Examine the Patient

In preparing to teach a course on Wendell Berry, I was fumbling with the technology used to address learners in person and online simultaneously – a combination some have named “Room and Zoom.” As I waited for various launch agents and plug-ins to bubble to the surface of my laptop screen, I turned to one of my colleagues watching with a look of bemused recognition and said, “Like I used to tell the residents on rounds, ‘If all else fails, examine the patient.’”

The layers of situational irony nesting within each other like Russian dolls did not entirely elude me. Messing with computers to teach a class on Wendell Berry to students scattered across a continent was bad enough. Making a joke that suggested, however implicitly, anything more than a passing resemblance between human body and machine left me queasy. For years, I’ve fought against that pernicious metaphor and its monstrous cousin – that the brain is nothing more than a meat computer. As Berry says about such things, a metaphor must always be “controlled by a sort of humorous intelligence, always mindful of the exact limits within which the comparison is meaningful.” “When,” he continues, “a metaphor begins to control intelligence, as this one of the machine has done for a long time, then we must look for costly distortions and absurdities.”

That the medical-industrial complex is rife with costly distortions and absurdities is beyond doubt, and technology bears a significant portion of the blame. I use the phrase “medical-industrial complex” to signify that conjunction of political, economic, scientific, technological, educational, and social interests, institutions, and investments that make the US health care system the most expensive in the world despite its relatively poor public health outcomes when compared to other economically developed countries. By “technology,” I mean not so much the expensive electronic gadgetry that shortens your hospital stay while inflating your medical bill, but the way of seeing the material world, including our material bodies, as a standing reserve to be manipulated as we wish.

Luke Fildes, The Doctor, oil on canvas, 1891

Therein lies the source of any new medical machine’s unexpected consequences: by making some things easier to do than others, new technologies – like unexamined metaphors – control our intelligence while colonizing our moral judgement. For example, who could have anticipated the introduction of prenatal ultrasound machines would drastically alter the ratio of boys to girls born in South and East Asia in the late twentieth century? Similarly, anyone familiar with the history of American bioethics will recall how the advent of hemodialysis led to heated discussions about who did or did not deserve access to this life-sustaining machinery.

It seems technological innovation in an economy of scarcity reduces most questions to a version of the trolley problem, that ethical chestnut that posits a rogue streetcar hurtling toward unsuspecting pedestrians and assumes that I know enough about light rail equipment to do something about it. The key question goes something like: Do I send the out-of-control trolley down line one, where it will mow down three people I don’t know, or down line two, where it will kill only one person, who happens to be my wife? I’ll let the utilitarians and deontologists hash that one out. Most versions of the trolley problem are silly since real life rarely provides moments of such simultaneous clarity and control. Furthermore, the popularity of the trolley problem betrays the cloaked neoliberal origins of secular American bioethics, which for all its flowery language about justice and nonmaleficence, really worships at the altars of autonomy and efficacy and favors those who have the agency and tools to get what they want. That’s why, when most of us hear the term “medical ethics,” we tend to think of technology-heavy puzzles at the margins of life: embryonic stem cells, prenatal diagnosis and selective elimination of the so-called defective, physician-assisted suicide, and so on – matters that the late Paul Farmer called “quandaries of the fortunate.” Bioethics has very little to say about those who lack agency: the world’s poor, the intellectually disabled, and other groups among the politically voiceless. Within the medical-industrial complex, all patients are equal, but some are more equal than others.

Compared to the bioethical riddles I’ve just mentioned, it’s hard to get worked up about virtual doctor visits and the pandemic-induced boom in telemedicine. In some ways, these are salutary practices whose time was long in coming. From my experience with indigenous child health care, I know how challenging it is to provide quality subspecialty care – such as mental health services – in rural areas. When this was a problem limited to the boondocks, it was nearly impossible to persuade insurance companies to cover these services.

The Covid pandemic changed all that. Virtual visits kept vast swathes of the medical-industrial complex afloat during the worst of the pandemic, making it possible for suburban and urban patients to see a health care provider without risk of contagion. Given the outsized role that lab data and imaging play in the American approach to medical diagnosis, the inability to examine the patient’s body struck many providers as a small price to pay for ongoing outpatient care. More to the point, the insurance sector of the complex suddenly saw reasons to pony up for online medical visits, even across state lines and in the absence of existing patient-physician relationships. Telemedicine finally found a way to pay for itself.

