The Priesthood of Medicine

A Response to Scott Alexander at Astral Codex Ten

Notes from a Family Meeting is a newsletter where I hope to join the curious conversations that hang about the intersections of health and the human condition. Poems and medical journals alike will join us in our explorations.

For those of you just joining, consider starting here to trace how I’ve been thinking about medicine and technology, a conversation I’ve been returning to time and again.

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In That Hideous Strength, the third in a science fiction trilogy by C.S. Lewis, a shady organization reanimates a decapitated head. They also try to recruit Merlin (yes, that one) to their cause. The story unfolds to reveal a terrifying amalgamation of magic and science.

Rather than battle the efforts of this organization on its own terms, the resistance party realizes the fundamental problem: these scientists have tampered with an evil power. Lewis developed a rich cosmology for this trilogy and I can’t summarize it here. Suffice it to say, those who had ambitions to make super-humans courted power far beyond their capacity to handle. The scientists of this organization had made themselves vulnerable to being used by this power rather than using it for their own purposes:

“The physical sciences, good and innocent in themselves, had already... begun to be warped, had been subtly maneuvered in a certain direction. Despair of objective truth had been increasingly insinuated into the scientists; indifference to it, and a concentration upon mere power, had been the result… The very experiences of the dissecting room and the pathological laboratory were breeding a conviction that the stifling of all deep-set repugnances was the first essential for progress.”

Whatever this organization was doing, it would require spiritual, not technical, resistance.

Lewis’s story came to mind as I read Scott Alexander’s reflections on priesthoods. Alexander, probably the most read psychiatrist in the world by his own humble admission, admits that he himself is a priest of the medical order, and he finds the metaphor helpful to describe how physicians and priests of other orders interact with the public. The metaphor also helps him think through how medicine became so vulnerable to manipulation by political forces over the past ten years or so.¹

Alexander argues the primary identifiers of a priesthood are its capacities to gather specialized knowledge and to self-regulate:

“What about discussing ideas in a group made of only the most intelligent and knowledgeable people? This gives you the debate and collaboration functions that you only get in group conversation. But it’ll have a better signal-to-noise ratio than all of society, and it might be small enough to manage. Also, you can make people sign on to good discussion norms before they enter, and you can expel them if they screw up.”

Priests use language and rituals to sustain purity in their ranks. Imagine the challenge facing the priesthood if it had no boundary between itself and the public. Much of its time would be spent explaining itself, and its priorities might be softened or redirected to those of the uneducated masses. So, they develop a special language to keep out interlopers, and have mechanisms for identifying one of their own.

Alexander concludes his essay with several questions, and I wanted to try to respond. Maybe the best way to do that is by exploring two more ways the metaphor of priesthood works.

Priests, at least in the Judeo-Christian tradition with which I’m most familiar, are mediators. They sustain a relationship by standing between the worshiping faithful and the divine. Although they know the right ways to approach God, their job isn’t merely curating knowledge. Without them, people can’t bridge the gap to reach God.

The priests bears special authority which allows them to mediate. Chosenness sets them apart. This usually happens through a ritual, like being anointed with oil. Yes, they must apply their knowledge correctly, but a different person with the same knowledge would have no authority to act in the way a priest does.

I’m going to rely on these additional facets of priesthood in my response to Alexander’s questions with medicine specifically in the frame.

How broken are priesthoods?

It’s interesting that Alexander mixes his metaphors with this question. Broke things need fixing. Fixing needs tools and techniques. However, we have perfectly good words to describe what happens when priesthoods don’t fulfill their function: apostasy and heresy. If we were to reframe the question to maintain the metaphor, we might ask, how far has the priesthood apostatized? Or, how deep are the heresies? Without a machine metaphor (“fixing”), we face the spiritual metaphor head on: priests need to contend with something bigger than themselves. What should this priesthood be doing? Let’s use apostasy and heresy as springboards into that discussion.

We could consider apostasy and heresy socially. Whether God exists or not, what these words describe are the behaviors of turning against the collective and what it believes. They’re anti-orthodox. In the case of the priesthood of medicine, apostates and heretics turn their backs on human-derived conventions and norms. By embracing quackery, Dr. Oz forsook evidence-based medicine. By becoming a charlatan, Dr. Weiner left the ranks of the respectable priesthood.

