David Hume, Scottish philosopher, said reason is slave to the passions.
Aristotle insisted knowledge required questions. If we cannot ask, ideas never improve. Policy becomes artifact. Then social media turns it into an endless siren of emotion: too often, doctors screeching at each other.
Historians tell us we live at the end of an age, perhaps even the twilight of a civilization. The fabric required to practice medicine wears thin.
Polybius (200-118 BC), a Greek historian, wrote that kings become tyrants, aristocrats become oligarchs, and members of democracies become mobs. A mob feels deeply, convinced of its own self-righteousness. Civility fades and barbarians emerge nasty and cruel, filled with anger and spite.
As Western civilization declines and democracy becomes mob rule, medicine becomes an anachronism, an artifact from the Greek age of reason. By age and disposition, medicine seems more and more out of place in modern society.
Medicine needs three things to survive: civility, logic, and free speech.
Civil Traditions
Civility is more than knowing the rules required to live in civil society. Social skill follows immersion in civil traditions. We develop a second nature of civility and become citizens (see Hannah Arendt quote below).
We have lost the spirit of civil traditions as well as the traditions themselves. We cannot regain the traditions without knowing the spirit animating them.
We cannot be Scottish by just donning kilt and pipes. To be a Scot means more than just doing Scottish things. We become Scots first, and Scottish things follow. A cowboy in a kilt with bagpipes on his saddle is not Scottish.
Can people regain civility if they never knew the institution in the first place?
Can those who were polite, simply because it was fashionable, learn to be polite when the fashion fades?
Did public virtue come from reason, by fiat? Or did it emerge over centuries of strife — shaped, learned, and adjusted to enflesh an ideal?
Logic
Care requires critical thinking. But logic and reason will offend those who refuse to think clearly.
Consider a few examples.
The pursuit of equality pushes hospitals to hire people for jobs they cannot do. With the right disposition, burly men make the best security guards. But hospitals cannot hire big guards. They must also hire small, frail, old men and tiny women too.
When journalists write about nurses rag dolled by 300-pound psychotic patients, they never mention the size and strength of the security guards on duty, only the need for more guards.
Drug dosing requires mathematical skill and accuracy. Can we demand this of all clinicians? Or is this Euro-centric, as some insist?
We teach clinicians how to stay safe with psychotic patients: Do not turn your back. Keep a path to the door. Though necessary, these survival tips are, by definition, prejudice — verboten in modern culture.
Free Speech
Clinical care starts with questions:
How can I help?
Why did you stop your meds?
Why did you take the whole bottle of Tylenol?
Today, doctors must affirm a list of things society has decided to support. Doctors avoid questions about anything on the list, and they must avoid any non-verbals which might imply a lack of support.
Cannabis? Yes, I know of a clinic close by.
Euthanasia? Yes, here’s a referral. Doctors dare not ask about depression, loneliness, or poor pain control. (The most contentious issues are even too scary to mention in a blog.)
Some things need to be said. It is not fat shaming to say someone is overweight. It is not insensitive to say a patient is not strong enough to throw hay bales all day.
Doctors need to be able to question a patient’s decisions which might be animated by depression, even if they fall on the list of things we must affirm.
Can Medicine Survive Modern Society?
Society opposes many of the presuppositions required to provide care. People find it offensive that medicine requires any pre-thought at all. It seems close-minded.
To be clear, presuppositions can fail. We need thoughtful change to improve.
Medicine is an ancient tradition. It requires things that modern society will not tolerate. We will never modernize medicine enough to smooth all the hard edges.
For now, physicians dance around the unseemly bits and pretend medicine can continue without them. How long can the pretence last?
Very interesting view, Shawn, definitely food for thought from my perspective. I had not thought of society divided by right and left, identity politics and cancel culture as experienced by physicians. Society’s current politically correctness can, indeed be detrimental to patient health and physicians’ ability to diagnose and treat. It’s very scary.
