These words, taken from a popular history of medicine course, have been cited to illustrate the “amazing progress humankind has made from the Stone Age until today.”Footnote ¹ They also bear witness to a widespread contemporary belief, namely, the tendency to associate medicine with the idea of progress. Today, the term “progress” is used by a wide range of people – including politicians, scientists, physicians, and patients – to speak of past medical developments and desired future changes. The notion that impressive progress is being made, and occurring in such a step-by-step fashion that it has the potential to “stall” or be “set back,” is a common way of making sense of the developments in medicine.Footnote ²

Despite its popularity in the medical field, the idea of progress is out of fashion as a concept with explanatory power. The notion of progress as a cumulative process that enables an individual or a society to attain something, and then go on to achieve something better, is largely seen as a naïve and misleading way of presenting historical change. The English historian Herbert Butterfield, in his famous work The Whig Interpretation of History (1931), drew attention to the flaws inherent in seeing the present as an improvement on the past.Footnote ³ In Butterfield’s account, and the generations of students who absorbed it, “Whig history,” or presenting history as a tale of progress, was exactly what not to do as a historian.Footnote ⁴ Numerous critics have pointed to the ways in which the idea presupposes a Eurocentric sense of civilizational and moral superiority and how narratives of progress are bound up with practices of domination, oppression, and violence. Genocide, the nuclear era, wars, and the persistent threat of war, global inequalities, and climate change; it is possible to argue that empirical claims for progress are undermined by reality. “How does it happen that serious people continue to believe in progress in the face of massive evidence that might have been expected to refute the idea of progress once and for all?”Footnote ⁵ With this rhetorical question, social critic Christopher Lasch sums up the widely held disdain for the notion of progress in history.

This book scrutinizes progress rhetoric in the post-World War II period by focusing on medicine, a field that is arguably the paradigm case for an intense belief in progress. Using the tools of intellectual history, it traces the rise and proliferation of the concept of medical progress, which is influenced in complex ways by changing definitions of health, technological capabilities, and politics. Uncovering and cataloging the multiple meanings of medical progress is important because of the concept’s impressive emotional power. The commitment to it is remarkably widespread and that commitment – regardless of its precise meaning – influences scientific and political agendas, as well as shared beliefs about the goals of medicine. Clarifying what people mean when they talk about medical progress shows what gets left out when it is associated with particular kinds of knowledge, as well as who benefits from a specific narrative of progress, and who is harmed by it. In particular, I argue that the most optimistic advocates of medical progress endorse simplified, static views of health and downplay the tensions between individual and social goods. Starting from the normative premise that health is a complex biopsychosocial state and that illness is not fixed, but rather influenced by norms and values, this study shows how progress in medicine is necessarily multidimensional.

I.1 Spotlight on Medical Progress

Why focus on medical progress in particular? Let me start by saying that it is certainly true that the term and the concept of progress have substantial rhetorical and political power in a number of fields. The commitment to measuring and facilitating progress is a fundamental part of the mandate of various international organizations, including the Organisation for Economic Cooperation and Development (OECD), the World Health Organization (WHO), and the United Nations (UN), which reflects the fact that discussions of progress often have explicitly global aspirations. Making progress is a fundamental motivation for both mainstream and alternative economic approaches.Footnote ⁶ It is also a notion able to transcend traditional political boundaries, as the same term “progress” is used by otherwise antagonistic politicians.Footnote ⁷ International science, meanwhile, generally considers the aspiration for progress to be its driving force; there is a virtually unanimous agreement that science is a progress discipline.Footnote ⁸

The interest in medical progress, however, is particularly diffuse; whenever I have looked for the term “progress” – and related notions of “better,” “improve,” and “advance” – with reference to medical practices and their effectiveness, I have found it. An interdisciplinary project devoted to understanding the goals of medicine highlighted precisely the commitment to “unbounded progress” as the main belief that has inordinately shaped modern medicine.Footnote ⁹ Today, the term progress is regularly used to characterize, among other things, health artificial intelligence (AI), brain imaging technologies, datasets of cancer genomes, and bionic limbs. For example, entrepreneur and philanthropist Mark Zuckerberg connects medical progress with the natural and engineering sciences and praises the AI software, chips, and monitoring devices his organization funds for that reason.Footnote ¹⁰

As I argue throughout this study, the myriad of criticisms of the idea of progress as a conceptual category have not had the same impact in medicine that they have had in other fields. It is well known that scientific and technological progress can be used for harm as well as for good, while economic progress, for example, has been roundly criticized for its association with environmental destruction. But medicine is regularly cited as the field in which the benefits of progress outweigh potential harms. Amid a new awareness of the ambivalent effects of progress, dedication to the idea of specifically medical progress in advertising, media, political rhetoric, and societal expectations grew steadily in the past decades. At times, progress in medicine became the answer to the question of “What, if anything, constitutes progress?” Medical progress is, I suspect, one field in which the hope for progress and the belief in technological power and its ability to be harnessed for human well-being are particularly intertwined. Even academics in the humanities, who have long been wary of using normative concepts to assess historical changes, agree that progress in medicine has occurred.Footnote ¹¹ I am not a relativist, and I believe that medical knowledge and practice can improve, but I also show that medicine is not immune to the multiple epistemological and ethical critiques of progress developed in the past century.

In his comprehensive study of the history of the idea of progress, sociologist Robert Nisbet acknowledges the impossibility of empirically or logically verifying the concept of progress per se, while noting that medicine is an exception to this rule:

Yet as I show in what follows, assessments of medical progress occur in the context of much broader beliefs about human health and well-being than simply “saving or healing life.” In particular, largely justified claims about first-order medical progress – the superiority of penicillin to blood-letting to treat a bacterial infection, for example – become bound up with second-order thinking, that is, normative visions of medical historical progress.Footnote ¹³ As a rule, this masks how progress in one dimension – for example, the development of an antibiotic – is entangled with its existence and distribution in complex social circumstances and power structures. What is at stake is the extent to which progress in different aspects of life relates to and interacts with each other.

