The treatment of End-Stage Renal Disease (ESRD) is one of the most widely debated topics in contemporary medicine. The high cost of the most usual treatment, hemodialysis, has been and still is the topic for numerous discussions concerning priorities in health care on the one hand, and various medical, psychological, and ethical problems of life “on the machine” on the other hand. The other treatment of ESRD, kidney transplantation, raises other, no less complicated questions such as the limits of medical experimentation, ownership of one's body, the donation of organs, organ procurement and allocation, and the definition of life and death. As Fox and Swazey put it “The importance of hemodialysis and human organ transplantation lies as much in their social and cultural significance as in their medical and surgical value” (27,376).

Artificial insemination with donor semen (AID) has recently come into public view—particularly in France—because of its association with a newer technique, the cryopreservation of semen. One of the oldest and simplest of reproductive techniques, used most frequently as a means of compensating for male infertility, artificial insemination was previously confined to the private clinician's office, where maximum confidentiality could be ensured. This shielded all of the parties involved—recipients, donor, and physician—from moral reprobation and the possible legal complications arising from the use of donor sperm. However, in the mid-twentieth century, some physicians and researchers in cyrogenics came up with the idea that the freezing and stocking of donor semen in banks might greatly improve the psychological conditions and facilitate the material arrangements for performing AID. Essentially, the donor's availability would no longer have to coincide with the woman's ovulation, meaning less inconvenience for the donor, more time for screening his medical history and running the necessary tests on his semen, and possibly a certain tempering of AID's adulterous connotations. Although results with frozen semen were not as satisfactory as with fresh (the probability of a pregnancy at any cycle is almost twice as great with fresh semen), the material and psychological benefits were considered greatly to outweigh the lesser efficiency of frozen sperm.

A widely held assumption today is that biomedicine is “scientific” and therefore “objective,” thus, “culture-free.” It epitomizes the objectivism falsely attributed to technology in general. Contemporary Japan is seen to epitomize non-Western modernity with its high development of industrialization and scientific technology. It follows then that biomedicine in Japan today should remain as such without cultural transformations. Yet, in post-industrial Japan today biomedicine takes an almost entirely different form and meaning from biomedicine practiced elsewhere, especially in Western societies such as the United States. The purpose of this paper is to describe the experience of hospitalization in contemporary Japan in order to demonstrate how Japanese culture and society have powerfully transformed the underlying concepts and practices of biomedicine, which was originally introduced from the West and has been highly acclaimed by the Japanese as the epitome of superior Western science and technology. Due to space limitations, however, it will not be possible to engage in an extensive discussion of theories about technological impact, or issues involved in the broader theoretical concern variously referred to as “modernization,” “industrialization,” “rationalization,” “secularization,” etc.

In a short story entitled “Second Opinion,” R. K. Narayan, one of India's foremost writers in English, introduces us to Sambu, a young man who spends his days and nights at the “Boardless” coffee shop with friends, avoiding work, marriage, and his widowed mother. One day a local doctor, Dr. Kishen, informs Sambu that his mother is suffering from fainting spells, possibly a heart condition, and is in a “leave-taking” (dying) mood. Dr. Kishen, who knows the family, suggests to Sambu that he marry, thereby easing his mother's anxieties and ill health, and making her last days happy. However, he also gives his usual advice to get a “second opinion.” Sambu does, taking his mother to Dr. Natwar, a foreign-trained doctor, who has a spotless clinic with many rooms housing the latest medical equipment, a contrast to Dr. Kishen's ill-equipped, disorderly clinic. After his mother has undergone tests, Sambu meets with Dr. Natwar. The doctor gives him various documents and states that they show there is nothing wrong with his mother. Thus, armed with irrefutable proof provided by technology, Sambu avoids marriage and responsibility; his mother, afraid of losing her son altogether, acquiesces to his wishes, telling him to do whatever he wants (5).

The treatment of End-Stage Renal Disease (ESRD) represents a victory for medical technology. Dialysis and kidney transplantation, developed in the early 1960s, offer alternative treatments to patients whose own kidneys no longer function; before, these patients faced a terminal diagnosis. Dialysis is a mechanical treatment in which the patient is connected to a machine that cleanses the blood of impurities and returns it to the body. Although recent innovations (e.g., continuous ambulatory peritoneal dialysis—CAPD) facilitate patient independence from a machine, replacement of the diseased kidneys is the most desirable and least expensive treatment for many patients (33;39). Kidney transplantation remains the most effective and common type of transplantation, and a new kidney (from a living-related or cadaver donor) often dramatically improves the recipient's health and general well-being (20;39). Now, in the mid-1980s, these technologies are no longer new and innovative. Further analysis of these established but costly technologies provides a perspective on the long-range implications of innovations in patient care: while some new issues have emerged, many problems originally associated with these treatments seem to have intensified. Access to treatment remains a central issue, closely linked to the dilemma of equity versus cost. The contrast in the access provided by the United States and Great Britain is dramatic (40); in 1982, the rate of ESRD treatment within the U.S. was twice that of the U.K. (353 versus 160 patients per million) (37). The U.S. policy is basically one of unlimited access, whereas the U.K. has restricted access.

In a recent article in Commentary, American medical sociologist Florence Ruderman observes that the evolution of medical practice and medical attitudes in the United States has been guided largely by the autonomous development of biomedical science and technology. “Science”, she asserts:

… is a profoundly unsettling force … it causes endless dislocations and conflicts. Most basically, science is a source of independent values, motives, norms of conduct, and criteria of judgment. It sets its own course, defines its own goals. As for technology, its impact on medicine is even more obvious and direct; again, not just in producing tools or power but in transmitting values and in shaping the field from within. One need only think of the artificial-heart cases now in the news to realize that the physicians involved … are impelled by a technological drive that has its own logic and values, its own momentum—and its own dangers (24,45).

If medicine is becoming mechanized, as many indications suggest, then those interested in policy making for medical matters have much to learn from the history of technology. The mechanization of medicine, as in the case of the mechanization of production, will accelerate the transfer of skill and knowledge from people to machines and the transition of health care to a capital intensive industry (19, 196–226). Furthermore, mechanization and increasing capital intensification may bring the increased systematization of health care. If the development of mechanized medicine follows the precedent of the mechanization of production, then our society must deal with the evolution of another set of extremely large systems, systems that will become virtually impervious to social control. Historians of technology are currently providing a better understanding of the evolution of large systems of production (3;9;10); there are lessons to be learned from this history by policy makers in health care.

There are three phenomena unique to medical research. First, unlike most historic events and their time- and culture-specific relationships, determination of the efficacy of medical care cuts across national and cultural boundaries in the Western world. Second, most of the study methods currently used to determine whether a specific medical intervention works have a long tradition, usually stretching back over centuries. Third, it is difficult to predict whether, and how readily, research results will be incorporated into medical practice.

It has been suggested that efficacy and safety are the core issues for technology assessment in health care (1). To this must be added the issue of appropriateness (2). Efficacy remains the first issue nonetheless, for surely no one would knowingly evaluate the safety of an ineffective technology.