“The greater the ignorance the greater the dogmatism”
-William Osler, MD
In the popular imagination there exists a dividing line between the long-gone period of barbaric medical practice in which snake-oil salesmen used leeches and patent medicine to deceptively trick people, vs today’s much more scientific and sophisticated brand of health care in which well-trained doctors utilize their knowledge and skills to truly improve one’s life. After all, one simply has to compare the average lifespan in 1800 with what it is now to see how much we have advanced medically.
And yet, have we? Are our physicians so different than the charlatans of long ago, or do they simply project a discursive authority that, after decades of performative adherence to a sanctioned gospel repeated over and over again by doctors and other “trusted” sources, has become an unassailable truth? How much of what doctors preach truly is rooted in science, how much of it truly improves and extends our lives, how many of the pills and tests and procedures are as necessary and lifesaving as they proport? Or how much of what they preach is wrapped in a veil of faith that we have come to correlate with increased lifespan, but which really has nothing to do with it and is better understood in a way that equates it to a belief in God, in salvation through prayer, in compliance with liturgy?
I will argue that the dogma of health care is akin to that of religion, and that its precepts and scriptures are no more grounded in a scientific and humanistic foundation than any religion that gained similar adherents by offering people hope and certainty against a backdrop of fear. Agamben suggests that of the three great religions of the West—Christianity, Capitalism, and Science—only the latter reigns supreme among nearly everyone. “It has been evident for quite a while that science has become our time’s religion, the thing which people believe that they believe in,” he writes, saying about medical science: “There is a malign god or principle — namely, the disease, whose specific agents are, say, bacteria and viruses — and a beneficent god or principle — which is not health, but recovery, whose cultic agents are doctors and therapy.” Medicine, he declares, with its priests and rituals and absolutism, is religion clothed in a faux scientific sheathe.
But aren’t we living longer? Surly, all that stuff that doctors tell us to do—all those pills and tests and fixes that our benign and wise doctors insist we need and for which they are often well compensated—have kept us alive and healthier? Well, not really. When public health truly cared about humanity—unlike today when it is more focused on bugs than people—it literally changed the course of illness. Through sanitation, an understanding of disease transmission, antibiotics, aseptic surgical techniques, and immunization, we drastically dropped the death rate among our youngest citizens, infants, children, and pregnant women. That alone accounts for about 90% of our improved longevity. The rest is related to fewer wars, better emergency care, better diet, some technological and surgical advances, some medicines (especially antibiotics), and sensible control of chronic disease such as high blood pressure and diabetes.
In Blue Zones, areas of the world with the longest lifespans, people don’t rely on statin cholesterol medicines, cardiologists, stents/stress tests, mammograms, diabetic monitors and all the other “necessities” of modern medical faith to stay healthy. Instead, they exercise and eat well, have access to urgent care when needed, keep a loose eye on their blood pressure and sugars, and practice sanitary behavior. During the past quarter century, when our doctors fed us a buffet of technological wonders and more drugs than one can swallow, as our annual health care budget leaped from $600 billion to over $4 trillion, life expectancy decreased. But because of our faith in our doctor-priests, we refuse to acknowledge that fact. Frankly, as with many religions, we dismiss most facts and stick instead to our perceptions of reality, which we label as scientific truth because our medical-religious leaders and their faithful flock have convinced ourselves of this.
When did a religion of medicine develop, and how has it persevered without being seriously challenged for these many decades? Foucault, who we discussed in a prior blog, and who wrote about the system of subtle disciplinary mechanisms that a liberal middle-class imposed under benign pretenses upon society in the 1800’s by defining a “normal” by which everyone was to be judged—a system that was implemented through tests, observation, judgments, education—shows how this normalizing process spilled over into the medical realm.
During this time doctors shifted their gaze from the patient as a person to the patient as a biologic entity that could be analyzed and defined as normal or abnormal by arbitrary measurements seen as being tied to rigid science. “In order to know the truth of the pathological fact, the doctor must abstract the patient,” writes Foucault in Birth of the Clinic. “Paradoxically, in relation to that which he is suffering from, the patient is only an external fact; the medical reading must take him into account only to place him in parentheses.” Doctors, as masters of this new gaze, became religious-like priests who alone understand the gospel of health and sickness. “Are not doctors priests of the body?” Foucault asks, stating of the new priest-doctor: “If one wishes to know the illness from which [the patient] is suffering, one must subtract the individual, with his particular qualities.” Like in society as a whole, argues Foucault, medicine reduced the patient to a binary of normal and abnormal, defined by a homogenous grading system, one in which the medical priests alone were capable of elucidating illness and health with minimal input from the patient (whose own subjective perceptions and individual nuances were seen as a hindrance to the notion of a universal norm of health) by slicing patients into data points. These priests were beholden to authoritative societies and written liturgies that constituted absolute and indisputable truths that transcended anything that the patient may say or feel.