I can’t predict the long-term future of telemedicine, though I expect it will persist in some form from now on. So will at-home diagnostic testing, online exposure risk calculators, and the expedited approval of certain vaccines and pharmaceuticals. These have, I think, secured their place in health care. When Olympic swimmer Michael Phelps is doing television commercials for virtual psychotherapy visits, there’s clearly money to be made. But have we lost something good and vital with the apparent triumph of virtual medical visits and Zoom consultations? Is there a case for the continued primacy of the face-to-face medical visit?

As a physician, I’m inclined to think that the human body is, in fact, a good thing, a creaturely given of some importance. This may sound self-evident, but in an era where the body is increasingly viewed as an envelope to be reconfigured according to the dictates of the autonomous, choosing will, perhaps it isn’t so obvious after all. When I hear people talking about health, wellbeing, and even identity as a product of the mind, I’m reminded of what scripture says about the body. The Creator sees our bodies as inherently good, not just when they get us what they want, but in and of themselves. Now is not the time to refute misreadings of Saint Paul as a Platonic dualist except to point out that, for Paul, πνεύμα, or “spirit,” is opposed to σαρξ, or “flesh,” which has more to do with wayward human habits and desires than our material existence, while Paul’s favorite metaphor for the nascent church is το σώμα, “the body.” And though the late-second-century church father Tertullian eventually went off the Montanist deep end, he was at his most orthodox in asserting caro cardo salutis, “the flesh is the hinge of salvation.” 

The trouble with virtual visits, by contrast, is the gnostic quality afforded by the pair of screens – the provider’s and the patient’s – that dematerialize place and body in ways we have yet to adequately address. I used to be appalled at what people would say to one another online via so-called social media that, I imagined, they would never say face to face. I fear now that twenty years of the internet’s bad example has been an all too effective training ground for today’s nasty exchanges that pass for public discourse. I don’t know if the internet has dumbed us down, but it certainly has nastied us down, and I’m not sure how to repair the damage to our shared life. When we stand in the presence of another person, it should be more difficult than it is now to condemn, denounce, or “own” those whose habits and affections offend us. With the advent of computerized medical record systems, it’s difficult enough to get a medical provider to look you in the face when you’re in the same room. Think how much harder it is for her to attend to and honor your physical presence when you’re only an image on a screen.

Putting aside the theological language for the moment, let me offer a provider’s-eye view of what it’s like to see a patient in the flesh. The doctor tugs at her stethoscope as she stands outside the examining room door. The patient on the other side is new to the practice. According to the electronic medical encounter document, he’s here to “establish care.” The front desk is calling his previous physician’s office to obtain his medical records but for now at least, there are none to review. The doctor knows nothing about the person she’s about to see except a name, age, and gender. In a matter of seconds, she will open the door, greet her new patient, and ask him to tell his story. But before any words are spoken, in the first moment they stand face-to-face, she is already responsible for a person she can never truly know. He has come in search of help – either to get well or remain so – a call to which she must somehow respond without coercion or intent to harm. No matter how medically informed or rights-conscious the patient is, the doctor’s skills, knowledge, and experience endow her with power, privileges, and duties he trusts will redound to his benefit. In a limited but very real sense, she is now responsible for his health, his wholeness, his life.

The particular features of the unmediated doctor-patient relationship – grave responsibilities, vast unknowns, and asymmetric duties – correspond rather well with the philosophy of Emmanuel Levinas, who found these particularities in all direct encounters, try as we may to ignore them. For Levinas, seeing the face of another person is a moment of fraught privilege. In it, an unknowable but recognizable other addresses me and calls me to account, a summons prior to and independent of words. This responsibility to the other is not a deduction from abstract principles, but an immediate and intuitive experience. Much of the awesome power of that experience dissipates with the gnostic effect of computer screens and internet connections. In the direct encounter, I apprehend a vulnerable, dependent human person beyond myself, and in that apprehension, I claim my own vulnerability, dependence, and – perhaps –compassion. The ultimately unknowable other challenges and disrupts the complacent “I” through recognition and concern for justice, modulated by my own cultural inheritance, experience, and expectations.

As a physician, I’m inclined to think that the human body is, in fact, a good thing.

