We would like to express our sincerest thanks to all the article authors who contributed to this issue, and to all the anonymous reviewers who helped to clarify each of the ideas presented. We would also like to thank Pierre Teissier and Pierre-Olivier Méthot, who were the referees for this volume, on the editorial board of the Cahiers François Viète. Special thanks go to Jenny Boucard for her fine proofreading and the quality of her follow-up throughout the editing process, and to Sylvie Guionnet for her final editorial accompaniment.
« No, technology is not external to human life. It emerges from life, finds its place within it, and inserts and composes its own norms» (Lecourt, 2011, p. 88)
- 1 Earlier traces of connections between technology and medicine can be identified as far back as Plat (...)
1From a philosophical point of view, the postulate of an interdependence between care and technique(s) in medicine can find an entry point in Cartesian thought.1 Obviously, we are talking about 'technique' here, not yet 'technology'. This well-known idea of technique as being designed to serve humanity in order to "make us like Masters and Possessors of Nature" (Descartes, 1637, p. 99 ) has one main objective: to maintain one's health, "which is undoubtedly the first good, and the foundation of all the other goods of this life: because even the mind depends so strongly on temperament, and on the disposition of body organs, that, if it is possible to find some means that will commonly make men wiser and more able than they have been until now, I believe that it is in medicine that it must be searched for." (ibid.). To reach this goal, medicine is required; it is the prerequisite. According to Descartes, the combination of technique and medicine, of gestures of production and knowledge, could enable humans to free themselves from disease, but also from ageing (ibid.). Echoing the myth of Prometheus, this quote views technique as the primary instrument of the human being and a condition for a better existence. After the 17th century, in particular, a proliferation of detailed descriptions of technical objects began to emerge, largely driven by the Age of Enlightenment. With the publication of Diderot and d'Alembert's Encyclopédie, objects became liberation symbols, since they represent, first and foremost, means of construction, use and thus, in a way, emancipation (Guchet, 2010). This optimistic, continuistic perspective on technical progress also necessarily influences the medical field. In the 19th century in particular, medicine became the scene of an unprecedented development of 'scientifisation', clarifying its methods and technicising its practice. Physiology asserted itself before anatomy (Canguilhem, 1964) and experimental methods expanded. More specifically, the second half of the 19th century was marked by a profusion of animal preparations and complex instruments, accompanying the growing importance of physiology relative to other approaches to the living (Logan, 2002). The increasing importance of experimentation, combined with the proliferation of physiological instruments, has brought medicine to a tension point between cure (referring to a technical medicine) and care (referring to medicine that is concerned for the individual). As Céline Lefève emphasises (2006, p. 27): "'Suffering people are basically physiological phenomena', Claude Bernard summed up in his Introduction à l’étude de la médecine expérimentale, sacrificing suffering subjectivity on the altar of scientific medicine". This so-called scientific medicine, blamed for sidelining people who were ill or suffering, was also developed during an industrial period marked by the mechanisation of work, aiming for profitability and efficient performance, where hands were replaced by machines. Workers must conform to their job and not the opposite (Noiriel, 2002, p. 24). Serial production led people to work on assembly lines. Having become slaves to a new economic mode of production, humans were effectively objectified and became alienated from their work through a reorganisation of labour that forced them to merely survive. Machines and the associated technical development were therefore accused of 'objectifying' humans and their condition.
2As for the 20th century, it was marked by the additional concern that machines would become autonomous. At the heart of this period, the concept of the 'alienation' of man caused by machines appeared (Guchet, 2010, p. 111). These fears have led to an awareness of the limits of previous technicist developments. Nevertheless, an argumentative problem persists: a machine, by itself, can never be held responsible for alienation. It is always humans who alienate other humans, through the intermediary of machines which are then seen, in a reductive way, as means and instruments.
- 2 We will summarise these three examples of scandal by quoting Simone Bateman (2004, p. 159): "In 196 (...)
