “beliefs, meanings, and purposes as [forms of] causality that cannot be fixed by antecedent mechanistic conditions.”[4] Technology thus induces forgetfulness of the human purposes for which it was originally pursued, making impossible what Heidegger calls a “bringing-forth,” in which one works with nature, including human nature, to develop its intrinsic excellence.

This technological rationality pervades contemporary American medicine. Consider primary care, my own field, which may seem like the least “technological” field of medicine. I chose the field in part because I hoped to develop relationships with patients rather than becoming a kind of mere technician. Yet when I am in clinic, my attention is constantly drawn away from the patient toward other tasks, which are mediated by one technology that has infiltrated all primary care offices, namely the electronic medical record. When I see a patient, the EMR immediately triggers a series of reminders on the screen in bright yellow boxes, instructing me to complete various tasks. Some of these will plausibly benefit the patient, such as quality measures for chronic disease management and preventive health measures, including screening tests and vaccines. Others are intended solely for billing purposes, such as updating the “problem list,” which contains the patient’s complaints and medical conditions. Regardless, they are time-consuming. One study estimated that the completion of all these tasks for a standard daily panel of patients in a primary care clinic would require twenty-six hours of work.[5]

The official justification for these practices is the rational application of science to improve patients’ health, but of course health, like love and other human goods, is “shaped by cultural meanings and traditions and does not exist in brute, timeless scientific isolation” as an object of medical study.[6] In fact, what really motivates hospital systems to implement such measures is revenue. Payers such as Medicare will reimburse at higher rates those institutions that deliver “high quality care,” where quality is defined simply in terms of the completion of these tasks in the EMR. These incentives explain why large private equity funds and major corporations such as Amazon, Walmart, and CVS have collectively spent $50 billion competing to purchase or build new primary care practices; economies of scale will favor whichever entity can successfully impose these measures on the most patients.[7]

This corporatization of health care has effects for both patients and physicians. On the patient side, this apparatus of government and corporate power looks upon the population as a kind of raw material to be optimized and from which resources can be extracted for the enrichment of others. Meanwhile, as physicians’ workplaces become increasingly dominated by impersonal bureaucracies and devices, physicians are ever more alienated from their work. Marx described alienation as a condition in which the worker “does not feel content but unhappy, does not develop freely his physical and mental energy, . . . [and] therefore only feels himself outside his work, and in his work feels outside himself.”[8] Alienation develops as machines, rather than human wants or needs, come to dictate the pace of work. Instead of having time for discernment and judgment about what might be best for the individual patient in his or her circumstances, the physician must simply apply quality measures to each patient, over and over. The physician no longer cultivates a unique relationship with the patient but rather becomes a fungible representative of the institution.

Under such conditions, the best physician is not one who has developed the Aristotelian virtue of practical wisdom but rather the “manager,” in the sense criticized by Alasdair MacIntyre in After Virtue: an expert in using technical means to control behavior and suppress conflict toward ends determined by his or her superiors.[9] At the same time, physicians find themselves ever more subject to Taylorist techniques of scientific management such as time-motion studies and productivity measures that will be familiar to any physician working today for a large institution or system, as most do. Whereas Aristotle had argued that social life ought to help individuals develop the virtues, forms of excellence that emerge from human nature, health systems and other social institutions today treat social life itself as a technology, in which various artifices are deployed to motivate fundamentally selfish individuals to cooperate. To quote T.S. Eliot, we “[dream] of systems so perfect / that no one will need to be good.”[10] The end result is a social milieu in which, as Heidegger argued, instrumental reason predominates. Physicians and patients are treated not as rational agents exercising discretion and cultivating their own excellence in pursuit of health, as they understand it, but rather challenged by social mechanisms and physical devices to conform themselves to impersonal standards. Thus, medicine works better the more machine-like both parties become, and relational goods such as empathy seem superfluous. As David Yu, medical director of a large southwest US health system, put it, “we see the hospital as a factory and our hospitalist group as an assembly line that is in the business of manufacturing perfect discharges.”[11]