How one responds to the call of the other suggests an ethic Levinas gestures toward without systematically defining. I can ignore, reject, or act counter to my responsibility, but the transcendent other is not for me to control. Levinas avoids theological language in his philosophical writing yet locates a “trace of the Divine” in the other who makes nearly infinite moral demands. “A face,” Levinas writes, is “a trace of itself, given over to my responsibility, but to which I am wanting and faulty. It is as though I were responsible for his mortality, and guilty for surviving.” As a twentieth-century European Jew who saw firsthand how readily abstract principles justified state-sponsored mass murder, Levinas did not shy from unfashionably ancient moral terms like “guilt” and “debt.”

How can we recover some of the goods that Levinas gestures toward here? Unlike Levinas, I’m not a Talmud scholar, and I must appeal to my own Christian tradition, shaped of late by my practices as a Benedictine oblate, trying – and, more often than not, failing – to embody some of Saint Benedict’s ancient rule in my life as a layperson in the world. I’ll name just two Benedictine practices relevant to my subject. The first is hospitality, something that seems conspicuously absent in hospitals today. Yet “hospitality” and “hospital” derive from the single Latin word, hospes, which can mean both “guest” and “host.” What’s more, these words share a root with the English word “hostile.” Linguists trace these surprising connections back to a Proto-Indoeuropean root *ghos-ti-, which can mean “guest,” “host,” “stranger,” and “foreigner.”

This jumble of contradictory meanings also appears in the ancient Greek word xenos, from which the fourth-century Byzantine xenodochia – the first true hospitals – took their name. Etymologically, then, xenophobia may be less about fearing the stranger than fearing what we, as the host, might be asked to do for her. In most traditional cultures, hospitality is understood as a duty and a danger at the same time. Host and guest enter a relationship of mutual obligation: the host offers protection and inquires after the guest’s needs, doing her best to meet them. The guest does not abuse the host’s generosity, and sincerely pledges to reciprocate. But a guest’s inability to repay the favor should make no difference to the host. Chapter fifty-three of the Rule of Saint Benedict says, “All guests who present themselves are to be welcomed as Christ.” That sets a pretty high bar – especially when it might literally make you sick – but the practice of hospitality requires the virtue of courage, which doesn’t mean you’re not afraid, but that you are afraid and you do it anyway. A hospitable hospital will welcome all patients, not at unnecessary risk to its health care workers, but through a series of calculated risks inherent to the profession, addressing present need before taking into account ability to pay, documentation status, cognitive ability, or productive potential. That’s well worth remembering in a time of contagion and social distancing, whether we’re staffing hospitals, debating public policy, thinking about shut-in neighbors, or opening the door to strangers. Hospitality is risky business, but from Abraham’s day to ours, when has it been otherwise?

The second habit is stewardship, a word whose long, fascinating history is too convoluted to recount here. As used today, however, faithful stewardship requires an awareness of place, need, and limits. Chapter thirty-one of Saint Benedict’s Rule lists duties of the monastery cellarer, the monk who manages the material goods of the community:

He must show every care and concern for the sick, children, guests and the poor, knowing for certain that he will be held accountable for all of them on the day of judgment. He will regard all utensils and goods of the monastery as sacred vessels of the altar, aware that nothing is to be neglected. He should not be prone to greed, nor be wasteful and extravagant with the goods of the monastery but should do everything with moderation and according to the abbot’s orders. Above all, let him be humble. If goods are not available to meet a request, he will offer a kind word in reply, for it is written: “A kind word is better than the best gift.”

Virtual visits, then, are of limited good and best used in moderation, attending to the place one practices, the needs of the particular patient, and the limits of what can and can’t be done without direct presence. The good of the body is honored by face-to-face encounters where the ritual of the physical exam is done attentively, indeed reverently, neglecting nothing. The apparent advantages of the online, virtual visit often prove a false economy, a missed opportunity to both confirm what the patient history and lab data indicate and to embody the sort of encounter Levinas describes, which can only be fully appreciated with physical presence. This applies even – and perhaps especially – for patients with mental illness, with its alienating effects that make true human contact so important.

What would it be like to conduct our debates about technology, medical resource allocation, and regional or local mitigation practices with this understanding of hospitality and good stewardship? How would our practices change if we took seriously Benedict’s injunction to be “aware that nothing is to be neglected?” What might happen if we accepted the limits of our technological fixes for individual problems and used what’s at hand for the community’s good – especially our presence, our embodied witness in a time of grief and isolation? That’s something we can’t afford to lose if we wish to remain human.

Brian Volck gave this talk at the 2022 Front Porch Republic Conference. You can listen to it and his subsequent conversation with philosopher Adam Smith (not the Adam Smith) here.