3The same period was marked by a new gaze on medical practices: the bioethical 'surge' (Courban, 1999, p. 138), triggered by the Nuremberg Trials served as a reminder of the importance of considering the patient as a living, thinking subject and not simply as an object of care or research. That surge, however, was not sufficient to ensure the transition from its principles, defined by the Nuremberg Code, to practices, as the Brooklyn, Willowbrook and Tuskegee scandals can attest (Bateman, 2004, p. 159).2 It was against this controversial background that psychoanalyst Donald Winnicott (1970, p. 22) deplored in the 1970s that "cure, in the sense of treatment, eradication of the disease and its cause, [tended] to take precedence over the meaning of care". In other words, as medicine became more technical, it certainly improved its diagnoses and prognoses and its ability to provide a curative response to certain diseases that had previously been incurable, but this came at a high price: an increasingly impersonal and 'objectifying' relationship with the patient, whose 'subjective' voice, suffering and expectations were no longer listened to. In other words, while from the 1950s onwards, the considerable progress made in biomedicine opened up new possibilities and therefore "new powers to intervene on the human body through the development of the pharmaceutical industry, surgery, imaging and biology" (Goffette & Malzac, 2011, p. 302), at the same time a number of health scandals erupted. As a result, "many citizens, particularly through patients' associations, have expressed the wish to be better informed and to participate in medical decisions in the name of the principle of autonomy", which has led to "the obligation to collect free and informed consent" (ibid.). These various elements also partly explain the success of the 'personalised medicine' concept over the last 20 years. It reflects the concerns raised by the technicisation of contemporary medicine and the very high expectations that patients, and more generally the lay public, have regarding a form of medicine which, whilst knowing how to take advantage of new technologies, is above all concerned about remaining 'human', i.e. not forgetting its primary vocation: an art involving not only a technical but also a moral relationship with its 'object'.
4As we have seen, particularly since the 19th century, the increasing development of medical techniques, instruments and tools has not occurred without conflict and tension: fears and feelings of loss of control or mastery of technical objects and instruments are emerging. These phenomena depend on broader contexts than just the medical environment. As a result, the current disarray felt by caregivers faced with the growing development of new technologies undoubtedly exists and can be explained, in part, by replacing these fears in their context. However, the risk of a pure and simple split between cure and care - between medicine as a technique seeking above all diagnostic, prognostic and curative efficacy ('providing care' or 'treating a body'), and medicine as attention to the vulnerability, suffering and subjective preferences of patients ('taking care of a being, a person') - now calls for a much more nuanced observation than Winnicott's. This is demonstrable both empirically and conceptually.
5This deep-rooted tension between cure and care, which persists to this day, is indeed indicative of an equally persistent contradiction between care and technology, which is not self-evident. The literature is full of empirical studies which show that this cleavage does not really exist; or, in any case, that new technologies are not as antinomic to the values of care as Winnicott might have thought. Whether it be dialysis (Hermès & Sifer, 2005), the design of artificial heart valves (Derksen, 2008), the prediction of epileptic seizures in children using algorithms (Soler & Trompette, 2010), care robots (Meacham & Studley, 2015), the manipulation of induced pluripotent stem cells (Meskus, 2018), deep brain stimulation devices (Lancelot, 2019) or upper or lower limb prostheses (Dalibert, Gourinat & Groud, 2022), these studies, among many others, all challenge the erroneous opposition between supposedly 'cold' and inhuman technologies and supposedly 'warm' and human care (Pols, 2012). In medicine as elsewhere, "how can we conceive of care that does not involve technical invention?" (Worms, 2013; Loute, 2020). In other words, how can we conceive a way, not only of 'providing care', but also of 'taking care', that does not involve technical invention? The logic of care consists above all in seeking, in context, the best way to combine the heterogeneous elements that make up the care situation, which includes technologies (Mol, 2008; Mol, Moser & Pols, 2010).
