In The Abolition of Man, C. S. Lewis uses the ancient Chinese concept of “the Tao” (“the Way”) as a synonym for the natural moral law. He remarks: “What purport to be new systems [of value] … all consist of fragments from the Tao itself, arbitrarily wrenched from their context in the whole and then swollen to madness in their isolation, yet still owing to the Tao and to it alone such validity as they possess.” Something like this thought lies at the heart of physician Farr Curlin and philosopher Christopher Tollefsen’s book The Way of Medicine: Ethics and the Healing Profession (Notre Dame Press, 2021). In it they argue that medical practice has become morally confused insofar as it has abandoned medicine’s Tao, understood according to a Hippocratic, natural-law framework, and they offer a fresh articulation of this traditional approach for our time. This is a rich and thought-provoking book, worth reading for anyone interested in the nature of medicine, the practice of medicine in a pluralistic society, and issues of conscience in medical practice.
PSM vs. The Way of Medicine
Central to the book is the contrast Curlin and Tollesfsen make between two fundamentally incompatible approaches to medicine: (1) the Provider of Services Model (the PSM) and (2) the Way of Medicine. In the PSM, patient autonomy is paramount, and physicians are expected to support patients’ decisions so long as they are legal and technologically feasible. This expectation, however, presupposes that medicine ultimately aims at the patient’s subjective notion of well-being, rather than at health, an objective and clearly defined end. Current medical practice, they think, generally assumes the PSM, albeit often inarticulately and inconsistently. Over and against this approach, the authors defend what they call the Way of Medicine, seeking to restore the age-old notion that medicine’s end is health and that medical practice should always be answerable to practical reason.
Curlin and Tollefsen think that the PSM leads to detrimental consequences for the medical profession. First, it makes physicians mere technicians providing services, when medicine should instead be a life-shaping vocation that requires moral discernment in addition to technical skill. Second, the PSM cannot offer clear guidance on when a procedure falls outside the bounds of medicine, and thus cannot consistently explain which practices physicians should be expected to perform. Third, the PSM increasingly ends up privatizing and trivializing the physician’s conscience. If supporting subjective well-being is the new goal of medicine, then declining to provide certain treatments appears harmful.
In this model, then, a physician’s conscientious objection to a procedure that a patient desires violates the very aim of the medical profession. Thus, the PSM increasingly pushes the view that if patients have the right to choose the healthcare services that they believe contributes to their well-being, then physicians are obligated to accommodate patients’ choices. Curlin and Tollefsen worry, therefore, that the PSM leads to demoralized medical practice, in which the physicians who have the fewest ethical concerns—and, hence, the fewest limits on how they will serve patients’ desires—are the most prized.
For these reasons, the authors think that medicine has lost its way and needs to return to the Way of Medicine. Much of the book, therefore, develops an account of what this traditional approach should look like in our current context. The first five chapters provide philosophical groundwork for the Way of Medicine; chapters six through nine show its implications for controversial issues such as contraception, abortion, reproductive technology, transgender surgery, and end-of-life issues; and the final chapter deals with conscientious medical practice in a pluralistic society. The authors helpfully contrast the Way of Medicine to the PSM throughout.
It is worth noting that this book (understandably) focuses on the ends of medicine and does not adequately explore the competing moral, philosophical, and religious outlooks that underlie these different approaches to medicine. (Here I have in mind not just our avowed commitments but, more fundamentally, how we differently experience the world, even if we are not fully aware of certain moral or philosophical assumptions shaping that experience.) Consequently, it does not fully articulate what might ultimately drive people to accept either approach. Curlin and Tollefsen’s central argument runs like this: (1) the end of medicine is health, (2) if medicine attempts to incorporate other ends, it will ultimately undermine medical practice, (3) therefore, medicine should only involve those procedures that foster health. They then argue that several controversial medical practices do not involve health and, thus, should not be a part of medical practice.
Moral and Philosophical Outlooks
But I doubt such arguments will be fully convincing to those whose worldview does not readily align with the Way of Medicine. The significant role that one’s moral and philosophical outlooks play in shaping one’s understanding of controversial procedures can be seen in every applied issue that the authors discuss. Take, for example, their argument that because contraceptives suppress a healthy function and carry certain (minor) health risks, providing them should not be part of medical practice. Those who see contraceptives as a great benefit to human well-being would probably fail to see why a concern about temporarily suppressing a healthy function is a strong enough reason to jettison the practice, especially since, of all people, doctors are the most competent to prescribe contraceptives. Likewise, physicians who do not want to prescribe contraceptives probably have moral reasons driving their positions, perhaps more than health considerations (e.g., a conviction that casual sex, made possible by contraceptives, is ultimately destructive or that sex is sacred and belongs within a marriage that is open to children).