Hey Martha
Thanks so much for this. Society has come inside the clinic and determined what and how physicians can speak and act. It is silly because critics have drawn lines doctors cannot follow. It is even more silly because the critics do not know the half of all the things they would find offensive. Patient care suffers for it.
Sure appreciate you taking time to share a comment!
The battle is between reason and feelings
Reason is the human’s only way of grasping reality and to acquire knowledge….Aristotle led the way in this regard….humans possessing the ability to think or to evade thinking, to utilize reason or to avoid reasoning .
Truth and facts do not depend on beliefs or feelings , reality exists no matter people’s beliefs and feelings….religions and religion substitutes depend on faith and feelings , with knowledge somehow transmitted to believers via intermediary priests, Mullahs, Party Commissars , activists and , these days, via monomaniacal celebrity influencers, the Gretas, from the “heavens” into the intestines of the susceptible which they then feel obliged to obey.
In the real world material feelings and passion may pull the cart , but reason has to hold the reins ( cribbed from Ben Franklin and Charlotte Brontë ) or it goes off the cliff.
Regarding feelings.
The human brain is , in many ways, distributed through the body, the gut and brain connected via a brain gut axis….the human brain possesses a 100 Billion brain cells and the human intestine has 100 million brain cells ( more than a cat possesses in its brain) , they can work independently of each other but communicate via the sympathetic / parasympathetic / hypothalamic pituitary adrenal axis…one should not ignore “gut feelings/ intuition” which are nature’s primitive early warning systems, but we should not be ruled by them as Arendt’s “children “ as is occurring at the present time and even within our own profession.
Modern western society seems to have become over dependent on gut feelings and is being led by them , wokeness and feelings go hand in hand with the moderns seemingly offended by practically anything.
Presently feelings are winning over reason in the west, in our institutions , media and political / bureaucratic class …but it’s no true elsewhere , there are hard nosed predators out there looking at the woke “ snowflake ” society as insipid prey.
Medicine, as practiced since Hippocrates and Galen, is in real trouble , historians will study its fall from grace pushed off the cliff by COVID, political action and inaction and the rise of virtual medicine.
“The bad drives out the good”.
( Gresham’s Law)
So many great comments, Andris. As usual, I cannot do them justice.
I wanted to highlight one thing” “…there are hard nosed predators out there looking at the woke “ snowflake ” society as insipid prey.” I’ve been mulling this over for most of the pandemic. We forget, or live oblivious to the fact, that our approach to civilization is deeply offensive to many other forms of civilization. We are, right now, in a war of ideas in which the opposing side harbours a desperate wish to see the west collapse. This is not fear mongering; it is the whole history of mankind.
Again, thanks so much for reading and adding more levels . . . quotes, anecdotes, references . . . fantastic!
Cheers
Quoting Ivison in a NP article today “ people with whom you disagree with are not your enemies”… a line that partially reflects my thoughts. “Beliefs come from intuition rather than rational thought”…however, intuition in an experienced medical doctor ( or plumber for that matter) is a combination of knowledge and experience…how many of us ordered a lab test or investigation on a “ feeling” that semi surprised us by turning positive.
Not all intuitions are equal.
We underplay the role of intuition, for sure. You might really enjoy Michael Polanyi’s book “Personal Knowledge“. He trained first as a surgeon then switched to philosophy. He has a great section on how a surgeon needs to know the anatomy of an abdomen in three dimensions without being able to see it. He needs to know where a structure should be and then be able to find and identify it by feel. It becomes exponentially harder if the operation involves and abscess which just collapsed. Of course, this isn’t the whole of surgery, but it helps get at the ‘tacit dimension’ of knowledge (yet another title of a Polyani book).
I don’t know about the modern day teaching of anatomy, likely virtual….working with visiting new graduates from the UK, I was horrified to find that they had been trained on models and were itching to palpate a real live abdomen and to feel an actual real prostate etc.
We were armed with Gray’s Anatomy and another that I can remember and spent 2 years dissecting cadavers…Cardiff was a haven of cadavers and when we were not dissecting in the summer, European med students, who trained in countries that restricted / banned such dissections , flocked in to dissect and learn anatomy.
