Resilient Cyborgs: Living and Dying with Pacemakers and Defibrillators

By Nelly Oudshoorn

This book examines how pacemakers and defibrillators participate in transforming life and death in high-tech societies. In both popular and medical accounts, these internal devices are often portrayed as almost magical technologies. Once implanted in bodies, they do not require any ‘user’ agency. In this unique and timely book, Nelly Oudshoorn argues that any discourse or policy assuming a passive role for people living with these implants silences the fact that keeping cyborg bodies alive involves their active engagement. Pacemakers and defibrillators not only act as potentially life-saving technologies, but simultaneously transform the fragility of bodies by introducing new vulnerabilities. Oudshoorn offers a fascinating examination of what it takes to become a resilient cyborg, and in the process develops a valuable new sociology of creating ‘resilient’ cyborgs.

• Language: English
• Publisher: Palgrave Macmillan
• Release date: Apr 2, 2020
• ISBN: 9789811525292

Book preview

Part IIntroduction: Theorizing the Resilience of Hybrid Bodies

© The Author(s) 2020

N. OudshoornResilient CyborgsHealth, Technology and Societyhttps://doi.org/10.1007/978-981-15-2529-2_1

1. Rematerializing the Cyborg: Understanding the Agency of People Living with Technologies Inside Their Bodies

Nelly Oudshoorn¹  

(1)

Department of Science, Technology and Policy Studies, University of Twente, Enschede, The Netherlands

Nelly Oudshoorn

Email: [e-mail]

Implanted heart devices transform lives. Consider , for example, the story of Joan, a lively woman who works in a pharmacy in a small Dutch village. At age 43, she collapsed in the street because of a sudden cardiac arrest when she was shopping during her lunch break. Because it was just before Christmas, it was very crowded in the street. Therefore, one of the passers-by who noticed her collapse was able to resuscitate her, which saved her life. In the hospital, they told her that they would give her an internal cardioverter defibrillator (ICD), because she might be at risk of another cardiac collapse. Because she was not familiar with this technology, she asked the cardiologist what kind of implant it actually was. Reflecting on what happened then, she told me that it was not a real choice. ‘You cannot tell them, no, I just want to go home and see what happens.’ At home, her husband instructed their children to be careful not to hit mama on her chest, because she had received a device to protect her: ‘a kind of watch dog.’ Joan had very vivid memories of how it felt when her ICD fired for the first time. She was changing clothes in her bedroom before going to work and felt a bit dizzy and then the ICD hit her. ‘I remember that I turned around because I thought that someone gave me a smash on my back, maybe one of my children; it was really weird.’ Unfortunately, Joan had to endure unnecessary shocks as well. The first time this happened was during the implantation of her ICD. Half a year later she experienced another series of unwanted shocks because of a short circuit caused by a fragmented lead of her implant, which required the replacement of her ICD. For the first year and a half after the implantation, the very fact that she had a device inside her body had preoccupied her greatly. Joan told me that she felt its persistent presence all the time: ‘It did not belong to me.’ Nevertheless, she learnt to view her implant as a ‘reassurance’ and ‘safeguard’ because her life did not depend on human assistance to resuscitate her in case of another cardiac arrest. For Joan, the implant gradually became a technology that enabled her to live ‘with a calm heart,’ a device ‘she did not dare to live without.’ She also realized that the ICD affected the way she would die because it diminished the chance of an ‘easy death’ caused by a cardiac collapse. She wondered whether her dying ‘would not become a deep suffering’ and if she would eventually ask for the removal of her ICD.¹

The story of Joan exemplifies some of the drastic changes people may experience when they have internal heart devices that regulate their heartbeats. Although there are many differences in the ways in which ICDs and pacemakers affect people’s lives and deaths, the agency of these devices, and the reasons why they were implanted in the first place, the experiences people having these devices shared with me included detailed accounts of the problems they faced in learning to live with their materially transformed, cyborg bodies. They learnt that ICDs and pacemakers act as potentially life-saving technologies by intervening into their heart-rhythm problems but simultaneously transform their fragile bodies by introducing new vulnerabilities, of which unwanted shocks or broken leads are only two examples. Listening to their sometimes painful accounts, I was impressed and touched by the resilience of people living with implanted heart devices, which became my major incentive in writing this book. What does it take to become a resilient cyborg?

