 Dan is the associate professor of medicine in the section of geriatrics and palliative medicine here at the University of Chicago. He's also an assistant director of the McLean Center and his interest in clinical medical ethics include the history of cardiac arrest and DNR and issues involving older patients and he has been one of the co-leaders of our ethics consultation service so it's my pleasure to welcome Dan. Thank you Peter. Everybody hear me? Yes. Good. I want to congratulate Mark on his recent honor from Hopkins and thank him for generously providing me with an intellectual home. Also like to thank the McLean's and Rachel Kohler for their commitment to the center. So today, so the inspiration for this talk came while reading Burruch Brody's foundational 1988 book, Life and Death Decision Making. On the very first page of the first chapter, which really is as far as I got, it starts off with the need for a moral theory. Brody begins with a fairly straightforward accounting of the new medical technologies, the triad of CPR, ICU and transplant. The tremendous scientific and technological advances of the second half of the 20th century have given physicians and other health care providers the ability to keep patients alive who would have died relatively quickly in the past. Successful techniques for resuscitating patients whose cardiopulmonary functioning has ceased for monitoring and responding to major organ failures in the intensive care unit and for transplanting kidneys, livers and hearts all exemplify the advances in medical knowledge and technology that have enabled patients to survive for a considerable length of time. So he then lays out a commonly held historical narrative that makes use of a term that became widely used at the time, the technological imperative. The initial response to these new capabilities was to use them in all cases with the hope of extending life even if the underlying problems of the patients could not be resolved. Experience with this fully aggressive approach eventually led many to the conclusion that it was excessive. Everybody, physicians and health care providers, patients and their families and the general public eventually came to accept the idea that the technological imperative which urges the use of these techniques on all occasions should be resisted. Out of that came the recognition arose, one of the fundamental problems of modern biomedical ethics. When to strive to preserve the life of the patient and one to simply allow the patient to die. I was going to practice this for the rest of the day, but now I have to give it today. So he situates the new field of ethics as applied to the medical endeavor as a remedy to the technological imperative of saving of lifesaving therapies. Today I want to interrogate this notion of the technological imperative, how it was used historically in the writing from that time as well as later secondary sources. So Tercier at UCSF has cast the role of advocates as blinded by the technological imperative of the new therapies of colluding in a modern fantasy of immortality and the denial of death. Another scholar Daniel Chandler had a less accusatory analysis of the technological imperative. The doctrine of the technological imperative is that because the particular technology means that we can do something, it is technologically possible, then this action either ought to as a moral imperative must as an operational requirement or inevitably will in time be taken. Just a writing in 2002, Hoffman wrote this paper on the technological imperative, how it is integrated into our reasoning in a wide variety of ways. There are actually many imperatives. The imperative of possibility in action, the imperative of command, the imperative of procedure, the imperative of demand, the imperative of the unknown, the imperative of means as ends, the imperative of implementation, the imperative of proliferation and the imperative of inappropriate use, which people would say applies to the life-saving technology when it's not going to work. Note that in these imperatives, the agent pushing the imperative is the technology itself. So looking more at this notion of the technological imperative and an early use of the term can be found in this monograph of the proceedings of a meeting of the TotsGap colloquium held in 1980. So this is the people who are in this TotsGap medical research laboratory. But more interesting were the participants in this meeting, who were some of the major players in the field of medicine as well as the history of medicine. We have Beeson, a riser, Howard Spiro, an early ethicist, and William Tisdale, a professor of community medicine at the University of Vermont. And in summarizing the meeting, Tisdale, the professor of community medicine, talks about medical technology and what they've talked about at the meeting, that it refers to techniques, drugs, and integrated systems of these elements that are considered useful in medical diagnosis, therapy, and monitoring. It has been noted by several of the speakers that the term, and all it implies, has to be viewed in historical, cultural, and scientific perspectives. As a thermometer was the elite high technology of one-to-looks time, so computerized axial tomography seems to be the prototype elite medical technology of the 70s. What has become abundantly clear by both assertion and implication is that the term imperative is all too appropriate. What began as simple tools and purely effective extensions of the physician's personal approach to the patient have, especially in the last 80 to 100 years, become intrinsic, self-propagated, requisite, and almost autonomous elements of today's biomedicine. So going back to, getting back to the historical narrative that these people are responding to, looking more closely at Brody's work, how he constructs this narrative, we can look at his