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Affordable Ashmordable … What About Desirable Care?

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I applaud efforts to make healthcare affordable, but in this blog post I’d like to offer up a caution: “As we make healthcare in specific and care in general more affordable, will it still remain desirable?” Looked at another way, does it make sense to make something that is quickly becoming undesirable, affordable? Should we be looking at a Desirable Care Act to go along with the Affordable Healthcare Act? To set the stage here, I’m old enough to remember when black bag carrying doctors made house calls. What a quaint notion given the current cattle-call environments we now have to regularly endure at medical clinics. OK, I know I’m spoiling the punch of this blog post but below I’ll argue that care has become increasingly cold, impersonal, and robotic, thus making it increasingly undesirable. I’ll use a bullet point format to make my point because, well, it’s easier and I’m in a slacker mood as the holidays approach.

• In his 1993 book entitled Technopoly: The Surrender of Culture to Technology, futurist and social critic Neil Postman points to the appearance of the stethoscope in the early 1800s as the beginning of the end of true, empathic care. (Yes, I know, we could go back to the time of Spinoza—the mid 1600s—and his work with microscopes and use this as the beginning of the end, but lets stick with the stethoscope.) Let’s listen in as Postman writes:

In his detailed book “Medicine and the Reign of Technology,” Stanley Joel Reiser compares the effects of the stethoscope to the effects of the printing press on Western culture. The printed book, he argues, helped to create the detached and objective thinker.

For more on how technological revolutions (like the printing press) across time have changed Western culture, see my multipart blog post summary of William Powers’ book Hamlet’s BlackBerry. (William Powers was our RYOL Lecture speaker back in October, 2013.) Postman continues by telling us that “similarly, the stethoscope (now quoting Reiser)” …

… helped to create the objective physician, who could move away from involvement with the patient’s experiences and sensations, to a more detached relationship, less with the patient but more with the sounds from the body. Undistacted by the motives and beliefs of the patient, the stethoscope could make a diagnosis from sounds that he alone heard emanating from body organs, sounds he believed to be objective, bias-free representations of the disease process.

• In her 2001 book Rediscovering Birth, breastfeeding expert Sheila Kitzinger argues that the ultrasound machine has succeeded in abstracting away infant from mother. In essence, the ultrasound machine objectifies the infant and renders the mother–infant relationship asunder. In contrast, it was object relations theorist Donald Winnicott (who was John Bowlby’s contemporary and, on occasion, collaborator) who argued that there is no such entity or concept infant. Winnicott tried to get us to accept the idea that there is only a mother–infant relationship (which Bowlby framed as an attachment relationship), and that one should not be abstracted from the other. In his 2003 book entitled Science, Seeds, and Cyborgs: Biotechnology and the Appropriation of Life, social critic Finn Bowring warns that abstracting infant from mother is the first step toward creating an artificial womb. Bowring argues that scientists wish to create an artificial, cyborg womb as a way of getting past all of the messiness, unpleasantness, and unpredictability of an evolutionarily conceived and biologically-based womb.

• The medical clinic I go to recently installed computer terminals in all of the exam rooms. These computer terminals allow “practitioners” (the word doctor is slowly disappearing) to add patient information into a digital charting system. Here’s a transcript from a recent visit of mine (PR – practitioner):

PR – (enters exam room and sits in front of the computer terminal) So, how are we today? (begins typing on the keyboard, banging is more like it)

ME – Well, for the most part I’ve …

PR – Hold on a moment. Susie (yelling)! How do I log in to the system? My password isn’t working for MedicoDat.

SUSIE – (yelling back) Put an asterisk at the end of your old password and it should work.

PR – Thanks Susie, that worked. Damn system (mumbling). OK, what were you saying?

ME – Well, my arm fell off.

PR – (typing) Arm fell off. What next?

ME – I was able to duct tape it back on.

PR – (typing) Was able to duct tape it back on. What color duct tape did you use?

ME – Silver.

PR – (typing) Silver. Ohhh … green duct tape is best for reattaching arms. I’ll write you a script for green duct tape. Anything else?

ME – No that’s it. I’ll use the green duct tape to patch up the large gash in my leg. Thanks.