From the social view, priests of medicine have their authority grounded in convention. Society gives them a license to use their special knowledge, but society could withdraw that license or change the terms of the agreement. There wouldn’t be any higher standard to which the priests or anyone else might appeal. Even the priests themselves could modify the conventions. Rather than sustaining an integrated pursuit of a singular good (e.g., health), physicians might diffuse their expertise across other goods (e.g., death, enhancement), or remove health altogether from the list of things about which they concern themselves.

The priests of medicine, in this view, mediate between the people and these conventions. Because they’re conventions, though, people might start wondering why they need priests. Maybe the priests are actually getting in the way. Clinical judgment, rather than being wise counsel, becomes an impediment to greater independence. People come to see physician’s judgment as a threat to their free choice. What we’ve seen in the world of healthcare over the past 20-30 years is something akin to the Protestant Reformation, in which Christians of the 16th century wanted direct access to God without the meddling mediation of a priest.²

We could also consider apostasy and heresy the way they’re intended. They are, after all, spiritual words. Even if you don’t believe in the spiritual, maybe you can bear with the extension of the metaphor.

Priests of Medicine: Authority to Mediate Between People and Health

Within the faith community, priests are anointed and set apart by and for God, not by and for convention. This gives them non-arbitrary authority. For the priests of medicine, their knowledge and their “anointing” are very closely linked, but they aren’t synonymous. Miriam Siegler and Humphry Osmond argue physicians (and increasingly, nurse practitioners and physician assistants) possess a unique kind of authority. First, they’re experts in disease and medicine. That’s the knowledge part. Second, they define the boundaries of health and the profession is largely self-regulating, and thus they at least recognize and at most authorize what’s right and good. This part is moral-metaphysical. Third, they have a venerated position in society. This part is social.

But there’s more than Siegler and Osmond envisioned. Rosamond Rhodes remarks:

“Society … permits doctors an extraordinary set of powers, privileges, and immunities. Physicians are allowed to ask probing questions and examine nakedness (i.e., invade privacy), they are given license to prescribe medications (i.e., poisons), they are granted the privilege to perform surgery (i.e., assault with deadly weapons) with immunity from prosecution, and they are also empowered to assess individuals’ decisional capacity and sometimes override the expressed wishes of their patients and impose unwanted treatment on them. … physicians are given license and immunity to do what nonphysicians are prohibited from doing.

…

Because society’s trust is essential to the practice of medicine, society and the medical profession itself have developed explicit and implicit conventions, laws, and penalties to constrain physician behavior and ensure the trustworthiness of the profession.”

To frame this in terms of the spiritual metaphor we’ve adopted, society has set apart this group of people to draw near to “health,” the ethereal ideal analogous to the divine, to study it, to understand how it flourishes and fades, and then bring back rituals for how the people might safely access that ideal for themselves. The physician’s role as mediator between health and the people, because they’ve been set apart, carries with it “powers, privileges, and immunities.” Knowledge is a tool that allows them to do that work, but it isn’t the anointing.³

Wayward Priests of Medicine

Apostasy, in this spiritual framing, isn’t just turning one’s back on the faithful community, but turning one’s back on God (analogously, health). Heresy isn’t just deviation from what’s commonly believed, but deviation from truth about God (analogously, health). This is dangerous in a number of ways. One I want to highlight here is that apostasy and heresy make one vulnerable to demons. Sometimes heretics even run toward demons, hoping to use some of the power they promise. This is what happened to the scientists from That Hideous Strength who, while believing themselves on the brink of a wonderful scientific advance, unwittingly summoned evil beyond their wildest nightmares.

Alexander again mixes in a different metaphor but shares a similar worry that priests can succumb to something beyond their control by suggesting they’re vulnerable to “memetic plagues.” Others have called these “mind viruses.”⁴ If we want to keep ourselves close to the metaphorical link with the spiritual, though, we could say something like an egregore or a demon has captured the imaginations of swaths of the once-faithful.

