Authority is received, not taken. You can take control but not authority. Authority is given.
Strength and intelligence may increase the likelihood of winning and retaining authority. They clearly increase power. But they do not guarantee authority. A leader can lose authority before power and retain authority long after losing power.
COVID uncovered a profound weakness in society and in medicine. We have abandoned our basis of authority.
Robert Nisbet, sociologist, wrote “The Twilight of Authority,” in 1975. At first, I thought it meant wet-diaper politics and the loss of consequences: weak sentences for horrific crimes, that sort of thing. But these consequences are just instruments of power. The one who wields them may have no authority in the eyes of those he afflicts.
A prime minister may choose to snorkel or surf on the day he set up for mourning. He can create the holiday and enforce compliance. But he undermines his own authority by ignoring his creation.
Authority Defined
Every system requires authority to function. To what will we bow? What will we never fight against?
It relates to legitimacy, but this too is another concept. Furthermore, authority is not respect. A position can retain authority even if the person in the position does not warrant respect. We can disrespect a leader but admit the authority of his office.
Consider a business meeting. Members agree to follow process. If the Chair ignores process, members can and should resist him.
He has no authority to ignore process. His authority rests on rules of order — Nathan’s in Canada, Robert’s in America, and so on. If he ignores process, chaos ensues. His only recourse is to end the meeting or ask his supporters to toss opponents out.
After authority, power.
Relics of Authority
Society cannot exist without authority and power. Western society used to base authority on Athens and Jerusalem: Greek logic and Christian morality. You can hate the Greeks and despise Christians, but you cannot do anything without some basis of reason and morality, and the freedom presupposed by each.
Logic and honesty, mathematics and virtue, Athens and Jerusalem: each held in tension, each shaping the other. Tension and shaping requires freedom. This was considered essential and self-evident until recently.
Today that version of Western society is gone. Nisbet wrote about twilight. We now have no light. Without authority, only power exists.
Authority in Medicine
Clinical medicine starts with anecdotes, incorporates experience, relies on individual reason, applies current research, and delivers it all within a fabric woven by several thousand years of tradition.
Colleagues challenge each other on every step: history, investigations, rationale, evidentiary support, standards of practice, and so on. In its ideal state, clinical care flows out of the tension between freedom to investigate and the authority of the profession as a social institution.
The Reality Gap
But medicine suffers from a gap between the officially sanctioned state of medicine versus how people talk about it. This is the same de jure–de facto, orthodoxy–orthopraxy gap we see in other fields.
COVID revealed the popular de jure basis of authority in medicine, which many (non-philosophical) academics have long wished was de facto also. COVID unified de jure and de facto . . . at least for the epidemiologists.
A generation of clinicians have been taught to put their faith in consensus statements — the bastard child of evidence-based medicine (EBM). Doctors learn to attribute legitimacy to expert consensus, but many miss the irony.
Aside from epidemiological reasoning, students learn that individual logic and reason should raise suspicion or even scorn as the deluded anecdotes of an isolated mind. EBM taught doctors to doubt their faculties and trust statistics.
The pandemic amplified epidemiology and gave it political legitimacy beyond imagination. Worst-case scenario modelling mattered more than actual hospital occupancy rates. Basic science was out; statistics were in. Forget about natural anything: pathology, immunity, . . . This was the new normal.
Wearing statistical Urim and Thummim, epidemiological priests swooned with the political power the pandemic gave. Convinced of reason’s failure, they could rationalize anything with statistics to support them. Though doubt remains whether they were ideological lackeys or leaders, they could finally advance a vision fuelled by the fear required for bold social change.
Loving Ideas
This discussion is not easy. It pulls us into ideas behind issues — something doctors often loathe. Most doctors prefer practical, non-theoretical things.
But most doctors also love ideas, if they have time to indulge their affection. In his classic, “The Nature of Suffering and the Goals of Medicine“, Eric Cassel wrote:
Despite the difficulty for physicians like myself, unused to the language of philosophical discourse, I believe I am correct that a new understanding of medicine will not be possible without a return to basic philosophical issues.
