“Technology is not demonic, but its essence is mysterious.”
This paper forms part of an ongoing project, the aim of which is to incorporate physiological sensing technologies (1) into consciousness studies and creative technologies.
Physiological sensor technologies are tools that allow their users to magnify, focus upon and amplify certain aspects of human bodily function. Whilst these technologies find application in a range of domains, predominantly, their use is informed by biomedical science and medical practice.
These fields (2) incorporate a model of the human subject (Samson, 1999) which is unsuitable paradigmatically for the purposes of this work. Instruments such as the electrocardiograph and plethysmograph as tools of western bioscientific medicine may therefore also be seen to embody certain attitudes towards the human subject.
Physiological sensors have much to offer for the exploration of the reality of the human body, experience and consciousness, and also applications in the arts (Rosenboom, 1976), (Brouse et al, 2006). Applications such as biofeedback offer the subject an opportunity to experience the body in new ways or enhance perception. However, a disparity arises when phenomenological engagement with bodily experience is then mediated by medical instrumentation if it embodies a biomedical discourse which has been criticised for its exclusion of the human subject. To proceed, this paper aims to clarify the nature of this mediation by examining relevant critiques of biomedical models of the subject and their relation to instrumental technologies, suggesting possible solutions to explore in further work.
EXTERNAL CRITICISM OF BIOMEDICINE
Biomedicine has been subject to criticism from a range of academic disciplines, in particular from practitioners and scholars of alternative medicine and CAM (Complimentary Alternative Medicine). In Complimentary Therapies in Context: The Psychology of Healing (1990), Helen Graham’s opening chapter is an astringent enumeration of the risks associated with the dominant western medical system such as the misuse of and over-reliance on drug therapies, invasive and unnecessary surgery, and the statistical dangers of hospitalisation. She cites Lynne McTaggart’s What Doctors Don’t Tell You;
“If you live in the US…. you are nevertheless three times more likely to be killed by a doctor than by a gun.” (McTaggart, 1996).
Graham’s attack draws upon Ivan Illich’s work Medical Nemesis, (1976) a text focussing on the the power of society to resist the effects of on the phenomenon of iatrogenesis, medically induced illness (from the Greek iatros, healer; literally meaning ‘brought forth by a healer’). In medical anthropology the main criticism of western healthcare is based around the claim that an objective conception of the body is neglectful of the phenomenological aspects of illness experience. Byron J. Good’s (1994) studies of medical training methods conclude that ‘medical knowledge consists of an objective representation of the diseased body’ (p.116). Whilst he acknowledges the effectiveness of the biomedical view, in some cases, such as childbirth or chronic illness these accounts abstract ‘physical objects and physiological processes from social and meaningful phenomena’ (p.117). He cites the condition of chronic pain as ‘largely unintelligible’ (p.117) within the tenets of biomedicine as a phenomenon that is situated entirely within human experience.
Health psychologist Alan Radley (1997) takes a similar perspective, biomedicine takes as ‘axiomatic the need to objectify its subject matter’. He comments that the simultaneous definition of the ‘reality of disease’ and its treatment by medical authorities reinforces the ‘popular conception’ that human bodies are ‘physical things’ or ‘machinery that goes wrong’ (p.51). Nursing Philosophy is a field that finds itself describing a split between responsibility to patient care and the scientific context in which nursing operates(Watson. J. & Smith, M. C., 2002). Caring science incorporates an imperative to provide holistic care, which includes addressing the spiritual needs of patients. However, Dyson et al. (1997) cite the ‘adoption of the scientific paradigm by the nursing community’ and the increased reliance on technology in care as challenges to the ‘significance of spirituality’ (p.1184).
CRITICISM FROM WITHIN BIOMEDICINE
As shown above, there are a number of disciplines which comment on problems relating to the epistemological grounding of biomedicine in materialism; reductivism and objectivism.
