Healing Modern Medicine
David Lorimer digs into themes in my recent book, Making the Cut.
David Lorimer wrote a terrific review of Making the Cut: How to Heal Modern Medicine for Paradigm Explorer. I republish it here with permission.
Aaron Kheriaty is currently director of the programme in bioethics, technology and human flourishing at the Ethics and Public Policy Centre. Prior to this, he was professor of psychiatry at UCI school of medicine and director of the medical ethics programme at UCI health. He is also author of The New Abnormal, which I reviewed in Paradigm Explorer 140, p. 44. The previous book tells the story of how he felt compelled as a medical ethicist to do what he was convinced was morally right under pressure when the university banned him from working on campus and eventually sacked him for not complying with their vaccine mandate on the grounds that there was good scientific evidence that natural immunity was superior to vaccine immunity – he himself had had Covid. In the present book, he makes very little reference to this life-changing episode, which I also discussed with him on my podcast Imaginal Inspirations. However, in the final paragraph of my review, there is continuity in the author making the case for universal rationality and pursuit of truth grounded in a transcendent logos beyond mere instrumental rationality. He also advocated restoring the moral authority of values and the dignity of work, while recognising our need for roots and living from enduring principles.
The present work is informed not only by medical science, but also by Aaron’s wide literary culture, a rarity these days – Karl Jaspers, TS Eliot, Tolstoy, Illich. Much of the text recounts his own medical training and experience, illustrated with key episodes involving his patients. He is concerned that medicine has squandered public trust and abandoned its mandate to heal, especially during the Covid period. The Pew Research Centre found that the number of US adults placing confidence in medical scientists to act in the best interests of the public declined from 40% in 2020 to 29% in 2022; moreover, almost half the population do not trust public health agencies to act in our interests (p. 199). The medical model is mechanistic, reductionist, and instrumental, taking the dead body as its starting point and casting the role of the physician as an efficient mechanic or technician. The living body is seen as a machine, as Claude Bernard advocated (p. 40) and is subject to the deterministic laws of physics and chemistry, hence to the principles of control. Aaron quotes Iain McGilchrist on the shortcomings of such a biomedical model that is also underpinned by the idea of fighting disease rather than promoting health.
Language becomes objectified, and the system is one of functionalism dedicated to efficiency. The physician has to accompany patients in their experiences of loss, pain and death. Death frames our entire life, and should be approached through processes of reconciliation, acceptance, and surrender rather than the language of succumbing. This is also why a group of us has recently put together the Death is not the End website (https://deathisnotend.com) to show that there is good evidence that death is a transition rather than extinction. Aaron himself is no stranger to suffering, having himself had a serious car crash and experienced five years of debilitating pain (p. 97). Some of his encounters are intensely personal, such as with his patient Lisa and his schoolfriend Matt, who succeeds in committing suicide at the third attempt. In another moving episode, he asks for the blessing of a dying priest (p. 181).
A key influence on Aaron’s life was Dr. Edmund Pellegrino, whose integrity and insight he seeks to emulate. He quotes one of his own speeches to students (p. 30) where he reminds them that ‘it is not science, but love and devotion, that transforms the world…we physicians are not robots who treat diseases; we are people who treat other people… always follow the light of your conscience, even when your decisions are unpopular… medicine is a vocation; it’s not just a career.’ On p. 170, he lists some of the most essential virtues recommended by Dr Pellegrino including fidelity to trust, intellectual honesty, compassion, courage, and prudence. The doctor-patient relationship is the absolute fulcrum of the issue, forming ‘the core of medicine.’ This reminded me of Jacob Needleman’s classic book which I reviewed 30 years ago, The Way of the Physician. We are always human beings before we are professionals. This means that the instrumental language of clients, consumers, contractors and providers mischaracterises the nature of the doctor-patient relationship. The primary good of care and compassion is in tension with the secondary goods of money, power, prestige, honour, ranking, and competitive advantage (p. 174) reflected in the institutional structure of medicine and which threatens to undermine these primary goods.
The final chapters chart a way forward for institutional medicine with a thoroughgoing critique of (left hemisphere) depersonalised managerialist ideology (pp. 200 ff.) The tenets include technocratic scientism, an emphasis on metrics and checklists, utopian progressivism, liberationism, homogenising universalism (one size fits all), interventionism, efficiency and throughput, pressure to conform through administrative control – and the failed reaction is interpreted as a call for further managerialism, in the same way that elite institutions call for ratcheting up centralisation and power. Aaron concludes that, paradoxically, ‘the cure for our epidemic of (chronic) ill-health will require less, not more, professionalised healthcare – the US system is Exhibit A (p. 110), where ‘hospitals and clinics have become factories with processed patients as the product.’
Aaron suggests that the way forward is small scale, decentralised initiatives, as the current totalising institutional juggernaut is too systemically controlled by corporate industry interests, where reform is fiercely resisted. To this end, he and other physicians have founded the Hippocratic Society (https://hippsoc.org) in the hope that every major academic medical centre will have a chapter by 2035. Individual physicians can strive to embody humanistic as well as biomedical principles, as suggested in a key essay by Karl Jaspers (p. 192), The Idea of the Physician and summarised by Aaron himself on his final page, p. 244: ‘to be a physician means to accompany patients through the enigma of human life, death, suffering, and healing without having the power to resolve these enigmas’ - combining professional skill, human kindness, and compassion. This bold book is essential reading for all health professionals and others concerned with rehumanising healthcare.
The book sounds like a good read. Dr Kheriaty’s ideas sound like a return to the kind of medical model I worked within as a young RN in the 60s. Your attending dr was with you in sickness and health until death. You saw him in the office, the ER and as he made rounds when you were hospitalized. When you died he met with your family, whom he probably knew. He was a support through life and death. Not the impersonal hospitalists now in practice, or the specialist who sees you for one complaint. Very impersonal. Dr Kheriaty’s is right. The medical model is not satisfactory as it stands, apparently not for physicians either.
This statistic is pretty dismal, “…declined from 40% in 2020 to 29% in 2022.” I believe that I’m at a lower percentage than that in 2026. However, I have hope that the winds are changing in a positive direction. God is in the wings and assisting humanity. We’ve come a long way in a few years since “Defeat the Mandates” because of efforts such as yours. Thanks so much, Dr. Kheriaty. You never set out to be a beacon of hope, but you are and for that we are grateful.