I think the idea of the demon best warns us about what can and does go wrong in the priesthood of medicine. First, it acknowledges there are forces outside of human control with agency (or something like agency, or behavior that isn’t totally predictable) at cross-purposes with human flourishing. Second, these forces can tempt even the best of us; smart people can fall to temptation just like anyone else. The language of the demonic share these advantages with the microbiological metaphor of “memetic plague,” with the second advantage slightly reframed to see that mind viruses can infect even the best of us, depending on the composition of our “immune system” (psychological and narrative-based defenses).

However, there’s a third advantage that makes the language of the demonic stand alone. It suggests there may be a different plane on which our conflict is really occurring. Like in That Hideous Strength, we should accept our responses can’t all be technical. We might, through ingenuity and technology, develop an immunization against a “memetic plague.” Not so for a demonic attack. Scrabbling after technical power might even twist back in our hands and hurt us. We need to enlist spiritual support. I’ll come to that shortly.

Belonging to Living Stories

This talk about demons and egregores raises a question implied by the use of any metaphor: in what kind of story does any of this make sense? Metaphors carry the most power in the context of a particular story. Even when people think they’re assenting to a list of doctrines, they’re more likely joining a story, with a history, a plot, a list of villains, heroes, quests, and so on.

Consider how Neil Postman described Technopoly:

“[Technopoly] puts in its place efficiency, interest, and economic advance. It promises heaven on earth through the conveniences of technological progress. It casts aside all traditional narratives and symbols that suggest stability and orderliness, and tells, instead, of a life of skills, technical expertise, and the ecstasy of consumption. Its purpose is to produce functionaries for an ongoing Technopoly.”

The content of his observation is interesting, but notice the agency he ascribes to Technopoly. The Technopoly story is out there, lumbering around, whispering in ears, pulling levers, twisting arms. Postman saw the world alive with activity beyond the physical plane: “Tools are not integrated into the culture; they attack the culture. They bid to become the culture. As a consequence, tradition, social mores, myth, politics, ritual, and religion have to fight for their lives.” I’ve written throughout this newsletter about the many ways the power of medical technology gets away from us, almost as if it has a mind of its own. Sometimes it behaves demonically - nothing as obvious as the demon from The Exorcist, but just as effectively thwarting human good despite our good intentions.

Take something like healthcare disparities. You could ask a hundred clinicians their views on any given disparity and you’ll likely hear a hundred stories of compassion, good will, and solidarity. You get those hundred clinicians to write a guideline or engineer a healthcare system, and these wicked disparities start popping up all over the place. In one sense, it’s some emergent property of psychology that slip out as individuals make dozens of compromises across a project. That would call for a certain set of responses. In another sense, we could call it demonic. We recognize we’re contending with things, even pseudo-agents, no one person can control. That framing would set us up for a different response. And just because demons are beyond our control doesn’t mean we’re bereft. Before we get to a response, though, it might be helpful to ask…

Where did the apostasy and heresy come from?

Alexander implies the priesthood “broke” because of pure greed (e.g., Dr. Oz’s $19.99 supplements), which would certainly be one temptation lurking about a profession like medicine. I think there are other issues at play too.

Thomas Kuhn, describing how revolutions happen in the development of scientific knowledge, wrote:

“Political revolutions are inaugurated by a growing sense, often restricted to a segment of the political community, that existing institutions have ceased adequately to meet the problems posed by an environment that they have in part created. In much the same way, scientific revolutions are inaugurated by a growing sense, again often restricted to a narrow subdivision of the scientific community, that an existing paradigm has ceased to function adequately in the exploration of an aspect of nature to which that paradigm itself had previously led the way.

In both political and scientific development the sense of malfunction that can lead to crisis is prerequisite to revolution.”

Alasdair MacIntyre agreed when considering matters of justice:

“Conflicts over rival answers to key questions can no longer be settled rationally. Moreover, it may indeed happen that the use of the methods of enquiry and of the forms of argument, by means of which rational progress had been achieved so far, begins to have the effect of increasingly disclosing new inadequacies, hitherto unrecognized incoherences, and new problems for the solution of which there seem to be insufficient or no resources within the established fabric of belief.

This kind of dissolution of historically founded certitudes is the mark of an epistemological crisis. The solution to a genuine epistemological crisis requires the invention or discovery of new concepts and the framing of some new type or types of theory which meet three highly exacting requirements.”