Foucault elucidates the binary conflict that seethed within the medical field. As more sophisticated medical techniques and treatments—grounded in science and pragmatic experience—became available to doctors, as the clinic enabled doctors to learn their craft by mastering both patient-derived and theoretical knowledge, an opportunity existed to purge the field of quacks and to elevate medicine to a field of well-trained doctors capable of truly helping human beings. But against that progressive advance stood a danger: that of instigating a top-down approach to health care in which all doctors must be beholden to regulatory agencies and well-demarcated notions of medical truth from which they could not verge, thus losing their freedom and their ability to treat each patient as a unique person.
Our health care system was forced to straddle this divide; even as technology and knowledge increased our ability to stay healthy and live longer, even as the new system cleansed doctors of their most incompetent ranks, a more dogmatic and regimented health care system could easily collapse into one in which the doctor and patient became irrelevant, and where power dynamics and normalization drove the processes that were purported to be necessary and lifesaving but which, in fact, were mere illusions that fixed measurable numbers but which did not help people much at all.
In America, the shift of medicine from a mix of charlatans and patient-centered healers without any central control, to one of a disciplined band of doctor-priests controlled by authoritative leaders and fed by industry, occurred at the beginning of the 20th century with the advent of the Flexner Report. My friend Alan Roth and I discuss this transformation in depth in our upcoming book. Suffice it to say that Flexner’s report pushed American health care onto a road of religious certitude that has paved our path for the last hundred years. It centralized medical care under the AMA and defined standards of normal and abnormal—absolutes to which all doctors must be beholden—that we still live with today.
Standing against the report was the man whose quote started this blog, William Osler, who too sought to expunge health care from its most corrupt and deceptive elements, but who believed in the primacy of a doctor-patient relationship freed from the fetters of regulations, dogma, industry, and authoritative oversight. Osler’s vision—encapsulated by such famous phrases as “the person who takes medicine must recover twice, once from the disease, and once from the medicine” and “The good physician treats the disease; the great physician treats the patient who has the disease.”—fell prey to the Flexnerian revolution of 1911 that changed health care forever by replacing a patient-centric approach to one that, as Foucault observed, removed the patient from the equation and relied on discrete and unchallengeable liturgy alone.
Upon what precepts is Flexnerian medicine based and how does it resemble religion? Its core beliefs share with its sister science of Eugenics a reliance on measurements and the normalization of anything deemed aberrant as the one and only path to truth. Eugenic scientists—who dominated the mainstream of American science from the beginning of the 20th century until World War Two, when their ideas were adapted by Hitler to provide scientific justification for the Holocaust—devised tests and precise tools to determine how to best divide people into categories based on factors like intelligence and generic superiority, deeming it scientifically and societally necessary (for the most humane reasons) to, for example, sterilize the handicapped, restrict immigration of inferior peoples, and limit who can marry whom. Read Imbeciles by Adam Cohen and The Guarded Gate by Daniel Okrent for more on this.
Flexnerian doctors similarly carved up the human body into measurable parts that, in a truly Eugenic and Foucault-like fashion, were divided into “normal” and “abnormal” and “fixed” to transform everyone into the universal normal. A famous Eugenicist once said that the human body is as measurable as a bar of steel, and it is to this credo that Flexner’s priests swore their allegiance. Many of the early medical pioneers of Flexner’s path even stated that the patient was irrelevant to the practice of medicine; patients were not able to objectively convey to doctors what was wrong with them and thus could lead doctors to make poor decisions. While Osler stressed the importance of treating each patient as an individual and learning the craft of medicine from the patient, Flexner’s path homogenized medical care so that “normal” was defined as being the same from person to person, and the “fix” was also uniform and unchangeable. Flexner’s report also altered the nidus of medical education, so that instead of beginning at the beside of real patients in the real world and them moving to the classroom, training started in the classroom and only moved to the bedside of hospitalized patients, with most teachers being not truly practicing doctors but medical researchers. A uniform educational model was mandated for every school that stressed “science” over clinical care, one that is still with us today.
