So, without realizing what has happened, the physician in the last two centuries has gradually relinquished his unsatisfactory attachment to subjective evidence—what the patient says—only to substitute a devotion to technological evidence—what the machine says. He has thus exchanged one partial view of disease for another. As the physician makes greater use of the technology of diagnosis, he perceives his patient more and more indirectly through a screen of machines and specialists; he also relinquishes control over more and more of the diagnostic process. These circumstances tend to estrange him from his patient and from his own judgment.
...
There are, one may be sure, very few doctors who are satisfied with technology’s stranglehold on medical practice. And there are far too many patients who have been its serious victims. What conclusions may we draw? First, technology is not a neutral element in the practice of medicine: doctors do not merely use technologies but are used by them. Second, technology creates its own imperatives and, at the same time, creates a wide-ranging social system to reinforce its imperatives. And third, technology changes the practice of medicine by redefining what doctors are, redirecting where they focus their attention, and reconceptualizing how they view their patients and illness.
Neil Postman, Technopoly, 1992 (pp. 77-79).
I think it was Pascal who made the distinction between the spirit of geometry and the spirit of finesse. We need both; what is lacking, particularly in the technocratic Liberal Order these days, is the latter. Finesse is another name for what Aristotle called phronesis, which is usually translated as 'practical wisdom'. It combines intuition with what we've learned from experience. The spirit of geometry is what we mostly encounter in the healthcare system and all the ways that healthcare judgments have been subordinated to statistical probabilities and the data generated by machines. One would think that the spirit of finesse is something that one would value in a competent health care provider, but that's rarely what one finds.
The problem, of course, is that in the technocratic ethos that defines the delivery of health care in American society, finesse and subjectivity are not privileged in the same way that data-driven decisions are. And while the spirit of finesse, like most talents, is something some people have more innate capacity for than others, it's a talent that needs to be developed through use and experience. But its chances for development are attenuated in a society that does not value it.
It doesn't require finesse to determine that 2 + 2 = 4. You just need a mind that operates in a mechanically logical way. And in our day-to-day life a lot of what passes for wisdom is really process knowledge that follows algorithms--it's automatic and mechanical. And too often this is the kind of solution you're going to get when you go to your doctor complaining about this or that ailment. His remedy is very algorithmic--x problem requires y procedure or z med. You're up the creek if you have a pattern of symptoms the algorithms don't recognize. Horror stories abound, and I have my own to share. It's no wonder to me why people would look outside the system for solutions to problems it seems unable to adequately to deal with.
Anybody who has dealt with healthcare system has probably had to deal with people who are nice and well meaning, but rigidly conventional in their thinking. In a technocracy that means that their thinking is circumscribed by the spirit of geometry. They will only tell you about solutions that research or the data support. They will reject personal testimony as unscientific and anecdotal. And that's fine so far as it goes, but much better is to find a provider who both knows the research and also has a well developed spirit of finesse. In other words, a mensch. But it's unlikely that you will ever find one.
While anybody who has read this blog over the years knows that my biases are with the Left, I have always found that I share common ground with the Right's distrust of technocracy. And I think that many on the Left might be more sympathetic to the underlying distrust that attracts so many Americans to MAGAism and its fear of big government and bureaucratic control if they spent some time reading Left-ish critiques of the technocracy, such as the critiques of Neil Postman and Christopher Lasch. And understanding their critiques might be helpful in understanding why all this distrust has come to a head during the pandemic.
And it's important for Democrat elites to use the pandemic as an opportunity to look at themselves in the mirror and face the fact that in the popular imagination the Democratic Party has become identified with the promotion of a soulless technocracy. I don't know that very many Democrats in this country fully understand the implications. That's because most educated Democrats are very well adapted to living in a technocracy and tend to be blind to its inadequacies until the have a personal crisis that requires that they deal with it, particularly in its health and legal systems.
The common ground shared by both Left and Right critiques is a distrust for a class of trained "experts" who know the data but who lack any common sense or any of what I'm describing here as the spirit of finesse. We want to deal with people who know what the rules are, but also know when to break them. That requires a well-developed spirit of finesse. But the healthcare system is mainly designed to protect itself and to enrich its principals. There can be no rule breaking because that makes the system vulnerable to lawsuits. So regardless of the competency or good will of individuals working within it, the system has given ordinary Americans little reason to trust or admire it.
Most Americans have encountered the healthcare system only when they have a personal or familial healthcare crisis, and that's when they learn what a soulless system it is. In that system, you are only your data, and while you might find a provider that has a cheery bedside manner, it's only a thin veneer that hides the training and protocols that require this person to make strictly algorithmic decisions about your care.
So the problem lies in that most people's experience of the healthcare system they often find that they are dealing with providers whose jobs are about serving them in moments of when they are coping with the profoundest issues of life and death, but who are forced by the system to work with them as if they were just data points on a spread sheet. It's understandable why so many Americans have come to see healthcare professionals as cheerful robots at best or arrogant Gregory Houses and imperious Nurse Ratcheds or at worst.
I'm not saying that healthcare providers don't care about their patients. I'm not saying that they are themselves soulless robots. But the system forces them to behave as if they were. Even if they would bring a certain menschiness to their treatment decisions, the threat of a lawsuit hangs over every decision they make that does not follow strict protocols. There are no incentives within the system for anyone to exercise the spirit of finesse.
I think that the pandemic has brought the contradictions inherent in the healthcare system to a head. This has been a time when we needed to trust the expertise of our healthcare professionals, but our experience with it has given us little reason to. Many Americans for good reasons are predisposed not to trust it.
But during a pandemic the tragedy lies in that what we need is what we most dislike about the healthcare system, which is the rigor of the spirit of geometry. A pandemic is the one place in medicine where the individual doesn't matter; he or she really is just a data point on a spread sheet because public health is all about statistical outcomes. The individual's well being is deeply implicated in the well being of billions of others. And whether freedom-loving Americans like it or not, they are all part of a global system where their individual well being and behavior is deeply linked to the well being and behaviors of people across the globe. A global pandemic is one situation where one's individual freedom must be subordinated to the common good, and it's one place where data and algorithmic calculation should shape national policy.
The tragedy lies in that people who understandably distrust the technocratic ethos of the healthcare system from their own personal experience of it, are likely to distrust it regarding public health. When they hear the pronouncements of the epidemiological bureaucrats, It feels like the same old soulless bureaucratic thing that they've come to hate about the healthcare system. If you dislike or distrust the healthcare system in one context, why should you trust it in this other? I think Anthony Fauci is a mensch, but I understand why he's so vulnerable to be vilified in the way he has been.
Over the last several weeks the talking-head docs on TV have been saying that the vaccine hesitant should trust their local health care providers and their exhortations to get vaccinated. But how many people have a personal relationship with their local healthcare provider? And so why would they be more likely to trust him or her? Why would they trust anybody whom they see as merely a functionary of the healthcare technocracy?
In my own case, my provider is a nice enough guy, but I don't know him and he doesn't know me except for what's on my chart. When I visit for my once-a-year check up, I listen and ask questions, but I take every thing he says with a grain of salt. He provides some information that I recognize as important, but I evaluate it within a broader spectrum of information I take into consideration when making decisions about my health.
For better or worse, I trust my own spirit of finesse over the recommendations of someone whose advice is legitimated only by the spirit of geometry. I have come to believe that I must supply what he lacks. Better if I could find a doc who had both, but good luck finding one.