PR – (typing) Large gash in leg. Patient says he will treat with green duct tape. OK then, I’ll send this script off to Home Depot.

OK, I made up the parts about my arm falling off and the large gash, but the rest is fairly accurate. My practitioner now looks at and almost exclusively interacts with the computer terminal. If you agree that the stethoscope marks the beginning of the objectified patient, then computer terminals in exam rooms mark the point at which patients turn to stone. Paraphrasing Reiser from above, today, we are looking at an even more “detached relationship, less with the patient but more with the data coming from the screen.” In his 2013 book entitled Our Final Invention: Artificial Intelligence and the End of the Human Era, social critic Barrat James talks about how IBM is planning to put its Watson technology into the medical arena. (Watson was the AI or artificial intelligence technology that IBM used to win a game of Jeopardy.) Lets listen in as James tells us that …

One of IBM’s goals is to shrink Watson down from its present size—a roomful of servers—to refrigerator-size and make it the world’s best medical diagnostician. One day not long from now you may have an appointment with a virtual assistant who’ll pepper you with questions, and provide your physician with a diagnosis. Unfornatunately Watson still cannot see, and so might overlook health indicators such as clear eyes, rosy cheeks, or fresh bullet wound [or an arm reattached with duct tape, silver duct tape]. IBM also plans to put Watson on your smartphone as the ultimate Q&A app [to rival Apple’s Siri].

Heck, in the not too distant future, we’ll just simply diagnose ourselves. We won’t need doctors … excuse me … practitioners. I’m sure self-surgery will come along soon thereafter. So, as healthcare in specific and care in general becomes more self-serve, I’m sure the cost will not come down correspondingly. I’m sorry but my own self-diagnosis or self-surgery just doesn’t sound desirable. And, thank you Dr. House, patients lie. Watson probably will not be able to handle deception. If a medical diagnosis app sounds farfetched to you, keep in mind that wide acceptance of Apple’s Siri (technology in part funded through DARPA or Defense Advanced Research Projects Agency, according to James) paves the way toward ready acceptance of medical Q&A systems. “Siri, how do I reattach my arm … silver or green duct tape?” Here’s an interesting anecdote.

• Over the summer I conducted a site visit at a hospital. (Interestingly, this hospital recently installed computer terminals and a digital charting system.) As I was walking along with the development director, the topic of robot surgery came up. This development director, who has a long career in medical fundraising, told me that studies show that, for now, robot surgery isn’t any better than regular old surgery by a highly trained surgeon. He went on to tell me that hospitals ignore this fact and instead push robot surgery because it is the current medical fad and the public thinks that robot surgery is better than regular surgery. (The medical community is doing nothing to dispel this myth.) Simply, this development director director told me that the public is being given the image that robot surgery is “cutting edge” (and I think he meant to make the pun) and that regular surgery is old fashion like black bag carrying doctors making house calls.

• In her 2010 book entitled Alone Together—Why We Expect More from Technology and Less from Each Other, AI observer and critic Sherry Turkle talks about how Japan (and, to a lesser degree, the US) is experiencing a crisis: too many old people and too few caregivers. The solution? Yup, robot caregivers. James makes the same observation and goes further by telling us that Honda—yes, the car company—has been at the forefront of developing robot caregivers for the elderly in Japan for years now. Honda’s robot caregiver is called ASIMO. “Since 1986,” writes James, “ASIMO has been developed to assist the elderly—Japan’s fastest growing demographic—at home.” Strangely, some within the Bowlbian attachment community (Everett Waters chief among them) feel that robots will not only make for great caregivers but could act as primary attachment figures. As Turkle points out, increasingly all different kinds of technology are being used as substitutes for parents (i.e., parental care, parental attachment, etc.): smartphones, Facebook, Twitter, the Internet, Instagram, tablets, etc. To play on Bowlby’s favorite saying that attachment is with us “from cradle to grave,” it would appear that robot caregivers are now with us from “cradle to grave.” And believe it or not, this has become an issue for conservatives who argue that you cannot “robotize” or industrialize caregiving or attachment without bringing on potentially nasty side effects. Before moving to the conservative position on industrializing care, I’d be remiss if I did not point out that Japan is also on the leading edge of creating sex robots for Japanese men. Sadly, recent articles (which I have blogged about) report that Japanese men are rapidly moving toward prefering sex with robots over sex with actual, flesh and blood women. In earlier blog posts I have talked about what I am calling the Grand Bowlbian Attachment Environment or GBAE. GBAE contains the motivational systems of attachment, caregiving, and sex. Just simply notice how much robotization is tearing apart GBAE: robot caregivers, robot sex workers, robot attachment figures.

