This article is a rewritten essay based on an episode of my podcast, Every Knee Shall Bow, from Ascension.
Whether you favor socialized medicine or oppose it entirely, I think most of us sense that something is wrong with the way health care is done, and that it would still be wrong even if we fixed the insurance and the billing. The problem is more fundamental than economics. It is philosophical. I am writing this especially for doctors and nurses, though every one of us is a patient sooner or later.
Sirach 38 is a passage every doctor and nurse ought to frame: "Honor the physician with the honor due him, according to your need of him, for the Lord created him; for healing comes from the Most High" (Sirach 38:1-2, RSV-CE). A man who entered OCIA at my parish once asked me whether Catholics really believed in doctors and modern medicine. His sister had been diagnosed with cancer, and the pastor of their nondenominational church told her that going to a doctor would show a lack of faith. By the time she went, it was beyond cure. I told him that not only do we believe in hospitals, we invented the whole thing. The Basileias, the house of care that Saint Basil the Great built outside Caesarea in the 370s, is counted by many historians as the first true hospital for the public.
The gallbladder in room three
My dad spent time in a wonderful hospital, staffed by people who did excellent work. Even so, I am going to say that it inhabited a structure of sin.
If you work in medicine, you have probably said something like this in the last week: the gallbladder in room three, the stroke in bed twelve. It is efficient shorthand, and no one means it cruelly. But somewhere in room three there is a woman. She has a name. Her kitchen smells a certain way in the morning, her son is worried about her, she has a rosary in her purse, and she has a fear she has not yet spoken aloud to anyone. The system caring for her, often heroically, has found it easier to call her a gallbladder.
Or picture a kind, competent doctor seventy minutes behind schedule, looking at the screen for most of the visit because the screen is where the visit officially happens. Nobody chose this. The patients, the clinicians, and even the administrators are unhappy with it. To those of you inside this system, your exhaustion is not a sign that you are weak; you are grieving something real.
Two kinds of doctors
Beneath every debate in medical ethics lies a prior question: what is medicine for? The obvious answer is healing, but that answer depends on agreeing about what health is and what a human being is. None of this is an attack on modern medicine. When I was setting up my dad's home dialysis machine, he reminded me that at any other time in history he would have died two years earlier, and painfully. My critique is that medicine has been trained to see too little, so that a true but partial view has begun to mistake itself for the whole.
Plato saw this coming. In his last work, the Laws, the Athenian Stranger describes two kinds of doctors. The doctors' servants learn medicine "by obeying and observing their masters; empirically and not according to the natural way of learning." These slave doctors treat slave patients, and they "never talk to their patients individually, or let them talk about their own individual complaints." The free doctor "carries his enquiries far back," "enters into discourse with the patient and with his friends," and "will not prescribe for him until he has first convinced him" (Laws IV, 720, Jowett). In Book Nine Plato returns to the image and says that the slave doctor, overhearing such a conversation, would "burst into a hearty laugh" and say, "Foolish fellow, . . . you are not healing the sick man, but you are educating him" (Laws IX, 857).
That laugh has been heard in American medicine for a hundred years, with a modern accent. There is no billing code for conversation and no productivity credit for winning a patient's understanding.
Notice where Plato locates the difference. It is knowledge, not bedside manner. The slave doctor gives orders because he cannot give reasons, while the free doctor understands the disease from its causes and so can teach and persuade. Plato assumed that tyrannical medicine flows from ignorant medicine. We have run the experiment the other way: we give physicians the most scientific training in history and then build a system that makes them practice like slave doctors anyway. The problem is not what medicine knows but what the system is ordered to. Modern medicine has learned to practice slave medicine on free people, and it is making slave doctors out of physicians and nurses who trained and prayed and sacrificed to be free ones.
Four gospels of health
It happened, as I see it, because we no longer agree on what health is. Our culture holds rival answers, each a kind of gospel that promises to save us. Each contains a truth, and each becomes false when it is taken for the whole.
The first gospel says health is the proper functioning of the body. It gave us antibiotics and transplants. But a person can have normal lab values and an empty life, while another carries chronic illness with courage and dignity. If health were only the absence of disease, the second would be the failure, but every honest clinician knows it is often the other way around. When this partial truth becomes the whole, medicine collapses into technicism.