A disjunction that philosopher Ruth Macklin highlights between “wholly uncontroversial” technological progress, on the one hand, and “highly controversial” moral progress on the other is at the heart of this study.Footnote ¹⁴ This is because medicine is an art that, while it relies on an extensive body of scientific knowledge and treatment possibilities, remains a humanistic practice. Medicine still requires that the doctor recognize the patient as a full human being with their own preferences, values, and uncertainties, which can change rapidly. Moreover, some medical goals – to save life, for example – do not fit together easily with others – such as the goal to provide equitable care to all. These humanistic and social dimensions of medicine sit uneasily with simplistic conceptions of medicine-as-technological-progress.

I.2 Scope and Aims

This book examines the recent focus on medical progress with reference to North America and Western Europe. I have chosen to focus on the Global North for both practical reasons – this study was composed in Switzerland and Canada – and conceptual ones. OECD countries are at the forefront of technological developments in medicine, and this has influenced their sense of embodying progress. For example, Geneva University Hospitals, one of the largest hospitals in Europe, presents itself as ensuring privileged access for its patients to the latest technological developments and medical progress.Footnote ¹⁵ At the same time, the use of medical technologies in these countries has significantly influenced rising healthcare costs, which has, in turn, intensified discussions about whether technology-driven medical progress can continue indefinitely. Contributing to these discussions are aging populations, as well as the fact that health inequalities within high-income countries persist and are sometimes glaring, even as they coexist alongside sophisticated medical facilities. In many respects, the rising popularity of complementary and alternative medicine in these regions can be understood as a reaction against traditional (biomedical) approaches to progress. The successes and limitations of scientific-technological medicine, then, have led to backlash and rethinking commonly held views of progress in medicine. The idea of simple, straight-line progress in medicine has encountered both theoretical and practical obstacles in the Global North.

In this book, I write about “modern,” “contemporary,” and “Western” medicine. These terms are not unproblematic, but I think that there are, nevertheless, justified reasons for employing them here. Current debates about medical progress are bound up with transnational scientific achievements, but they are also informed by developments occurring in what used to be designated “the West.” Chinese medicine, for example, at times acts as a counterpoint for the focus on progress I describe here.Footnote ¹⁶ To be sure, it would be a mistake to consider contemporary Western medicine a monolithic entity that contrasts with other medical systems; it is certainly possible to argue that the term “Western” subsumes substantial differences and can therefore be misleading. That said, I do want to argue for thinking about attitudes toward progress in medicine in light of a set of traditions in which individuals and societies participate and share to different degrees. Valuable philosophical work has shown that we participate in shared social practices founded on assumptions that we have difficulty perceiving because they appear to be self-evident.Footnote ¹⁷ With this approach to Western/globalized medicine, we can see that even as biomedicine is grounded in specific, localized cultural assumptions and practices, it nevertheless claims neutrality and universality.Footnote ¹⁸ Furthermore, we can conceive of the commitment to the idea of progress as a tenacious assumption of Western medicine.Footnote ¹⁹ Indeed, the notion of progress in medicine is rarely made explicit and problematized, but rather accepted as something inherently good.

That shared ideas about progress influence how we perceive the goals of medicine has not gone unnoticed. Research by bioethicists,Footnote ²⁰ historians of medicine,Footnote ²¹ philosophers,Footnote ²² physicians, and public health workersFootnote ²³ has used medicine as a case study for ideas about progress in a way that resonates with my approach. Studies of progress have, in their own right, sometimes mentioned medicine as a field in which the theoretical concept could benefit from further empirical inquiry but have not undertaken this task themselves.Footnote ²⁴ Thus, it is possible to conclude that the idea of progress in medicine, while crucial, has only ever been studied in a limited way, or discussed briefly, for example, in an article or as the topic of a chapter in an edited volume. At present, there is a lack of academic studies that attempt to bridge the divide between philosophical–historical engagements with progress and the use of the term and concept of progress in the medical context. To my knowledge, there are no full-length studies devoted to the topic, and that is the gap that this work attempts to fill.

In this book, I show, first, that the shared agreement about the value of medical progress rests on the assumption that no one wants to be sick or to die.Footnote ²⁵ But this purported agreement does not translate into any one conception of progress; health is a complex biopsychosocial state, and illness is not fixed, but rather influenced by norms and values. This poses problems for simplistic definitions of progress such as, for example, eliminating pathogens. While narrowly scientific conceptions of medical progress have captured the public imagination, the possibilities of meaningful medical progress are much more chastened than the claims of techno-optimists. But inclusive visions of medical progress as better health for the largest number of citizens are also political appeals that entail trade-offs, for example, with regard to expensive procedures or rare disease research. It is for this reason that multidimensional approaches to persons and to health are less likely to channel reductionist and potentially harmful views of medical progress.

Second, I demonstrate that answers to the question “What is medical progress?” have always been contested; the answer that predominates in any particular context is bound up with a specific approach to health and is also a question of power. In what follows I document how medicine – an art that deals with existential questions about human finitude – experiences firsthand the tensions between different kinds of progress and resolves them differently in particular circumstances. Current ways of thinking about medical progress are, therefore, historically contingent. As detailed in subsequent chapters, progress rhetoric in medicine has been associated with a range of ideas about personhood, knowledge, freedom, and justice in the post-Cold War Global North. As I illustrate, these ideas depend on historical and geographical contexts, as well as on personal experiences of illness and therapy, and there are certainly further iterations of medical progress to come. The title of this book Making Medical Progress – also a nod to Miriam Solomon’s study Making Medical KnowledgeFootnote ²⁶ – reflects the fluidity with which progress can be associated with different dimensions of selfhood and health.