Culturally, there has been simmering discontent with the priesthood of medicine. To be sure, the establishment has presumed upon its authority, thinking we should be trusted just because we wear the right mantle. This hasn’t been sufficient to sustain trust, particularly with minority communities:

“Qualitative studies have illustrated that interpersonal [medical mistrust, MM] often arises from prior negative experiences in the healthcare system, many of which are perceived to be discriminatory. Many participants who belong to marginalized communities also report mistrust due to historical experiences of discrimination and injustice that their community have faced. Quantitative studies demonstrate that MM is an important influence on behavioral patterns and responses, often negatively affecting satisfaction with care (or trust in the provider), treatment adherence or cancer screening”

Priests of medicine and public health exacerbated the problem of mistrust with the messaging about and management of COVID. Now the problem is self-perpetuating because those with traditional authority are trying to reassert their power without regaining trust.

There’s another problem, adjacent to but distinct from the problem of mistrust. In an attempt to “respect autonomy” over the past 50 years, the priests of medicine have ironically eroded their capacity to mediate between people and health. The temptations of technological power are too great to be relegated to the health-worshiping rituals of this priesthood; they should be put to work for other desires, anyone’s desires. This is patient choice. This is, “the customer’s always right.”⁵

Out of the old tradition come heretic priests. Some of them are true believers in the revolution, others are swindlers, but they’re riding the wave of this paradigm shift about how we’ll use medical technology and why.

MacIntyre sees this as a critical moment in the life of any tradition:

“A tradition becomes mature just insofar as its adherents confront and find a rational way through or around those encounters with radically different and incompatible positions which pose the problems of incommensurability and untranslatability. An ability to recognize when one's conceptual resources are inadequate in such an encounter, or when one is unable to frame satisfactorily what others have to say to one in criticism and rebuttal, and a sensitivity to the distortions which may arise in trying to capture within one's own framework theses originally at home in another are all essential to the growth of a tradition whose conflicts are of any complexity or whose mutations involve transitions from one kind of social and cultural order to another and from one language to another.”

That’s not what I see happening in healthcare. Adherents to the old tradition of medicine only know to assert old authority: listen to the experts. The doctor knows best. But now bedeviling questions won’t leave us alone: whose expertise? Which facts? Kuhn recognized this is a feature, not a bug, of paradigmatic conflict and crisis:

“Like the choice between competing political institutions, that between competing paradigms proves to be a choice between incompatible modes of community life. Because it has that character, the choice is not and cannot be determined merely by the evaluative procedures characteristic of normal science, for these depend in part upon a particular paradigm, and that paradigm is at issue.

When paradigms enter, as they must, into a debate about paradigm choice, their role is necessarily circular. Each group uses its own paradigm to argue in that paradigm's defense.”

What we’re dealing with here aren’t mere questions about what to do. Like the prophet Daniel beholding beasts rising up out of the sea of his nightmare-vision, we’re confronted with strange and incompatible philosophies. Every ethic requires a metaphysic - ways of seeing ourselves, the world, and that strange parallel plane full of ideas, concepts, angels, and demons. That doesn’t make the task of translation and communication impossible, but it does make it very difficult.

One way to avoid the problem of translation is to rely on the data offered to us by our machines. Drew Leder described how the clinician and patient move (and are eventually carried) through various forms of the body-as-text, eventually reaching the objectivity of labs and scans that has washed out both humans. This is also the problem of “value collapse” described by C. Thi Nguyen, in which a surrogate marker, reduced in nuance and meaning from the reality it represents, becomes the sole focus of striving. Who cares about value conflicts if we can all agree chasing after a hemoglobin A1c is “good?”

A pedagogical task accompanying this objectification of healthcare is the vanquishing of virtue, to adopt a phrase from Jack Coulehan and Peter Williams. A hidden (and now not-so-hidden) curriculum seeks to treat clinicians as tools rather than people. The subjective squishiness of the human element in the clinical encounter is becoming intolerable in a world where machines set the standard. So, medical curricula suggest that the cultivation of virtue is peripheral, or not even necessary, for the work of good medicine.

Virtues, as MacIntyre recognized, are those characteristics someone needs to carry a practice toward its fulfillment, its end, its telos. What kind of physician do we need to practice medicine? The answer to that question necessarily depends on what you think about the purpose of medicine. The modern bureaucracy, with its own aims, will have a different response from the traditional priesthood, which has sought to restore and sustain patients’ health.

