The August 8 issue of Sports Illustrated includes an article titled, “Prosthetics: Between Man and Machine.” In that piece, one of the leading voices on the future of prosthetic technology, Hugh Herr (a bilateral amputee himself), is quoted as follows:
“[Prosthetic technologies of the future will] be so exciting that regular old arms and legs will seem dull,” Herr says. “If the Paralympics accept advances in technology, there’ll come a time when the Paralympics will be more popular than the Olympics. There’ll be these insane human-machine events.”
“In the future there’ll be a class of transportation devices in which limbs are augmented,” says Herr. “And if you’re an amputee born today, there’s a good chance that, in your 20s or 30s, your athletic performance will be augmented [beyond that of a nonamputee] and your daily life at least normalized.”
I don’t doubt the ability of Herr and others like him to eventually deliver some version of this reality. But there’s a bigger issue here that I’ve discussed previously: is an era of prosthetic augmentation what the limb loss/disability community wants or needs?
1. the world of prosthetic equivalence
Both people with LL/D and those without would, I think, agree with the following principle: if you lose/are born without your limb(s), you should have the right to technology that allows you to replace what’s not there. Indeed, most Americans reflexively think that if they lost a limb today or were born without it, their insurance would provide them a replacement. (Most Americans are wrong, but that’s a discussion for another day.)
If you dug a little deeper and asked the question, “What does it mean to replace what’s not there?”, you’d end up with a similarly consistent response: “It means getting a replacement limb that functions as well as a regular limb.” Or, stated another way, every person with LL/D has a fundamental right to a prosthesis that allows them to do everything an able-bodied person does the same way an able-bodied person does it. If such technology existed today, you would have what I call the World of Prosthetic Equivalence: no difference between having a prosthetic limb and a fully functional limb of flesh and bone.
In the World of Prosthetic Equivalence, the debate wouldn’t be “Should people with LL/D have access to this technology?”, but rather, “Can we deliver it to them in a way that’s economically feasible?” The only barrier to utilization by all individuals with LL/D would be cost-related factors. I don’t think you’d see any philosophical obstacles to providing people with such devices. But the World of Prosthetic Equivalence and the future Hugh Herr describes are, I think, quite different. (Not better or worse – different.)
2. the world of prosthetic augmentation
In the World of Prosthetic Augmentation, the replacement limbs received by people with LL/D would enable them to do things that able-bodied individuals couldn’t. A prosthesis would now imbue them with capabilities beyond that or fundamentally different than that of a normal human. Whether Herr’s statement that “[i]f the Paralympics accept advances in technology, there’ll come a time when the Paralympics will be more popular than the Olympics” proves true or not, his vision of augmentation raises some interesting questions that deserve consideration.
Before I dive into that analysis, one caveat: the views that I’m expressing are mine and mine alone. I don’t pretend or imagine myself to be the voice of the LL/D community on this (or any) topic.
a. do people with LL/D want to be something more than able-bodied?
I don’t get excited about the possibility of being able to do more with some future prosthetic technology than I ever could as an able-bodied person. I suspect that opinion finds its roots in how I chose to reconstruct my life after my accident. My primary rehabilitative goal was to navigate the able-bodied world without detection. I wanted to become what I had always been – “normal.” (Insert your own joke here.) Or, stated another way, I wanted to fit in, to be part of the universal Us as opposed to Them.
Now, I will freely admit that my attitude towards prosthetic invisibility may, at first glance, appear hypocritical. I’ve never wanted or used any kind of silicone skin over my prosthesis. The longer I’ve been an amputee, the less I’ve cared about cosmetics, to the point where I totally eschew any kind of cover today. But I think there’s a big difference between being comfortable with how something looks on the one hand and how it functions on the other.
I’ve written about ego before. I now choose to show my “bionic” left leg, a decision that generally attracts attention. And if I’m completely honest with myself, I’m ok with – perhaps I even need? – attention like what I heard a young woman whisper to her girlfriend as I jogged past them on the banks of False Creek in Vancouver three weeks ago: “That’s so cool!”
But putting aside my rampant egotism for a moment, her statement leads to an interesting question. Why is running on a prosthetic leg so cool? The reason – both in my own mind and, I suspect, hers – is that I’m doing something that’s generally understood to be unusual (i.e., difficult to do). Running leg over leg as an above-knee amputee just isn’t easy. As a result, few people choose to do it. And that makes the sighting of one of Us running a noteworthy event.
However, when technology fundamentally changes that dynamic – makes it easier for me to run faster and farther than an able-bodied person – it’s no longer “cool” in the same way. At that point, I’ve transitioned from “trying to make up the gap” to creating a new one. I’ve moved from, to say it bluntly, the freak who’s trying to replicate what the able can do to the freak who’s using mind-bending technology to separate himself from what the able can do. Instead of being a guy doing something incredibly difficult, I’m a guy who’s enhanced – augmented – beyond what’s physiologically possible. For me, that would feel like I’m gaming the system.
