Winter 2006 Edition

January 18, 2006

The onset of computers in medicine a few decades back provoked Orwellian fears about doctors being replaced by machines. Today, of course, computers are everywhere, and doctors have survived. And yet there remains a persistent fear within medicine and society in general about an over-reliance on computers and other technologies, as if by too heartily embracing the future we might forfeit something essentially human within ourselves and cede control of our lives to machines.

This concern did not start with computers. It traces back at least to the dawn of the industrial age, and probably much further. British novelist E.M. Forster addressed this problem brilliantly in his 1909 story, “The Machine Stops” [1,2]. Forster envisioned a society in which the people have descended to underground quarters—one person per hexagonal room—where their day-to-day needs and desires are met by an all-pervasive, all-accommodating automaton, the Machine. With no reason to venture forth, people leave their rooms less and less frequently until, eventually, “egression” is prohibited by law. Early on, there are those who understand the Machine in its entirety, but as time passes self-serving managers proliferate at the expense of able mechanics, and there comes a crucial moment—the symbolically pivotal transition—when no one understands the Machine as a whole. The Machine assumes the stature of a deity, with the handbook a tome to be worshipped rather than understood. When the Machine stops, as Forster’s title portends, it is the cessation of the Machine rather than the Machine itself that is for the sub terrestrial residents, the weapon of mass destruction.

In Forster’s mind, it was excessive dependence on the Machine, rather than any inherent evil in the Machine itself, that led to the inability of people to function without mechanical aid and the ultimate dissolution of society. In other words, the citizens of Forster’s futuristic society could have maintained their human independence and enjoyed the marvelous benefits of the machine (including good medical care) had they only made a conscious effort to use it with wisdom and restraint.

“Render unto man the things that are man’s and unto the computer the things that are the computer’s,” the eminent mathematician Norbert Weiner once wisely admonished [3]. Sometimes, of course, it is hard to know where to put the boundaries. At what point does automation dehumanize? At what point does virtual reality destroy true reality? And in this era of high-priced medical care, technology is sometimes pointed to more as the problem than the solution; the machine, it is argued by well-meaning observers, is to blame for harmful practice and inflated costs. But in modern medicine as in Forster’s prophetic tale, it is the misuse and overuse of the machine that is at fault, not the machine itself. If a machine helps in medical care, and as a corollary, the benefits of its use outweigh the risks—the autoanalyzer, the CAT scan, and the MRI machine come quickly to mind—then it should be used if at all possible. If it is expensive, then we must do our best to find the funds to pay for it, while of course striving to reduce the costs.

The most pressing question now is not whether computers have a place in medicine (they unquestionably do), but whether this still-emerging field of cybermedicine will fulfill its potential for enhancing the clinical transaction, reducing errors of omission and commission, and improving the quality of medical care. The current struggle turns on the question of whether clinical computing systems are designed and implemented primarily for administrators or for doctors and patients. In other words, does the “M” in MIS stand for “Management” or “Medicine?” The answer to this question may well determine whether doctors and (most importantly) patients reap the full reward of this powerful technology.

Warner V. Slack, M.D.
Beth Israel Deaconess Medical Center
Faculty Member, Patient-Centered Computing and eHealth: State of the Field

References:
Forster EM. The machine stops. In: The eternal moment and other stories. New York: Harcourt Brace, 1928.

Slack WV. Cybermedicine: how computing empowers doctors and patients for better health care (revised and updated edition). San Francisco: Jossey-Bass, 2001.

Weiner N. God & Golem, Inc.: a comment on certain points where cybernetics impinges on religion. Cambridge, Mass.: MIT Press, 1963.

The views expressed in this article are those of the author and do not imply endorsement by The Robert Wood Johnson Foundation or the Health e-Technologies Initiative.