Chasing after numbers for the sake of efficiency alone is not the purpose our priesthood was meant to serve. Rather than mediating between people and health, or even people and convention, the priests are sometimes tempted, sometimes pummeled, into mediating between people and the Machine. That is, after all, the end result of chasing after these numbers: efficiency for efficiency’s sake. The Machine sets the terms. The EMR dominates.⁶

The problem, then, is much further reaching and much deeper than Alexander suggests. It’s not merely a problem of a few priests besmirching the good name of an otherwise trustworthy priesthood. The crisis we’re facing is one of how we see the human person and how and why we should care for persons. Even as we continue to develop and adopt new medical technologies, I don’t think we can expect the salvation of our priesthood to come from those technologies. We can’t invent our way out of this one.

Spiritual problems require spiritual responses.

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Vincent Van Gogh. “Prayer Before the Meal.” 1882.

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If the answer is “significantly [broken]”, should we be trying to fix them, or to replicate their function in a different structure? How would we even begin to do either of those things? In the very likely case where we fail to do either of those things, what is our least-bad course of action? When should we continue to trust priesthoods, on the grounds that at least they require their mistruths to be subtle (which limits the amount of damage they can do and ensures some correlation with truth)? And when should we trust non-priest public intellectuals / bloggers / influencers / etc, on the grounds that at least they have a million uncorrelated failure modes instead of one big one?

Isaiah, an ancient Israelite prophet, reflected on a strange blindness afflicting those who worship false gods:

“The carpenter stretches a line; he marks it out with a pencil. He shapes it with planes and marks it with a compass. He shapes it into the figure of a man, with the beauty of a man, to dwell in a house. He cuts down cedars, or he chooses a cypress tree or an oak and lets it grow strong among the trees of the forest. He plants a cedar and the rain nourishes it. Then it becomes fuel for a man. He takes a part of it and warms himself; he kindles a fire and bakes bread. Also he makes a god and worships it; he makes it an idol and falls down before it. Half of it he burns in the fire. Over the half he eats meat; he roasts it and is satisfied. Also he warms himself and says, ‘Aha, I am warm, I have seen the fire!’ And the rest of it he makes into a god, his idol, and falls down to it and worships it. He prays to it and says, ‘Deliver me, for you are my god!’

…No one considers, nor is there knowledge or discernment to say, ‘Half of it I burned in the fire; I also baked bread on its coals; I roasted meat and have eaten. And shall I make the rest of it an abomination? Shall I fall down before a block of wood?’ He feeds on ashes; a deluded heart has led him astray, and he cannot deliver himself or say, ‘Is there not a lie in my right hand?’” (Isaiah 44:13-20)

Isaiah’s carpenter didn’t worship this statue because it was a block of wood, but because it either represented a god or they thought it really was a god. This desire to worship stuff is ancient. We haven’t figured out a way to get around it. Today, we don’t worship chemotherapy or surgeries or hospitals as they are. We worship them for what they represent: power, life, and, for some, money. And worship them we do, even if any given person isn’t likely to believe there’s a deity associated with them. We invest them with deep meaning and hope. We submit our agendas and budgets to them. We sacrifice for them.

Isaiah didn’t recommend some change in carpentry that might reduce the likelihood of faulty worship. He knew that wouldn’t be sufficient to overcome a “deluded heart.” He recognized that spiritual problems require spiritual responses. What Isaiah, and other prophets like him, recommended, even commanded, were remembrance and repentance. The story that made sense of these commands spanned ages before Isaiah was born. Israel had abandoned that story, which meant abandoning God and forsaking its identity. Even the priests had gone astray.

If the priests of medicine are going to face their problems head on, they should start by remembering. Looking into the past can feel regressive when the promises of technology lay in the future, but I’m not saying we need to return an era where antibiotics didn’t exist. I’m also not claiming there was a golden age when physicians ever did this better than the way we’re doing it right now. Before we had science, we had magic, with promises just as tempting (albeit less fruitful). Remembrance matters because some of the challenges we face as humans are very old, and some of the best responses are old too. We’ve yet to invent a pill for virtue (nor will we).