And the report changed medicine in more fundamental ways than that, transforming it from an art/science in the spirit of Osler to an absolutist creed led by doctor-priests that we also live with today. The AMA—which orchestrated the Flexnerian revolution—and corporate societies like Rockefeller and Carnegie—which financed it—possess total control over the education, practice, and licensing of physicians. There are now overseers, strict rules and creeds, right and wrong answers, and a disciplined uniformity of medical care to which every doctor must adhere. The report was not geared toward the patient but rather to the doctor and the health care industry, using discursive absolutism clothed in a scientific garb—a science that was in the hands of the industries that helped finance the report and that paid for medical education—whose goal was to convince people that they needed more and more medical intervention lest they fall into states of poor health and death. And on this score, they succeeded brilliantly.
In his book The Undoing Project, author Michael Lewis (who wrote Money Ball, and the Big Short and, like those, this one will most certainly be a movie, although it is well worth a good read) describes the lives of two Israeli psychologists, Daniel Kahneman and Amos Tversky, who changed the way we look at people’s decision-making processes. By delving into the psychology of how people make decisions, these psychologists unwittingly opened the door for advertisers to swindle people into doing things against their own interest and politicians to convince people to vote this way or that. Similarly, these manipulative tools are the very ones used by priests and religious leaders to convince people to be pious and adherent to religious ritual. Now these techniques are doing the same thing for our new religion, that of health care.
Five of Kahneman/Tversky’s ideas deserve mentioning, and all of them relate to cognitive biases/dissonance which drive our decision making and are central to our willingness to believe the religion of health care. Because people do not like uncertainty, these devises remove uncertainty. Because people do not like to live with fear, these devices remove fear. Because people want answers that are not clouded by nuance, these devices provide answers that are unassailable and absolute. When a priest—whether the reverend of a church or someone’s doctor—utilizes these cognitive biases, people willingly embrace their gospel because it alleviates the psychological burden of uncertainty, fear, and ignorance.
The five elements of cognitive dissonance relevant to the religion of health care (which I describe using traditionally religious examples) are:
● Anchoring bias: We tend to stick to our preconceived notions and are not willing to change. I don’t care what the scientists say, I know there is a God and that there is a heaven.
● Confirmation bias: We favor information that conforms to what makes sense to us even if data and reality show it not to be true. We most certainly have souls and will live forever in the afterlife; we can’t simply become nothing; it makes no sense.
● Availability bias: If we know someone who had a certain outcome with an intervention, then we will believe that the intervention works. My friend Joe prayed for my dad’s health and then my dad made a miraculous recovery; praying most certainly helped.
● Gambler’s fallacy: We have a hard time understanding statistics that deal with uncertainty and usually err on the side of avoiding bad outcomes by acting rather than being idle. I will keep going to church every week because why take a chance of upsetting God?
● Authority bias: We attribute greater accuracy to the opinion of an authoritative figure. How can my reverend be wrong; he knows what he’s talking about and so many other men of the cloth say the same thing he does.
To show the power of our medical religion through the lens of cognitive biases, let’s look at an example of a medical procedure that is widely utilized to the tune of $100 billion a year and widely accepted as being lifesaving and beneficial. Often cardiologists conduct stress tests to find problems and then, if they do find a blocked artery in the heart, they open the artery with a stent of heart bypass. The science here is clear: there is no evidence that cardiac stress testing or opening blocked heart vessels in people without symptoms saves any lives or prevents any heart attacks; in fact, it leads to more harm than not doing these tests or procedures. And yet, our cardiology-priests widely disseminate the myth that these well-compensated tests are in fact necessary and have saved countless lives, and virtually all of my patients who have had such interventions believe that their lives have been saved, often just in the nick of time. That’s what happened to Joe.