citations. So the first citation about the initial response to the new technology being to use them in all cases, can you see it there? No, it's a little bit off, but it's all right. So what was that initial citation that he used? So he uses, although he initially said that technology involves CPR, ICU, and transplant, what he moves to is the use of CPR. And these are the two articles that are cited. And as people have heard me talk before, these are the first two papers describing closed chest compressions. What's interesting is that by the 1980s what actually happened has already been lost. If we look at the actual papers that Brody cited and that are often cited in this regard as examples of the technological imperative, we do see the enthusiasm which Brody notes introducing the papers that enthusiasm is indeed correct. This is that first paper that he's referencing. And the last sentence of the abstract is very enthusiastic. Anyone, anywhere can now initiate cardiac resuscitation procedures. All that are needed are two hands. However, but if we look at the success rate, which is a sentence prior to that, the use of the technique on 20 patients is given an overall permanence of viral rate of 70%. We see that they're obviously not applying this technique to everyone. They don't talk about that explicitly in the paper, but it's fairly obvious from their success rate, as we know. If we look at the second paper that he mentions, there are many more cases. But again, the vast majority of patients who undergo resuscitation are either in the operating room or immediately post-op or have sustained MI as a group early on recognized as being amenable to resuscitation. There's a small miscellaneous group that's not further characterized, but there's good evidence that these people were not, did not include everybody who was actually dying in the hospital. The evidence from that comes from the only clinician in that group, two of the people in that group are electrical engineers. The only clinician was James Jude, and he was the one who was actually doing the resuscitations of those people, and he was actually a cardiac surgeon. And he goes on to talk about the indications for CPR in the first manual that he wrote with James E. Lam. If we see here, this is the introduction. And number one in the introduction, he states, quite clearly, the patient must be salvable. Cardiopulmonary resuscitation is indicated for the patient who at the time of cardiopulmonary arrest is not in the terminal stage of an incurable disease. Resuscitation measures on terminal patients will at best return them to the dying state. The physician should concentrate on resuscitating patients who are in good health, preceding arrest, and who are likely to resume normal existence. If we see here, just to remind you, you see the time magazine there. I've described these pictures in a previous paper when I talked about nurses and the CPR, the cardiac arrest paradigm, and the role of nurses that these pictures were actually taken from actual photographs. And part of the proof of that is if you look at the time magazine there, that's actually that time magazine from April 30th, 1965. So in the mid-60s, Jude was actually, the father of CPR was actually talking about not doing it, that you don't do this therapy on everybody who dies. And I actually had the honor of interviewing James Jude, who since died, back in 2010, and we were talking about that second paper on which he was the first author. And I show this interview not to say that this is how CPR should be administered, but to say that Brody and the canonical early history of CPR is simply wrong. They were not doing it to everybody. If we look then at the second reference, so we see that the initial recommendation by Jude, the first practitioner of what would become CPR was not to use it in all cases, but then we see something sometimes afterwards, as Brody described it, that they developed this fully aggressive approach and led many to the inclusion that it was excessive. Sometime after Jude's description of the indications for CPR, something changed. So in the second end, though, justifying the statement about resistance of the technological imperative, we see a group of papers that start in the 70s, and the first paper is this optimal care for the hopelessly ill patient. And this paper was published with the three other papers on end of life care that came out with an editorial entitled, Terminating Life Support Out of the Closet. And this was an important issue in the New England Journal of Medicine. It was, they were able to publish this because of the way discourse opened up after the Quinlan case, and they described what was going on in their hospitals. Actually, the more interesting paper, I mean the one that Brody cites is sort of an arcane paper by the MGH, what they were doing in their ICUs in terms of classifying patients with how aggressively to care for them, including CPR. But really more interesting to the whole notion of the technological imperative is this order not to resuscitate that came out the second paper, which I've shown before as well. This is a paper by Mitchell Brody and two lawyers that introduces the notion of patient autonomy as it relates to resuscitation decisions. Prior to this, the order not to resuscitate was a strictly medical decision. And again, his history is again interesting. Having witnessed impressive medical developments over the past 25 years, the health care community is now confronted with complex questions arising from the interplay of two such developments, the technological advances and the increased emphasis on the patient's role and decisions concerning his own health care. There is growing concern that it may be inappropriate to apply technological capabilities to the fullest extent in all cases and without limitation, basically the technological