Finally, this book fits with recent attempts to blend intellectual and cultural history by paying attention to the significance of an idea for its own sake, as well as tracking its broad diffusion and circulation. Medical progress is, I think, particularly able to illustrate the porosity between cultural and intellectual divides and to illuminate how an idea is absorbed into broader patterns of cultural beliefs and expectations. It is arguably in medicine that the agreement about progress is the greatest, it is with reference to medicine that “progress” is popularly used, and it is in medicine that the search for progress acts as an agenda that drives research and shapes the aims of those applying for funding.Footnote ²⁷ Moreover, a study of the idea of progress in medicine cannot be separated from medical practices and the varieties of experiences of healthcare recipients. With this in mind, this book adopts a research agenda that breaks down traditional distinctions between the professional and popular. More specifically, my analysis draws on a variety of sources, often academic engagements with the history and philosophy of progress, but also the insights of physicians, patients, and tech actors. Combining these perspectives provides the resources for an in-depth analysis of the idea of progress outlined above.

I.3 Dimensions of Personhood and Patienthood

Any theory of progress in medicine rests on or defends some vision of individual persons and what it means to live together. Indeed, the problems of what it means to be a healthy person or an ill person in a given social context are foundational for coming to grips with medical progress. Historian Jerrold Seigel describes three interconnected aspects of the self that are helpful for understanding how these underpin different views of progress.Footnote ²⁸ The first way of approaching the self is bodily or material, involving the corporeal existence of individuals, our physical needs, and the conditions that, for example, make us more or less susceptible to experiencing pain. This facet of the self considers that our health and wellness are determined primarily by our physiological demands and that progress is evaluated in relation to its ability to meet those needs. The second dimension is the self as a reflexive being, able to take distance from bodies, physical limits, impairments, and social relations, and examine them critically, thereby actively participating in its own self-realization. On this level, the self is able to judge its feelings and symptoms, make choices, and pursue self-knowledge; this is the dimension most likely to be associated with self-determination or autonomy. Progress in such an account takes into account the capacity of human beings to give meaning to their lives, their illnesses, and their suffering. Third, the self can be understood as relational, with collective identities, orientations, and values that are shaped within particular social and cultural contexts. Health is relational, to the extent that people consider their own health in relation to the health of others, their environment, their capacity to perform their work or occupation, and so on. In relational views of medical progress, the health of one cannot be detached from the health of others.

These categories help demonstrate how approaches to selfhood and to progress are inextricably bound up with context. For example, ideas about the physical self are very different if one links bodily functions to certain temperaments, as Greek thinkers did, if the body is seen as the means by which genes can achieve their end, as some evolutionary biologists have argued, or if the body is perceived as matter governed by the rules of physics and chemistry, as Director of the Massachusetts Institute of Technology (MIT) Artificial Intelligence Laboratory Rodney Brooks describes it.Footnote ²⁹ In the specific case of medical progress, the three dimensions of the self have played different roles at different times. Recently, relational approaches to the self have become fundamental in narrative accounts of illness, in care ethics, and in nursing philosophy. Such approaches also underpin increased attention to the social determinants of health. But the bodily dimension continues to be exalted in optimistic visions of medical progress, and the reduction of the person to the body and its mechanisms is a recurring theme underpinning contemporary visions of medical progress. Brooks, cited above, argues that since humans are composed of biological mechanisms, albeit complex ones, they are mere machines. If a self is reducible to the fundamental science behind basic body functions, medical progress is virtually identical to technological progress. “More medical research, more medical technology, more progress,” is how Mark Hanson has characterized this way of thinking.Footnote ³⁰

In addition to acknowledging different dimensions of the self, it is important to recognize the dangers of reductionism when thinking about persons. Philosophical theories that hold that human beings are not merely highly complex organisms but that they are persons do not fit neatly into any one category. Yet what joins them is their interest in the multifaceted realities associated with personhood.Footnote ³¹ Sociologist Christian Smith, for example, shows that human persons are “emergent,” in that they cannot be reduced to their component parts, and that the capacity for free will, the ability to create meaning and an identity, relationships, and a sense of virtuous action all contribute to how persons understand themselves and each other.Footnote ³² Physician and bioethicist Eric J. Cassell argues in a similar fashion that a person is a composite entity made up of its body, its history, its beliefs, its imagined future, and its subconscious life.Footnote ³³ A great deal of medical literature has drawn attention to the importance of person-centered care, which involves knowledge of social relationships and normativity.Footnote ³⁴ Healing illness requires more than healing specific body parts; it requires acknowledging persons as complex entities, with hopes and needs that go beyond purely physical ones. Such an approach to persons means that reducing a person to any one dimension of the self, for example, the body, is a misguided, reductionistic exercise that flattens what is ultimately a stratified reality.

As I argue throughout this study, views of personhood that emphasize the integrated nature of and inner tensions within persons – for example, that a person is a complex, thinking, feeling, relational entity – are less likely to develop one-dimensional views of medical progress. Multidimensionality resists these tendencies because it accepts that the knowledge of any one aspect of a person is fundamentally incomplete. It also illustrates how the demands of different dimensions of the self are sometimes in tension. This multiform approach is necessary to develop a more nuanced and realistic approach to medical progress.