Arguably this tendency in medicine is not new. In his book, for example, Jeffrey Bishop follows Foucault in tracing the “medical gaze,” which objectifies and applies instrumental reason to the human body, to the eighteenth century.[12] Yet I would argue that this trend has accelerated in the twenty-first century, due in part to the sheer number of resources, public and private, that have been dedicated to these efforts to manage the population by the application of newer and more effective techniques. As Heidegger and other critics have emphasized, technology is no mere tool but rather recursively shapes human perception and action in a hermeneutic feedback loop. In elaborating techniques to control the human body, contemporary medicine focuses attention on those aspects of human life that are amenable to such control and encourages optimism about the prospect that medical technology will continue to overcome the limitations of human nature. Because medicine is bound up in this technological enframing, it cannot resist applying new technologies that extend its reach.

As an example, consider the prospect that artificial intelligence might come to replace human physicians. A Silicon Valley startup called Forward has made the most dramatic attempt at such replacement to date, having placed “CarePods” in shopping malls and other public places that offer fully automated diagnosis and treatment powered by generative AI.[13] Yet other companies are racing to bring AI tools to the medical market in more subtle ways, such as scribes that write physicians’ notes for them. If my above description of contemporary primary care is correct, then these AI tools will owe their success just as much to medicine’s own techno-social imaginary as to advances in AI itself. In other words, physicians can only be replaced by AI because health care has already been made “robotic.” An AI might very well write a physician’s note today because, in the era of the EMR, these notes are not records of a physician’s relationship with individual patients but have become entirely a tool to maximize billing, filled with boilerplate language and automatically generated data to the extent that the physician and patient as unique human beings have already been effaced. The replacement of human writing becomes conceivable because physicians have already forfeited any conception of the note as an aid to their thinking about their patients, a tool that “brings forth” their own attention to their patients.

Lacking a coherent account of the goods toward which its instrumental reason ought to be directed, medicine seeks instead to expand the ambit of that instrumental reason. Heidegger’s analysis implies that the ongoing deployment of devices in medicine is a symptom of a deeper malady that is moral and indeed spiritual. As Peter Harrison points out in his Territories of Science and Religion, Christian belief motivated many of those who originated the techno-scientific project.[14] Yet for many of us moderns, technology has eclipsed Christ as savior. Our faith that instrumental reason will bring about an earthly utopia has substituted for belief that divine grace, offered to all by Christ on the Cross, will unite humanity with God in his Kingdom. In medicine, these utopian aspirations create desires to optimize the human body and overcome its limitations. Yet when this project inevitably fails, since we remain, as ever, susceptible to disease and death, physicians and patients within the enframing can only comprehend the constraints of human nature as oppressive and meaningless rather than occasions for discernment and, possibly, God’s grace.

Because technology cannot ultimately satisfy the human yearning for transcendence, its triumph in medicine may appear rather banal. For example, we can glimpse the incipient “AI revolution” in medicine in the company Service Now, which is attempting to create AI tools capable of replacing humans in such roles as customer service and human resources. We have all had the soul-crushing experience of calling a customer service line and working through the interminable menu of options, hoping desperately and with increasing frustration that we will eventually encounter a genuine human being. Now imagine having no hope whatsoever of talking to another person, and you will foresee the world that Service Now is bringing into being. Indeed, it is one of the only AI companies that has already become profitable, suggesting its model will be applied even more broadly.[15]

Part of what we want when we call customer service is to find someone who will listen to our complaint, even though we must suspect they may not ultimately be capable of solving our problem. We hope not only to have the problem solved efficiently and effectively, but also to be heard and recognized by a fellow human being. We want someone to attend to us, uniquely, not just to be shunted into a pre-existing decision tree. Today, these moments of encounter are increasingly rare and therefore increasingly precious. They are moments in which what we receive exceeds our needs, our expectations, and even what we paid for: moments of excess, gratuity, and gift. Such a hope is present too when a patient seeks out a physician. Certainly, patients want efficient and effective solutions to the problems that beset them. Yet if they also encounter a human being who attends to them and cares for them, they might experience it as a gift, one that contributes in some way to their healing.