Pacemakers and Internal Defibrillators as Ordinary Medicine in the Global North

Pacemakers and ICDs as Invasive Technologies

Introduced in the early 1960s, pacemakers can best be described as small, battery-powered generators that supply electric pulses to the heart when the heartbeat is too slow.² They consist of three parts: a metal case containing a battery and electronic circuitry; one or more insulated wires, called leads, connected to the generator at one end and the heart muscle at the other; and electrodes on the end of each lead for monitoring the electricactivity of the heart stored on an electrocardiogram (ECG; Fig. 1.1) The pacemaker uses an algorithm to detect possible heart-rhythm irregularities and is programmed in such a way that it gives electrical pulses to increase the heart rate when it is slower than the programmed limit. This agency of the device is called pacing, hence the name of the device. Slow heart rhythms can cause dizziness, tiredness, and even fainting and make it difficult for people to live an active life. Because pacemakers bring the heart back to a normal rate, they contribute to improving the quality of life and may even increase longevity. Pacemakers can be programmed externally by a technician to select the optimum pacing modes for each person (Snipes et al. 2011, 1). The ICD looks very similar to a pacemaker but is designed to do the opposite.³ It may give very fast pulses (called over-pacing), a small electric shock (called cardioversion), or a larger one (called defibrillation) to bring the heart into a regular rhythm in the case of very fast, life-threatening heart rhythms, as exemplified in the story of Joan.⁴ Nowadays, most ICDs include a pacemaker function as well.

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Fig. 1.1

Pacemaker (Picture of pacemaker. Images courtesy of Olafpictures via Pixabay. Free download 14 October 2019)

Pacemakers and defibrillators are invasive technologies surgically implanted in patients’ bodies. During surgery, which is performed under local anaesthesia, the leads are placed first by guiding them, with the help of X-ray images, through a vein into the lower heart chamber, the ventricle (Fig. 1.2). The cardiologist then connects the leads to the device and programs it. Then the pacemaker or ICD is inserted in a so-called pocket, a space that is created by the cardiologist between the muscles, usually beneath the left collarbone. Finally, one of the technicians present during the surgery tests the device to ensure that it is working properly. People usually stay in the hospital overnight and go home the following day. Because pacemakers and ICDs work on batteries that cannot be charged from outside the body, they will be replaced by a new device when the battery loses too much power, which requires another surgery. Because batteries last approximately 5–10 years, many people have to undergo multiple implantations during their lifetimes.⁵ The clinical care for people living with pacemakers and defibrillators is not restricted to the implantation of these devices but also involves regular follow-ups provided by specifically trained technicians, nurses, and cardiologists in specialized clinics.

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Fig. 1.2

The site of a pacemaker in the body (Drawing of an illustration of the site of a pacemaker in the body as included in https://​www.​cwz.​nl/​patient/​behandelingen/​pacemaker/​. Accessed 13 November 2018. Images courtesy of Rob Vrakking)

The production of pacemakers and ICDs is dominated by three large medical device companies in the US and one company in Germany, which are continually engaged in the further technological sophistication of these devices, including remote monitoring,⁶ thinner leads, wireless devices, and developing implants that are more sensitive and personalized (Afolabi and Kusumoto 2012).⁷ Although there is a large competition among these companies to increase their market shares, analysts expect a further, moderate growth not only because of an expected increase in the incidence of heart diseases and a growing and ageing population but also because of an expected increase in implantations in countries such as India, Brazil, and China (Anonymous 2017).⁸

On Primary Prevention and the Treatment Imperative

The use of pacemakers and ICDs in particular has changed radically over the past 17 years. Until 2002, implantable defibrillators, first introduced in 1985, were only used sparingly for patients who had survived a resuscitated sudden cardiac arrest (SCA) and were at risk for another life-threatening heart event (Yarnoz and Curtis 2007, 367).⁹ The story of Joan exemplifies this particular group of ICD recipients. They receive an ICD to treat dangerously fast heart rhythms, which can cause a serious decrease in the ability of the heart to pump blood that can lead to a sudden cardiac arrest (Snipes et al. 2011, 1). Nowadays, defibrillators are also prescribed for people who never experienced a heart-rhythm problem before but may be at risk because of an underlying heart disease , including heart failure,¹⁰ a deviating electrocardiogram (ECG), and unexplained fainting that may be caused by heart-rhythm disturbances, or a genetic predisposition for moderate or severe heart-rhythm disturbances (Anonymous 2017; Gillick 2004; Goldstein and Lynn 2006; Hlatky 2004; Kaufman et al. 2011, 9). In a short period of time, the use of the defibrillator thus shifted from a treatment of last resort for a restricted group of patients to a preventive tool used to reduce potential risks of death from cardiac events among a much larger population.

