Is a prosthetic arm customized PRADA? A critical perspective on the social aspects of prosthetic arms

Abstract

The development of prosthetic arms has progressed dramatically over the last 100 years, from simple tools made of wood to arms that virtually imitate their biological counterparts. Investment in the development of prosthetic arms has also increased sharply, but the practicality of these arms is questionable. Prosthetic arms now cost between $5000 for a simpler type and over $100,000 for a neuro-prosthetic model in the United States. Considering that consumers of this technology are people with disabilities who are often vulnerable to poverty, such prices are at odds with the principle of maximum help and assistance to people with disabilities. In this article we call for the attention of governments and policy-makers, both in developing and developed countries, to consider social and policy barriers to developing and distributing prosthetic arms and to enact equal entitlement to prosthetic use despite one’s socioeconomic status.

Keywords:

• Disparities
• inequality
• social exclusion
• assistive technology
• quality of life technology

What is the distinctive line between what humanity considers ‘man-made’ and what occurs by ‘nature?’ In 1965, the co-founder of Intel and Fairchild Semiconductor, Gordon E. Moore (originator of the popular Moore’s Law), noted that technological devices were becoming considerably smaller and yet more powerful with time (Computer History Museum 2016). In the present day, technology is so intricately woven into our lives that the very distinction between what is artificial and what is not is to a large extent obscure. Yet technologies that literally knit – physically – into our lives as in popular science fiction media featuring cyborgs still seem distant from everyday lives.

Prosthetic arms – employed to aid individuals experiencing limb losses because of war, accidents or congenital disorder – form a portion of this growing technology. Over the course of human history the development of prosthetic arms has made dramatic progress, from simple tools made of wood (during the ancient Egyptian era) to arms that virtually imitate their biological counterparts. Investment in the development of these arms – comprised of complex combinations involving sensors, microprocessors and many other sophisticated components – has sharply increased during recent decades. For example, the US Department of Veteran Affairs saw a roughly exponential growth in funds for prosthetic research from $1,005,350 in 1948 to $819,000,000 in 2007 (Gershenson and Holsberg 1974; Research America 2008). Moreover, today, projects like the Defense Advanced Research Projects Agency Revolutionizing Prosthetics Program, among others, attract increasingly significant contributions to design and develop advanced prosthetic arms that perform technically challenging daily activities such as typing or writing for the more than 12 million amputees in the United States, not to mention the even larger population of the world.

While these determined efforts to make the future of prosthetic augmentation an ideal option for amputees are vital, they conform almost solely to the premise of pure technical or design innovation as opposed to a more holistic approach that addresses wider themes of access, user needs, eligibility and affordability. A study of user reviews of the Dean Kamen (DEKA) Arm – one of the most advanced prosthetic arms – by the US Department of Veterans Affairs (2014) reported that as many as 30% of the people were dissatisfied, mainly due to issues linked to optimization (Resnik and Matthew 2014). Unlike other electronic gadgets that can be identically mass produced, optimal use of a prosthetic arm is not just about the list of capacities of the device, but is also about how suitable and how safe it is for each user.

This limitation is due to the fundamental nature of a device that is physically attached to the biological body, in that a complex set of factors from antigen resistance, to neural damage, all the way to risks of software intrusion uniquely affecting each body. This unprecedented level of ‘personalization and care’ required of every prosthetic arm calls for difficult procedures, which in turn stimulate: high total costs for implementation; limited service points in certain areas; and the need for costly maintenance.