Psychoneuroimmunology and somatic medicine are two research fields within biomedicine that seek in some degree to reincorporate subjective understandings of disease. Psychoneuroimmunology is the interdisciplinary study of the bi-directional interactions between psychological factors such as stress and the complex behavior of the immune system (Ader 1995). This study re-invests the subjective reality of the patient with significance in the understanding and treatment of disease. Somatic medicine is an approach to medical practice that seeks to integrate psychotherapy with conventional biomedicine. It foregrounds the interdependence of psychological factors with physical manifestation of illness and models the causes and experience of illness as an emotional story (3) (Broom, 1997).
James Lynch’s research into the medical effects of emotional states such as loneliness on cardiac health (1979) and studies of patients cardiac responses to human contact in coronary care units in the 1970’s (1999), demonstrated that neglect of the internal experience of the patient could have very real consequences for health. His paper Human Contact in Life-Threatening Environments (1999) makes his thoughts on scientific understanding of the subject very clear;
“Sitting in such units as observers, we could monitor this essential aspect of life… we could literally look into the very heart of human relationships… this remarkable technical capacity also made it clear how limited a scientific view of human relationships really was…There simply is a limit to science.” (p.86).
However, the main ‘limit to science’ that Lynch seems to describe is embodied within the instrumentation used to monitor the patients rather than the attitudes held by the medical practitioners working with them. Even noting the ‘remarkable capacity’ of the instruments, the human relationships that are so clearly manifest to the people working within the cardiac unit are obscured by a combination of experimental controls and the limitations of the recording devices. As we have seen, it is possible to identify methodological and pedagogical factors in western medical tradition that may be criticised as inefficient. It should be noted here that objectivity has provided in many cases a sound basis for the biomedical approach to understanding and treating disease. The examination of evidence through the adoption of the empirical, scientific method, has led to the reduction in mortality from a mass of diseases and the near elimination of some extremely common killers; such as tuberculosis and cholera (Porter 1997).
Critics often argue for the superiority of alternative or traditional medical approaches to patients and their bodies. In practice, medics are criticised for their dismissive attitude towards the psychological aspects of disease and illness experience. The common feature of these analyses is that their claim that the biomedical approach is reductive and materialist; concentrating on specific parts of the organism or on specific pathologies and treatments, and excluding elements of discourse that might refer to the effects of the non material such as psychological effects or causes for illness.
For the past twenty years there has been an increasing adoption by health consumers in the west of alternative and complementary medicine; a move which has now been accepted and on some fronts supported by the biomedical establishment. A considerable percentage of UK GPs now offer referrals to complementary therapists, and in 1990 the number of visits to ‘unconventional healers’ outnumbered those to primary care physicians by approximately 37 million (Porter, 1997; p.668). The approaches used by alternative practitioners can be seen to address the problems described by critics and patients above.
The terms alternative and holistic medicine can refer to a wide range of healing traditions, some are characterized by their non material view of the body such as energy and spiritual healing or meditation. Others, such as herbalism, aromatherapy and acupuncture are based on a more material view of healing, but still may not have been validated experimentally in biomedical terms.
In contrast to the narrow biomedical model of the body as a wholly material entity, many alternative medical and therapeutic traditions attempt deal with the human subject in an holistic fashion. In these practices ‘individuals are seen as singular wholes and as constituent parts of some larger reality’ (Frohock, 1999; p.151).
Alternative therapies utilise a range of different metaphors in their interactions with the body, such as energetic, vitalist, computational or networked (Agdal 2005). Commonly they stress the interrelationship of mind and body within the understanding of health. However, they can still be seen to encompass methodologies of cause and effect, encompassing approaches which are ‘alternative’ but still in some cases themselves analytical and reductive models of the body.
Stanley J.Reiser (1993) points out that the major issues regarding biomedicine discussed above are related to the use of physiological instrumentation. He traces the replacement of the senses of physicians in medical diagnosis, resulting in a loss of contact and dialogue between them and their patients, to the development of technologies such as laboratory tests, physiological monitoring, and imaging technologies (p.262).
