When God was in Heaven, our images of the Divine split between Justice and Mercy – the Shock and Awe figure of the Last Judgement or someone more like Portia letting us know the quality of mercy is not strained, that it droppeth as the gentle rain from Heaven upon the place beneath. A person with the love of a Mother for her child.
Through to the 1750 or so, the Monarch stood in for God. Hierarchy means rule by the sacred (Hieros) or the sacred’s anointed – it does not mean rule by the powerful one. The monarch’s role was to dispense Justice and Beneficence, aimed at securing the people – the flock, Good Shepherd like (even if some monarchs took their flock to war). An important function was to protect the people against corporations (guilds or powerful cities with vested interests like London). In 1542, for instance, Henry VIII passed an Act to curb an emerging medical monopoly – Original and Translation.
When we started decapitating our own monarchs, rather than other peoples’, we had to find a new way to ensure Justice and Beneficence. We turned to constitutions and procedures and ultimately insurance and welfare states. Those doing so saw themselves as progressive.
The progressives seemed to have history on their side because this move coincided with the rise of science, which led to material prosperity and later better health. It seemed that thinking for ourselves and claiming our rights rather than carrying out our duties worked.
Exit from Eden
Our exit from Eden into the Modern World came with an Original Default. The default was to procedure. Mercy or Care are, or can seem, arbitrary. Justice cannot be, or even appear to be, arbitrary. It requires procedures and adherence to procedures – to bureaucracy.
The problem is its difficult to place a limit on procedures. Once you start down a procedural route, how do you justify a procedure-free space? But a world in which the head always rules over the heart, to put it in first millennium language, is an inhuman one.
This is an age-old dilemma. Aristotle grappled with it and likely others before him. David Hume did too just before modern procedures began to take hold. Max Weber, 2300 years after Aristotle, was greatly troubled by it. In 1920 he saw procedures crowding in on all sides. He worried we would trap ourselves in an Iron Cage of procedure – his worries were intense enough for some like Zygmunt Bauman to think he all but foresaw the Holocaust.
I Consume therefore I Am
A hundred years after the death of Weber from the Spanish flu, the last great pendemic, our subjugation by the knee of procedure pressing down on our throats has reached the George Floyd 9-minute level.
Procedures lend themselves to algorithms and operationalism, both of which focus on doing rather than thinking or making judgement calls. In our day, Descartes ‘I think therefore I am’, which replaced Luther’s ‘I believe therefore I am’, has become I do therefore I am.
In the last two decades this has been internalised in the form of I shop therefore I am, where the shopping or consuming extends to medical procedures and even death.
We transited from being subjects with duties to citizens with rights and now to being consumers at the mercy of fashions. In the words of Herbert Marcuse, we became one-dimensional. This happened as much in medicine, if not more so there, as in any other walk of life.
What were once political or philosophical matters in the world around us have migrated into us to be sorted by consuming some medical procedure.
With the medical breakthroughs of the 1940s and 1950s, a bunch of theologians spotted that, besides the nuclear bomb, the bulk of the ethical action in our new world was happening in medicine. There were new and huge issues to rival the bomb from organ transplants and a trade in organs for transplanting to brain death to possible modifications of our genes and ultimately perhaps a capacity to engineer humans.
While we had dumped monarchs 150 years before and science had become the dominant driving force in history, engagement with ethical issues still took place in theology or philosophy departments. It was theologians who initially drew attention to the new dilemmas we were facing. By virtue of their background, they did so with what was viewed in the 1960s as an opening to the transcendent. It might work better now to reframe this as an openness to something greater than our individual selves.
This openness quickly closed. In the 1960s and 1970s, operationalism, which had begun in the 1930s and gained traction in the 1940s because it meshed with the needs of the US military, triumphed.
In the 1960s doctors, rather than engaging with the problems we brought them, began to measure our blood pressures, or glucose levels, or moods with rating scales. This medical operationalism began to give us problems, where before we had brought ‘our’ problems to doctors.
This was an era, when in psychiatry we thought it made sense to bridge the divide between different visions of mental illness with operational criteria (DSM-III).
An era when we thought it made sense to bridge the divide between capitalism and socialism with an operation – manage the money supply, initially called monetarism and later called neo-liberalism.
