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27/08/2022
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Financial concerns-and desires-have also affected the mix of services offered by voluntary and for-profit hospitals. Rather than fighting managed care insurers over which treatments and services the insurers will cover, these hospitals now increasingly offer extra services that patients are willing to pay for out of pocket such as yoga, meditation, and massage (Abelson and Brown, 2002; Rosenthal, 2017). Meanwhile, the search for profits has encouraged these hospitals to offer new, technologically intensive treatments and tests even if evidence of their benefits is weak and other nearby hospitals already offer them. The result has been a proliferation of expensive technologies such as magnetic resonance imaging machines, intensive care units, and open-heart surgical suites. Conversely, many hospitals have closed, shrunk, or outsourced money-losing units such as obstetrics wards, emergency departments, and psychiatric units (Rosenthal, 2017). Finally, an astounding number of hospitals have merged in recent years. By so doing, they have essentially created monopolies that allow them to set whatever prices they want for services because there is little or no competition (Rosenthal, 2017).
At the same time, as voluntary and for-profit hospitals have shifted toward providing more intensive care for middle-class Americans, public hospitals have increasingly become primary care providers for the poor. Patients who have neither health insurance nor money to pay for care sometimes turn to hospital outpatient clinics and emergency departments not only for treatment of acute problems such as gunshot wounds but also for chronic problems such as backaches.
The Social Construction of Technology
In the same way that we talk about the social construction of illness, we can talk about the social construction of technology: the process through which groups decide which potential technologies should be pursued and which should be adopted. This concept in turn leads us to question who promotes and who benefits from the social construction of any given technology.
Like the social construction of illness, the social construction of technology is a political process that reflects the needs, desires, and relative power of various social groups. These groups can include manufacturers, physicians, the government, and consumers. As a result, harmful technologies are sometimes developed and adopted, and needed technologies sometimes are not.
The history of cardiopulmonary resuscitation (CPR) offers a fascinating example of the social construction of technology. The purpose of CPR is to restore life to those whose hearts and lungs have stopped working. In earlier times, the very notion of such resuscitation would not have made sense to doctors or the public. Death was considered to be in Gods hands, and dead was dead. But since the rise of modern medicine, doctors have struggled to find ways to restore life to those who die suddenly.
At the same time, doctors have grown increasingly able to understand the slow trajectory of dying associated with cancer. And with the rise of the hospice movement (described earlier in this chapter), both doctors and the public have come to hold as an ideal the good death in which an individual comes to terms with his or her dying, makes peace with family and friends, and receives appropriate terminal care to minimize physical and emotional suffering.
None of this, however, applies to the sudden-and-common-deaths caused by stroke or heart disease. In his award-winning book Sudden Death and the Myth of CPR, sociologist Stefan Timmermans (1999) argues that CPR and associated resuscitation techniques have become part of American medical culture because they appear to offer a good death in these circumstances. Innumerable television dramas portray heroic doctors who save apparently dead patients through CPR, and millions of dollars have been spent in teaching the general public to perform CPR and outfitting community emergency response teams and hospital emergency rooms with resuscitation equipment (Lidhoo, 2012). Yet CPR almost never succeeds except when healthy individuals drown or are struck by lightning. The typical person who receives CPR has at best a 1% to 3% chanceand probably much lessof surviving, at an estimated cost of $500,000 per survivor. Moreover, survival may be brief and may be accompanied by severe neurological damage (Warraich, 2017). As a result, surveys suggest, almost no doctors want CPR performed on them if their hearts should stop (Periyakoil et al., 2014).
Why, then, has CPR become so widely adopted? Timmermans argues that the widespread use of CPR reflects modern Americans discomfort with death. The real benefit of CPR, according to Timmermans, is that it takes some of the suddenness of sudden death away (1999:110). CPR allows families and friends to believe they have done everything possible by getting their loved ones to treatment as fast as possible. It also gives families and friends time to gather and to recognize that death may be imminent, and it gives medical personnel a sense of technical accomplishment as they fight to keep their patients bodily organs functioning as long as possible. The use of CPR, then, is part of the broader project of death brokering: the process through which medical authorities make deaths explainable, culturally acceptable, and individually meaningful such as through pain management, death counseling, or the gradual removal of life supports from dying patients (Timmermans and Berg, 2005). For these reasons and despite all its emotional and financial costs, CPR has become a valued and expected ritual in American culture.
At the same time, adoption of CPR illustrates the economics and politics as well as the cultural forces that underlie the social construction of technology. CPR would not have been so widely adopted if corporations had not had a vested economic interest in promoting it. Nor is it likely that CPR would have become the norm if corporations had been required to demonstrate its effectiveness before selling it. In fact, however, there are almost no legal requirements for manufacturers to demonstrate the safety or effectiveness of technical devices, so they rarely fund such research. As a result, doctors must depend on promotional materials from manufacturers and on their own clinical experiences in deciding whether to use a technology, and patients must rely on doctors judgments.
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