I.4 Health and Values

In addition to endorsing some vision of personhood, any theory of medical progress rests on a conception of human health, that is, a set of ideas about what we need to sustain health and its connection to life. The fact that health is linked to maintaining life, and is important – though not sufficient – for a good life is, I contend, the basis of a sturdy societal consensus that promoting health is a worthy social and medical goal. If a person’s arm is bleeding profusely, there is a robust, shared agreement that medical intervention and treatment are necessary and that a person in a difficult, life-threatening situation should be helped. This is analogous to the notion that basic physiological requirements are primary goods, normally regarded as such by all human beings, who similarly desire to be protected from primary evils, including avoidable ill-health.Footnote ³⁵

The shared commitment to health as a valuable social good appears more robust than other areas of political life; health has been described as one of those rare goods that benefits from continuous public support.Footnote ³⁶ At the descriptive level, healing or attempting to heal the sick has been identified as a “human universal” because it occurs in all societies across time.Footnote ³⁷ But what exactly is the health that so many people seek? At times, the question of what is health is approached less through the lens of what it means to be a person who is ill and seeks to be healthy and more often reduced to the bodily dimension of the self. This approach to health underlies medical education, which teaches students that healthcare interventions are designed to restore biological functioning. The biomedical sciences, meanwhile, have appropriated the task of defining what a normally functioning organism – and therefore what health – is. The use of technologies in the medical encounter also tends to rely on a somatic view of health that diminishes the significance of the mind or other factors. It is possible to argue that the entire biomedical model of disease is predicated on the idea that the body and the mind are two distinct substances and that the body is the locus of health.Footnote ³⁸

Physicalist models of health have been associated with ambitious aims for medical progress and significant achievements. But other approaches to health have illuminated various shortcomings with a narrow, somatic definition. Numerous examples – from a nervous stomach and tension headaches to the effects of racism on stress and mental health – attest to how emotional reactions or social life affect bodily systems. In 1977, George L. Engel presented a classic paper on the biopsychosocial model of illness, which sought to address the lacunae of reductionist and mechanistic conceptions of health by adding psychological and social factors.Footnote ³⁹ Indeed, health has a reflexive aspect: Being healthy involves feeling healthy, which integrates a necessarily subjective element into the idea of normal functioning. Mental suffering is as real as physical suffering, yet more difficult to grasp and treat; a recent study notes that blurred boundaries between the normal and the pathological are a persistent theme in research attempting to classify mental disorders.Footnote ⁴⁰ Meanwhile, in Western countries, neuropsychiatric conditions such as depression and anxiety are the diseases that cause the most sickness overall. Moreover, health has an inherently relational dimension; French philosopher Georges Canguilhem famously has shown that disease is a deviation from societally defined norms.Footnote ⁴¹ The social aspects of health are in view, for example, in the World Health Organization’s definition of health as “a state of complete physical, mental and social well-being” (my emphasis).Footnote ⁴² They also inform the social model of disability, which depicts how society is constructed around a particular idea of normal and thus creates barriers for people with disabilities that would not exist in other circumstances.Footnote ⁴³ Much recent work in epidemiology and public health has revealed to what extent health depends on background social and cultural factors that occur beyond the boundaries of classical disease notions.

The conceptual flaws in refusing to consider factors beyond the body are significant: Symptoms with no identifiable physiological cause are a common reason that patients visit doctors.Footnote ⁴⁴ Medicine that reduces persons to their bodies, without taking into account their personal and social contexts, can be dehumanizing as well as misguided because it misses possible causes of illness. This is linked to how patients experience illness. Questions like “Why me?” and “Why now?” matter to patients: Contributions from narrative ethics show that patients benefit when physicians understand the importance patients attribute to their health in relation to different aspects of their lives.Footnote ⁴⁵ Another failure of a reductionist attitude to health concerns its ability to provide comfort. In an interventionist medical system, if the disease is real but little or nothing can be done, patients tend to experience this negatively. That is, if patients have unrealistic expectations of medical progress, they experience their illness situation as a failure of medical actors, rather than an aspect of the human condition with which they must cope.

Views of personhood that emphasize the complexity and contradictions of life as a person tend to align with conceptions of health that refer to a complex state of affairs that includes individual experience and social context. But recognizing that physical, mental, and social health are not cleanly divided challenges definitive claims for medical progress. Engel, the “father” of the biopsychosocial model of health, flagged progress toward bridging the biological and psychosocial aspects of health as “slow and halting,” both because of the complexities inherent to the endeavor and due to unremitting pressures to favor the more tangible, physical aspect of health.Footnote ⁴⁶ And in a reflective article considering his tenure as a prominent WHO employee, Kenneth Newell argued that there are so many facets of health that have to be seen together, “There is no objective way of judging whether one mix is better or worse than another.”Footnote ⁴⁷ By these accounts, medical progress is a complicated process with multiple dimensions, and the goal is an ephemeral, constantly changing one.

I.5 Problematizing Medical Progress

In light of these reflections regarding health and persons, what do people referring to progress in medicine in the media, in politics, in scholarly interventions, and in conversations mean when they use the term? There is no easy answer to that question. The wide range of ways in which health and persons can be understood, and how the term progress is used, makes it difficult to grasp; progress is a popularly used but fundamentally vague concept.Footnote ⁴⁸ “Progress” is a noun, but sometimes a verb or the root of the adjective “progressing,” a variety that enables it to carry different amounts of political baggage. In its most common use, “progress” refers to advancement to a better state or condition. But etymologically, “progress” has not always implied betterment; the notion that a disease is “progressing” is one of the few contemporary uses of progress in its negative valence.