In an age in which devices such as the EMR often threaten to draw our focus away from one another, a decision to give someone else one’s full attention feels like a radical act. The terms attention and attending, as in an “attending physician,” derive from the Latin attendere, which means “to turn or stretch toward,” suggesting a capacity to engage with and care for something.[16] Byung-Chul Han contrasts this kind of care with what he calls “hyperattention,” a rash change of focus between different tasks and sources of information.[17] Although the ability to multi-task may seem to be an advanced human capacity, Han points out that it is in fact primitive, and indeed, wild animals must multi-task as they constantly and simultaneously search for food, watch for predators and rivals, and guard their young. By contrast, only human beings are capable of contemplation, defined as deep sustained attention to a concept or object. This ability to pause in contemplation open to “the Other,” not only other human beings but also the world at large, is uniquely human and distinguishes humans from their technologies. Such focus is necessary for endeavors such as medicine in which decisions hinge on small details, for things that are inconspicuous only reveal themselves to contemplative attention.

We might be surprised to find what is possible when we give the gift of attention to one another. In a 1988 interview, Ivan Illich criticized the replacement in contemporary discourse of the “good” with the language of “values.” For Illich, value is a “generalization of economics,” whereas “when we speak about the good, we show a totally different appreciation of what is before us. The good is convertible with being, convertible with the beautiful, convertible with the true.” When his interlocutor asks if we can recover the language of the “good,” Illich replies, “Between the two of us, at this moment, yes!”[18] The apprehension of the good can perhaps begin with this kind of personal relationship. The questions we must ask in order to know what to do with our many devices—What is the human being? What is good for us?—can begin with a relationship in which two persons attend to one another and open a dialogue about how to seek after the good.

Many physicians initially pursued a career in medicine due to some inchoate desire to have this kind of encounter with other persons in a physician-patient relationship. Yet the reality of contemporary medicine conflicts with this deep desire at the heart of the physician’s vocation. In ways both large and small, the health care system today seems almost designed to undermine attention to the human Other. The Book of Genesis speaks of this need for relationship as part of the human good: it is not good for the human person to be alone (Genesis 2:18). We cannot “bring forth” the goodness of human nature in isolation. Yet this concern with the human “good” is nearly illegible within a health care system focused more on “value”: the application of the will toward the extraction of resources and the expansion of its control over nature. Much depends on whether contemporary medicine can preserve what Heidegger calls a “clearing,” a space wherein the patient can encounter a fellow human being and perhaps experience healing as an opening toward God.[19]

I want to end with a story that I experienced as such a clearing. My first daughter was born in a hospital that, like many in the US, was founded and operated for decades by an order of religious sisters. The room in labor and delivery to which my wife and I were assigned looked out over the convent where they had lived. Today, a Catholic corporation owns the hospital, and there is not one sister among its senior leadership. As a result, during our stay there, the hospital was demolishing the convent. As I looked out the window during the anxious hours of labor, I could see through the early morning fog the ceiling of the apse, the only remaining part of the chapel where the sisters had worshiped. In its place, the hospital has since then constructed, of all things, a parking lot. It is perhaps an apt metaphor; the small group of sisters who conceived of the hospital as a place for the poor to encounter God’s mercy for the sick, alongside whom they lived, has been replaced by an army of laypersons who, after all, need someplace to park. The hospital today generates profits efficiently enough to support so many staff members, few if any of whom have taken a vow of poverty as the sisters had done.

My wife and I experienced modern technological medicine during that hospital admission when she had an unforeseen C-section and my daughter went briefly to the NICU. Happily, both patients recovered well. Yet we also experienced a legacy of the sisters in a moment of grace. Just after the nurse wheeled our daughter away from our post-natal room to the NICU, a chaplain came unexpectedly to offer my wife and me the Eucharist. Even in the midst of our fear and grief, even though modern technological medicine has arguably effaced much of that hospital’s original mission, Christ nevertheless came. Catholics pray in the Mass, “Lord, I am not worthy that you should enter under my roof, but only say the word, and my soul shall be healed,” and in that moment, in that place, we were healed.

EDITORIAL NOTE: A longer version of this paper was given at a conference for the Lumen Christi Institute, "The Quandaries of Biotechnology," in March 2024.