6Do these formulas mean that the slightest gesture relating to care, to taking care of, cannot be conceived without the mobilisation of technical instruments? If so, they must be rejected immediately. A caress, a hand grasped, an attentive ear - these are all gestures that can testify to authentic 'caring' for the other person, without the technique having any direct part in it. Who would deny it? However, in order for nurses to make these gestures, and take the time to caress and listen, certain conditions must be met - organisational, structural, social, but also technical. Of course, these gestures are also, and even often, carried out even when these conditions are lacking, because the carers' devotion can extend the limits indefinitely. However, this creates unstable situations, bordering on the unbearable. The fact that there can still be care in a context of widespread decay of institutions and of the resources available for care work (particularly technical resources) is, in a way, the negative proof of the importance of the socio-technical conditions of all care. The concept of 'taking care' as a relationship from one subject to another, without mediation, is an abstraction that masks all the conditions that make this relationship possible, intensify it and enable it, or not. So, while it is wrong to assert that techniques are necessarily involved as means, as instruments, in 'taking care', it should be emphasised that 'taking care' presupposes that certain conditions, particularly technical conditions, are met, which form a kind of care environment (milieu). Inversely, the implementation of a technique presupposes the existence of a favourable environment, i.e. an environment in which caregivers find the necessary conditions for the appropriation and proper use of the technique. Professional education, the management of care teams, and maintenance, repair, upkeep, calibration, etc. (which are also care activities, i.e. "care of things", see Denis & Pontille, 2022), are part of these conditions. This is also what ethicist Chris Gastmans (2002, p. 9) said 20 years earlier: "we interpret technology and care to be two dimensions of health care possessing equal merit. Care cannot be provided in the absence of adequate technological means, since care needs to be effective and economically efficient."
7These studies and findings have very recently been revisited by sociologist Éric Dagiral and his colleagues (2022, p. 3), who point out that "many anthropological studies [in particular] have sought to go beyond the care/cure opposition". While anthropology "more than any other discipline in the humanities and social sciences has, from the beginning and by necessity, given a central place to objects, instruments and other technical devices in describing the course of human action" (p. 4), due in part to the close attention paid to the different forms of "care materialities" and to the conditions of their existence and circulation (ibid.), research in the philosophy of medicine and the ethics of care is largely lacking on this subject. However, the studies cited above show, as do those presented in this issue, that an analysis of the place and role of contemporary medical techniques and technologies in healthcare practices, or in the process of being designed and intended for healthcare purposes, is in line with the broader perspective according to which techniques and technologies (medical or otherwise) produce relationships and mediations - understood in the sense of exchanges, mutual contributions and reciprocal influences with humans and their environments (Simondon, 1989; Ihde, 1990; Verbeek, 2006, 2015). Whether these mediations are new or commonplace, they remain, in all conditions, carriers of meaning and "systems of signification". (Pickstone, 2004, p. 1122).
8The concept of 'technological care' therefore aims to emphasise the inseparability of care and contemporary technologies, by linking two terms that are rarely thought of together and simultaneously (Lancelot, 2019). In this way, we are showing the extent to which these different types of care have much to teach us about the different modes of relationship, entanglement and interdependence that are created between technologies and care practices. To affirm the existence of relationships of interdependence rather than opposition between humans and technologies does not mean, of course, that these relationships are created without tension: the historical elements and empirical literature cited above demonstrate this. Talking about 'technological care' allows us to distinguish it, in particular, from the concepts of 'health technologies' and 'care technologies'. In these latter concepts, technology is understood primarily as an instrument in the service of health and/or care. Of course, techniques and technologies can be mediums and conditions for these activities, but they cannot be reduced to them. The term 'technological care' is intended to emphasise the production of relationships and mediations which are inherent to the insertion of a technique or technology into a particular living environment. This concept therefore stems from a broader premise: because our lives and modes of existence are fundamentally interwoven with techniques, and because these techniques are embedded in every space and interstice of our living environments, care is necessarily also, and by extension, interwoven with techniques. And if we want these technologies to act, function and operate correctly, we need to take care of them. In other words, techniques and technologies are not only the conditions that make most care possible, they can also constitute it, and vice versa.
9To sum up, care in its broadest sense - 'to provide care', 'to be concerned about', 'to pay attention to', 'to take care of' - has technical conditions for its exercise, and reciprocally technique finds its conditions of effectiveness in an environment of work, of life, which must be the object of the greatest care (Guchet, 2022). This is what is meant by the concept of 'technological care', which indissociably joins together cure and care, and implies both a technical environment of care and an environment where techniques are taken care of.