To be clear – I’m not saying that such a development would lack some form of objective utility. But focusing solely on how such creations would affect my sense of self, I believe that augmentation beyond what’s normally (humanly) possible would so fundamentally change the nature of the underlying activity that I wouldn’t want to engage in it.
Reading Hugh Herr’s comment, I get the sense that he might welcome operating outside of those physical boundaries that have historically circumscribed human performance. And that’s not a “bad” or “good” opinion in my view. It’s just one that I can’t get comfortable with. And I’m curious how the rest of the LL/D community feels about it.
b. will the able-bodied population accept the kind of augmentation that Herr envisions?
I can already hear the reaction of many people with LL/D to this question: who cares? Navigating life with LL/D is difficult enough without trying to take into account how the “temporarily able” view you. But this is an important issue that, I fear, can’t be easily dismissed.
Just look at the debate that has restarted as a result of Oscar Pistorius’s successful qualification for the upcoming track and field World Championships. At the same time that many are celebrating his accomplishment, you hear a steady undercurrent of discourse about the purported advantage provided by his “blades.” Even the scientists who studied Oscar have staked out violently opposing positions, as illustrated by these point/counterpoint pieces in the Journal of Applied Physiology. (Herr is one of the scientists who is part of this debate.)
All of this, I think, only underscores the legitimacy of a question I raised almost a year ago:
In a world conditioned to see successful individuals with LL/D as “inspirational” and/or “heroic” – largely, I suspect, because of the able-bodied perception that the disabled are nobly striving to overcome the limitations thrust upon them – how will people react when they see these previously brave souls blasting by them on a track or regularly accomplishing things physically that people with all their limbs cannot?
Just imagine, for a second, the debate that will ensue if Oscar actually qualifies for and medals at the 2012 Olympics. If the most informed people in the world – the scientists who studied Oscar – can’t agree on the issue, I can’t foresee the court of public opinion peacefully resolving it. In fact, as I’ve stated before, I fear that the most groundbreaking future physical achievements of the LL/D community – those that involve surpassing the best able-bodied performers – will result in a hard backlash against the previously “inspirational”.
I’m not saying that the quest for that level of performance should stop or that some individuals shouldn’t embrace pushing those boundaries. I am saying that we better begin to figure out how to articulate a message around what that actually means. Because if we wait until that day comes to start figuring it out, I think the story will have already been told. And the narrative won’t be one that people with LL/D like.
c. how will augmentation impact access to prosthetics?
Moving from the more theoretical to the practical and, coincidentally, into my area of professional interest, how would prosthetic devices that augment performance affect the LL/D community in the real world? In particular, since most people with LL/D depend on governmental or private payers for their prostheses, how would those payers respond?
Anyone who has tried to get a prosthesis paid for over the last decade is well aware that payers – especially private insurance companies – restrict or prohibit access to these devices, even though the best ones still don’t come close to replacing the full functionality of what was lost or missing. And these same payers exclude from coverage those treatments and devices that they classify as “not medically necessary” and “cosmetic.”
I suspect you’ll have a hard time convincing many people in the public at large, much less at Aetna and United Healthcare, that their premiums should go towards the payment of prosthetics that allow you to move faster, farther, and more easily than the average “able-bodied” person. Hell, as a person with LL/D, I don’t think insurers should pay for such technologies. Indeed, today insurers only pay for one prosthesis that allows the user to perform their “normal activities of daily living.” And as the press, as it undoubtedly will, starts publishing headlines in the future like “Building Superman” and “Going Beyond Human Capability” to describe those using augmenting prosthetics, insurance companies will do two things.
First, they’ll exclude those devices from coverage. That’s my guarantee to you, today, August 15, 2011. I don’t think it’s even a close question. I’ll discuss the ramifications of that below.
Second, surrounded by the swirl of articles and blog posts and videos of people with LL/D obtaining results outside the realm of normal human physiology, insurers will perform a fundamental re-examination of those devices that are purely restorative. And if there’s any argument at all that those devices augment any aspect of the user’s performance beyond that of an able-bodied individual, they’ll be added to the list of excluded technologies, because they’ve now crossed from restorative to “cosmetic” or “high-performance.” And the average person with LL/D will suffer as a result, because legitimately restorative technologies will get caught up in the wake of augmenting devices.
So, when you strip away all the philosophical discussion and debate, here’s where I think you’ll end up. People like Hugh Herr will (and should) develop prosthetic technologies that augment the user’s performance beyond what was ever physiologically possible as an “able-bodied” individual. That will lead to insurers trying to draw very clear lines between “restorative” and “luxury” technologies that will probably limit – at least in the short run – the average amputee’s access to devices that truly are restorative. And the technology that will make normal arms and legs seem “dull”? That will be on the fringe – the cosmetic surgery of the prosthetic world – available to the wealthy and those willing to take out a loan or a second mortgage to access the prosthetic equivalent of a Ferrari – something that you don’t need to get through your day, but that many will undoubtedly want.