This shift from so-called secondary to primary prevention treatment has affected both elderly and younger people. For older people, the implantation of the multifunctional ICD has become a routine and standard treatment in wealthy, industrialized countries (Jeffrey 2001). As Sharon Kaufman and her colleagues have described, the inclusion of heart failure as an indication for the implantation of ICDs has resulted in the growing use of these implants among the very old, particularly but not exclusively in the US, where 20% of ICDs are implanted in people aged 80 and above (Kaufman et al. 2011, 9; Swindle et al. 2010). This increase in implantations cannot be understood only in terms of the shift towards primary prevention but also by the emergence of the ‘treatment imperative’ in contemporary clinical medicine. The health economist Victor Fuchs introduced this term to refer to the way in which decisions about appropriate medical treatment are driven by the availability and values given to technological interventions, particularly the newest and most advanced technologies (Fuchs 1968). Because the notion of medical progress has become inextricably intertwined with technological innovation in medicines and devices, the treatment imperative has increasingly become a moral obligation for clinicians to continue medical interventions in ever older people, particularly but not exclusively cardiac treatments such as the ICD (Kaufman et al. 2011, 15; Koenig 1988, 467; Shim et al. 2008).¹¹

The availability of a proliferating number of treatments affects not only clinicians but also those diagnosed with heart-rhythm problems and their families. As the story of Joan exemplifies, it is extremely difficult to say no to life-sustaining technologies. Deciding against a treatment, even when someone is 80 or older, has become considered as suspect (Dickerson 2002; Kaufman 2015, 1). Or, as Anne Pollock has described, ICDs have become ‘technologies where not choosing treatment is presented as tantamount to suicide’ (Pollock 2008, 99).

Health-care professionals, patients, and their families are increasingly caught in a system in which more and more medical treatments have become the standard of health care. Although doctors and patients are often inclined to think that these technologies are simply there for them to choose or reject, Sharon Kaufman has convincingly shown that the increased use of life-extending technologies among elderly people in the US should be understood in the context of the infrastructure of biomedical research, the growing influence of the medical and pharmaceutical industry, and the reimbursement policies that facilitate access to these often very expensive treatments (Kaufman 2015). Although health insurance arrangements and policies vary in different national contexts, the treatment imperative has become a major characteristic of health care in many European countries as well—However, it may be less persistent than in the US. ICDs have thus become ‘the new normal’ and are considered as ‘ordinary medicine ’ (Kaufman 2015, 1). This transition in health care concerns not only people in their 80s and 90s but people of all ages. Younger people may receive ICDs as primary prevention as well, although for other reasons than elderly people. Since the mid-1990s family members of people who died from a SCA are subjected to genetic screening to detect genetic distortions that may cause severe heart-rhythm problems. The detection of such a gene may result in the implantation of defibrillators in all affected family members, including young children (Olde Nordkamp et al. 2013).¹²

Disparities in Access

The normalization of ICDs has resulted in an enormous increase in ICD implants. In the US, for example, each year more than 100,000 people receive an implantable defibrillator, and the annual implantation rate of ICDs has increased 20-fold in less than 15 years. Primary prevention constitutes more than two-thirds of the total number of implants (Tung et al. 2008; FDA 2011; Anonymous 2010). Although ICD implantation rates have increased in Europe as well, the use of defibrillators in Europe is four times lower than in the US.¹³ This difference between the US and Europe is often explained by the lower number of implanting centres and electrophysiologists in Europe, which leads to fewer referrals to cardiologists or implantation centres (Camm and Nisam 2010). ICD implantations are much lower, or even absent, in many low- and middle-income countries in the Global South,¹⁴ not only because of the absence of the required medical infrastructure but also because of the high costs of these advanced technologies.¹⁵