Rather than trying to make as much money as possible giving people what they want or becoming heroes who relieve the human condition, our story as priests of medicine begins with the humble and compassionate relationship between a person in need and a person who claims to be able to help. The needs aren’t just any needs, and the help isn’t just any help, of course. There are boundaries and limits because we’re not aiming for all things at once, but for one thing: health.

Edmund Pellegrino observed that this relationship between someone in need and a clinician is “a peculiar constellation of urgency, intimacy, unavoidability, unpredictability, and extraordinary vulnerability.” That hasn’t changed with the development of new technologies. If anything, the plight of patients has become even more acute as the techniques we use carry greater risks.

That’s it, if we can remember it: medicine is about someone in need seeking help in pursuing health from someone who claims to know what to do about it.

If this is the case, then correcting the apostasies and heresies of the priesthood doesn’t begin with an innovation or with education, but with repentance.

Repentance recognizes how bad things have become and then turning back toward that which is good. It’s admitting there is a bad and a good. It’s changing your mind, sure, but that’s hard enough, because changing your mind is the first step into a new life. For the priests of medicine, it means waking up to how they might be worshiping their tools, chasing after the metrics of success provided by those tools, rather than using tools to pursue health. It means turning back toward health. It means recognizing that pursuing health requires of us more than tools and techniques. Pursuing health requires us. I’ve warned before:

“Healing, in the deepest sense of the term, isn’t merely fixing. Its restoration to wholeness, including one’s involvement in community and story. The healer is a part of that. Whether all the technical promises of AI come to fruition or AI fades away like so many other fads, the fervent hope in the promise of such technology betrays how much we believe the human clinician is not themselves an instrument of healing when indeed they so often are - or else, if they aren’t, how badly they can hurt someone even as they prescribe the right things. Yes, yes, humans should be involved for now, but only because they’re necessary. What happens when we believe they’re no longer necessary?”

If the point of this relationship is to make someone as much money as possible or to provide whatever service a customer requests, certain characteristics will be more valued than others. If the point of such a relationship is to support and restore the health of the one who has such “extraordinary vulnerability,” that will call for different characteristics, different virtues.

We can’t program or engineer virtues. When we try to do so, we make a category error, assuming virtue is a product like a wooden statue. Instead, virtues develop inefficiently, in all these messy, human ways. But we can’t get around it. We need them to help our patients heal. Warren Kinghorn, Matthew McEvoy, Andrew Michel, and Michael Balboni reflect on the irony of cultivating virtue in medical practice: “If students have already cultivated these virtues within a living moral community, formal education in medical professionalism may be largely unnecessary. If they have not cultivated these virtues, professionalism education is necessary but, unfortunately, often ineffective.” This means “any effective moral education of students should acknowledge that moral formation occurs primarily through participation in moral communities and only secondarily through discursive reasoning.” In short, you’re not argued into virtue.

What they recommend is engagement with “open pluralism: a commitment to explore, understand, and hear the voices of the particular moral communities that constitute our culture.” A curriculum of such open pluralism “would invite (particularly minority) cultural and religious leaders to address students and trainees about the particularities of their moral communities. It would also encourage respectful, charitable discussion regarding the value of the moral commitments of those communities. Students would be encouraged to acknowledge, explore, and critically examine their own a priori moral convictions, allowing for the recognition of orienting and substantive narratives out of which profession and professional duty can flow.”

Repentance and remembrance are bound together because the inner disposition we need to cultivate in pursuing anything worthwhile is very old. We don’t need to innovate on compassion. We don’t need to innovate on wisdom, courage, integrity, faithfulness, or honesty. There’s no tool that will make these better or easier to grow.

Demons are very old too. Believing that more technique and better technology will somehow dispel their power is like believing Isaiah’s carpenter can carve a statue that somehow evades worship. It just doesn’t work that way. Likewise, the resources we need to resist wicked problems in medicine aren’t in the latest innovation (though innovations might yield useful tools), but in guarding our hearts against straying from the pursuit of the health of our patients.

The priests of medicine had hoped to tame power with technology, but it’s only made us vulnerable and weak. While researching and inventing, we also should have asked, “What is required of us in order to use our tools well in pursuit of that for which our profession exists? What virtues do we need?” Instead we ask, “How can I do this faster? What’s the box I need to check?” This is a far cry from our original calling.

