Friends can speak without using words. Marketers used people sharing private looks to create a brilliant ad for Lexus. It sells cars using relationship.
Medicine starts and ends with the doctor-patient relationship.
Patients want their doctors to care most about them, not about society, or the greater good. Patients want to feel they have an exclusive relationship with their doctor; one that sees them as a unique and important.
This creates a problem:
How can doctors have exclusive, therapeutic relationships with patients and, at the same time, be stewards for the greater good?
With unlimited money, doctors can pretend to put their patient’s interests first and try to please society at the same time.
But at some point, doctors must choose: Do they do what’s best for the patient in front of them, or do they do what’s best for the community as a whole?
Medicine became loved and respected for choosing individuals. Medicine works on relationships, exclusivity and individuality.
Relationship: An Offensive Idea?
At minimum, relationships are:
They rest on mutual sacrifice, commitment and a level of devotion not shared with those outside of the relationship.
No matter how hard parents try to keep teenagers apart, relationships happen. Time, shared circumstance and adversity build deep connections.
People expect help from friends and family in a way they could never expect from a stranger. Relationships build on immaterial privilege; financial gain follows, if opportunity allows.
Serve people, not ends
People benefit from relationships. Only sociopaths consider how a relationship functions for the greater good. No one stays in a relationship to serve the greater good. Healthy relationships are not strictly utilitarian.
Relationships place expectations on us. We cannot do or say whatever we want without risking the health of our relationships.
At minimum, relationships are exclusive, privileged, restrictive, organic and anti-utilitarian.
Relationships seem to offend most progressive social virtues.
Take equality: Social activists appeal to equality to justify everything from Occupy Wall Street to outlawing private medical insurance in Canada.
Equality has intrinsic ‘truthiness’. We equate equality with democracy. Everyone gets an equal voice. One person, one vote. We are all equal in the eyes of God.
But if we use death toll as a measure, social experiments of forced equality have created the greatest amount of human suffering in the history of the world.
Relationship vs. Stewardship
The doctor-patient relationship is the starting point for doctors to decrease suffering. It is the sine qua non of medicine.
All things being equal, doctors welcome stewardship and the chance to avoid waste, to work for the greater good of society.
But when a doctor sits with her patient, she must not think of the greater good, before the good of the patient in front of her. If she does, she stops being a doctor. She becomes a bureaucrat. We need bureaucrats, who work for the greater good, just not in the doctor’s office.
If doctors became utilitarians, it would take a generation to recover patients’ lost faith in the medical profession.
Utilitarian doctors supported involuntary sterilization in Canada until the early 1970s. European utilitarians saw the benefit of caring for ‘productive’ members of society, before those who would never leave a hospital bed.
The cold logic of utilitarianism must always clash with the doctor-patient relationship, at some point.
What does this mean for healthcare?
We describe what is, not what should be. Description imposes limits, not by fiat, but by nature: Square pegs do not fit into round holes, without changing the nature of either one, or both.
Well-intentioned calls for stewardship must face the nature of medicine.
Medicine is based on exclusive relationships. The doctor-patient relationship, by definition, excludes other people.
Medicine is, at its core, non-utilitarian. It is individualistic.
Grand ideas to fix healthcare must start with basic facts about medicine, if we hope to make things better, not worse.