These very important issues are often less emphasized when it comes to an amputee’s real circumstances in opting for prosthetic use. A quintessential example is the cost incurred in the United States for a prosthetic arm. Costs range from $5000 for the simplest type of arm, up to over $100,000 for an arm comparable with the DEKA or ‘neuro-prosthetics’ models; certainly not a small amount (McGimpsey and Bradford 2008). Additionally, a 1998 study conducted over a period of eight years by the National Center of Biotechnology Information established that the necessary regular maintenance of prosthetic devices added 20% to the total cost of a prosthesis (Hermodsson and Persson 1998). Given that the costs have continued to rise and that prosthetics are not a mass market, these costs today if the study was repeated would in absolute terms be much more. Moreover, disparities in the access and use of maintenance services and care by the cause of limb loss need to be considered in understanding the needs of prosthetic arm users. For example, veterans tend to get better access to maintenance services compared with accident victims. Although the high costs may be appropriate for the substantial work and resources poured into the development of prosthetic arms, the reality is that the consumers of the technology are people with disabilities who are often vulnerable to poverty. Charging a patient who already faces considerable hurdles with his or her daily activities, let alone with his or her job, is not a plausible choice, because it defeats the entire purpose of providing maximum help for amputees in fostering their greater social inclusion. Furthermore, statistics in 2013 (Noss 2014) showed that the annual median income of the US population was $51,939, which simply meant that more than 50% of the people did not have the means to acquire a DEKA-style arm as a viable option. Third-party programs concerned with the support or reimbursement of the expenses (e.g. healthcare programs, US Department of Veteran Affairs services, etc.) are present, but evidence suggests a need to offer more in the way of practical and effective prosthetic implementation (McGimpsey and Bradford 2008). It is understandable that the inherent requirement for distinctive customizations based on the individual’s needs makes the criteria for insurers all the more difficult to establish. However, services as well as budgets for such programs should not be frozen, much less reduced. A study in 2011 (McGimpsey and Bradford 2008) nonetheless reflected grim findings, showing that 24% of the survey participants witnessed a decrease in prosthetic coverage by private insurers over the past three years. Indeed, some even had their coverage for these services completely withdrawn (McGimpsey and Bradford 2008).

Although these concerns in the United States and the western world as a whole may be more severe than expected, the cases in the developing world perhaps reflect an even graver reality for those needing prosthetics. In many low–medium=income countries, there are very few or no manufacturers of more advanced prosthetic arms. One example, the Nevedac Prosthetic Center in India (Strait 2006), may perhaps be the sole example of these industries in developing countries. This means that most individuals planning to opt for a more sophisticated arm in various parts of the developing world have to rely on imported products that cost drastically more than they would in the West, whereas the average income of the population is far less. Technical support and maintenance are also scarcely available. The coverage of prosthetic arm technology for the overwhelming number of users in the developing world is therefore largely limited to small domains. Coverage by insurance plans provided by private companies and governmental agencies is also remarkably less in scale in developing countries. Indonesia, for instance, introduced the Askeskin program in 2005 as a means to facilitate universal health care for every individual, particularly the poor (Sparrow, Suryahadi, and Widyanti 2013). Yet this program does not give support for prosthetic-related impairments while doing so for conditions that involve surgery and the like (Sparrow, Suryahadi, and Widyanti 2013).

Prosthetic technology may not be as essential to a person’s life as a heart transplant, but given the enabling potential of prostheses it certainly should not be an expensive luxury that can go without attention by the government or the public. With the ever-present emphasis on innovation and development, it is often easy to forget that – unlike a large majority of common technology – prosthetic technology serves the ‘needs’ of individuals with disabilities. This being so, the pace as well as the direction in which such a technology progresses must be carefully balanced with the social factors that dictate its relationship with its end users. A combination of overly fast technological sophistication, rationing policies and levels of inaccessibility has made it difficult for prosthetic technology to serve its rightful users and to enable people with disabilities to participate in society. Within the principle of maximum assistance, providing meaningful aid for individuals who need them, the entitlement of prosthetic use regardless of one’s background should not be a privilege to only some, but rather an equal right for as many as possible. After all, a healthy arm can never have a finite value and nor is it considered a luxury, so why should a prosthetic arm be?

Funding

This work was supported by the 2015 Summer/Fall Undergraduate Research Participation (URP) Program at KAIST. M. Choi was supported by the Ministry of Education of the Republic of Korea and the National Research Foundation of Korea [NRF-2015S1A5A8018593].

Disclosure statement

No potential conflict of interest was reported by the authors.