• In his article entitled The Fractured Dream of Social Parenting—Child-Care Policy Lessons and Losses, conservative social commentator Allan Carlson frames the process of institutionalizing child care in the following way:

[T]here is mounting evidence that … child care may be a human activity that cannot be industrialized. The psychological evidence is overwhelming, and still mounting, that children in extended day care—even very good day care—are on average more aggressive, less sociable, and less emotionally secure: traits that, ironically, undo the key socialist goal of enhanced human cooperation.

Carlson’s article appears in a special issue on childcare entitled The Child-Care ‘Crisis’ And Its Remedies (Family Policy Review, Fall 2003). The evidence that Carlson points to comes from attachment researchers such as Jay Belsky. Even Sir Richard Bowlby (John’s son) has spoken out against use of poor and/or extended day care (i.e., more than 20 hours per week). (Contact the Foundation for a summary of the talk that Sir Richard gave up in Canada back in 2005.) In essence, conservative social critics agree that, sure, we can relieve parents of their private burden of raising kids by delivering said kids to all manner of institutionalized or robotized care, but at what cost? And will the unintended costs associated with robo-care—more aggressive, less sociable, and less emotionally secure kids/adults—more than offset efforts to make care affordable? Hard questions, but I think they are worth considering before it’s too late.

For me personally, robots coming at me with scalpels, robots coming at me with a bedpan, robots coming at me with sex toys, robots coming at me with a diagnosis, or robots coming at me wanting to be my best friend forever, none of this sounds desirable at any price. So, I just feel that affordable should be appropriately paired with desirable. Let’s not lose sight of a sobering fact: in spite of all of our technology and resources, the US typically falls in the mid-twenties in terms of infant mortality. Affordable care does not always produce desirable outcomes. I know some developed countries have gone low tech using WHO guidelines—i.e., programs that encourage breastfeeding and discourage the use of junk baby food—and it has worked. Ideally, “affordable” programs should also point us in the direction of “desirable programs.” Just saying.

OK, one more example. It’s no secret that psychology and psychiatry groups are hard at work medicalizing every burp and hiccup of normal childhood development. These groups then use these largely trumped-up medical conditions to push behavioral drugs (i.e., Ritalin and Adderall) on an unsuspecting public. As Bowring (mentioned above) points out, these so-called legal stimulant drugs are more potent than illegal stimulant drugs like cocaine. In his 2003 book entitled Chemicals for the Mind, psychology professor Ernest Keen suggests that the current wave of behavioral drug use should be correctly framed as chemical lobotomy. In essence, Keen warns that the rise of behavioral drug use represents the second coming of lobotomy. Writing in his 2012 book entitled Executive Functions, ADHD expert Russell Barkley points out that effectively behavioral drugs put children (and, increasingly, adults) into cognitive wheelchairs. These drugs do control behavior but they do very little as far as helping people gain access to and develop better executive function skills. Is this a desirable form of care? one that puts millions if not billions of dollars into the pockets of psychology and psychiatry types while cognitively crippling (e.g., chemically lobotomizing) children and adults? For more on all of this, see Artificial Happiness by anesthesiologist Ronanld Dworkin, and The Book of Woe: The DSM and the Unmaking of Psychiatry by psychotherapist Gary Greenberg.

To end with a little humor (while we still have the luxury of laughing before the robots fully decend), try viewing this Geico commercial. It starts out with a mom talking to the camera after dropping her child off at day care. Here’s the first few lines:

“Day care can be expensive. So, to save money, I found one that uses robots instead of real people. Cause robots work for free.”

Oh, by the way, Happy Holidays from all of us at the FHL Foundation! I’ll reboot my blogging duties in the New Year (that is if the robots don’t get me before then).