When we hear the word technology, we tend to think about computers, software, artificial intelligence, etc. But one form of technology that we tend to overlook has been a part of our lives for centuries: pharmacy. Jeffrey Bishop, MD, Ph.D, Tenet Endowed Chair of Bioethics and Professor of Philosophy, Health Care Ethics and Philosophy at St. Louis University, joins the show to discuss how we can think critically about pharmaceuticals as technology. He discusses the etymology of the word "pharmacy," shares how power dynamics play into the decisions we make and offers advice on how to make sound, informed decisions about the drugs we take.
When we hear the word technology, we tend to think about computers, software, artificial intelligence, etc. But one form of technology that we tend to overlook has been a part of our lives for centuries: pharmacy.
Jeffrey Bishop, MD, Ph.D, Tenet Endowed Chair of Bioethics and Professor of Philosophy, Health Care Ethics and Philosophy at St. Louis University, joins the show to discuss how we can think critically about pharmaceuticals as technology. He discusses the etymology of the word "pharmacy," shares how power dynamics play into the decisions we make and offers advice on how to make sound, informed decisions about the drugs we take.
Brian Reardon (00:07):
Welcome to Health Calls, the podcast of the Catholic Health Association. I'm your host, Brian Reardon. And with me as always is Josh Matejka. Hey Josh.
Josh Matejka (00:15):
Hey Brian.
Brian Reardon (00:16):
So on this episode, we're continuing the theme of technology and humanity, but we're going to take a little bit of a different angle. We're going to bring in a minute. Dr. Jeffrey Bishop, he's with St. Louis University, and we'll introduce him formally here in just a moment. But Josh, to start off with, we spent a lot of time talking about digital technology this season, particularly artificial intelligence. We've talked about data gathering and analysis, various softwares, but we're, I think in this episode, looking to expand on that definition a little bit. Can you set the scene for us?
Josh Matejka (00:46):
Yeah. So as listeners will see, I should say, when we get into our conversation with Dr. Bishop who teaches ethics and philosophy, there's almost a more philosophical bent to this conversation. We tend to get so cornered into when we say the word technology, we immediately have these assumptions of what that means. It's artificial intelligence, it's the latest, I don't know, robot stocking the shelves at our local supermarket.
Josh Matejka (01:14):
But technology is way bigger than that. It always has been bigger than that. And pharmaceuticals are a form of technology and a really important technology that pretty much everybody participates in on a day-to-day basis and drive a huge portion of our healthcare delivery. And so we brought Dr. Bishop in is because we want to start thinking about how the conversations we're having, how the flourishing of humans and dignity for all people apply to this very prevalent technology in our lives. And I think this conversation where Dr. Bishop and we're going to talk about what is good, what is bad, what is natural versus unnatural, and how do all these terms kind of coalesce into a better way of thinking about pharmaceutical technology is really helpful and probably something that our listeners don't think about a lot in the care delivery continuum. So I'm really excited to hear what Dr. Bishop has to say because obviously with his many titles, he's very smart and he's very helpful in helping us think about this in a more nuanced way.
Brian Reardon (02:15):
And I think that's what we want to do is give this topic a thought. Because again, like you said, we don't always think of the drugs that are prescribed by physicians as being technology, but we know how rapidly the pharmaceutical industry is moving. So without further ado, let's bring in Dr. Jeffrey Bishop. He's the Tenet Endowed Chair in Bioethics, Professor of Healthcare Ethics and Professor of Philosophy at St. Louis University. Dr. Bishop, welcome.
Dr. Jeffrey Bishop (02:39):
Thanks for having me.
Brian Reardon (02:40):
So the first question we kind of teed this up was with your background as a bioethicist and a professor of philosophy, you give us kind of a nuanced perspective when we talk about pharmaceuticals. And I think when we talked earlier, nuances in what you generally associate with that field. People tend to maybe fall on the side of prescriptions as being good or natural remedies are good or bad. Can you walk us through why this perspective maybe isn't helpful to put natural versus sort of the prescription thing of medicine into two buckets like that?