I have been using the word progress freely up until now, but in the main, I am interested in a specific idea of progress that has been accepted for centuries in Western culture, whereby progress refers to a cumulative process that enables an individual or a society to obtain something and then go on to attain something better.Footnote ⁴⁹ This kind of progress has a normative component in that it evaluates change according to a broadly shared framework or a goal. Such progress also involves an epistemological claim, in that it valorizes certain kinds of knowledge – biomedical knowledge, for example – and posits specific relationships between knowledge gains and other spheres of life. Thus conceived, progress is also an ontological phenomenon, linked to an understanding of how historical change occurs. Examples of such assumptions about reality can be found in statements such as “you can’t stand in the way of progress” made by enthusiastic engineers or in the well-known definition of progress as “irreversible meliorative change” (my emphasis).Footnote ⁵⁰

In the medical case, there is a persistent tendency to associate medical progress with the above cumulative-historical view, even as progress in medicine is often best described in a much more limited fashion. Speaking to broader cultural desires that associate medicine with notions of progress, surgeon and writer Atul Gawande observes that Western medicine is singularly focused on the idea of machinelike perfection.Footnote ⁵¹ The high stakes involved in healthcare mean that there is an urgent and intense need to believe that medical intervention can be constructive for patients. The very notion of progress is associated with the benefits of intervention, as opposed to resignation, or being with the patient, as in the conceptual framework of palliative care. Hope, an emotional attitude that desires an outcome, implies the possibility – if not the certainty – of progress.Footnote ⁵² Given the importance of hope when confronted with one’s own vulnerability and finitude, Adrienne Martin describes it as the watchword for the medical research industry as a whole.Footnote ⁵³

This study does not attempt to provide a comprehensive answer to the question of whether a given intervention or development “genuinely” constitutes progress, in the sense of improvement over time. It makes no attempt to conclusively prove that any specific practice or technique can be unambiguously designated as medical progress or not. What interests me rather is the belief in the existence of progress, what can be called progress as a second-order concept, and the variety of forms this belief takes on. This contrasts with various existing engagements with medical progress, which often are evaluative, and seek to demonstrate that a particular change constitutes a first-order advance.Footnote ⁵⁴ What I am particularly concerned with is the widespread rejection of the idea of progress as a valid conceptual category for describing historical change – a tendency that became particularly pronounced in the post-war period – and the insights that these debates offer into the widely held attachments to the idea of medical progress today. Therefore, I focus on the medical story where the term and concept of progress have been especially widely used, but the medical case is important to me as part of the larger, transdisciplinary story of the vagaries of progress as a conceptual category.

I want to acknowledge the more questionable assumptions inherent in its Enlightenment heritage but also to contend that progress need not be teleological nor linear, as well as to show that I do think there are justified reasons for believing in it. With regard to the epistemological dimension of progress, we must consider how every statement about progress is a statement about change in relation to a contested time slice. Depending on the time reference chosen, statements about progress will look very different; it is harder to describe the industrial revolution as “progress” in light of climate change. Particularly in the medical case, factors such as side effects – a necessary part of intervening in the human body – and unintended consequences are likely to gain or to lose prominence.Footnote ⁵⁵ For instance, the achievements of “frontier” fields like neonatal medicine and their ability to allow very premature babies to survive are often cited as exemplary medical progress.Footnote ⁵⁶ But depending on when we take stock of the effects thereof – on the date babies are released from the neonatal intensive care unit or later in life with reference to their overall health – there is a very different sense of the progress involved; while more babies survive, a premature birth means higher risks of chronic health problems and disability.Footnote ⁵⁷ Other examples abound; while penicillin has been widely recognized as a “perfectly objective” example of progress – as per Robert Nisbet above – no full account of the antibiotic era can be given without reference to the antibiotic resistance challenges of the present day. Or consider, for example, how the drive to have pain taken seriously as a medical condition and to provide relief is bound up with the current opioid crisis, which itself has been described as caused by modern medicine. In short, claims of medical progress are valid with reference to a particular time frame.

Furthermore, the knowledge we require to grasp the health of a holistic entity such as a person is complex. Gaining knowledge of a particular dimension of health, biophysical for example, remains fundamentally incomplete. A biophysical model of health presumes that health problems are measurable and therefore can be solved by well-defined interventions, procedures, and technologies, something that needs to be considered alongside insights from health’s other dimensions. In general, knowledge gains raise the standards for justification and require that related interventions be evaluated by more demanding criteria. Increased knowledge also uncovers new uncertainties and new sources of potential error. Such gains also increase the responsibility to act on them, actions that, in turn, have secondary and unintended consequences.

The normative framework we might use to evaluate medical progress is similarly contested. The fact that health has multiple dimensions, and the ways that different dimensions may be in tension with each other, means that there is no objective measure of health nor standard for measuring progress. Medicine has multiple fundamental goals, the way these goals fit together cannot be determined in advance, and there are conflicts among them. The mandate of medicine to save and extend life, for example, may be in tension with the relief of suffering and the pursuit of a peaceful death. Privileging resource-intensive techniques is not reconcilable with the goals of an equitable medicine accessible to all. Medicine is constantly performing a balancing act between the pursuit of individual health and well-being and the common good. Indeed, for a single goal of medicine against which progress can be measured, local solutions generate new difficulties. In essence, this provides that there are only limiting cases in which progress could be judged. We can claim that medical progress exists in relation to the shared commitment to a vital minimum of health needed to sustain life since we know that there are health conditions that we are morally compelled to treat given available material resources. But any further progress in medicine will remain relative to mitigating what we consider shared evils with regard to health.

Moreover, we have to take into account the fact that rather than having a stable ontological status, the confines and scope of medicine and health are the subject of ongoing disputes and are constantly renegotiated. Far from having a unified, consistent mandate, medicine can be defined as a diverse set of ideas, methods, procedures, and practices that have constantly varied depending on time and place.Footnote ⁵⁸ There now exist entire categories of disease that doctors did not use to treat, including attention-deficit hyperactivity disorder, obsessive-compulsive disorder, phobias, chronic fatigue, social anxiety disorder, post-traumatic stress disorder, and various kinds of depression. In a similar vein, there are multiple examples of behaviors that were previously labeled as diseases, such as drapetomania, a disease that caused slaves to run away, masturbation, or hysteria.Footnote ⁵⁹ Concepts of diseases emerge from specific cultural and scientific priorities, while diagnostic innovation goes hand in hand with both treatment innovation and the experience of both illness and therapy.