We quickly learned that nature does not place nerves , arteries and ducts etc., as per the anatomy books…sometimes placing them where they should not be.
One learned to respect surgeons who had to navigate between structures that may or not be where they should be and who found themselves in a quagmire from which they had to extricate themselves for their sake and that of their Patient.
“ It ain’t what you don’t know that gets you into trouble.It’s what you know for sure that just ain’t so” ( Not Mark Twain)
You brought back fond memories of hours spent hovering over a greasy neck dissection.
I think cadavers are harder to come by now? Maybe that has changed. The other change was a move away from teaching anatomy beyond a very limited exposure. After all, how much does a pediatrician (or most other docs) need to know about the annular, cruciate, and oblique pulleys in the hand?
Great comments all. Love it.
Great article Shawn.
Good comments Andris.
Agree with you both……medecine is in real trouble.
Fascinating to see how we spin out of covid as a profession.
Things will be very different,for sure.
Hopefully,young docs will maintain the tenets upon which this once great profession was based.
Agree, Ram.
Perhaps it has gone too far? Crisis often forces a return to first principles. COVID has done the opposite.
Thanks again for taking time to share your thoughts! As you know, readers love the comments most.
Cheers
Dear Shawn,
Respectfully, your book and your perspective and recommendation is part of the problem – a return to a physician knows best about your “health”. When you truly are pressing a medical model which does not scratch the surface on how to improve a person’s or the population’s health. You perspective propagates the Medical Establishment (which is very self-serving as a MD and a past head of OMA) . Your book and perspective is so biased that you do not even give mention to the determinants of health – knowing full-well that medicine only plays the smallest part of human’s holistic health – and in fact medicine is just fail-safe illness fix when health fails.
I submit to you, that your book and your agenda is serving to only protect the interests of the Medical Establishment and very insincerely promotes a benefit to “healthcare” or the system. Further more promoting the old status quo will lead to a catastrophic failure of Canada’s medical system. If you were being honest you would recognize that we need to evolve past the old model to a progressive focus on broader health determinants and in fact medical services need to respect in align with other forms of health practice vs blind focus on medical diagnosis and treatment. From a recent Longwoods article, I site the following:
“Improving Canada’s healthcare system starts with focusing on overall health and wellbeing, [and] not just on [Medical Service] care delivery. When we do that, we can rethink the future of work, which includes rethinking the work itself, who performs it, where it is done and the model of delivery. This will lead to an opening up of the workforce, create greater access to services and improve overall productivity so [that] we can support health and wellbeing more effectively within available resources.” (Lisa Purdy)
“It’s about being clinician-agnostic and getting care to people at the right place at the right time. We’re really encouraged to see the momentum and acceleration of mobile integrated health. In an uncertain time, it’s brought stability and continuity to patient care and allowed us to build out collaborative teams. It’s also allowed us to appreciate how digital tools and virtual channels can work in tandem with face-to-face healthcare delivery.” (Erik Sande)
Would be happy to discuss alternate perspectives
Mark,
(I didn’t realize you posted your comment above initially on the contact forms page. I transitioned your comments here, where all the comments go. For some reason, comments had been turned on again on the contact page. I hope that’s okay. Again, thanks for posting!!)
Thank you for taking the time to write and share quotes from Longwoods.
I agree with your comments about health as a broad concept with many inputs. A lifetime of behaviours — diet, exercise, stress, sleep, etc — impacts health far more than an annual check up with your doctor! No argument there. Furthermore, a homeless person will never achieve the same level of health as someone growing up in a two-parent, stable home regardless of income.
What’s worse, people of the lowest socioeconomic levels in Canada have the hardest time accessing care … but you already know that since you read the chapter about it in my book, right? 😉
Which brings me to a gentle pushback. My book describes why and how the Canadian healthcare system fails. I did not write a book about why and how people are unhealthy. That would be a good book too, but it has already been written many times. It seems you criticize me as being “so biased” for not writing the book you had hoped to read.