Or, to give another example, the authors point out that abortion involves killing a distinct human life (and thus should have no part in medical practice). That fact alone, however, has obviously not convinced many doctors that it should be banned from medicine. Opponents of abortion have some sense of the sacredness or special dignity of all human life, and this is why they see it as wrongful killing. But those inclined toward the autonomy-centered PSM are more likely to see early stages of human life as having less worth than the mother’s developed selfhood. Every controversial issue in medicine involves differences in moral ways of seeing, which probably have greater influence than arguments about medicine’s proper end.
One fundamental philosophical commitment of the Way of Medicine is a key source of disagreement between it and the PSM. The Way of Medicine seems to rest on a view of the person as a unity of mind/soul and body, whereby the human body is sacred. In this view, to care for the body is to care for the person, and our embodied life limits what we ought to do in medical practice—an understanding that accords with traditional medicine. Proponents of the PSM, on the other hand, seem generally to assume a consciousness-centered view of the person. For them, patients’ identity claims and important desires carry central sacredness or moral inviolability, and the body can be manipulated to support the desires and identity claims of the inner self. From this perspective, refusing to help people achieve their aims or actualize their identity is felt as an affront to their dignity. Health is still medicine’s general goal, but it can, nevertheless, be subordinated to a higher end of promoting the patient’s own sense of well-being.
On this point, and contrary to Curlin and Tollefsen’s account, I do not think that the vast majority of PSM advocates value autonomy full-stop as medicine’s ultimate and defining good. PSM advocates do have recourse to the language of autonomy when it is needed as a justification for acquiescing in patients’ deeper identity claims. Most PSMers, however, probably think some identity/desire claims are legitimate, while others do not contribute to any reasonable view of individual well-being. In other words, “subjective” well-being is not wholly subjective. This boundary of what counts as legitimate identity/desire claims will no doubt be influenced by prevailing cultural opinion, and, accordingly, this boundary will shift over time. Curlin and Tollefsen think that if the PSM were logically consistent in making autonomy its end, then doctors would be professionally obligated to perform any legal procedure that patients request, however bizarre, ineffectual, or harmful a doctor thought it to be. However, because most PSMers actually think that bodily health must be subordinated only to legitimate identity/desire claims, they can consistently argue that doctors may refuse, for example, to give ineffectual treatments that a patient might want, or to fulfill certain strange and harmful requests (e.g., severe modifications of the body to make one look like an animal or alien, etc.).
For this reason, I don’t think Curlin and Tollefsen are quite right in describing the two dominant approaches to medicine as requiring either an absolute commitment to autonomy or to bodily health. Both the Way of Medicine and the PSM as we find them in current medical practice see the objective end of health as medicine’s main business. Because of differences in moral and philosophical views, however, they disagree about whether, when, and to what extent doctors can use their technical expertise to serve ends that go beyond health.
However, because very few, if any, actually believe that pure autonomy is the end of medicine, the authors’ proposal for dealing with medical practice in a pluralistic society is especially promising. They argue that, so long as medicine purports to be about health, physicians should be allowed to refuse to participate in procedures that they can show to be contrary or irrelevant to health (and need not appeal to morally controversial reasons to do so).
Many PSM advocates, however, mistakenly regard the current dominant conception of legitimate identity/desire claims as the standard to which all reasonable people should agree. Furthermore, they think that physicians should be professionally obligated to subordinate health to a patient’s subjective sense of well-being (or they expand the definition of health to include a patient’s subjective view of his or her own well-being). Such proponents of the PSM fail to see, however, that they are importing a particular moral and philosophical vision into the medical profession.
Contrary to this view, Curlin and Tollefsen’s book implies that the burden of justification should be on those who wish to subordinate health to other ends, not on those who want to opt out of legally available procedures that do not strictly pertain to health. The authors also provide an excellent discussion of conscience and argue for the importance of allowing conscientious refusals in a time when the law and the medical establishment have permitted controversial procedures to become standard practice.
In sum, The Way of Medicine offers an engaging account of an ancient approach to medicine that seeks to care for people through caring for their health. It shows how doctors who are committed to the Way can practice medicine in a manner that restores them to this vocation of healing, even in our pluralistic age. In order to deepen the argument for adopting this approach, I hope that others will build on this project by more robustly articulating the moral and philosophical vision within which the Way of Medicine is at home.