Taken together, these remarks show that there is no stable standard for measuring progress, nor any stable goal toward which medical progress could orient itself. The criteria we can apply to compare and judge medicine, health, and disease in different contexts are complex and ultimately value based.Footnote ⁶⁰ Determining what progress is necessary to overcome disease and to achieve health is always a social and political act. In sum, the standards by which we might evaluate progress change over time, progress consists in confronting a new set of problems in each historical moment and trying to overcome them, and this means that we can only determine progress in hindsight.Footnote ⁶¹ Progress might consist in improved epistemic or moral assumptions, but human learning also implies forgetting; progress comes with pauses and regressions. Therefore, rather than seeing progress as a unified process proceeding lawfully across societies, it is better described as localized and circumscribed. Crucially, if progress is nonlinear, but rather multidimensional, progress in one domain – such as one aspect of health – may coexist alongside losses in another.Footnote ⁶² Part of making progress that is neither metaphysical nor deterministic therefore involves facing up to the difficulties involved in weighing the relative importance of problems. Such progress is necessarily a chastened idea of progress.

I.6 Historiography of Progress

Given the wide range of contexts in which progress-talk occurs, it will come as no surprise that the academic literature on the concept is vast. As we shall see in Chapter 1, the eighteenth century is usually considered the heyday of the concept of progress, while it continues to be referred to as the guiding idea (Leitbegriff) of the nineteenth century.Footnote ⁶³ At the time, the idea was bound up with the optimistic hope that human reason can and will construct a better, more enlightened society. It was also the term of choice to describe new knowledge, improved material conditions, and better societal institutions and to understand them as part of an overarching scheme of improvement.

The theme of progress fundamentally changed the character of history writing by introducing a developmental structure to global history, and it merged with a simultaneous interest in universal histories of the world. Implicit in this idea of progress was the notion of the superior state and civilizing mission of European nations; with the idea of progress, the history of humankind as told in the West became identical with the history of civilization.Footnote ⁶⁴ Documenting the enlightened and reasoned developments that count as progress was bound up with history writing, which aimed at documenting the errors of the past and the present inferiority of non-Western nations.

And yet, tales of progress have always had their skeptics.Footnote ⁶⁵ By the end of the nineteenth century, the widespread fascination with progress in the West was matched by a significant revolt against the view that the future development of human societies was moving in any discernible direction or whether there were common standards or objective truths achievable by reason. In the twentieth century, different families of theories, including critical theory, moral relativism, postmodernism, and postcolonialism, further questioned and undermined the notion. When I told a medical historian colleague that I was working on the idea of progress in medicine, she asked me, “haven’t you read Foucault?” Today, prominent critics of progress and the violence that has been conducted in its name abound.Footnote ⁶⁶ A global crisis in the ideology of progress has been linked to phenomena ranging from the enthusiasm for “post” words to the resurgence of popularity of analog objects. Historian and philosopher of science Naomi Oreskes writes that history has come to be seen, no longer as a linear story of progress, but as a story in which the notion of progress can only be considered in relation to the question: progress for whom?Footnote ⁶⁷

Given its charged history, progress is by no means a neglected topic in academia.Footnote ⁶⁸ The concept has recently benefited from increased scholarly attention across a range of fields including in philosophy of science,Footnote ⁶⁹ law,Footnote ⁷⁰ anthropology,Footnote ⁷¹ sociology,Footnote ⁷² and intellectual history.Footnote ⁷³ Attention has also been paid to how the idea of progress has been shaped by and itself influenced different historical periods.Footnote ⁷⁴

The popularity of the concept is further reflected in the number of recent international events and related publications devoted to progress.Footnote ⁷⁵ Some of the most sustained supporters of the idea of progress are a cluster of academics and thinktank operatives – sometimes called “New Optimists,” the most prominent of whom is psychologist Steven Pinker – who argue that humanity should be much more sanguine about the genuine progress it has made.Footnote ⁷⁶ Such commentators point to different measures – first and foremost modern medicine – to show that the world is becoming a better place. As a rule, such interventions have a stabilizing function in that they validate current systems, namely, capitalism and democracy. They assume that whatever political and economic arrangements we currently have are working well and therefore ought to be maintained.Footnote ⁷⁷

Other engagements with progress seek to reclaim the concept’s emancipatory potential and link it to a more disruptive politics. Philosopher Axel Honneth observes that “‘progress’ is a necessary and unavoidable perspective for all those of us today who aim at revitalizing emancipatory action.”Footnote ⁷⁸ The notion that progress is essential but problematic, and requires new, reconstructed conceptual foundations, runs through a number of works in contemporary philosophy and political theory. Thus, scholars have probed the different meanings of progress in history and the need for a reformulation of the idea today,Footnote ⁷⁹ the potential tensions between scientific and technological progress and other more humanistic forms of progress,Footnote ⁸⁰ the links between progress, normativity, and social change,Footnote ⁸¹ the extent of moral progress in history,Footnote ⁸² as well as the question of what it means to make political progress.Footnote ⁸³ Among other things, representatives of “neoprogressivism,”Footnote ⁸⁴ as Jakob Huber terms contemporary philosophical reappraisals of progress, have sought to reconceive progress in a nondogmatic way, which relies on the notion of learning processes in which human agency plays an important but unstable role.