Nursing philosophy has attempted to address the negative role of instrumentation within the context of patient care itself, in response to tensions such as that described above by James Lynch in the technologically saturated environment of the Intensive Care Unit (ICU). The thought of Martin Heidegger and Don Ihde, who apply phenomenology in the philosophy of technology, (Walters, 1995) has provided scholars in this field with a framework in which the relationship of practitioner, patient and technology in the real world setting of the ICU can be examined. Two empirical studies by Sophia Almerund et al. (2008) reported in Beleaguered by technology: care in technologically intense environments describe the problem thus;
“Despite being constantly monitored and observed, intensive care patients express that they feel invisible as people, reduced to the status of organs, objects, or diagnoses…While demonstrating keen vigilance over technoligcal devices and measured parameters, caregivers pay scant attention to patients’ timid attempts to tell stories and share experiences” (Almerund et al., 2007, p.56).
Taking the popular example of the ‘ready to hand’ hammer from Heidegger (1962) who suggested that a well matched ‘tool’ becomes an invisible extension of the user, Almerund suggests that the technologies of nursing practice resist being embodied by care staff. She goes on to observe that the ‘numerical and graphical forms’ of technological information made available by instrumentation technologies which encourage caregivers to approach the physical body as something ‘measurable’ or ‘predictable’ (p.58).
This mode of technology relation is described by Don Ihde (1993) as a hermeneutic relation, incorporated by the user cognitively, rather than an embodied relation, (p.112) where the tool becomes ‘phenomenologically transparent’ (Almerund et al., 2007, p.59). This transparency means that the tool itself does not divert attention from the focus of activity. Almerund concludes however, by suggesting that this the resolution to this issue lies with care givers themselves, through the act of doing things ‘thoughtfully’ and finding ‘self aware approaches’ to their interactions with patients and technology, rather than a modification of the technology itself. Whilst a move from hermeneutic to embodied relations for physiological sensors might be suggested by Almerund’s work, it is valuable here to examine the historical precedence for instrumentation where the ‘analogue is to reading and language rather than sensory perception’ (Ihde, 1993). The post enlightenment appropriation of scientific instruments and the experimental method into medical practice was partly motivated by physician’s desire to make objective examinations of disease entities; avoiding the uncertainties of observer bias on the part of the physician, and the difficulty inherent in training students to correctly perceive subjective evidence of illness from direct examinations of the body (Kuriuyama, 1999), (Reiser, 1993), (Porter, 1997).
Scientific instrumentation also offered a superior authority, allowing those within the scientific disciplines to ‘make claims about reality that were not easily tested by non-professionals’ (Punt, 2000; p.140). In this sense diagnostic testing, and physiological instruments and record making become an extension of Foucault’s ‘clinical gaze’. (Samson, 1999)
The historical debate amongst physicians regarding objective diagnosis is exemplified by discussions of pulse taking and the unreliable nature of semantic description of the pulse. Instrumental and numerical rather than descriptive records of the behavior of the body presented a remedy to this dilema. The activity was narrowed from the taking of a reading that Galen might have described fancifully as ‘anting’ or ‘gazelling’, through to descriptions of ‘strong’ or ‘weak’ pulses, down to numerical methods of counting the beat of the pulse itself (Kuriuyama, 1999). The use of mathematics to record and describe elements of human physiology is now the prevailing technique throughout biomedical methodology, and integral to modern medical sensing (4).
Holistic medical models
The limitations of bioscientific epistemology appear to have been answered in medicine by a move towards alternatives which hold holistic accounts of the body. Could an holistic or subjective approach be incorporated into the existing understanding of bodily systems presented by instrumentation, or into instrumentation itself?
The project title, ‘Gestalt Biometrics’, relates to the intuition that gestalt presentations or perceptions of body state data could be a revealing alternative to reductive and narrow forms of physiological monitoring. Following an holistic model, there is a potential to combine information from multiple data sources, resulting in integrated and relational representations of general body states, rather than the functions of individual organs and their correlates.