Dr. Jeffrey Bishop (03:14):
Yeah, let's take a little step back for a moment and think about how technologies are often thought of as being artificial. They're usually thought to have be some sort of tool that a person who wants to do something takes a tool and then makes something happen with that tool in the world. And normally we think of tools as things like hammers or things like robots or things like maybe an artificial intelligence. But if you have this broader definition, then you start to realize that, oh, if I'm taking an herb and I'm grinding that herb up and I'm brewing it in a tea and then trying to get those elements that are in that herb into my body to do certain kinds of things for my body, say to cause me to be more healthy, that too is a kind of technology. And so on the one hand, we think of technology as these kind of discreet tools. We don't think of these things like herbs and plants and things that we eat as technologies. We often think of technologies as the things that accomplish what we intend them to accomplish. And we sort of have a straight line that goes from my intention through my body to the hammer to the hitting of a nail. And there's a straight line that goes there and that we think of a technology as kind of creating this straight line.
(04:44)
But there's a couple of other things that could happen. When I'm using that hammer, I might strike the nail and hit it kind of at an angle and break it off. And then that means that my intention of driving that nail in now has been distorted because I've used it in a way that I should have used it and yet something bad still happened. So that's one way that the tool does more than I intend, right? It's reaching into the world. It also changes me. The hammer does, right? The hammer changes me because now I'm using my arm to swing and to hit that nail. And then the use of that hammer is reverberating back and it's making my right hand stronger. So there's another kind of effect. So there's the effect. I intend there are the potential effects I don't intend, and then there are the effects that I'm not even being aware of, namely the effect that it comes back to shape my arm, to make my right arm stronger than my left arm.
(05:43)
And it might even lean to my right side hurting more or being malaligned because the muscles are hypertrophied over here as opposed to let's say my left arm, which I'm not using. And then there's another effect that technology has on us. It has an intellectual effect such that if I see a screw sticking out and I don't have a screwdriver, I come to think, aha, I can use my hammer to hit that screw. So the hammer itself changes the way I perceive the world. So there are the multiple kinds of effects that technologies have, and we tend to just think, well, I just intend this one thing and occasionally there's some bad things that happen. I just have to worry about the one good thing I'm doing and hope that the bad things that might fall from it don't happen.
Brian Reardon (06:28):
And in Catholic healthcare ethics, a lot of folks listening are going to be familiar with the term, the double effect.
Dr. Jeffrey Bishop (06:34):
That's right.
Brian Reardon (06:34):
And so intent in this case, and I really like the hammer analogies, we're thinking about the use of pharmaceuticals. The intent may be good, but the outcome could be something completely different.
Dr. Jeffrey Bishop (06:47):
So with things like pharmaceuticals, particularly, there are not just good effects and bad effects, there are desired effects and undesired effects. And the think about pharmaceuticals particularly, it's really hard to tell. And let one point pharmacon itself in ancient Greek actually meant a pharmacon was both a remedy, a medication, but also a poison.
(07:20)
And the word it carries both of those meanings at the same time precisely because things like medications carry both of those things at the same time. It's a potential remedy but also a potential poison. So every medication we give, there are the things I hope it does that we hope will be good for you. And there are the things that I hope won't happen, but I can't necessarily prevent those things from happening. Once it goes into the system, it kind of has its effects. So it's really hard to say good effects and bad effects. And it's probably a little bit of a misnomer to talk about the rule of double effect because it's not just these two effects. There are multiple effects, some of which have good consequences, some of which would have bad consequences, some of which I intend, some of which I won't intend, all of those kinds of things.
(08:12)
And so the rule of double effect is kind of a simplified version of dealing with the fact that when we act in the world, we're not just acting with a good thing in mind that the good effect we hope for or the bad effects we hope for, or the intended effects that we hope for, or the unintended effects that might fall from it. Anyway. So the rule of double effects is kind of a misnomer because it kind of overly simplifies a very, very complex world. But again, it's a rule and rules are often simplifications. So that's exactly what the rule of double effect is designed for, is to help us think more carefully through the various kinds of things we can do with our tools. And in this case, it's the tools of pharmaceuticals.
Brian Reardon (08:56):
All right. I'm going to pull another concept in. You've written about pharmaceuticals a lot, and one of the interesting concepts that we noticed is you've raised about how power dynamics play into these decisions. So where do you see power dynamics a lot for me to say they're power dynamics becoming perhaps unbalanced, and how can all of us help to get them back into balance? So
Dr. Jeffrey Bishop (09:18):
This is one of the hardest things because it's not just me, the actor and the patient, and the tool that somehow moves between me and the patient, right? There's me as a doctor in a context of other doctors where we have standards of care that I have to consider when I'm acting as a doctor, knowing that I'm going to be judged by those doctors. There are also players in the legal realm where I am licensed to practice, well, I'm not licensed anymore to practice medicine, but doctors are licensed to practice medicine by a legal authority, by a political body. So they're not just accountable to themselves, they're accountable to the legal structures of the government as well. So there's these other two players in the midst of all of this. And not only that, the patient as well, the patient sits in the midst of other kinds of other dynamics because they too have to abide by the law.