I.7 Historiography of Medicine and Progress

Given the ubiquitous use of the term progress in professional medical contexts and popular ideas about medicine, it may come as a surprise that the topic has not been more investigated in academia. Historians of medicine have a particular relationship with and perhaps a particular aversion to the idea of progress. One reason is that the history of medicine was originally told by doctors and from a heroic perspective. The first specialized historians of medicine in the nineteenth and early twentieth centuries were themselves practitioners, and they characterized medicine as a continuous tale of progress. In the English-speaking world, the best-known spokesperson for this model was Canadian physician and educator William Osler (1849–1919), who saw medicine as a fundamentally progressive science and sought in his history lectures to provide a bird’s eye view of medical progress.Footnote ⁸⁵ It was only in the 1970s and 1980s that trained historians began to engage substantially with the history of medicine, something that occasioned new historiographic controversies about whether nonphysicians could sufficiently grasp medical practices.Footnote ⁸⁶ At stake was also the question of whether the history of medicine should be embedded in a narrative of progress, which both confirmed the superiority of science-based medicine to what came before and perpetuated that view of history.

“Unilinear scientific progress,”Footnote ⁸⁷ a “linear march of progress,”Footnote ⁸⁸ “the march of medical progress,”Footnote ⁸⁹ as a rule, such depictions of medical history were seen as the worst kind of presentism by academic historians. Today, historians of medicine are uniquely aware of the pitfalls of seeing the development of history as a straightforward path to current truths. Rather, history is perceived as uniquely able to raise inconvenient perspectives and an antidote to perpetuating the “dangerous illusion” that medicine is on a progress track from religion to science.Footnote ⁹⁰ In addition to history, insights from science and technology studies highlight how medical innovations and their application are bound up with social contexts and constraints. Medicine, increasingly, has come to be seen as part of an intricate network, involving market forces, institutions, power hierarchies, and ideologies, and one in which lawful, inevitable progress has little meaning.

The interest of the medical humanities, then, has largely been to move away from triumphalist narratives by recapturing the complexities, roads not taken, and undocumented effects of simplistic accounts of medical progress. The notion of linearity that clings to progress implies that the acceptance of new, more refined techniques is nearly inevitable and therefore inherently oversimplifies what are often complex and circuitous adoption procedures.Footnote ⁹¹ In many cases, there is no clear move from theory to practice, as shown, for example, by the introduction of antisepsis and asepsis or the adoption of surgical gloves.Footnote ⁹² Moreover, many therapeutics initially perceived as cutting-edge and desirable are ineffective or end up harming patients.Footnote ⁹³ Other studies meticulously document how views of disease – for example, diagnostic judgments based on “objective,” laboratory evidence rather than “subjective” evidence such as patients’ sensations – are inherently partial, with losses as well as gains.Footnote ⁹⁴ This has led some historians to argue that the technological orientation of modern medicine is a contingent development.Footnote ⁹⁵

The critique of progress by medical historians also means reflecting on the relativistic implications thereof. In a well-known intervention on nineteenth-century therapeutics, historian Charles Rosenberg sought to break with past scholars who presented change as equating progress.Footnote ⁹⁶ In doing so, he tried to move the study of past medicine away from questions of physiological efficacy and to connect it to broader contexts of explanation and meaning-making. Once historical context was taken into account, he argued, medical therapies of the past “worked” in the sense that they produced physiological effects that were predictable for physicians and experienced by patients as relief. Reflecting on the wider import of Rosenberg’s conclusions for medical progress, John Harley Warner argues that relativism is an important tool for historical understanding because it forces us to acknowledge that the very claim about whether a treatment “works” is context dependent.Footnote ⁹⁷ Ultimately, this methodological premise implies that techniques such as blood-letting “worked” for those physicians and patients who used them, and antibiotics “works” in a later era.Footnote ⁹⁸ But if each system of therapeutics works according to its own criteria, determining progress becomes more complex. The upshot of this line of reasoning is that while we are invested in the therapeutic regimes of our own time and can prefer them on that basis, broader claims of progress are difficult.

Progress-oriented stories of medicine often focused on a series of breakthroughs in medical science, accompanied by “heroic” acts of a small number of affluent, influential white men, who were ideally positioned to reap the fruits of progress. In 1985, Roy Porter published a seminal article, “The Patient’s View,” that questioned writing the history of medicine as a story of scientific progress and called for taking into account the views of patients, and linked medical events to social rituals, in which families and communities play a part.Footnote ⁹⁹ New historical sensibilities to the voices of patients, including the stories of women, minorities, and communities facing barriers, have drawn attention to the fact that social positions associated with age, abilities, class, gender, and race intersect to determine who benefits from specific kinds of medical progress and who suffers from it.Footnote ¹⁰⁰ This insight exists alongside the awareness of the difficulty inherent in recovering such voices when few of them recorded their views on illness and treatment. But it also draws attention to the fact that historical narratives of progress are necessarily selective, and these are precisely the viewpoints that have been omitted to allow a relatively uncomplicated story of progress to emerge.

It would, however, be an exaggeration to say that historians of medicine have not at times been very clear about what constitutes progress. Historian David Wootton, for example, set 1865, the date that Joseph Lister used antiseptic surgery, as the moment marking the beginning of the first real progress in medical therapy.Footnote ¹⁰¹ He argues that historians of medicine have a simple choice: either understanding the past on its own terms, in which case Hippocrates’ and Galen’s cures saved lives, or in light of modern science, in which case these cures were often deadly.Footnote ¹⁰² Wootton, however, remains the exception; as historian of science Steven Shapin observes, in the past few decades, academic historians of medicine “didn’t – with rare exceptions – criticize the idea of medical progress so much as fall silent about it, seeing their job as something other than its documentation and celebration.”Footnote ¹⁰³ And if academic historians did not so much talk about progress as avoid it, popular accounts have filled the gap. Given medicine’s extraordinary technical prowess, triumphant histories of medicine remain remarkably popular today. Widely read books aimed at a general public, in the genre of Physicians, Plagues and Progress: The History of Western Medicine from Antiquity to Antibiotics and The Medical Book: From Witch Doctors to Robot Surgeons, contribute to our understanding of medicine as the locus of progress in contemporary society.Footnote ¹⁰⁴ Often, they use evolutionary metaphors to portray modern medicine as an inevitable history of progress, emphasizing cumulative achievements and minimizing the ways in which these are entangled with significant failures and rejections.