I’ve offered a bit of “open pluralism” here with Isaiah’s words, which are found in a particular tradition. I can’t possibly provide the whole remedy because what’s proposed isn’t a technique but a way of living. By playing around with this metaphor, I’m not suggesting we cannabalize religions for their techniques and apply them to medicine. That’s a sure-fire way to co-opt those practices for the purposes of the Machine. Instead, you just need to dive in to see for yourself, as I’ve suggested by relying on Shannon Vallor’s work. Maybe eventually you’ll start seeing spirits too.

Stepping Out of the Metaphor

Okay, that was fun. Now I want to make a few points without the metaphor in hand. First, health isn’t really divine. I’ve only considered it analogously to make the metaphor work.

Second, the spiritual metaphor has offered some interesting insights for how we might deal with problems within medicine, and you don’t need to believe in a spiritual realm to handle and learn from those metaphorical reflections. However, I also really do believe in a spiritual realm, as do many other people. This means there are some concerns I have about the overlap between medicine and the spiritual that aren’t metaphorical. Maybe I’ll save those for a future essay.

Third, I do believe there is a more insidious sense in which physicians act as priests of a form of health-worship that is spiritually distracting, even spiritually damaging. For this reason, I don’t think the priesthood metaphor is best suited for describing what we do in medicine, but I’ve elaborated on it at length here in response to Scott Alexander’s essay. Although it wouldn’t be the first metaphor I’d reach for to describe the work of clinicians, I’ve shared a few lessons I hope are helpful in thinking about it this way.

Fourth, the point of this exercise (and “open pluralism” more broadly) isn’t to mine religions so the work of professions like medicine can do their job more effectively. Faith traditions stand on their own merits. Metaphor is also but one means by which these traditions can exert their influence over a clinician’s work. The clinician may also be directly formed to be a particular kind of person who practices a certain way.

1. It seems to me professions have always been vulnerable to this. Look how zealously physicians became eugenicists, especially in Germany in the early 20th century, or how compromised Roman Catholic priests became throughout the Middle Ages.

2. I admit the historical record is more complicated than that, as it always is, but concerns about the priesthood were certainly a part of the Reformation.

3. One key mechanism through which society sets limits is through consent. Patients (or their surrogates) activate a clinician’s duty (and authority) through consent. A clinician can’t be said to have duty to treat a patient who hasn’t consented to treatment (except in limited, emergent circumstances). However, clinicians, by virtue of their office, do have a duty to provide the information necessary for someone to determine whether they’ll consent to whatever is being offered.

Consent is (usually) necessary but insufficient. On the one hand, someone may consent for their uncle, who is not a clinician, to attempt a craniotomy on them. We can’t say that creates a duty for the uncle to perform the craniotomy, and in fact, the consent itself likely wouldn’t exonerate the uncle from whatever befell this poor person. On the other hand, they may consent (or want to consent, anyway) for their primary care physician to also be their chauffeur. That also doesn’t create the duty for the physician to drive this person around town. Consent activates a duty that is already, in a way, latent within the role of the person, but it doesn’t create duties. Consent without the other’s capacity to act is just a wish. Likewise, the spiritual work of priests is most efficacious for the willing participant.

Obviously the metaphor can be stretched too far. Many religions have allowances for people who can’t participate (e.g., cognitive impairment). Furthermore, in the ancient Israelite context, there were times when one priest would make sacrifices for the entire nation, representing them corporately before God. There’s no analogue like that in the world of medicine.

4. Richard Dawkins famously claimed religion itself is a mind virus.

5. This comes at a time when physicians are incredibly distracted managing the burdens of the bureaucracy, chief among them treating the electronic medical record (EMR). We can cast distraction, typically styled as a psychological problem, as a spiritual problem. Acedia, called the noonday demon by ancient monks, is the restlessness that can accompany long hours of spiritual discipline. Not a perfect parallel, but there usually isn’t when translating between languages.

6. The beleaguered priests cast their eyes about and see a new god on the horizon, that of artificial intelligence (AI). Maybe that will help! It might help more rapidly identify pathology on slides and scans, but it won’t help with mistrust, and it won’t help us better align with what we’re supposed to be doing. In those cases, I worry it’s at best an idol, at worst another demon.