(10:19)
If I prescribe a narcotic pain medication, the patient is only supposed to take it exactly as the doctor says, and they're not to sell it, and they're not. So everybody already exists in these power structures that are shaping and molding the kinds of things that we hope that our little tools, our pharmaceuticals will do for us. So there's a whole set of relationships in there. We tend to want to reduce the world to me, acting the patient, receiving the action and a tool in between. But there are all these other relations that are conditioning what I'm thinking as a doctor, political, other doctors, and what the patient is hoping for from the medication, what the patient's family is hoping for from the medication, what the patient believes the medication will or won't do for their spiritual lives. I mean, there are all kinds of things that have to be taken into consideration. So it's not just me with a tool operating on a patient. All of this is going on at the social political level as well.
Brian Reardon (11:21):
And that's, I think, really important to note. So let's get a little practical. I love these concepts. I think it's really good that we're exploring these. And when you think about patients who are suffering from chronic diseases that have pain involved, and the conversation with their physician, their clinician, like, I'm looking for relief. I'm looking for healing. A lot of times, maybe the most direct path is to use that tool you describe to say, okay, here's two aspirin, call me in the morning, type of thing. But when we look at things like palliative care, so in Catholic healthcare, we again look at the whole person, not just their physical ailment, their spiritual emotional wellbeing. So if we were to take the two concepts you've just talked about and apply that to, for example, palliative care, how do these concepts start to manifest themselves?
Dr. Jeffrey Bishop (12:10):
So we have to think about two or three different things here. One is palliative care for those who are dying, and then pain relief for those who have chronic illness. Those would be two different contexts that we have to kind of explore, not just on the use of the medications, but all of those dimensions that I was talking about. And so when a patient is, let's say it's a chronic kind of pain, the goal is to get some relief that has the minimal number of bad effects or unwanted effects. And so sometimes chronic pain is best treated, certainly through medications like narcotics or anti-inflammatories or multimodal approaches to the patient's pain. But there can also be other things that I think are important for us to think about. We've all had the experience of playing a sport, especially as a kid. This always happened when I was a kid.
(13:09)
You're playing a sport and you look down and you're bleeding and you have no idea how the bleeding happened. And that's something that normally when bleeding happens, normally that's accompanied with pain, but when you're playing, you've got endorphins surging, your attention is on something else, and then the thing doesn't start to hurt until you notice the bleeding or after the game, it starts to really hurt, right? In other words, there are other features of pain that are really important to consider, both for chronic pain but also for pain for patients who are dying. And that is the spiritual and the social dimension of it. My medical education began in the late eighties and into the early nineties, and I began to notice in the early nineties that there were a lot of patients who were being admitted to die from hiv aids. And I began to notice that if those people were surrounded by people that loved them and by people who could be there with them, they required less narcotic pain medication. There was something about the social context of it that made some of this pain more bearable.
(14:22)
We might call it a spiritual dimension of pain, but if they didn't have friends and family, they'd often require more narcotic pain medication. So the human animals is enormously complex. The social dimension, the friendship dimension, the distractions that others provide, sometimes the humor that others provide will be helpful in treating pain. So when we come to something like pain, we have to be broader and more aware of the world around it taking, as you pointed out, taking the whole person into consideration, including the spiritual, the emotional, the interpersonal, and the psychological dimensions into consideration. That said, there will be times when we have to use pain medications, and there will be times when we have to use high enough doses of those pain medications that some of the other things that are important in a person's life have to start. You start having to weigh those against each other.