It is hard to even start discussion about fundamental ideas, because they weave together with so many other fundamentals. Freedom. Order. Legitimacy.
And they take so much time! Who has energy for big ideas after the hamster wheel of urgent COVID updates?
After Authority, Power
Regular working doctors must embrace a crash course on political philosophy, if we want to hang on to our profession. If we do not, the activist doctors will continue to push for a profession shaped and controlled by themselves.
I know working docs do not have time. But we must become experts on the social prerequisites for our practice to exist.
If we do not, physicians will (once again) suffer our profession remade in the image of academics and the professional managerial class. We must understand the essence of authority in medicine or lose it forever.
If physicians do not champion a plurality of reason, evidence, logic, intuition, and tradition all aligned towards helping patients, we will be left with the brutal power of a monistic vision applied by the state. After authority, power.
Photo credit: Pixabay
Amen…but your own Association has rather forcefully shut-down any ‘discussion’ but for that along party lines. Case in point, German physician-scientists reported last week that not a single healthy child between the ages of 5 and 18 died of Covid in Germany in the first 15 months of the epidemic. (https://www.medrxiv.org/content/10.1101/2021.11.30.21267048v1.full.pdf). This in Europe’s largest country (similar to the UK’s ONS numbers). Yet governments (with endorsement of Medical Associations) are full-steam-ahead with vaccinating this population to protect them from what? All the while egregiously dismissing any adverse events as minor nothings. Some might say we are in a pandemic of coincidences (not sickness).
Cui bono…
True. I suppose, to play Devil’s advocate, they have taken an unadulterated public health ethic. For them, this has nothing to do with medicine per se . . . which is odd given their ostensible role as advocates for the profession.
But I hope we can dig beneath the issue of the virus and get at why it seemed to uncover so much bad thinking. Where did we fail for us to fall so easily to black-and-white thinking, all-or-nothing scenarios, and affective polarization? What made it so easy for us to abandon the liberal values which seemed to serve us reasonably well before?
Like any game random game of pick-up — soccer, hockey, basketball — people have to accede authority to some unwritten rules in order to enjoy a great game. As soon as players act outside the assumed authority (remember, no referees in pick-up), the game ends and a brawl ensues. After authority, power.
Thanks so much for taking time to read and share a comment!
Cheers
Authority, hierarchy and dominance occurs in all aspects of life…in some cases they are legitimate , in some they are illegitimate.
The medical profession has gradually abandoned any authority it had within its field and has handed it over to the political class with their biases and agendas , and the health care bureaucratic classes with their epidemiologists and over reliance on pliable statistics.
We were taught to be skeptical about statistics ( as Disraeli put it, “ there are lies, damn lies and statistics “) , one of the characteristics of our profession has been its ability to indulge in open debate ,as Shawn pointed out in the Authority of Medicine section in this this posting , where members of the medical profession challenge each other civilly, slicing and dicing studies and ever questioning the statistics available.
No longer…the politicization of COVID is destroying it….criticism is forbidden and punishable with colleagues even denouncing “ deviants”.
“ Nothing strengthens authority so much as silence” ( surprisingly that quote comes from Leonardo da Vinci)….and our profession has been far too silent about the transference to those less competent to wield it…in fact it has become verboten to even question them.
Quoting Galileo “ for in the sciences the authority of thousands of opinions is not worth as much as one tiny spark of reason in an individual man ( or woman)”.
Sage and salient comments, Andris.
Don Prior
Thanks Don!
Fabulous comments, Andris … and excellent quotes, as always.
You mention the transfer of authority to those less competent. I agree. Although I call it usurpation; I find transference too polite by half.
I think the institution of medicine is sick. Physicians tried to keep up with an exponential increase in knowledge by eliminating anything not explicitly science or technology. And as students, we loved it. What could be more painful to a 22 year old student than a lecture on philosophy? Tell me where to cut. Don’t tell me all the different ways I could think. The failure happened first with the teachers. They became experts on an ever-narrowed focus. Expertise demands ignorance on most other things. They taught students to see and think this way. A few generations later, we have physicians who know and see on the science and tech they’ve been taught to see.