The second gospel says health is well-being, the experience of feeling whole. Pain and loneliness are real. But if feeling becomes the highest measure, we come close to saying that a life is valuable only when it feels valuable. Suffering is not the same thing as meaninglessness, weakness is not the same thing as worthlessness, and dependence is not the same thing as indignity.
The third gospel treats health as a commodity. The physician and Catholic philosopher Edmund Pellegrino answered it, in my view definitively, in a 1999 essay, "The Commodification of Medical and Health Care." A commodity is produced for sale, interchangeable, owned by its seller, and exchanged between people who have no personal interest in each other beyond the transaction, and health care fails every clause. The physician does not even own what he is supposedly selling, since medical knowledge comes from centuries of observation and from research society funded. Medical and nursing students, in Pellegrino's words, "enter implicitly into a covenant with society to use their knowledge for the benefit of the sick," and so they become "stewards rather than proprietors" of what they know. You cannot sell at market rates what you hold in covenant. Christians have an older name for this: "You received without pay, give without pay" (Matthew 10:8). A market also presumes a free consumer, but a person bleeding in the emergency room cannot go to the competition. The commodity model applies maximum commercial logic at the moment of minimum human freedom, and our vocabulary shows it. Patients become consumers, and physicians become providers.
The fourth gospel says health is salvation. Nietzsche, my favorite atheist, predicted that when God died in our culture, people would make new idols, and health as the point of life is one of ours. The irony is that Nietzsche's "great health," described in The Gay Science (section 382), meant the vitality to affirm life even in suffering. Byung-Chul Han, in The Burnout Society, argues that we have moved from a disciplinary society, governed by "should" and "may not," to an achievement society, whose word is "can." The body becomes a project, and we are exhausted by the demand to improve it.
The question we agreed not to answer
None of these gospels can hold because health is a teleological concept. The Greek telos means end or purpose, and a living thing is healthy when it flourishes according to the purpose proper to its nature. But you cannot say what a healthy human being is until you say what a human being is for, and that is the one question our culture has agreed for centuries not to answer. So every definition of health smuggles in a hidden picture of man: the machine, the bundle of feelings, the consumer, the project. The crisis in the hospital is a crisis in anthropology, and medicine cannot fix it from inside, because it borrows its picture of man from a culture whose picture is broken.
The Church has an answer, and she built the hospital on it. The human person is a unity of body and soul, and body, soul, relationships, truth, goodness, and ultimately God all matter. Saint Thomas Aquinas wrote that "person" signifies "what is most perfect in all nature" (Summa Theologiae I, q. 29, a. 3). Health is a real good, and caring for the body is holy work, but health is not the highest good. Medicine exists to serve human flourishing, and human flourishing does not exist to serve medicine.
I met Pellegrino in 2005 in my bioethics class at Franciscan University. An internist and a former president of the Catholic University of America, he directed the Kennedy Institute of Ethics at Georgetown, chaired the President's Council on Bioethics, and went to Mass every day. He began with the experience of being sick. Illness wounds the whole person, who must place herself, body and soul, in the hands of a stranger, and that vulnerability makes medicine a moral practice and not a technical trade. "Profession" comes from the Latin profiteri, to declare publicly, so "How can I help you today?" is a public promise to act for the patient's good.
Our word "health" comes from the Old English hǣlþ, built on hāl, "whole," and "holy" (Old English hālig) grows from the same root. Because the person is layered, her good is layered too, and Pellegrino distinguished four levels. At the bottom is the medical good, such as the fixed fracture. Above it are the patient's own good, meaning what she lives for, then her good as a human person, meaning her dignity and freedom, and at the top her ultimate good, her relationship to the final meaning of her life. Modern medicine measures the bottom level best, and a treatment can succeed there while failing everything above it. That reduction is technicism, which is the philosophy of Plato's slave doctor.
The hierarchy also carries a mercy for every clinician. Curing repairs the body, and healing makes the person whole, so healing remains possible when curing is not. A dying woman can be reconciled, accompanied, and at peace with God, and medicine never runs out of work at the deathbed even when it runs out of cures. Pellegrino called medicine "the most humane of sciences, the most empiric of arts, and the most scientific of humanities." Set that beside "the gallbladder in room three" and you can see what we have lost.