Like defibrillators, pacemakers have become part of ordinary medicine, particularly in the wealthy part of the world.¹⁶ Although pacemakers are less expensive than defibrillators,¹⁷ a device that costs several thousand US dollars is simply unaffordable for many people in the Global South (Kirkpatrick et al. 2010; Baman et al. 2010; Greene 2018). A world survey of cardiac implantable devices conducted in 2009 described an implantation rate of 767 pacemakers per million people in the US and 782 per million in France, whereas in Peru, Bangladesh, and Pakistan, respectively, 30, 5, and 4 pacemakers per million were implanted.¹⁸ Access to pacemakers is also very limited in many African countries where the implantation rates are 200-fold lower than in Europe. This disparity between wealthy and poor countries seems to be growing each year. Whereas in the US the use of pacemakers has increased 20-fold due to the extension of indication criteria and because of the ageing population, the implantation rates in the Global South remain rather stable (Butler 2013, 179; Baman et al. 2011). In recent decades, pacemakers and ICDs have thus become part of ordinary medicine in the Global North, whereas poor people living in low- and middle-income countries in the Global South have hardly any access to these potentially life-saving technologies.¹⁹

Hybrid Bodies as Passive?

On Old and New Cyborgs

People with implanted pacemakers and defibrillators are definitely not the only ones who have to learn to live with a technologically transformed body. In recent decades, we have seen the introduction of more and more technologies that operate under the surface of the body, including artificial hips, knees, and hearts; breast and cochlear implants; prosthetic arms and legs; spinal cord stimulators; and emerging human enhancement technologies such as brain implants and nano-chips for diagnosis and drug delivery. This trend towards developing technologies that merge with bodies is also illustrated by the Gartner Hype Cycle for Digital Government Technology (2018), in which five of the technologies that are expected to have ‘the most transformational benefit for government organizations over the next 10 years’ concern techniques that blur the boundaries between humans and machines, including bio-chips, artificial human tissues, and brain-computer interfaces’ (Moore 2018; Noort 2018). Because of this trend and the persistent and widespread presence of hybrid bodies in wealthy societies, understanding the agency, vulnerabilities, and resilience of people living as cyborgs has become even more urgent.²⁰ Related to the development of human enhancement technologies , there has been a recent renewed interest in new and emerging fusions of humans and technologies.²¹ Although this focus on new hybrid bodies remains very relevant, I suggest that it is important to study ‘older’ and more familiar cyborgs as well. What happens to the cyborgs who have lived among us for several decades already, bodies kept alive and active by pacemakers and implantable cardioverter defibrillators (ICDs)? Despite the wide presence of these hybrids—perhaps some of whom are reading this book—there have been surprisingly few examinations of these cyborgs in Science and Technology Studies (STS).²² This tendency to neglect the mundane is not restricted to heart devices but also includes internal devices such as knee and hip implants, although some important work has been done on prosthetic limbs (Dalibert 2014; Nelson 2001; Sobchack 2006) and cochlear implants (Blume 2010; Mauldin 2014; Virdi 2020).

Studying ‘the old’ is important because it enables us to include the embodied experience of what it means to live with a hybrid body. A focus on existing, living cyborgs shifts attention away from the laboratory and clinical work involved in trying to create new hybrids, and how this may affect human-technology relations in speculative futures, towards the sites and actors and the work involved in sustaining hybrid bodies in the here and now. As I show in this book, the fusion of bodies and technologies involves work that extends beyond the laboratory and the operating room. Focusing exclusively on new and emerging cyborgs runs the risk of creating and reifying an image of cyborgs as a result of the unlimited power of the life sciences to improve human bodies by means of surgical intervention, ignoring that these interventions involve lifelong processes of monitoring hybrid bodies to maintain the fusion of humans and technologies.²³ I therefore suggest that it is important to open the black box of the established merging of humans and internal devices in order to understand what it takes to keep hybrid bodies alive. To do so, we need to conceptualize the agency of people living with technologies inside their bodies.

Rethinking Dominant Views on Human-Technology Relations

Technologies implanted in bodies challenge a long-standing tradition of theorizing human-technology relations in STS and the philosophy of technology . For a long time, most theories of human agency only addressed technologies external to the body. Bruno Latour (2005), for example, who argued that we should include the agency of non-humans in studying human-technology relations, only addressed external technologies that can be used at specific moments and places and are more or less under the control of humans, such as car seat belts and door keys. As others have suggested already, his emphasis on the symmetry of agencies of human and non-human actors fails to account for the specificity of human agency, including the agency of cyborg bodies. By reducing all forms of activity to actions, the question of how bodies are constituted in and by technologies and the specificity of bodily practices and human agency is not addressed (Barad 2007; Dalibert 2014; Lettow 2011; Oudshoorn et al. 2005). Like Latour, Don Ihde’s widely used typology of human-technology relations, which tries to classify how technological devices mediate the ways in which people perceive, experience, and interpret the world, also focuses exclusively on technologies external to the body (Ihde 1990).²⁴