I.8 Medical Progress: A Multidimensional View

This book is about the politics of medical progress and the real-world implications of conceptual choices. For example, we might describe a specific medical technology as progress, we may associate progress with the ability of individuals to determine what happens to them in healthcare, or we might see progress in a given procedure being made available to all. These differing visions are better understood not as more or less accurate reflections of what medical progress “really” is – arguably they are all justified first-order instances of progress – but rather as normative positions underpinned by specific ideas of personhood, of society, and of health.

In the chapters that follow, I unpack and historically contextualize ideas of progress that hold currency in particular circumstances. I do so with a special interest in the terms “medicine” and “progress.” To avoid overuse, I alternate the usage of progress with other words such as advance, improvement, or even development. I am, of course, aware that these terms are not entirely synonymous with progress; in particular, they do not link back to the larger tradition of progress rhetoric that I am particularly interested in. In the case of medicine, I do at times refer to health progress, as do the actors who are interested in minimizing the role of biomedicine and who favor broader conceptions of health. That said, rather than focusing on a wider thematic cluster of terms, I look specifically at medical progress to offer a Begriffsgeschichte – a conceptual, semantic history – of the term “progress” and its recent incarnations in medicine.

Chapter 1 offers a historical overview of progress rhetoric up to 1945, and specifically how the interest – or disinterest – in progress is entangled with contemporary understandings of what it means to be a healthy/ill person, and the medical priorities of the time. While present-day ideas about medical progress rest on very different understandings of the human person from other cultural and historical contexts, their emergence from a combination of scientific knowledge and ethical preoccupations recurs throughout history. Indeed, both utopian and modest visions of medical progress have historical antecedents. This rough historical guide, therefore, explores the roots of contemporary statements about progress and explains how they relate to current epistemological and ethical priorities.

Subsequent chapters offer a more or less chronological survey from 1945 to the present day, each of them focusing on different operative concepts for medical progress – knowledge, freedom, and justice – before concluding with an epilogue on sustainability. Chapter 2 describes the heady excitement surrounding scientific medical progress in the post-war period and subsequent theoretical challenges culminating in the idea that progress claims are only valid in relation to context. It also scrutinizes how, in light of relativistic questions about to what extent knowledge can be progressive, medicine continues to be portrayed as uniquely immune to these uncertainties. It concludes by analyzing two recent examples, evidence-based medicine and health AI, both of which have been praised as objective examples of a particular kind of medical knowledge progress.

Chapter 3, on freedom, begins by showing how awareness of the insufficiencies of medical progress as “merely” scientific knowledge gains led to a new interest in knowledge with the ability to empower patients. This chapter also details how, in some cases, taking individual freedom seriously meant challenging traditional (technological) forms of medical progress because they were not patients’ preferred methods of intervention. It concludes with a detailed examination of the most recent instances in which technological progress is presented as being highly compatible with personal freedom. To that end, I discuss the way in which genomic medicine promises to make “empowered patients in the twenty-first century” – to paraphrase the title of a recent book.Footnote ¹⁰⁵

The final chapter traces debates on progress and social justice focusing on the late 1980s onward. The critique of a medical marketplace, the perceived need to challenge an autonomy-based notion of progress, and a certain sociopolitical optimism all contributed to reimagining medical progress by placing left-wing sensibilities front and center. Effectively, the idea of progress lost its narrower “medical” focus, in favor of the idea of health progress and became associated with ambitious projects for achieving social equality. Part of the story told in this chapter is the extent to which increased knowledge of health inequalities has come to embody progress. But here too, a single-minded commitment to the notion of progress as health justice comes replete with trade-offs and unresolved tensions.

The book concludes by considering one possible future incarnation of the idea of medical progress, progress as achieving sustainability. Visions of sustainable medical progress enlarge the concept of human health to include the health of nature, call for expanding the time frame in which medical progress is assessed, and posit environmental limits as a constraint on open-ended progress. At the same time, few of these visions engage with the pluralistic nature of medical progress, preferring to understand measures that support a robust natural environment as intrinsically good for the health of individuals and societies.

In structuring my chapters this way, I am not arguing that these incarnations of medical progress are somehow exclusive to a particular time or were ever hegemonic; I rather think they occur simultaneously and all have deep historical roots. Nevertheless, there are moments in which specific ideas gain a particular resonance. My research shows that the notion of medical progress grafts particularly well onto the normative high ground of a particular historical moment. Within the chapters, I do two main things. First, I show the way in which the progress of knowledge, freedom, and justice has been both justified and contested and the implications for specifically medical progress of these debates. This task is epistemological, that is related to investigating the methods, validity, and scope of different kinds of medical knowledge.

The second aim is ethical and related to ideas about what is a person and what constitutes health. Throughout the book, I contend that the most vocal proponents of medical progress have tended to believe one of two things. Either they have focused on one particular element of health (biological or psychological or social) or they have argued that the three elements (biopsychosocial) are mutually reinforcing and progress in one aspect leads to progress in the other two. I, therefore, show that when thinking about medical progress, not only do we have to consider the epistemological aspects of how progress in any one dimension of health is not uncomplicated but also that health has multiple dimensions and that progress in one dimension does not necessarily mean progress in another.