imperative. Moreover, increased awareness of the rights of patients to be treated in accordance with their own decisions and expectations means that the use of heroic measures to sustain life can be justified only by adherence to the dictates of those sounded medical practice and the patient's right to elect or decline the benefits of medical technology. So we see here that by 1976, the default for CPR is solidly in place. And the question is, what happens? Besides what happened? Besides the imperatives, which, you know, technology does have some force of use, we need to remember that it's actually, you know, practitioners who are the agents of the technology. Technology is not an agent of itself. And one of the things that I've talked about in the past and that is directly temporally related to the development of the default is the listing of CPR for cardiac arrest in the second edition of the current procedural terminology. This is paradigmatic of third-party payment system that in the 1980s, some were intimately aware of. And the person I'd like to quote here now is from that technological imperative conference that was held in 1980 and published in 1981 by Howard Spiro who had this interesting insight because in 1980 people could still remember a time before CPT and the change in sort of how people were practicing using the technology. So Spiro starts off by, I have the prejudice that we will never catch up with technological assessment because technology is advancing so rapidly. He's mostly talking about endoscopies because he's a GI guy. It is like the tortoise and Xenos paradox. You can never catch up. Therefore my prejudice is that we ought to focus more on the individual practitioners that we represent and on the reimbursement schemes that motivate us rather than trying to compete with the machines. For example, we are all encouraged to do more in the way of technological activities today than 10 or 30 years ago simply because the third-party payers pay for technology and not for thinking. When you talk with the officials, they point out that it is easy to assess the cost of the procedure but difficult to assess the cost of a thought. And I thought that was pretty prescient. So then the question is, out of that recognition arose one of the fundamental problems of modern biomedical ethics, when to strive to preserve the life of the patient and when to simply allow the patient to die. So how is this to be decided? The principles of ethics that ethics brought have been repeated many times in this conference, beneficence, non-maleficence and respect for persons or autonomy. This last principle, autonomy, became the dominant one in opposing the technological imperative or as Tizzle called it, the almost autonomous elements of today's biomedicine. So I showed this paper not because it's an accurate description of the derivation of the autonomy principle that ethics brought to medicine. In fact, it's probably wrong according to my philosopher friends. But because it contains the vestiges of the argument about how decisions should be made as it makes the case against the newly instituted autonomy model. So what I found really interesting about this paper written in 1983, similar time of the monograph and also Brody's writing, is that they're more interesting than their critique of autonomy replacing ethics based on naturalistic norms, is their call for a return to traditional medical values, which provides a really interesting perspective of thinking at that time. So we see here, they're listing of what they're calling for traditional medical values, which they're afraid have been lost. This is a paper written by a philosopher and a physician. So the basic notion of this, there are scientifically determinable norms, homeostatic mechanisms and physiologic and psychological criteria for functioning of the human organism. And this notion I think is sort of evolved into the whole idea of evidence-based medicine. Then reading two I think is very interesting. What ought to be done in case management is determined by the facts of the situation. And I think it's interesting to remember here that in 1983, putting quotes around something is different than when we put quotes around it now. These are not scare quotes questioning the validity of these statements. These are quotes that show that these are important, significant facts. Now I think we think that these are somewhat dubious, like just who determines what the facts are, what are the choices, and who decides. So number three, the physician's role is to restore as far as possible normal functioning, the whole basic notion of what is health. For the role obligations, this role obligation holds in the physician-patient relationship, of course, primary to good doctoring. And number five is really interesting that this is written in 83. This role obligation involves caring for the patient, in some cases, even over his objection for his best interest. So I think it's pretty interesting that 33 years ago, people were still advocating for this. And so that autonomy has obviously an important concept in that patients should be able to refuse therapies like this. But that autonomy has sort of the notion has gone a little bit beyond that. So the question then is, well, so what are the shocking conclusions of my talk? That's like a shock. So the technological imperative invoked to explain the persistent application of ineffective therapies lacks historical validity. It comes from a little bit of forgetting what actually happened in the 60s. Instead, a constellation of forces created the default application for a variety of therapies. The perception of the almost autonomous elements of today's biomedicine was countered by a move towards patient autonomy. And the question then is, if technology is actually not autonomous, how should decisions about this technology be made? Thank you.