When his trusted cardiologist told Joe that a stress test would help determine if he has a blockage he may not know about, Joe told him to go for it. The stress test was abnormal, and a subsequent catheter procedure showed that Joe had an 80% blockage of an artery in his heart. The cardiologist told Joe that they better hurry and open that blockage, and Joe too wanted the procedure done immediately, thanking his cardiologist for being so thorough and finding a silent problem that was just days away from killing him. His trust in the cardiologist who has been well trained and must know the truth convinced him that the test was necessary and that the blocked vessel had to be opened immediately. (Authority bias) His good friend Pete, and several other people who he knows, had stents put in and are alive and well now, whereas they likely would be otherwise dead, proving that the stent works. (Availability bias). To Joe, it makes complete sense that opening a blocked artery is the only rational path to take, because otherwise it will definitely close off and kill him; it would be crazy to think otherwise. (Confirmation bias) Joe has heard people say that studies show no benefit from opening such arteries, but that makes no sense to him, and he’s not about to change his mind when he knows that blocked arteries kill people and so many lives were saved with stents. (Anchoring bias) He would much rather take the tiny risk of fixing the blocked vessel than live the rest of his life wondering if the vessel will block completely. (Gambler’s fallacy)
In the realm of medicine, it is believed that at least 50% of the tests, drugs, and procedures sold to patients by doctors, and wrapped in alluring myths that alleviate their biases, have no benefit at all and may cause harm. I discuss many of these in Curing Medicare, Interpreting Health Benefits and Risks, and in my new book with Alan due out next year. Other authors—including Shannon Brownlee, Nortin Hadler, Gilbert Welch, Jeanne Lenzer, and Vinay Prasad—have shown definitively how much of our medical system is built upon the bricks of myth and misinformation. And yet, the public eats it all up, so happy to have their fears and uncertainties alleviated by what seems to be the unassailable truth of faith.
Thus has the medial religion prospered. Through our Flexnerian devices, doctors slice people into numerical measurements that can be defined as normal and abnormal. Based on a gospel that is sanctified by authoritative agencies—whether the CDC or AMA or American College of Cardiology or the Alzheimer’s Association—and backed up by “scientific evidence,” the doctor-priests assure their patients that it is necessary to conduct regular measurements and fix what is wrong lest they fall into the pit of medical hell. As Foucault showed, the patient himself or herself is irrelevant; his/her wishes, symptoms, lifestyle, and story meaning nothing against the liturgy of normalizing measurements. Biased and manipulative medical studies—all financed by pharmaceutical and device companies—provide both doctor-priests and their practitioners with a compelling justification for their compliance to the medical gospel. Any doctors who stray from or question medical dogma are perceived as heretics. Any patients who question medical dogma are perceived as being ignorant and self-destructive.
Doctors who perform more procedures and tests that find and “fix” abnormalities are rewarded with higher pay. Non-procedural doctors who are most proficient at fixing their patients’ “abnormal” numbers are also paid more. The media, medical agencies, and schools all proclaim the wisdom of doctors and of all the drugs/tests/procedures that are credited for saving so many lives. True science is bulldozed by a powerful medical faith that has won the hearts and minds of Americans. Flexner’s vision of a corporate, top-down, numbers-over-patients ideology has become the one and only medical gospel that has taken root. Our doctor-priests are trained by the very same curriculum scripted by Flexner over a hundred years ago, in institutions whose very existence is predicated on corporate funding and on compliance with the medial-religious gospel. Everyone, it seems, has bought into this religion, even those who have deceived themselves into believing that it is science and not faith, and that any and all skeptics are anti-science and thus must be disregarded for their foolishness. Of course, this is no different than the Middle Ages, when the Catholic Church wielded a similar authority by easing people’s fears, appealing to their biases, convincing them that they spoke the one and only truth, and that all doubters were heretics destined to land in hell.
“One special advantage of the skeptical attitude of mind is that a man is never vexed to find that after all he has been in the wrong,” Osler wrote before his patient-centered vision of health care evaporated amidst the medical religion of Flexner. “Listen to your patient; he is telling you the diagnosis. ”This is not what we are left with today. Patients trust their doctor-priests and medical authorities more than they trust their instincts, their own sense of health, or any reliance on scientists who challenge medical dogma. They have bought into the more-is-better philosophy that pushes them to test and treat everything and to rely on the necessity of normalizing their numbers. They are faithful to the medical religion in every way. Today's doctors fix numbers, not people, something they are trained to do and for which they are well rewarded, as are all religious leaders who perform miracles. As we will show in the next blog, such faith has spilled over to COVID in a way that has come at a dire price to compliant parishioners of the medical faith and to our entire society.