Technologies implanted in bodies challenge these approaches to human-technology relations in two different ways. First, most devices that operate under the surface of the body delegate no agency to its ‘users’ in terms of how they are supposed to interact with these technologies.²⁵ These implants thus conflict with STS approaches that emphasize the ways in which designers inscribe programs of action in technologies that enable or constrain the agency of users (Woolgar 1991; Akrich 1992; Akrich and Latour 1992; Oudshoorn and Pinch 2003). As Steve Woolgar has described, technologies are designed in such a way that they configure the user: through a process of ‘defining the identity of putative users, and setting constraints upon their likely future actions’ (Woolgar 1991, 59). Similarly, the concept of the ‘script’ introduced by Madeleine Akrich also emphasized how designers delegate agencies to users, although it includes the delegation of agencies to devices as well (Akrich 1992). Pacemakers and ICDs, however, exemplify technologies designed in such a way that agency is delegated only to the device. Their programs of action or scripts directly concern the interactions between the heart and the device rather than with their users. As I described earlier, the electric pulses generated by these devices have direct control over the heartbeats of patients implanted with them. Pacemakers and ICDs were the first electronic implants to exert agency on their own accord without any directions from their users. Other agentive implants include some of the emerging and new technologies such as prosthetic knees equipped with microprocessors and cochlear implants. The latter, consisting of internal and external devices, are directed at mediating one’s relation to the world (i.e., hearing sounds) rather than primarily redefining the relations to one’s body (Dalibert 2014).²⁶ Technologies implanted in bodies thus don’t configure the user but, as they merge with it, the body. Pacemakers and ICDs therefore represent a crucial case for understanding human agency in relation to technology. Whereas external devices invite us to act in specific ways, internal devices delegate hardly any agency to their users. This difference is reflected in daily language as well: pacemaker hybrids are referred to as recipients or wearers²⁷ rather than users, which suggests a rather passive relation to these technologies. Compared with external devices, people with heart-rhythm regulators inside their bodies cannot decide when, where, or how to ‘use’ them. Although pharmaceuticals also intervene in the body, one can decide to stop taking medicines. In contrast, people living with pacemakers and defibrillators cannot turn these devices off. Another difference is that medicines dissolve in the body and will then no longer intervene in bodily processes, whereas implants are stable objects that remain active until they are removed. People living with internal heart devices are thus confronted with something radically new. They depend on health-care providers not only to have their pacemakers or defibrillators implanted in their bodies, they also depend on them to replace or remove them (the latter rarely happens),²⁸ and, as we have seen in the previous section, they often have little influence on decisions about whether they should receive such an implant or not. Moreover, people living with implants are not granted any agency in decisions about what kind of implant or brand they would prefer.²⁹

A second important way in which technologies that operate within the body challenge dominant views on human-technology relations is that most of these devices are implanted in bodies to stay there until the end of life. Or, as Sherry Turkle phrases it: ‘becoming cyborgs is not a reversible step’ (Turkle 2008, 12). This novelty of technologies implanted in bodies is also reflected in the governance of medical technologies in Europe, where the European Union introduced the ‘EU Active Implantable Medical Devices Directive’ (1993) to define the characteristics of implants. Article 2 of this Directive categorized these devices as ‘any medical device intended to be partially introduced, surgically or medically, into the human body, and which is intended to remain […] after the procedure.’³⁰ Pacemakers and ICDs are implanted in bodies to stay there for a whole lifetime. Although deactivating or removing pacemakers and defibrillators once they are implanted in the body could be done in principle, current practices illustrate that most health-care professionals and patients don’t consider removal as an option, except for ICD patients in the phase of dying.³¹ Technologies implanted in bodies are thus not bounded by a temporality of use, but should be understood as continuous devices. However, many approaches to human-technology relations, including the work of Ihde and Latour, conceptualize the interactions between humans and technologies as finite and limited temporal events. Therefore, they cannot account for technologies that involve continuous interactions between human bodies and technologies (Dalibert 2014; Lettow 2011; Verbeek 2008). ‘User’ is therefore not an appropriate term for these human-technology relations.

