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Technology assessment: the missing human dimension.

There is a powerful faith in America that, when there are problems with technology, other technologies can solve them. Nowhere is this more evident than in medicine, which routinely calls upon one technology to undo, or ameliorate, the effects of another. As often as not, that probably works. Then again, it sometimes does not. The obvious challenge of course is to know when something might work and when it might not; or even better, knowing how to make the remedy fit the problem in just the right way.

The technology assessment movement is a response to that challenge. The movement has been around in one form or another for at least two decades, and has been actively pursued in medicine since the 1970s. Of late, however, it has gained a new urgency, in great part because of a widespread conviction that many medical technologies (drugs, devices, diagnostic tests, and therapies)--especially some that are expensive--are either not much good, or good only under some circumstances, or of uncertain value altogether. The demand for outcome assessment (a term preferred by some) of diagnostic and therapeutic modalities both to improve patient welfare and to control costs has been powerful. The recently established federal Agency for Health Care Policy and Research is an important government response to this problem. Many medical and related groups, moreover, are turning to practice guidelines as a way of making use of medical outcome data.

This is a welcome development, but there is a surprising gap in the studies. Most of the effort is being focused on the assessment of technology itself, for the most part a highly technical and sophisticated enterprise. Almost totally neglected so far are comparable studies on how outcome data will be received in the clinic. To what extent will doctors pay attention to the studies? How will they respond when studies challenge deeply ingrained practices and attitudes? What will happen when outcome assessments begin posing serious moral problems for physicians as they feel pressured to adjust clinical practice? No one really knows the answers to those questions--questions that are, in any case, not much explored.

Yet unless the human setting and context in which the data will be deployed is studied with the same care as the technologies themselves, there is every possibility the data will be ignored, minimized, or even openly resisted on occasion. In that case, technology assessment would itself become one more failed technological fix, in great part because of a failure to remember that it is human beings who deploy technology--human beings who have many motives for behavior other than scientific evidence. Case examples, such as the high rate of electronic fetal monitoring associated with unwarranted cesarean sections, suggest that outcome data is overlooked and that other factors influence technology use.

An important project on technology assessment at the Center has been examining this issue in cooperation with St. Joseph's Hospital of Atlanta. In an unusually bold move, the hospital has welcomed the initiation of staff dialogue about and self-examination of its own response to outcome data. The Center's role has been to facilitate this dialogue and to help unearth the main worries and problems felt by physicians as they try to take account of new outcome data in their own practice.

The project was initiated in the fall of 1991 with a talk by Dr. Seymour Perry, director of the Program on Technology and Health Care at the Georgetown University Medical School, who described the emergence, the main thrust, and the politics of the technology assessment movement. In subsequent meetings with the staff a number of technological case studies were used, focusing in particular on those areas for which significant outcome data is available--and for which any gap between the results of outcome studies and actual medical practices could be compared. Among the technologies used as cases were: endarterectomy as surgical procedure to prevent stroke; the use of prostate-specific antigen to screen for cancer of the prostate; sigmoidoscopy to help identify colorectal cancer; mammography screening for breast cancer; and coronary artery bypass grafting in patients over the age of eighty who are suffering from coronary artery disease.

Our study group discussions have revealed a certain degree of ambivalence about the deployment of outcome data, and pinpointed clinical hotspots likely to be the source of expanded moral interest. On the one hand, most physicians are eager to know just how good their technologies are and what the most up-to-date studies show. On the other hand, they are not always certain just what to make of such data when they have it. Part of the problem is the ocean of facts about existing technologies--obtained from clinical trials, expert opinion, and insurance data bases--that is difficult to evaluate when much of it appears contradictory. What data should be followed and to what extent should the results of national studies be allowed to override a physician's clinical experience, which may point in a different direction? The ancient issue of whether medicine is a science or an art, or some combination of both, frequently surfaced in the discussions. An equally important source of ambivalence toward outcome data arises in an era of patient autonomy, when a patient requests technologies that are not patently ridiculous, yet are demonstrated to be only marginally beneficial by outcome studies. Must physicians accede to patient's wishes against the recommendations, for example, of practice guidelines? To what extent should legal worries, real or imagined, be allowed to color a reading of the scientific information?

Although we have not encountered many obstacles in our work at St. Joseph's, the literature reports many impediments--clinical, legal, or quasi-moral--to the good use of outcome data. They include: (1) a widespread fear of lawsuits if a full range of diagnostic tests (sometimes redundant) is not deployed, even if there is negligible evidence for their value; (2) a belief that the welfare of individual patients should count more than efforts to control costs; (3) an enticement to continue marginally beneficial technologies based on higher remuneration; and (4) a predilection toward established, conservative treatment even if recent evidence suggests that treatment to be questionable.

As the project at St. Joseph's Hospital and the Center continues, there will be a strong effort made to determine what better forms of education and communication can be developed to ensure that physicians rely on the best available data. There will be no less significant an effort made to examine the typical moral and legal worries raised by technology assessment to determine the extent to which they are well based and, if so, how we might better respond to them.