Isn’t it any wonder doctors fight in a game for which they haven’t learned the rules … they aren’t even aware the game could be different?
Thanks again for reading and posting a comment!
Cheers
This is an important line of inquiry, Shawn. Thank you for this article. I agree with your argument about the diminution of doctoring and the corresponding rise of politicians and managers in the clinic. I agree that it goes well beyond COVID. Given your concerns and your background in literature and leadership, do you have any specific advice for an action step a working doc could take to mount a response here?
Nowadays, most doctors have no background in liberal arts nor even a single credit in logic. Our knowledge of statistics is wafer thin. We don’t really understand the tools of inference. I think all the policy documents we’re sent, all the Zoom talks we’re signed up for, and all the documentation we’re to prepare are actually teleologically aimed, at least in part, at preventing us from truly understanding matters. A doctor is like any other citizen: People who are anxious and exhausted just want to be told what to do.
I came across a fascinating article by the late English geriatrician, Sir John Grimley Evans. It was written in 1995 when he was the editor of Age and Aging. Yes, 1995. As an early career physician, it is hard to imagine reaching anything close to this gentleman’s level of elocution and clarity of thought. Statesmen like this are a dying breed. I think he passed in 2018. One wonders what he would make of everything since then.
From Evidence-based and Evidence-biased Medicine*:
“The anxiety is aroused by the simple-minded enthusiasm of some politicians and health service managers for imposing the results of EBM as mandatory guidelines. Soundly based guidelines may in the short term give the good average outcomes that preoccupy health-care purveyors. In the long term they may prevent advance by fossilizing clinical practice. More importantly, some patients may be harmed by mandatory guidelines…There is a fear that in the absence of evidence clearly applicable to the case in hand a clinician might be forced by guidelines to make use of evidence which is only doubtfully relevant, generated perhaps in a different grouping of patients in another country and some other time and using a similar but not identical treatment. This is … to use evidence in the manner of the fabled drunkard who searched under the street lamp for his door key because that is where the light was, even though he had dropped the key somewhere else…”
* https://academic.oup.com/ageing/article-abstract/24/6/461/33537?redirectedFrom=fulltext
Wow! Fantastic quote, Thom. Thank you so much for sharing. Can’t wait to read the whole article. I’ve seen the best pushback against EBM from the geriatricians. Most studies exclude anything but perfectly healthy ‘old’ people, if they allow old people into the study at all.
But your own comments before were brilliant also. We expect docs to consume a steady stream of COVID updates which seem designed to create a single outcome. And we are tired. Without tools or energy to resist, we aim to survive and stay out of trouble.
What can be done? you ask. Where might an average working doc start?
These are only suggestions. Ignore anything that does not resonate.
1. Start with what you love.
Do you like money, stuff, people, or events? Do you prefer economics or history? Psychology or political philosophy? Everything — and I truly mean EVERYTHING — can overlap and relate back to healthcare, health policy, and the governance of medicine. Go deep on what you love. It won’t feel like work. Then weave it back with medicine. For example, your love of microeconomics makes you a natural fit for addressing fees. Maybe you like history or foreign affairs. This makes you a natural for lending wisdom to all the pontification we hear about cultures, colonialism, and clinical equality. To be clear, I am not presupposing what side of an issue you may take. Just dig deep. If you are honest, you will want to learn all sides of it. Either way, we will all be better off for having your nuanced input to enlighten us in the face of the cut-and-dried pronouncements favoured by the activist and managerial classes. I’d rather hear an opinionated Marxist, who has read deeply in his opponent’s ideas, than a populist Marxist who knows little but is never in doubt.
2. Start asking, Why? What if? Maybe we could…?
Most doctors walk out of their exam room and look for the next patient to see. We work. We do not have time to think about how care is structured. As soon as you start asking, you will realize that most things are structured with intention. Are you finding it hard to see more than 30 people in an 8 hour clinic? Someone designed it that way. They may not have aimed at the 30 patients or 8 hours, but they build systems which force you to deliver what they want thereby impeding your ability to care for more people. Ask. Probe. Ponder. Even a gentle scratch into the surface of your clinical environment will reveal dozens of assumptions about safety, regulation, who gets to make decisions, who should make decisions, responsibility, accountability, reporting, oversight, and 100 other things.
