Abstract
Market metaphors have come to dominate discourse on medical practice. In this essay, we revisit Peter Berger and colleagues’ analysis of modernization in their book The Homeless Mind and place that analysis in conversation with Max Weber’s 1917 lecture “Science as a Vocation” to argue that the rise of market metaphors betokens the carry-over to medical practice of various features from the institutions of technological production and bureaucratic administration. We refer to this carry-over as the product presumption. The product presumption foregrounds accidental features of medicine while hiding its essential features. It thereby confounds the public understanding of medicine and impedes the professional achievement of the excellences most central to medical practice. In demonstrating this pattern, we focus on a recent article, “Physicians, Not Conscripts—Conscientious Objection in Health Care,” in which Ronit Stahl and Ezekiel Emanuel decry conscientious refusals by medical practitioners. We demonstrate that Stahl and Emanuel’s argument depends on the product presumption, ignoring and undermining central features of good medicine. We conclude by encouraging conscientious resistance to the product presumption and the language it engenders.
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Notes
We have chosen the language of “practices” and “practitioners” in order to ally ourselves with Alasdair MacIntyre’s discussion of “practices” [1, p. 187]. Since our primary concern in this article is the critique of current ways of speaking and thinking, we are attempting to hew to a less familiar way of speaking and thinking in order to provide contrast for our contemporary readers.
This shift is explicitly recognized as early as 1982, as can be seen in Rashi Fein’s “What is Wrong with the Language of Medicine” [2].
Malone provides an erudite explanation of some of the types of assumptions underpinning the notion of products, which are deeply inimical to many of the goods of medicine as they have been understood conventionally [3].
Berger, Berger, and Kellner use the term carry-over “to designate any diffusion of structures of consciousness from their original institutional carriers to other contexts” [11, p. 22].
Physicians do, of course, presuppose that there are no mysterious incalculable forces with respect to the sciences that they utilize in their clinical practice, but this disenchanted way of thinking and acting fails to adequately describe and support either the physician–patient relationship or the ethical and political concerns that pervade clinical practice. In these latter domains, “mysterious incalculable forces” abound [4, p. 139].
A 2003 survey of United States physicians from all specialties found that 71% agreed (32% strongly) with the statement “For me, the practice of medicine is a calling” [14]. A 2010 survey of United States primary care physicians and psychiatrists found that more than 80% of both groups agreed (approximately 40% strongly) with the same statement; even among those who indicated they have no religion, or never attend religious services, one in four strongly agreed that, for them, the practice of medicine is a calling [15].
Medicine here might be best understood as a term describing one of MacIntyre’s practices; in other words, medicine is a “coherent and complex form of socially established cooperative human activity through which goods internal to that form of activity are realized in the course of trying to achieve those standards of excellence which are appropriate to, and partially definitive of, that form of activity, with the result that human powers to achieve excellence, and human conceptions of the ends and goods involved, are systematically extended” [1, p. 187].
In this case, we mean professional politics understood in its best light.
Mark Osiel investigates this feature of soldiering by appealing to the notion of courage: “Courage itself, the quintessential martial virtue, is best understood not as a sudden and unthinking outburst of will, but as a form of practical judgment under especially exigent circumstances. …Courage in battle, then, can never be simply a matter of following orders unreflectively. Instead, it entails a process of interpreting orders wisely, in light of current conditions, which may alter rapidly and radically as a particular confrontation develops. … Courage thus entails the exercise of practical judgment, and practical judgment involves a specifically moral element. … This is to acknowledge that moral considerations are never alien to tactical deliberations of the most seemingly pragmatic, instrumental sort” [18, pp. 1071–1072].
For an elegant investigation into the inadequacy of rules and duties when they lack the assistance of well-tutored perception and an ability to improvise successfully, see Martha Nussbaum’s essay “Finely Aware and Richly Responsible: Literature and the Moral Imagination” in her collection Love’s Knowledge [19].
Blinders, in this passage, should not carry a pejorative connotation. Many human practices demand the capacity to limit one’s view in order to achieve the requisite depth for the attainment of the excellences proper to these practices. While this is certainly true of certain aspects of medical education and training, it is not true of the daily practice of medicine. The goal, as always, is the preservation of appropriate distinctions.
A question worth considering is whether we want to entrust ourselves, in our most vulnerable moments, to so-called providers who habitually subordinate their deepest moral convictions. What types of people are capable of this sort of subordination?
In Dan Brock’s words:
According to the conventional compromise, a physician/pharmacist who has a serious moral objection to providing a service/product to a patient/customer is not required to do so only if the following three conditions are satisfied:
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1.
The physician/pharmacist informs the patient/customer about the service/product if it is medically relevant to their medical condition;
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2.
The physician/pharmacist refers the patient/customer to another professional willing and able to provide the service/product;
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3.
The referral does not impose an unreasonable burden on the patient/customer. [22, p. 194]
Notice that Brock cannot avoid language dependent on the product presumption.
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1.
Weber defines intellectualization not as an “increased and general knowledge of the conditions under which one lives” but instead as the “knowledge or belief” that if one desired to know these conditions, one could learn them at any time. In other words, “there are no mysterious incalculable forces … one can, in principle, master all things by calculation. This means that the world is disenchanted” [4, p. 139].
For example, one might think of the ways that some elective medications, such as cough medications, seem like simple goods and some elective surgeries, such as knee replacements, seem like simple services.
Tellingly, rather than caricature the Christian physician, which would be less likely to elicit reflexive intolerance, Stahl and Emanuel choose to focus on the prospect of a religiously motivated practitioner who refuses to treat patients that have committed the “deadly sins” of “gluttony and sloth” [12, p. 1383].
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Blythe, J.A., Curlin, F.A. “Just do your job”: technology, bureaucracy, and the eclipse of conscience in contemporary medicine. Theor Med Bioeth 39, 431–452 (2018). https://doi.org/10.1007/s11017-018-9474-8
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DOI: https://doi.org/10.1007/s11017-018-9474-8