Understanding the agency of people living with technologies inside their bodies thus remains an urgent question, not only for academic reasons. Ultimately, internal heart devices provide a crucial case for patients having these implants also because the proper working of these devices is a matter of life and death. Of course, there may be good reasons for delegating overriding agency to the devices. People suffering from severe heart-rhythm problems may not be willing, or physically able, to control heart-regulating devices themselves. Nevertheless, the absence of programs of action for patients still raises the question of whether people living with pacemakers or ICDs are really so passive. As I argue in this book, any discourse or policy that assumes a passive role of patients with implanted devices silences the fact that keeping cyborgs alive involves their active engagement. I describe how people living with pacemakers and defibrillators participate in a lifelong trajectory of specialized monitoring to check whether the devices still function properly, whether they need replacement, and to adjust the agencies of the devices and the heart. Moreover, they have to learn to cope with the vulnerabilities of their technologically transformed bodies, which may involve changes in daily routines and social relations and a re-appropriation of how they experience their bodies.

Understanding the Agency of Hybrid Bodies

Everyday Cyborgs

How can the agency of people who live with implants that are beyond their control be understood? The concept of the cyborg, which I have used loosely in the previous sections, provides a useful heuristic because it refers to a hybrid of machine and organism. The term cyborg, an abbreviation of cybernetic organism, was coined by Manfred Clynes and Nathan Kline in an article in Astronautics: ‘Cyborgs and space’ (1960). They introduced the term to describe the reconstruction of humans needed to enable them to live in space, for example, by changing the human bodily functions involved in breathing. The notion of the cyborg was framed as a technical term in the context of the space race during the Cold War and referred to a literal fusion of human/animal and machine. Clyne and Kline illustrated this merging with the results of experiments in which they had implanted an osmotic pump in a laboratory mouse.³² Although their ideas about cyborgs included modifications of human bodies (such as artificial organs, sensory deprivation, and, interestingly, cardiovascular adaptations), their cyborg model was restricted to survival in space. Or, as the historian of technology Ron Kline put it: ‘Cyborgs would be humans with some organs only temporarily altered or replaced by mechanical devices. On returning to earth, the devices would be removed and normal body functions restored’ (Kline 2009).³³

In her seminal Cyborg Manifesto (1985), Donna Haraway appropriated the cyborg figure to call for a critical engagement with the politics of techno-science and for taking responsibility for technology (Gray 2011, 85). Criticizing approaches that merely celebrate or condemn the increasing dependency of humans on technology, she challenged us to rethink human ontology to grasp what constitutes our contemporary lifeworld. For Haraway, ‘the cyborg is our ontology’ (Haraway 1991, 150). In a world permeated by techno-science, bodies and technologies should no longer be considered as ontologically separate but as co-producing each other. What bodies are and can do is not given by nature but co-evolves with technology (Mol 2002; Dalibert 2014). In her feminist intervention into cyborg discourse, Haraway not only challenged the rigid binary opposition between organisms and machines but also other long-standing dualisms such as nature/culture and male/female (Balsamo 1996). By redefining the meaning of cyborg from a technical metaphor into a concept that can be used to subvert and displace troublesome dualisms, Donna Haraway urged us to create alternative views, languages, and practices of techno-science and hybrid subjects.

The cyborg as a concept has inspired many scholars to address human-technology relations, which has resulted in an extensive cyborg literature.³⁴ However, most studies conceptualize the cyborg merely as a linguistic or metaphorical entity, which is problematic because they silence the lived experiences of cyborgs (Sobchack 2006). In this scholarship, cyborgs are not given a voice to articulate what it means to live with technologies inside their bodies (Betcher 2001, 38).³⁵ Literary and cultural studies, for example, have mainly focused on how humans are depicted in science fiction and popular conceptions of cyborgs. Scholars in these fields have described how films such as Robocop and The Terminator, for example, present cyborgs as extreme, often male, post-human monsters that are omnipotent but incapable of feelings and emotions (Goldberg 1995; Haddow et al. 2015). However, cyborgs are not just fictional or speculative imaginaries of the future. As Haraway has emphasized, the cyborg is ‘a creature of social reality as well as a creature of fiction’ (Haraway 1991).