I agree there are many ways to reorganize the healthcare system. You criticize me for not putting these ideas in my book. But as I said in the book (many times), a proper discussion of solutions comes in my next book. The most recent volume dealt with diagnosis. The next tackles treatment.
Finally, you say I am self-serving and trying to propagate the medical establishment. I wonder, have you read this blog at all? I have dozens and dozens of posts criticizing the medical establishment, medical associations, bureaucracy, medical politics, medical academics, and healthcare in general. Indeed, I have spent the last 9 years “challenging accepted thinking and offering solutions” as best I can, when I can.
If you get a chance to re-read my last book, I’d love to discuss any specifics about which you disagree. Seriously, I love learning to see where I can improve the arguments and evidence I publish.
Again, thanks for taking the time to write.
Best regards,
Shawn
I cannot wait to see that book Shawn, as I feel that even with this post, you are just dancing around the problems without actually addressing them.
“Medicine needs three things to survive: civility, logic, and free speech”
Really??? That’s it? that’s all?
It makes about as much sense as saying that bread baking needs three things to survive: friendship, chemistry and outdoor activities.
Besides, what is ‘modern society’?
Medicine has one and only one problem: politics.
That it is defined, managed and run in the interest of political considerations.
You may never get to real answers until you muster the courage to acknowledge that.
The problem with medicine is that, especially in Canada, it is an essentially communist institution.
Hey Zork
Glad to hear you are looking forward to my next book … I hope it doesn’t cause you as much frustration as my last one! 😉
Although I think your comments are a bit harsh, I do appreciate you sharing them. It looks like I’ve misled you to think I was talking about Medicare, when the post was about medicine.
Can medicine, as a social institution (‘profession’ comes close, but is slightly different), survive given the thought patterns prevalent in modern society?
You make a good point about defining ‘modern society’. I chose the rhetorical approach of offering examples of the conflict without delving into a long (and controversial) attempt to win agreement on the definition of ‘modern society’.
I agree with your comment about politics being a major problem facing the practice of medicine. But that is a separate topic. This blog post attempted to show that current assumptions and approaches to discussion in broader society go against the presuppositions required to practice medicine.
As for your closing comment about courage to call medicine a communist institution, I would ask you the same thing: What do you mean by ‘communist’? What variety of communism did you have in mind? (Chinese? Cuban? Soviet?) I’d also love to hear how successful you have been at convincing others to change their mind by demonstrating the ‘courage’ you suggest?
I find that labelling something communist, Nazi, or satanic only resonates with those who already agree with your message. They are useless terms when trying to convince someone to change their minds, in my opinion. You are better off discussing ideas than labels.
Thanks again for taking the time to read and share a comment!
Best regards,
Being the ‘trained Marxist’ I am, I use the term communism quite judiciously and always ideologically.
The definition was provided by Karl Marx in “The Critique of the Gotha Programme”
“From each according to his ability, to each according to his needs”
Which is the essence of the Canadian Health Care system. Of course, it does not work that way, and of course all communists feel uncomfortable when their ideology is exposed for what it is.
You can call it “thought patterns prevalent in modern society”, I would prefer to call it what it is: a very dangerous, very destructive and unworkable ideology.
Yes, we can ask questions such as Can medicine survive the fall of Western civilization?
Can medicine survive a global post-civilizational tyranny?
We can even ask: Can medicine survive modern medical science?
…but any of these discussions must start with calling a spade a spade.
Thanks Zork.
I’ve yet to find a Marxist who will agree that anything about society anywhere truly represents Marxism. Every example is a marxist heresy for some reason or another. So again, I do not find it a helpful tactic when trying to convince other people.
Having said that, I do think it is helpful to understand ideologies and see how they influence current thinking. To that end I’ve been planning a post on Marxism in medicine for some time. Hopefully it won’t frustrate you! 😉
Cheers
Mark, I’m curious – what do you do for a living? Would like to understand your frame of reference.
Thx,
Matt