10The contributions in this issue of Cahiers François Viète use empirical material to develop this conception of the relationship between technology and care as something other than a relationship between an activity (care) and its means (technology). They propose analyses of this relationship understood as an interlacing of conditions forming an enabling environment for the deployment of care in its many aspects: care of the receivers of care, care of the institutions and what holds them together, care of the caregivers, care of the techniques.
11Philosopher Emanuele Clarizio’s article offers a detailed analysis of the place occupied by technology in the ethics of care. Starting from the observation, made by some, that technology is only very marginally addressed in these ethics, Clarizio proposes to take a step further and introduce a third term between technology and care, namely life. His thesis is that the place of technology in a particular ethic of care depends on the way in which life is conceived. An essentialist conception of life leads to an ethic that is rather indifferent to technology; conversely, a non-essentialist conception of life, stipulating that there is no such thing as Life but always 'forms of life', each configured by a certain state of technicality, leads to a better articulation of care and technology. In this way, the idea is already emerging that technology is not just the instrumental counterpart of care, but also an essential component of the environment (milieu) in which care for the living, both human and non-human, can unfold.
12The other five articles are all based on investigations, with analyses underpinned by rich and varied empirical material.
- 3 This situation is reminiscent of the Canguilhemian formula: "If the current relationship between te (...)
13Philosopher Claire Grino looks at the technique of age-related oocyte self-preservation - a technique that allows women aged between 30 and 37 to freeze their eggs in anticipation of a potentially late pregnancy. At first sight, this technique would seem to confirm the thesis of the opposition between biomedical techniques, in the service of a hyper-technicalised medicine, and the values of care: are women not the objects of an ever more insistent biomedical power, forced to agree to feed a lucrative market by freezing their ova? Grino's study reveals a very different reality. She shows that age-related oocyte self-preservation, far from being a technique foreign to care, has very strong care implications, since it is primarily women who request it. Doctors, on the other hand, are more reticent about it, not primarily because the results of the technique are questionable (i.e. for reasons that would be linked to practitioners' concern for their patients), but above all because age-related oocyte self-preservation disrupts the traditional distribution of roles between doctors and patients. In particular, this technique is not prescribed following the diagnosis of a pathological condition, which is indeed disconcerting for the doctor.3 However, Grino clearly demonstrates that the doctor is not reduced to being simply the provider of the technique. The indication for age-related oocyte self-preservation is only implemented within a broader context of care, in which the technique prefigures care.
14Anthropologist Giulia Anichini’s article focuses on a decision-making support system designed to enable 'personalised' therapeutic management of patients suffering from multiple sclerosis. The aim of this algorithm is to model individual disease trajectories and thus enable practitioners and patients to opt for the most effective drug strategy, taking into account the specific characteristics of each patient's disease progression. Anichini's study examines the concept of 'efficacy' itself and the many different meanings given to it by the various actors involved, in particular engineers and caregivers. Far from an opposition between technique and care, it appears that the effectiveness of therapeutic prescription (technical effectiveness, in short) depends on environmental conditions, among which attention to the values and subjective preferences of patients predominates. Technical effectiveness is therefore not confined within the limits of the algorithm and its specifications: here again, it can only be effective within a wider care environment. In addition, and in the same way as Claire Grino's previous contribution, the technological care discussed here highlights an (expected) shift in care relationships and, consequently, in relations of power and decision-making. Agency is redistributed, and the associated clinical reasoning no longer necessarily begins with a diagnosis. Once again, technique prefigures care.
15Philosopher Marilena Pateraki looks at the practice of deep brain stimulation (DBS) in Greece. Taking a step back from the voluminous literature examining the effects of this technique on personal identity and the sense of 'self', Pateraki focuses her attention instead on the activities and representations surrounding a very specific aspect of this technique: the fine calibration and maintenance of the device, so that the stimulation is finely adapted and best suited to the patient. An eminently empirical, trial-and-error activity that takes place over a long period of time, the calibration of the DBS device involves a veritable "dance of agentivity", as Pateraki says. Her analysis places particular emphasis on the different spaces and temporalities that make up this dance and condition it. The description and analysis of the socio-material conditions of this technological care, in a Greek context, shows the extent to which the proper functioning of the device depends on environmental conditions. Furthermore, her study shows, indirectly, that if we wish to discuss the 'effects' of DBS care pragmatically, we need to be able to pay attention to the various adjustments, long and often restrictive, between a multitude of bodies, lived experiences and technical objects.