People living with internal heart devices and many other hybrids testify that cyborgs have become a lived reality, or ‘everyday cyborgs.’ I borrow this term from Gill Haddow and her colleagues (2015), who introduced this version of the cyborg to differentiate those living with ‘bionic modifications’ from the cyborg metaphors used in space discourses, science fiction, and literary and cultural studies. The everyday cyborg is an important heuristic because it ‘adds the dimension of participant voice currently missing in existing cyborg literatures and imaginations’ (Haddow et al. 2015, 484). Moreover, the everyday cyborg approach enables us to account for the fact that people with technologies inside their bodies have to live with these implants literally every day. This is in sharp contrast to how cyborgs were envisioned by the bio-astronauts Clyne and Kline, who, as we have seen above, considered the technological modifications of the body as temporary interventions.³⁶ What sets everyday cyborgs apart from other human-technology relations is that they are implanted with devices that become part of their bodies and are automated, taking them beyond the control of their hosts. To be sure, conceptualizing human-machine hybrids as everyday cyborgs is not meant to reduce the complexities involved in living with implants. For everyday cyborgs, the everyday itself cannot be taken for granted but must be constantly reinvented, and thus should be considered as an achievement (Haddow et al. 2015, 490). As I describe in this book, living with implants each day requires the active involvement of people having these devices in different circumstances, environments, and social relations.

Equally important, conceptualizing human-machine hybrids as everyday cyborgs also allows us to go beyond the imaginaries of cyborgs as male. In Clyne and Kline’s (1960) original approach to cyborgs, the bodily adaptations were described as interventions needed for ‘men’ to survive in space, although it would not affect their gender identity . Cyborgs in science fiction and popular media, which are also mostly male,³⁷ represent a more radical gendering of the cyborg because the technology changes their identity and humanity (Haddow et al. 2015, 486). As Raewyn Connell (2005) has described, cyborgs in science fiction often have the physical attributes of power and strength that reflect the dominant views of masculinity in Western culture (Connell 2005). To avoid a reiteration of the male imaginary of the cyborg, I have included both women and men in my research. Including the accounts of women living with internal heart devices is important as well to correct the image that only men suffer from heart problems, and that pacemakers and ICDs are technologies used only by men.³⁸ In this book, I use the everyday cyborg concept therefore as a heuristic to go beyond the cyborg as a fictional, male, or temporary figure to make visible how both women and men having internal heart devices learn to cope with their technologically transformed bodies in everyday life.

Rematerializing the Cyborg

However, there is another conceptual problem that should be addressed if we want to understand what it takes to live and die with technologically transformed bodies. The linguistic turn in cyborg studies and other fields not only silences the lived experiences and voices of everyday cyborgs , it also neglects the materiality of bodies (Dalibert 2014, 2016; Jain 1999; Sobchack 2006). As Vivian Sobchack, who lives with a prosthetic leg, has argued, the use of the cyborg or prosthetic³⁹ figure as a metaphor has resulted in a discourse in which ‘the literal and material ground is forgotten or even disavowed’ (Sobchack 2006, 20). In her article with the telling title ‘A leg to stand on: prosthetics, metaphor, and materiality,’ she vividly describes how the materiality of her prosthetic limb shapes her everyday life: ‘When I put my leg on in the morning […] I also know intimately my prosthetic leg’s inertia and lack of motivating volition’ (Sobchack 2006, 17). The practicalities as well as the changes that take place in the intimate relationships between bodies and technologies have been largely overlooked in cyborg and prosthetic studies. Cyborgs have thus lost their materiality. Although Donna Haraway introduced a material-semiotic approach to human-machine hybrids, and pacemakers and other implanted technologies are frequently used as vivid examples of cyborgs, the materiality of the fusion of bodies and technologies remains unexamined. However, people living with internal devices represent distinctive human-machine hybrids in which the material agencies of bodies and technologies are inextricably entangled. Or as Pollock (2008) put it in her reflection on ICD patients: ‘there is no self that is independent of the device: patients and defibrillators are one’ (p. 12).

Inspired by recent feminist post-humanist studies on the intimate relationships between bodies and technologies (Alaimo and Hekman 2008; Dalibert 2014, 2016; Lettow 2011), I argue that it is important to re-materialize the cyborg. This scholarship calls for new conceptual tools to recognize and account for the intimacy of human-technology relations as material and normative. Or as Lucy Dalibert phrased it: ‘Humans and technology are not abstractions but material and normative relations’ (Dalibert 2014, 123). This approach to hybrid bodies is important because it makes visible how technologies implanted in bodies bring those living with them into closer proximity with the materiality of their bodies (Alaimo and Hekman 2008; Dalibert 2014, 2016; Lettow 2011; Oudshoorn 2015). To capture the