Medicine without a Soul

In the midst of an extensive legal discussion about proper compensation for medical injuries, the Babylonian Talmud offers some stark pronouncements on human nature—several of which point to the need for a healthy skepticism of the medical profession.

The premise is simple: If Bob injures Joe, Bob is liable for the cost of Joe’s medical treatment. But Joe maintains a good deal of say over how the treatment is arranged. If Bob suggests hiring a remote doctor, Joe can insist on someone local. If Bob offers to administer treatment himself—thereby avoiding the expense of a physician—Joe can refuse it. Finally, if Bob suggests hiring a doctor who will treat Joe for free, Joe may justifiably retort that “a doctor who works for nothing is worth nothing.”

The Talmud’s basic insight is that interpersonal and financial arrangements directly affect the quality of medical care—two doctors of equal skill might be paid the same fee for their services, but a local doctor is more likely to feel accountable toward his neighbors. Conditions must be carefully arranged to facilitate the physician-patient relationship; it is vital for patients to trust their doctors, and for doctors to feel an immediate and substantive obligation to patients. In short, the Talmud suspects doctors, but seems to understand them exceptionally well.

In his new book, Losing our Dignity: How Secularized Medicine is Undermining Fundamental Human Equality, Charles Camosy expresses a related suspicion, not of doctors but of medical culture. He argues that Western medicine since the 1970s has heeded the wrong bioethicists. Advocates of a “secular inquisition” have come to dominate the field of public bioethics, driving out theologians and other traditionalists. The upshot is that health care authorities have slowly relinquished their belief in fundamental human equality, or the innate dignity shared by every human person.

To Camosy, restoring this idea is key to restoring the proper purpose of Western medicine. He laments a tendency among medical practitioners to rank “types” of human beings by traits such as autonomy and self-awareness, and to provide or deny medical care based on these rankings.

He cites a transplant surgeon who argued that people with extreme brain damage should be declared legally dead in order to make their organs available for life-saving transplants. Suggesting otherwise, the surgeon claimed, would be immoral. Camosy also cites an economist who lamented the annual cost of keeping a woman who had suffered severe brain damage attached to a feeding tube for years. But measuring the worth of human beings solely by their autonomy or other capacities obscures the fundamental end of medicine—caring for the vulnerable among us while acknowledging their full humanity.

There is a good deal of truth here. In debates over pricing and resource allocation, it is tempting to quantify people in ways that are arbitrary, misguided, or immoral. Camosy makes a forceful case that an “irreligious understanding of medicine” has contributed to a distorted view of what makes life worth living. Medical systems often operate on the belief that life can be measured along material lines, dismissing the idea that human life is inherently sacred. In such cases, people who are chronically ill, disabled, or elderly are not given the same consideration as those with the potential to contribute materially to society. Thus Camosy, a pro-life Catholic, hopes to find common cause with those on the left who are inclined to advocate for such marginalized groups—an issue that came to the forefront during the pandemic, as people in nursing homes were housed with contagious Covid-19 patients.

Respecting life at different stages, though, is not the same thing as arriving at a common understanding of death. This is one wrinkle in the book: As technologies for sustaining human organs and basic functions (including breathing) have improved, it has become more challenging to identify death, particularly in cases of catastrophic brain injury. This is less a question of equal care than of life itself, and of our capacity to know when it is over.

In writing about Jahi McMath, a thirteen-year-old girl who was declared brain dead following a botched surgery in 2013 but who was later found to be experiencing brain activity, Camosy firmly rejects a “neurological definition of death.” He contends that people in such conditions are simply profoundly disabled. His argument is forceful, but it is not a straightforward example of a religious perspective clashing with a secular one; many religious scholars do not share his view.

Camosy is on stronger ground when discussing the case of Alfie Evans, who was admitted to the Alder Hey Children’s Hospital in Liverpool, England, when he was just six months old. Despite his parents’ best efforts to remove him, Alfie was kept at Alder Hey for the rest of his short life. After determining that he suffered from a neurodegenerative disorder, the Alder Hey medical team concluded that nothing could be done for him and insisted on removing his life support. A hospital in Italy requested that Alfie be transferred there at no expense to England’s National Health Service (NHS); other foreign doctors asked to examine him; his parents fought the decision in court; even the pope pleaded for Alfie to at least be allowed to return home to spend his last days with family.

Despite all this, a British court ruled against Alfie’s parents, and his life support was removed on April 23, 2018. He breathed independently for five days before dying on April 28. There was no question that Alfie was alive when his treatment was removed.

Camosy rightfully skewers the NHS’s Quality-Adjusted Life Year (QALY) system, which was applied in Alfie’s case and which is used to determine “whether a treatment or intervention’s cost can be justified.” The NHS employs a tortured calculation based in part on how long a person might be expected to live after receiving treatment, as well as (in the NHS’s language) his “ability to carry out the activities of daily life, and freedom from pain and mental disturbance.”