3. Seek options.
Once you know what you love and you’ve begun to probe your environment, start looking for books/articles/opinions/systems which do it differently. Canadian medicare does not foster this type of thinking. It is unnecessary. The system is what it is … you’d be farther ahead by just working harder. But in non-state-controlled industries, people spend their days asking themselves whether there’s a better way to do everything. Do teams work better than individuals? Always or only in specific situations? Do teams reflect someone’s ideological bias? Are they trying to impose their ideology under the guise of convincing that teams are always better/more-moral/more-efficient?
If you know what you love, ask why things are they way they are, and start exploring options, you cannot escape the conflict of ideas. But the fun part is that this conflict will be perfectly aligned with things you already love and have thought about. So when you finally find a book such as Tom Sowell’s “A Conflict of Visions”, you will keep shouting “Exactly! That’s what I’ve been saying!” “Life is about trade-offs, not perfection!”
Feel free to shoot me an email if you want to chat about specific books. I could dump a list on you, but they would reflect my quest, not yours. You might find them too simple, irrelevant, or just plain boring.
I hope this helps! Great question.
Thanks so much for posting.
Cheers
Good post Shawn …. again.
I have watched in horror as previously back room public health/ID docs have become ‘doctators’,often times with good intention ‘throwing the baby out with the bath water’.
The previous relationship that docs had with the public at large is no more. From refusing to see unvaccinated,to solely virtual care,to political statements in social media,the public will view docs differently.How that will shake out practically remains unclear.
Clinical/grass roots docs have been beaten down like dogs,and most no longer have the energy to fight the good fight.
Hence,authority will be ceded to the political/bureacratic lackies that take interest in such things.This,if course,began before the pandemic which has accelerated the process.
I will continue to fight medical misinformation on Twitter,and implore the grass roots to get involved,as you have.Otherwise…..we’re doomed.
Thank you, Ram.
Ram, “Doctators” — ha! Love it. I hadn’t heard that one. Excellent.
You make very important comments about our relationship with the public at large. We seem to be punching ourselves by doing all the things you list: solely virtual care, etc. If I was in government and wanted to make major changes, I’d use this animus to support focussed legislation that I might not have been able to achieve in the past.
Your comment about “lackeys that take interest in such things” reminds me of Yeats’ “The best lack all conviction while the worst are filled with passionate intensity.”
I think you have the best approach, although it is hard and often depressing. We want definitive wins and crushing arguments. I’ve never seen these create the lasting change we expect. Instead, it takes years — decades often — of several hundred comments, quips, and thoughtful questions to slowly turn the minds of those around us. And they may never turn. But at least we can give them pause from following those who champion full steam ahead for a bold, one-size-fits-all, centralized, tightly regulated, and scientifically efficient system. (Hip, hip, hooray!)
Sure appreciate you taking time to read and post. As always, you’ve packed decades of observation and advice into a few paragraphs. Brilliant.
Cheers
Good day Shawn. Once again you do not disappoint – great article.
Here’s another superb quote that is so à propos:
“The welfare of the people in particular has always been the alibi of tyrants, and it provides the further advantage of giving the servants of tyranny a good conscience.” – by Albert Camus (French philosopher)
Published as an essay in Actuelles III (from Resistance, Rebellion, Death. Page 101 – translated by Justin O’Brien. New York: Alfred A. Knopf, 1961),
originally a speech “delivered 7 December 1955 at a banquet in honor of President Eduardo Santos, editor of El Tiempo, driven out of Colombia by the dictatorship”.
Merry Christmas!
Fantastic quote, Robert. Thanks so much for sharing it.
It reminds me of Bismark’s quip about health insurance as a way to “bribe the working class.” However, I’m not sure Bismark was a tyrant 😉
Merry Christmas to you too!
PS. I changed the edit you mentioned in your second note — thanks for catching that! Cheers