Pellegrino learned this from the Church, and the Church learned it from Christ. Jesus could have healed the leper from a distance, but he touched him first, as if to say that before he cured the skin he would end the exile. And the Gospel overturns even Plato, who was never troubled that slaves got the slave doctor. Christ gives the full encounter to lepers, beggars, and the dying thief, because every human being bears the image of God. That conviction built the hospital, and the religious orders who founded hospitals named for Mercy and Providence were acting on it.
A culture that cannot say what health is will let the patient's wishes set the ends of medicine, and some patients wish for death. Such a culture will eventually ask medicine to deliver it, in abortion, euthanasia, and assisted suicide, and when the healer becomes the one who kills, the meaning of medicine changes. If health is function, the failing body is worthless, and if health is a commodity, the dying are bad customers. The Catholic answer is that dignity comes from being human, not from usefulness. Rules can tell a physician what he must not do, but they only set the floor and cannot call anyone upward, so the Church's teaching is finally not a fence but a summons. The physician is not called to conquer death, a job given to no one but Jesus, but to accompany us through life and through its final passage.
Patient and physician together
Patients share responsibility for this structure of sin. A doctor told me how often he prescribes diet, exercise, and sleep, only to be asked whether there is a pill. We turn physicians into technicians and treat our bodies like a car we drop off at the mechanic. I once heard a general practitioner from the UK describe how he reached fifty-five, the age at which many general practitioners retire, feeling like a failure. Then he changed his practice and helped well over a hundred patients put type two diabetes into remission by working alongside them. When a younger doctor objected that such results did not fit the guidelines, he concluded that such doctors had become slaves to the guidelines because they had never actually encountered their own patients.
Medicine is an art and a science, and it involves the patient every bit as much as the physician. Once we understand that, health is ordered to the wholeness of the human person, and ultimately to holiness.
References
Giordano, James. "Foni Phronimos: An Interview with Edmund D. Pellegrino." Philosophy, Ethics, and Humanities in Medicine 5 (2010): 16. https://doi.org/10.1186/1747-5341-5-16.
Han, Byung-Chul. The Burnout Society. Translated by Erik Butler. Stanford, CA: Stanford University Press, 2015.
Harper, Douglas. "Health." Online Etymology Dictionary. https://www.etymonline.com/word/health.
Harper, Douglas. "Profess." Online Etymology Dictionary. https://www.etymonline.com/word/profess.
The Holy Bible: Revised Standard Version, Catholic Edition. Matthew 10:8. https://www.biblegateway.com/passage/?search=Matthew+10%3A8&version=RSVCE.
The Holy Bible: Revised Standard Version, Catholic Edition. San Francisco: Ignatius Press, 1966. https://www.biblegateway.com/passage/?search=Sirach+38&version=RSVCE.
Miller, Timothy S. "Basil's House of Healing." Christian History, no. 101 (2011). https://christianhistoryinstitute.org/magazine/article/basils-house-of-healing.
Nietzsche, Friedrich. The Gay Science. Translated by Walter Kaufmann. New York: Vintage, 1974.
Pellegrino, Edmund D. "The Commodification of Medical and Health Care: The Moral Consequences of a Paradigm Shift from a Professional to a Market Ethic." Journal of Medicine and Philosophy 24, no. 3 (1999): 243-66. https://bioetyka.uw.edu.pl/wp-content/uploads/2014/10/Pellegrino.pdf.
Pellegrino, Edmund D., and David C. Thomasma. For the Patient's Good: The Restoration of Beneficence in Health Care. New York: Oxford University Press, 1988.
Plato. Laws. Translated by Benjamin Jowett. Internet Classics Archive. http://classics.mit.edu/Plato/laws.html.
Stony Brook University, Program in Bioethics. "Medical Humanities." https://www.llrc.stonybrook.edu/commcms/bioethics/about/humanities.
Sulmasy, Daniel P. "The Good Doctor." The New Atlantis, no. 39 (Summer 2013). https://www.thenewatlantis.com/docLib/20130911_TNA39Sulmasy.pdf.
Thomas Aquinas. Summa Theologiae. Translated by the Fathers of the English Dominican Province. 2nd rev. ed., 1920. New Advent. https://www.newadvent.org/summa/1029.htm.
This article is adapted from episode 349 of Every Knee Shall Bow, "Modern Medicine Has Forgotten What It Means to Heal", part of the Healthcare series.