(15:30)
And when it comes to narcotic pain medication, sometimes if a person, let's say, is in the end stages of some sort of cancer or some other painful sort of disease, which you have to take into consideration is this narcotic pain medication could make you a little more drowsy, and it might even make you so drowsy that you fall asleep and you're unable to be present with others. And so you have to realize that that's going to be part of what happens when you take a narcotic pain medication. And I've had patients, and I think every practitioner who's ever practiced will have had patients that say, I can't even be with my family. The pain is so bad. And so in those cases, they would prefer to be a little more drowsy to take the pain away so that when they are awake, they can interact with their families. And then I've had patients who are like, I can suffer through some of this pain and I'd rather have the little more pain just so I can be with my family or my friends. So these are always judgment calls, and these are always, and again, we cannot take it strictly. I've got a med, here's the med. I'm going to do this with this med as if there's a straight line from my intention through the medication, through the tool to the patient.
Brian Reardon (16:45):
Oh, I love how you frame that up. I'm going to bring Josh back into the conversation. You've been listening. Questions, thoughts.
Josh Matejka (16:51):
Yeah. Dr. Bishop, thank you so much. I am really fascinated by the almost every day implications of a question like this or questions like this, because I think a lot of people, especially who are online or on social media, understand that there's almost this ecosystem of what you talked about at the beginning, like pharmaceuticals, are medicines bad natural remedies good or vice versa? And that can be really overwhelming to take that all in every day and having to make these decisions. What are some helpful everyday practices or even questions to ask yourself as you're being inundated with all this advertising or messages from people who may not have your best interest in mind or just have a personal opinion on the matter?
Dr. Jeffrey Bishop (17:38):
Yeah, I probably should have said this upfront, but sometimes we think the doctor wrote the prescription, it must be good, or This came from nature. It must good. And what's fascinating is when you have someone who says, the doctor wrote the prescription, it must be good. They usually have a high level of trust of the institution that produces doctors, that the science that surrounds it, all of the stuff that goes with being a doctor, they trust that. And when people say, oh, nature must be good for you, it's usually because they're not thinking of poisonous snakes. They're not thinking of poison ivy. And again, this is just, the idea is that it's not that these things are just morally neutral, it's just that the world is so complex that there are multiple kinds of effects. Some of them, we hope for some of them we hope against all hope that they won't happen, but these are just effects, and we have to get used to that.
(18:42)
But part of the reason that we do that is we get habituated into thinking in a certain kind of pattern, and one of the habituated ways we think about technology and pharmaceuticals is that way. I was saying, well, I intend it. It goes through the tool, and then the effect happens. That is the simplified version of the complexity. So we get lulled into these habits of accepting the simplified explanations of something rather than kind of critically engaging with those somethings, with all of the questions that kind of gather around it. And that's part of the problem that we have with technologies. We get so used to them that we start to see the whole world through it. If all you have is a hammer and that's all you think you have, everything's a nail. Everything looks like a nail. Exactly. Those are the habitual ways of thinking that we have to always be careful of when we use any sort of pharmaceutical or any kind of technology at all. So that's the biggest problem Now on the advertising side of all of that. Wow.
Brian Reardon (19:52):
We could do a whole other episode on that.
Dr. Jeffrey Bishop (19:53):
Yeah. I mean, who's doing what are the intentions? It's part of that power dynamic
Brian Reardon (19:59):
You talked about.
Dr. Jeffrey Bishop (19:59):
Exactly.
Josh Matejka (20:01):
It helps to have a healthy skepticism, but like you said, in asking all those questions of yourself, I do think those analogies are really helpful, so thanks for bringing those up.
Brian Reardon (20:10):
Yeah, no, and thanks for just spending time to again frame this, because again, we don't think necessarily of a drug as being a technology, and so I think you did a really great job of just giving us that perspective. And so hopefully those listening, this gives us something to think about. So appreciate you taking time out with us to discuss this topic. Again, that was Dr. Jeffrey Bishop. He's the Tenet Endowed Chair in Bioethics and Professor of Healthcare Ethics and a Professor of Philosophy at St. Louis University. Thanks again, Jeff, for being with us.
Dr. Jeffrey Bishop (20:38):
Thank you all for having me.
Brian Reardon (20:40):
And this has been another episode of Health Calls, the podcast of the Catholic Health Association of the United States. Again, I'm your host, Brian Reardon, Health Calls executive producer, and my co-host is Josh Matejka. We have additional production support from Yvonne Stroder. This episode, again, was engineered by Brian Hartmann here in St. Louis at Clayton Studios, and you can find Health Calls on all of your favorite podcast apps and services, as well as on our website, chausa.org/podcast. If you enjoyed the show, again, we always ask that you give us a five-star rating, maybe share your feedback. We'd love to hear from you. As always, thanks for listening.