Hermeneutic or embodied relations
The concept of a ‘phenomenologically transparent’ tool may suggest that alternative, embodied, interfaces for physiological sensors as an alternative to hermeneutic, objectifying interfaces. However, in the case of nursing and medicine, current technologies which provide patient data are still reliant on analysis and processing by technicians. It may be the case that further development of expert systems which deal with this information will further free caregivers from this onerous and absorbing task of maintaining the machinery which monitors their patients, and to embody more natural interactions with the patients themselves.
Subjective models of the medicine body and the ‘ineffable’
Kuriuyama’s (1999) comparative study of the development of pulse taking in Western (Greek and European) and Chinese medical practices juxtaposes the debates amongst European physicians who lamented the lack of objective measurement and description of the pulse, with the ancient Chinese tradition of Qiemo where the pulse is described in entirely figurative language or in beautiful, yet abstract pictograms (p.73). Contemporary Chinese commentary on the practice acknowledged the problems caused by the subjective and ‘ineffable’ quality of pulse reading, however, the practice still flourishes today.
Kuriyama suggests that the seemingly opaque descriptions in the Qiemo literature may be so because of the entirely subjective nature of the pulse taking practice, and so figurative descriptions may be more suitable (p.98). He also contrasts the later western tradition of anatomical dissection in the west, where models of bodily function and treatment methods followed the internal structure of the body. In contrast, the Chinese system of the mo follows maps of subjective experience of treatment upon the living body. It is for this reason that they do not appear to correlate to the ‘anatomically correct’ understanding of Western traditions. Evidence that a medical system based upon subjective knowledge of medical experience, described in terms of the ‘ineffable’ rather than the objective suggests a route for investigation of alternative methods for display and weighting of information from physiological sensors and for physically interacting with instrumentation.
Biomedicine has been widely criticised for its denial of the subject in medical reality, which results in certain forms of illness (such as chronic pain) appearing irreconcilable with its claims about reality. The biomedical project has historically achieved the understanding and control of a complex of diseases; but in recent years there has been a dramatic increase in patients seeking alternative and traditional medical treatments which incorporate non-materialist epistemologies.
The reductive/hermeneutic approach to understanding the body was an outcome of a persistent quest for objectivity in recording and measuring the body. This technology is one outcome of the project to remove the subjective qualities of patient examination and the inherent risk to physician objectivity. For this reason it results in the objectification of the patient as a collection of bodily functions, detached from the internal experience of illness. Physiological instrumentation which developed as part of this shift towards the biomedical world view has also reduced patient-physician contact time and reinforced a more general mechanistic conception of the body.
It would seem that the inherently numerical and digital nature of physiological sensing technology reinforces the limitations of bioscientific epistemology. In addition to this, what we might understand to be hermeneutic technological relationships intervene to distance technology users such as care staff from patient subjectivities by demanding attention.
Analysis of the issues relating to biomedicine and its tools reveals suggestions for some constructive responses to these issues. In considering how they might be incorporated into future use of, or modifications to, physiological sensing technologies it is important to note the complex nature of the technologies not as simple tools in themselves, but as part of a larger technoscientific apparatus.
It may be that problems relating to the relationship of subjectivity to medical technologies represents an inherent bias which will limit their use in disciplines where integrated models of the subject are used and phenomenological accounts are prominent. To address this, this project aims to re-asses the nature of physiological sensing by incorporating new models of body state and bodily reality.
(1) Modern physiological sensing technologies constitute a range of sensors combined with digital computing that measure the function of various systems and organs of the body.
(2) The term ‘biomedicine’ is used in sociology to define the branch of western medicine with roots in the European Enlightenment, ‘predicated on a materialist and biological conception of the human body’ (Samson 1999).
(3) Broom (1997) reports a number of case studies of patients whose organic illness was treated with psychotherapy. He offers a prismatic (three sided) model of the patient. This prism is sided by somatic, psychological and spiritural elements, and each side has its own projection, language, physical or taxonomic; each dealt with by different disciplines. Within the prismatic form is the emotional story of the patient, which might manifest in any of the three projections.
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