This arbitrary and materialist approach to health care places elderly and disabled people at risk of being rejected wholesale by the U.K.’s medical system. It also places a patina of rigor over a fundamentally irrational scheme. There is no sense of the human person here—the octogenarian who may not be able to walk or hear well, but who rejoices in her granddaughter’s daily visits; the developmentally disabled teenager who is a beloved sibling and friend.

But in placing all the blame for such grotesqueries on a single trend in a single discipline—bioethics—Camosy misses the broader picture. Specifically, he does not adequately acknowledge how this academic attitude is driven by, or at least interacts with, the political and technological realities of modern medicine.

Writing in City Journal in 2012, Theodore Dalrymple,  the Dietrich Weismann Fellow at the Manhattan Institute and a retired physician, lamented the British government’s increasing intrusion into the professional lives of doctors. He argued that it now dictates “the drugs and other treatments that may be prescribed, the way in which doctors must be trained, and even what should be contained in applicants’ references for jobs,” transforming doctors into “production workers under strict bureaucratic control, paid not so much by result as by degree of conformity to directives.”

Invoking the adage, “he who pays the piper calls the tune,” Dalrymple noted the dangers of having only one paymaster in a medical system. When the paymaster gets something wrong, the consequences are vast. Even when he gets something right, the simple act of requiring that physicians obey a single paymaster inflicts “an intangible harm.” As Dalrymple explained, “In obeying directives not because they are right but because they are directives, doctors lose their self-respect, their probity, and their intellectual honesty.”

They may also lose their sense of personal responsibility to patients. Physicians are among the few truly responsible actors in health-care systems; unlike policymakers in government or insurance companies, they meet each person affected by their decisions. They are often, and justly, held to account when things go wrong.

To undermine this relationship is to put health care at serious risk, though that risk is not easily quantifiable. In the U.S., we see threats to this relationship through seemingly minor changes such as the Affordable Care Act’s imposition of complicated electronic health-care record systems (EHRs). These systems have become a serious distraction in medical care. Among other things, doctors must now spend excessive time on paperwork, cutting into the time they spend with patients, or else hire specialized note-takers.

In the era of Big Data, EHRs are just one among many data tools. Medical researchers—including those in the academy and the FDA—also pressure doctors to elevate the organized collection of medical information over individual welfare.

A striking example of this appeared early in the Covid-19 pandemic. In a March 2020 essay in the Journal of the American Medical Association, Dr. Andre Kalil bemoaned the “tragedy” of the 2014 Ebola outbreak in the United States, in which all Ebola patients recovered. To Kalil, this was not a success story: because the few infected individuals had been provided with so many treatment options, it was impossible to conclude which ones had actually worked. He urged American physicians not to repeat this mistake with Covid-19, and to include a placebo group (patients who receive a “sugar pill” rather than a potential treatment) in every medical trial. In this way, he argued, doctors would be better equipped in future crises.

To many frontline physicians, such an approach is unconscionable when dealing with potentially fatal illnesses. (There are many ways around this, such as comparing the effects of two different potential treatments between two groups, as opposed to allowing only one group to receive any treatment.) It casts patients in trials as guinea pigs rather than full human beings, seeking real treatment, who deserve particular care. Frontline physicians do not see their role as serving the cause of medicine, but rather the vulnerable people in front of them. By adopting a framework in which people serve as mere data points, policymakers risk distancing patients from their doctors in a way that is reminiscent of the hypothetical scenario presented by the Talmud.

Camosy’s suggested reforms focus on how people outside the medical system can encourage a culture that emphasizes human equality—volunteering at nursing homes, living with or near elderly family members, aspiring to raise large families to provide long-term support. But there are other means of restoring medicine, starting from the way the profession is ordered by regulators. In offering solutions only for those outside of the medical profession or government, Camosy misses the opportunity to offer a vision for concrete, systemic change. He makes the case that medicine has become secularized, but not a case for how to restore it from within.

Since antiquity, doctors have been trained to be skeptical of their own motives. Oaths of ethics attributed to Hippocrates and Maimonides, along with more modern iterations such as the Declaration of Geneva, all emphasize the humanity and vulnerability of patients, warning doctors not to harm those in their care. In other words, a suspicion of physicians is baked into their own professional self-image. Any number of institutions have been put in place to maintain the profession’s integrity, but central to all this is the proper arrangement of the physician-patient relationship, which is too often casually undermined in medical policymaking.

Devorah Goldman, a senior editor at Mosaic magazine and contributing editor of American Purpose, is the Tikvah Visiting Fellow at the Ethics and Public Policy Center.