16The article written by sociologist Pauline Launay and philosopher Alain Loute gives the clearest picture of the mesological dimension of care - that is, its environmental conditions, and especially its technical conditions. Using three case studies - palliative care in hospital units, teleconsultation and home hospitalisation - they analyse the ambivalent relationship between care and 'home'. This relationship is seen as an environment of care, not only in the reconstitution of a semblance of home within the hospital, but also, conversely, when the hospital invites itself into patients' homes. Launay and Loute show that 'home' is a source of ambivalence, both in its practical arrangements and in its symbolic significance: it represents an ideal of the 'naturalness' of care, compared with the hospital, which evokes the impersonality of an over-technicalised and bureaucratic environment. However, in order to host care activities, the home must be transformed, reorganised and invested by technology. So, while the literature on care often emphasises the temporality of care and the reconfigurations of subjectivities, Launay & Loute focus instead on its 'spatialisation', following the teaching of Foucault in Naissance de la clinique.
17Finally, philosopher Elodie Gratreau’s article discusses a technique that is not directly related to care, but rather to psychiatric research. The Research Domain Criteria (RDoC) propose a new way of approaching psychiatric facts in research, by moving away from the classifications of these facts accepted until now (based mainly on the Diagnostic and Statistical Manual for Mental Disorders of the American Psychiatric Association and the International Classification of Diseases of the WHO). Gratreau analyses the epistemic ins and outs of RDoCs, which she describes as a technical object with certain values. Far from confining her analysis to considerations of the type of knowledge and research that RDoCs aim to promote, she emphasises the fact that this new approach to psychiatric research is bound to have a major impact on the therapeutic management of this type of pathology. Indirectly, the technique also prefigures care.
18In their own way, each of these contributions unfolds modes of existence of technological care. In order to do this, a practical approach based on philosophical reflection involving a cross-disciplinary approach - particularly anthropological and sociological here - seems necessary, since no object of research presented in this issue is pre-constituted, nor does it have a complete corpus. This perspective, which exists in its own right, nonetheless always works alongside and/or in conjunction with social science methods (Malherbe, 1976; Toulmin, 1988; Molewijk & al., 2004; Mol, 2002, 2008; Gaille, 2014; Vollaire, 2017; Dekeuwer, 2020; Benetreau & al., 2023).
19According to these perspectives, the contributions presented here all propose, through their different subjects of study, to go beyond this simple cleavage between cure and care. Indeed, they show a relationship to care that necessarily includes attention to technologies, which sometimes even prefigures this care. Consequently, they highlight a plurality of environments (milieu), conditions and 'forms of care' within and with which, indissociably, a plurality of humans adjust and negotiate, in space and time, the 'agentive' power of technologies. Far from being mere instruments available to caregivers, technologies appear to be agents of care in their own right. Whether it is a question of reproductive technologies, medical decision support systems, deep brain stimulation devices, technical development of living space, or even guiding the treatment of psychiatric illnesses through a new approach to pathological mental phenomena: in all these cases, the technologies deployed are helping to give the care provided an 'aspect' and modalities that it would not otherwise have. However, this does not mean that technologies have a deterministic effect on care, which would relegate caregivers (and the people receiving care) to the status of passive, powerless observers of the technological transformations underway. Technologies are neither mere instruments, nor the determining power of care, but they exert an 'agentivity' in the sense that they contribute, by virtue of their own characteristics (of operation, of materiality), to shaping the 'aspects' of care, in conjunction with the 'agentivity' that other agents - caregivers, patients, administrators, etc. - also exert. The articles in this issue reveal the complexity of what should be called not just a dance of agentivity, but a dance of agentivities.
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