The project is also looking at institutional efforts to deal with the clinical response to technology assessment data. Dr. John Wennberg of Dartmouth Medical School, who has done most to demonstrate the great geographical variations in the employment of surgical and other procedures in this country, described to the St. Joseph's study group an interactive video program he and his colleagues have designed to help patients choose between immediate surgery and "watchful waiting" as a response to urinary tract obstruction (benign prostatic hyperplasia). Dr. Wilmer Rutt, director of the Center for Clinical Effectiveness at the Henry Ford Health System in Detroit, described to the group the effort at his institution to evaluate the new and highly expensive drug Centoxin (for the treatment of some forms of sepsis), and then to develop an institutional policy for its use. That was not an easy task, politically or morally, but the Ford system, aided by Dr. Rutt's center, was able to develop a thoughtful policy that recommends restricted use of the drug. Because Centoxin has an estimated one-time cost of $3,700, the policy advises that the drug be administered only to nonterminally ill patients who meet strict physiologic criteria for gram negative sepsis.

The Center's work with St. Joseph's Hospital will continue, with additional cooperative efforts with Dr. Rutt's center. This collaboration will be used to identify, to analyze, and to determine possible responses to the moral and quasi-moral obstacles that may impede the dissemination, acceptance, and implementation of outcome data. In addition we will continue to investigate background value factors that might influence the response to, and use of, technology assessment results. Our evaluation is intended to enhance the development of strategies such as educational programs and practice guidelines.--Philip Boyle, associate for medical ethics, and Daniel Callahan, director

The Scene at the Center

Only after the official commencement of spring did the late March snowfall bring New York its harshest moments of this year's winter. Even though much of Westchester county was immobilized by the blizzard, the research staff at The Hastings Center plowed ahead, breaking occasionally for a sledding run.

It is moments like these that remind autonomous, free-wheeling human beings just how dependent we are upon the natural world around us. With such ideas in mind, a Center research group considered the moral status of nature and how our vision of nature affects environmental policy formation. The Idea of Nature Project is a part of the larger program, Humans, Animals, and the Environment: Ethical Responsibilities and Decisionmaking.

A group of environmental philosophers, lawyers, and policy analysts came together to examine the long history of appeals to nature or the natural as a source for moral guidance. To what extent is it appropriate to use nature as a norm in philosophical deliberation? The Hastings Center, with its strength in bioethics, is joining forces with environmental experts to consider how concepts of health and integrity play out in both the medical and the ecological realm. How can we best call upon notions of health and integrity to illuminate our thinking about environmental problems?

The goal of the project is to develop a useful set of concepts and strategies for argumentation that will contribute to the process of public deliberation and policy formation on issues concerning the human relationship to the rest of nature.

At the February meeting, three case studies were examined that showed the complexity of the ways in which we think about the environment, how we decide which parts of nature are most important to preserve, and how these notions play out on the policy level.

One case chronicled a study by the U.S. government on the threat of acid rain to humans and the ecosystem, exposing the limitations of science particularly when attempting to use science in ways that allow policy makers to make good decisions. Another case study examined the evolution of the concept of wetlands, once known as swamps, and how the shift in this social construction is reflected in legislation concerning conservation. A third case study considered the compromises that went into managing the elk population in Yellow-stone.

These ideas were also examined at a workshop entitled Transgenic Animals, Philosophies of Nature, and Ethics, which was held in Amsterdam, the Netherlands, in early March as part of the Hastings Center's continued engagement with European bioethics. Fourteen European participants joined Center staff in an effort to enrich the ongoing project, Animal Biotechnology. Possible ethical problems in the genetic manipulation of animals have been discussed much more widely on the Continent than in the U.S., and the European scholars brought an array of philosophical perspectives to the workshop table, some of which are seldom encountered in American discussions.

Some majors questions were considered. How ought we to understand various uses of the notion of 'nature'? Is genetic manipulation of animals more or less natural than other kinds of interactions with animals? What are the implications for our understanding of animals of the emphasis on the genetic level of manipulation? What are the options for understanding the role of genetics in the overall nature of the animal, and how might these options affect our ethical understanding of what sort of respect animals are due?

Medicine and the Market

As health care costs continue to sky-rocket and the health care system consumes an even greater percentage of the Gross National Product, The Hastings Center has become increasingly interested in the changing nature of American medicine. A small research group considered these questions at an exploratory meeting for a project entitled Medicine and the Market. Is medicine becoming a business at the expense of its professional ethos?

At the March meeting, the group considered the nature and scope of the conflict between medicine's traditional altruistic nature and the growing financial interests permeating the field. A historian pointed out that physicians have always needed to make a living through their practice. What is different today is the sheer scope of the market and the expense of the technologies. Another difference is the unprecedented ability of modern medicine to save and maintain life.

An economist then described the nature of the marketplace. He described how fundamental the notion of commerce was to the founders of the United States and how such notions continue to be embedded deeply in the American psyche. Future meetings will attempt to delineate clearly the threat the market poses to medicine, examining the options for the profession and for business, and the implications of each of these options for medicine, the market, and society.--Julie Rothstein, research assistant
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Author:Boyle, Philip; Callahan, Daniel
Publication:The Hastings Center Report
Date:May 1, 1992
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