Medicine and Moral Authority

Trusting Doctors, in large measure a history of the relationship between American medicine and religion during the nineteenth and twentieth centuries, is a captivating book. Jonathan Imber, a sociology professor at Wellesley, illuminates the evolving relationship between doctors, clergy, and patients in the decades before and after 1900 — a time during which medicine became more scientific and professional. Drawing on a fascinating collection of medical school commencement addresses from that period, mostly delivered by Protestant clergy, he demonstrates that medicine was during that time still viewed as a vocation, and that physicians worked hand in hand with clergy. Indeed, many physicians of that era, including the famous William Osler, were initially drawn to the ministry before deciding to study medicine. (Osler later wrote a famous essay entitled “Internal Medicine as a Vocation,” and another called “Vocation in Medicine and Nursing.”)

Even in the nineteenth century, however, the secularization of America was already underway — inchoately, perhaps, but steadily and relentlessly. Consequently, the moral authority of the clergy was gradually waning. By contrast, with its scientific successes and its recommitment to professionalism, medicine began to gain in cultural authority. Imber argues persuasively that during this period physicians were, in a sense, “ordained” by Protestant clergy to use the authority of the medical profession to promote personal virtue as an important aspect of health, and even asked to intervene to help save souls. With the help of the clergy, medicine came to be seen as a noble profession, replete with special altruistic duties such as a duty for all physicians to care for the poor. Imber makes the case for a subtle cultural transition — a passing of the baton of moral authority from the men of the cloth to the men of medicine.

In the meantime, Catholic clergy, while sidelined by the vehement anti-Catholicism of the day, were nonetheless developing in parallel a taxonomy of clinical cases and a moral approach to medical decision-making that eventually found its way into mainstream medical thinking in the United States. (This was an exercise in casuistry, a term which Imber hastens to explain he does not use in its contemporary and “slightly sinister” meaning, but in its traditional meaning: “the application by theologians of general principles of morality to specific cases — especially those in which a person might face conflicts of conscience or duty — in order to determine what should be done and how responsibility should be defined.”) Imber dubs this body of work “Pastoral Medicine” and argues that certain prominent physicians were instrumental in making Catholic thinking inform the way a largely Protestant physician workforce viewed the ethics of clinical decision-making.

This task was made easier by the fact that mainstream Protestantism of the day was as opposed to abortion as was Catholicism, yet had to come to terms with advances in care that would allow life-saving surgery on pregnant women even when risking the life of the fetus. The casuistry of pastoral medicine provided the solution. What emerged was a professional ethic that was “Protestant in character but professional in outlook,” with no specific reference to any religion. The public was inclined to accept the moral authority of medicine because of the profession’s commitment to be trustworthy in wielding the increasingly powerful and increasingly successful interventions of a scientifically-based medical craft.

For quite some time, this symbiotic relationship between the clergy and medicine held up, even in the face of increasing attacks on religion from the scientific world, from debates over evolution to the materialist philosophical declarations of the positivists, and beyond. Imber notes that even in the 1960s, the American Medical Association (AMA) established a “Department on Medicine and Religion.” In 1964, that department sponsored a presentation to the assembled delegates at the national AMA meeting in San Francisco, featuring addresses by Rabbi Abraham Joshua Heschel and the Christian psychiatrist William C. Menninger.

Soon thereafter, religious authority in the broader culture, which had been slowly waning for decades, began to collapse altogether. Meanwhile, medical authority had continued to grow thanks to astonishing technological advances. Yet the basis for this authority had shifted from medicine’s quasi-religious character as a profession to its power as an applied science. Imber suggests that the combination of authority and technological power proved toxic: medicine began to abuse its authority. A backlash ensued, fanned by the cultural upheaval of the 1960s and the rise of the consumerist movement. Bioethics emerged as part of that consumer movement, founded largely upon the idea that informed patients could question doctors and say “no” to the overuse of medical technology.

We now live, Imber declares, in the era of “Epidemiological Anxiety.” The world of medicine has become thoroughly “disenchanted.” The morals of a consumerist health care system have become the morals of prevention. Instead of striving to be religiously aware and faithful, Americans now seek a kind of temporal salvation through medicine. The main task of public health is now the effort to change individuals’ behavior, not to remove toxins from water or microbes from food. We have passed from “feeling anxiously hopeful about what medicine might achieve to demanding compensation for what medicine fails to deliver.” Medicine’s relationship to death has become completely unbalanced. Whereas under the old synthesis, medicine could strive to preserve biological life while religion could remind us that life had limits, having jettisoned religion we look to medicine to control the one remaining thing it has heretofore seemed incapable of controlling: death. This sets the stage for the age of stem cells, regenerative medicine, and our new quest for the fountain of youth. The head of Ted Williams sits gruesomely frozen — waiting, one supposes, for the stem cell treatment that will bring him back to life.

Imber’s tale of the rise and fall of the moral authority of physicians in America differs radically from the mainstream account among sociologists. As others tell it, avowals of professionalism and the exercise of moral authority by physicians were always self-serving smokescreens that allowed physicians to exercise a monopoly on power over life and death and to accumulate massive wealth, trading on the finitude of the human body. It is a tired, dogmatic, postmodern sociological tale of the unmasking of those who exercise power in the name of a pretense to a virtue that is just as dogmatically believed impossible for anyone actually to exercise. Only contemporary consumerism, on this account, has enabled the public to reclaim for itself some of its own lost authority.

Imber’s fresh approach is thus much subtler than the usual telling. He is not naïve, however; he tells of medicine’s having fallen prey to temptations of power and greed, but in the context of his much richer historical sociology.

That said, his book is by no means perfect. The outline I have just offered of the book’s overarching argument is not readily apparent as one is reading it. At times it reads more like a disjointed pastiche of interesting stories about American medical history and tantalizing tidbits of sociological analysis with little synthesis or organizing insight. The elements are there, but the reader must struggle to put it all together. Imber’s account of more recent developments in medicine is also a bit shaky compared with his treatment of the nineteenth and early twentieth centuries. Then again, it is always more difficult to write historically about the recent past.

And despite the book’s title, Imber actually has little to say directly about trust. Trust in physicians has been declining, that is true. As a sociologist himself, Imber knows that sociology has had much to say about this. The word “trust” appears in several chapter headings and there are quite a few entries under “trust” in the index — but nowhere in the book does Imber attempt to define trust, and almost none of the many quotations in the book refer directly to anything about trust. Perhaps he believes that moral authority is synonymous with trustworthiness. But I am not certain that this is the case. For example, I can trust my auto mechanic without investing much moral authority in him. I would have liked to have heard more from Imber about the relationship between trust and moral authority.

Nonetheless, I learned a great deal from reading this book. Since academic presses now prefer endnotes to footnotes in order to accommodate more casual readers, I frequently use two bookmarks when I read books these days — one for the text and one for the notes. In the case of Trusting Doctors, that exercise proved well worth the effort. The book is exceedingly well documented, the notes are very illuminating, and I’ve already bought or downloaded a number of Imber’s sources for further reading. Anyone interested in medical ethics, medical sociology, or the history of medicine will find this book a very worthwhile read.