Beware Health Totalitarianism

by Theodore Dalrymple

Richard Gunderman begins his essay with an exposure of the intellectual absurdities, historical deficiencies, and inconsistencies of the notorious new oath administered to freshmen at the Minnesota Medical School. This is not very difficult to do and has by now been done many times, but Gunderman then goes on to say something much more original, namely that the oath is a manifestation of idealism, albeit of a mistaken or even perverted variety, and of a subliminal awareness that practitioners of medicine ought to have a much wider social perspective than they have now. To an increasing extent, he says, doctors have become but sophisticated technicians narrowly focused on some small aspect of human existence, a particular cancer shall we say, without considering the social context in which the disease develops and is caused, treated, and cured.

I think that Gunderman is rather too generous to those who wrote and imposed this oath. Its aim (I surmise, though I cannot definitively prove) is not to produce any tangible benefit for the Dakota people on whose supposed ancestral land the medical school functions, even if such people could be unambiguously identified. The purpose of the oath is quite otherwise: it is an instrument for the achievement of power.

The instrument destroys the moral probity of those who take it, and by doing so, breaks their spirit. Political propaganda has never been intended to inform, and under totalitarian regimes, it is not even intended to persuade. In conditions in which it is obligatory to assent to, applaud, and even repeat and intone it, doing violence to the truth can itself become an aim. The less truthful propaganda is, the more it is at variance with common sense and common experience, the better: for by forcing people publicly to assent to what they know to be false, the propagandists humiliate them and do violence to their self-respect. Such people are easy to herd and dominate: their locus standi to resist future impositions has been destroyed in advance.

The students who took the oath either believed what they said or they did not. If they did believe it, they believed what Gunderman himself believes was an egregious falsehood; if they did not believe it but took it nonetheless so that they could progress to the next stage of their education, they knew themselves to be careerists, which is to say persons easily manipulated by future practitioners of managerialism, who will use similar methods to ensure their compliance.

Thus, there is more to the Minnesota oath than Gunderman allows: it is the shape of things to come. We have seen the future and it is unfreedom.

Gunderman laments, in essence, that doctors are being turned out by medical schools who are not educated people but merely operatives of technology. And certainly, it is a common complaint of patients (including me) that their doctors seem more interested in their computer screens than in the living being before them. There is a new medical tendency to regard people as if they were the permanent possibilities of technical problems, just as John Stuart Mill defined a physical object as the permanent possibility of sensation.

While it is true that people should always be treated humanely and with as much human understanding as possible, the degree to which they present technical problems varies. A broken tibia is not a broken heart, though a sufferer from either may seek medical attention. Whether sympathy or empathy can be taught is a matter of dispute; I suspect that example is better than precept, and apprenticeship is better than book- (or computer screen-) learning. It has to be remembered, furthermore, that the profession of medicine has hitherto been a house of many mansions, and the human qualities necessary to be a good histologist or forensic pathologist are very different from those necessary to be a good gynecologist or psychiatrist. Any attempt to educate a good medical profession as a whole must therefore be, grosso modo, rather than finely tuned, and there should be no standardisation of medical students’ character other than the exclusion of obvious psychopaths and the need for a decent level of intelligence and diligence. Nature will do the rest.

Gunderman makes a plea for a humanistic as well as a technical education and I am viscerally in favour of what he asks for, though in these times of evidence-based medicine, someone is bound to demand to know the evidence that a well-read family doctor, say, has better results than one who reads nothing more elevated than USA Today, or indeed who reads nothing at all outside medical literature. I am inclined to doubt that medical schools are well-placed to educate doctors humanistically or instill in them a liking for the humanities; this should surely have been done in high school. There is a danger that humanistic learning, if prescribed as a part of the curriculum, will simply become just one more hoop for medical students to jump through, quite possibly a detested one; moreover, as things now stand, humanistic learning, especially at university level, is almost entirely in the hands of teachers with the mentality that produced the new oath at Minnesota Medical School. The humanities as they are at present taught would probably be better designated as the inhumanities.

Surely, the principle or archetypal activity of doctors will remain that of a consultation with a patient who has an illness or indisposition that he wants cured. For example, a friend of mine was recently diagnosed with lung cancer. He does not need, nor did he want, a disquisition on smoking as the cause of his cancer, still less a disquisition on the social determinants (or correlatives, which is not quite the same thing) of the habit of smoking. He does not want to know that smoking is now, statistically speaking, a lower-class habit, that the price of cigarettes affects the number consumed, that tax on tobacco is highly regressive, that tobacco companies have consistently and dishonestly tried to minimise the harms done by smoking, that passive smoking harms children and may have harmed his, that the law could be altered to prohibit smoking, and so on and so forth. What he wants is for the cancer to be removed and for his life to be prolonged as far as possible. The surgeon removed the cancer in its entirety according to the naked eye and subsequent highly-technical investigations showed that, within the limits of these investigations, the cancer had not spread. This is precisely what he wanted from, and expected of, his doctors.

None of this is to deny that smoking causes cancer or the value of epidemiological investigations that first established the link. But the surgeon who removed the cancer from my friend’s lung was not an epidemiologist any more than an epidemiologist is a surgeon. There is inevitably a division of labour in medicine, and while it is important that doctors should be aware of epidemiology, it is not necessary or even advisable for all doctors to be amateur epidemiologists, still less amateur social reformers.

Any doctor who read the general medical journals—the Lancet, the Journal of the American Medical Association, the New England Journal of Medicine, the British Medical Journal—could not possibly be unaware of epidemiology as a medical discipline, because a great proportion of what is published in these journals is epidemiological in nature. Much of it is concerned, to the point of obsession, with racial or economic disparities, correlations almost always being taken as causation in the most straightforward, indeed crude, way. One sometimes has the impression that one is reading Pravda, at least to the extent that opposing or even mildly dissenting or nuanced views are rarely heard.

While epidemiological investigations are clearly important and valuable, they have their dangers, as perhaps the response to the COVID-19 pandemic demonstrates. During this pandemic, the distinction that Frederic Bastiat so brilliantly pointed out in the 1840s, between the seen and the unseen, was lost sight of: and the fact that locking down whole societies to prevent an illness from spreading to people in whom it would do little harm might have very serious consequences was ignored by many epidemiologists. They were like people who would halt all traffic because traffic results in accidents.

There is a danger of what might be called health totalitarianism implicit in the views of Virchow, the great pathologist and Gunderman’s hero. Of course, when Virchow was writing, there was no clean water, there was poor sewage disposal, the immediate environment for humans was far more polluted than it is today, it was difficult for people to keep clean, fatal accidents were far more numerous, nutritional deficiencies and occupational diseases were gross and common, there were no effective treatments for infections, the most minor injury often resulting in septicemia, more than a tenth of children died before their first birthday, and so forth. It was therefore understandable and forgivable that Virchow wrote as follows:

Medicine is a social science and politics is nothing else but medicine on a large scale. Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution.

But Gunderman fails to see the sinister implications of this in the modern context.

Shelley said that poets were the unacknowledged legislators of the world; Gunderman would appear to want doctors, trained as he thinks they ought, to be the acknowledged legislators of the world. The doctor should not only treat sore throats but everything from poverty to injustice to wrong opinions. If this is the conclusion of the liberal education that Gunderman thinks doctors ought to undergo, I’ll take my chances with doctors as they are now.

First published in Law and Liberty.