When it came to the big ethical questions in medicine, philosophy and theology got operationalized and became bioethics. Like figures and tick boxes for blood pressure or mood scales, the big ethical questions were reduced to tick boxes.
- Does the person have capacity? If they do, they meet the principle of autonomy over their self and have rights to do whatever they decide for themselves.
- Is the procedure being proposed something that offers what for this person is a good – if so it meets the principle of beneficence.
- Is the procedure being proposing not unduly likely to do more harm than good – if so it meets the principle of non-maleficence.
- Does the procedure meet the requirements of justice? No bioethicist feels comfortable denying something on the basis that there might be a bunch of poor people who can’t afford a procedure.
Somewhere in the midst of this, the progressive dream slipped off the rails. We had fought for rights to access abortion, gender reassignment and medical assistance in death but rather than having gained ground from which we can survey the advances made, these have now become consumer items and we seem diminished.
Boxes get ticked – yes we have capacity, and we regard these things as a good and don’t see a problem. The procedures go ahead. What we don’t have any more is an opening to question what we are doing to ourselves.
Pretty well everyone who was given an antidepressant had capacity. Who dares say then that we might now have a public health crisis with 15+% of the population on them and mostly unable to get off them? Where is even the white supremacist to ask why is it primarily white people on them and why are white birth rates falling? Where are the anti-abortionists to ask why are so many women of child-bearing years on these drugs that cause miscarriages and are linked to increased rates of terminations and birth defects?
If these guys can’t spot a problem, its no surprise our doctors can’t either – especially given that its all good for business.
Everything has become a matter of bureaucracy and procedure. This was partly what Weber foresaw. It was us, the people, socialists mostly, who fought for rights but in order to hold what we had gained we wanted them enshrined in procedures – not realising that once this happens that those the deepest pockets and the most power can always make our procedures work for them.
We fought pharmaceutical companies for the rights of people in the developing world to access Triple Therapy for AIDs and are now tone-deaf to the fact that pharmaceutical companies love our continuing fight for access to costly medicines which leads to a polypharmacy that seems likely to be contributing to reductions in our life expectancies.
The Health of Drugs
The most ghoulish aspect of all is seen most clearly in drug wrecks.
We no longer operate on the rule of an eye for an eye, or on the basis of honour. We have agreed to trade these for due process. If a grieving parent now seeks to bring some good out of the death of a child at the hands of a drug that has destroyed his or her mind or a parent seeks to make sense when someone on an inexplicable manic killing spree shoots their child, they will find themselves up against what can only laughingly be called ‘due process’.
Their obvious truth is pitted against a ghost-written and fraudulent literature that Courts psychotically designate as science. At the very top of government and the top of the legal system, there is an awareness that when it comes to drugs the system will always find people to blame and will never blame the drug.
Pharmacovigilance which began life in the 1950s aimed at alerting us to risks of the poisons we took is now more concerned with the health of medicines – ensuring the sacramental status of our medicines is maintained (a sacrament is something from which only good can come). The powers that be go into overdrive to ensure that no Adverse Drug Reactions are accepted as credible.
Not a Drop of Blood
When it comes to a crunch in the Merchant of Venice, Portia invites Shylock to take his pound of flesh, noting the agreement does not specify an entitlement to a single drop of blood.
When it comes to a crunch, Justice hinges on people not procedures. In Court, it is the story a person tells, or those who are witnesses on her behalf, and whether the story holds up under cross-examination that counts.
All the expert testimony in the world saying this drug never caused anyone to commit suicide or homicide or lose the ability to make love is worthless if 12 people listening to the story figure there is no other way to explain what happened except that this drug caused or played a huge part in that event.
They have to be brave people, as they will likely have to accept that in coming to this verdict they acknowledge that pretty well the entire medical literature on these drugs is ghost-written and there is no access to the clinical trial data and FDA or whichever medicines regulator they have is more concerned about the health of a drug than their health.
You can’t fool all of the people all of the time, especially when you collect them together in a jury or citizen’s assembly. Especially when these are drugs their sons and daughters are taking in ever increasing amounts, and they see marriages being laid waste to, pregnancies compromised and lives lost. Something will give.
Magic is from Venus offers a view on what might make a difference
This Algorithm is from Mars post has been delayed because it grew and grew and will be revisited in posts to come. To my surprise there have been previous similar posts – see