Ideological Medicine

    A while back, many commentators (and dopes like me) were losing their collective minds because of a new and highly progressive oath taken by members of the class of 2025 at the University of Minnesota School of Medicine. One organization characterized it as making students who wish to become physicians “read verbatim from ideological pledges,” branding it a “new low.” Another, noting that the oath had been penned by a small group of students on behalf of a much larger class, decried the finished product as just another example of “activists” speaking with “the loudest megaphone.” One critic even speculated that if such trends continued, the school might soon do away with the white coat, the traditional garb of physicians, simply because it is white. Actually, that line would be funny if it were not so depressing, seeing that these types of oaths are continuing to this day.  

    Among the features of this particular oath  that came in for especially harsh criticism were these: The oath noted that the institution is located on “Dakota land” and that “many indigenous peoples from throughout the state, including Dakota and Ojibwe (ooj-jib-way), call the Twin Cities home,” while also admitting that “this acknowledgment is not enough.” Nothing is ever enough, is it.

    Those who recited the oath committed to “uprooting the legacy and perpetuation of structural violence deeply embedded within the healthcare system.” They recognized “inequities built by past and present traumas rooted in white supremacy, colonialism, the gender binary, ableism, and all forms of oppression.” I would have loved to hear something about caring for the sick…but maybe that’s coming later. 

    They committed to “promoting a culture of anti-racism, listening, and amplifying voices for positive change.” They pledged “to honor all indigenous ways of healing that have been historically marginalized by Western medicine.” Of course, the inclusion of such elements in a professional oath does not by itself generate a diagnosis but merely represents a symptom of broader cultural phenomena. Still, not to be a pest…but can we at least hear the phrase… “Do No Harm?”

    These elements of the oath proved ripe for criticism and sarcasm on many grounds, and by many people. First, there was the matter of the Dakota people. In fact (if anyone were to care), according to pesky little things like historical records and documents, the Dakota had not been the only prior inhabitants of the land now partitioned into the Twin Cities, and in the 18th century the Dakota AND the Anishinaabe had been engaged in vicious conflicts over control over Minnesota’s wild rice beds, their principal source of food. These vicious conflicts included, but were not limited to, rape, beheadings, mutilation, and human sacrifice. Doesn’t it just warm the soul when you read that the so-called peaceful North American Indian can be just as treacherous and evil as everybody else? Anyway… The medical students who drafted this oath would have benefited from a deeper grasp of the heritage they sought so desperately to acknowledge.

    Moreover, in saying that their acknowledgment was “not enough,” they raised the question of what would be…enough? Asked one commentator, “What else will they do for the Dakota people? Will they give the land back, or compensate the original ‘owners’?” Should they, perhaps, offer free or reduced-cost care to the descendants of indigenous peoples, or strive extra diligently to ensure that they receive the very best care?

    As to the “uprooting” of the “legacy and perpetuation of structural violence deeply embedded within the healthcare system,” commentators attacked the notion of “structural violence.” Coined in 1969 by Norwegian sociologist Johan Galtung, structural violence commonly refers to institutionalized ageism, racism, sexism, and speciesism (I’m sure that I am forgetting a few “isms”…but I got a lot on my plate, lately), among other forms of “social injustice.” As one might expect, the fact that such biases are seen as “structural” has led to calls for, the gods help us, structural interventions.

    Ironically, however, two of the countries in which such structural interventions have been most prominently attempted, Haiti and Rwanda, remain among the poorest and least healthy nations on earth. Merely prohibiting the commodification of health needs and establishing a social “safety net” does not necessarily translate into enhanced health or a better life. Which begs the question, what structural interventions were the first-year medical students at the University of Minnesota making, or planning to make, to overcome such structural violence at their own institution, and how are the medical school and university responding to them?

    Commentators also seized on the students’ determination to ferret out “inequities built by past and present traumas rooted in white supremacy, colonialism, the gender binary, ableism, and all forms of oppression.” This immediately raises the thorny problem of establishing responsibility for these traumas. For example, is the responsibility for the enslavement of blacks in the Americas shared only by those actively involved in the slave trade or who held slaves? Or does it extend to their descendants over a certain number of generations? Or is it shared by all white people, whether they or their ancestors happen to have been personally associated with slavery or not? Inquiring minds want to know. And yes, I am being snarky AND sarcastic…because I hate stupid. 

    There are other questions, so forgive me while I obsess and take more than my allotted time. Should apologies and perhaps reparations for such injustices be directed only at those who suffered under slavery, their descendants over a certain number of generations, or all people who self-identify as black (however infinitesimal that percentage might be), regardless of whether their ancestors were held as slaves or not? Likewise, who is responsible for perpetuating the gender binary, and what should be done about it? Does the use of such heinous words as boy, girl, man, woman, male, and female establish complicity, and should medical students avoid all such binary terms? Finally, does medical research and treatment of disabilities—or perhaps different abilities—such as vision and hearing loss, restricted mobility, and dementia represent and perpetuate “ableism”? You see where I’m going with all of this? I thought you might. 

    Returning to the oath; the students, and their med school student descendants, also committed to “promoting a culture of anti-racism, listening, and amplifying voices for positive change.” What, commentators asked, would a culture of anti-racism in medicine look like? For example, what are students to make of race in the first place? Is it a biological category or a social construct? If the latter, perhaps the best way of reducing racism would be not to make anti-racism a pillar of medical education and practice, but to take race out of medical discourse entirely. In many cases, it hides more than it reveals.

    The suggestion that persons be treated as members of categories rather than as distinct individuals should give anyone with ANY sense of history serious pause. For example, I read about two recent medical school applicants, one who identified as black and the other as white. The black student grew up in affluence because both of her parents were physicians. The white student grew up in poverty, with unemployed, self-described “hippie” parents who lived in a trailer in the woods. The black student attended elite educational institutions her whole life. The white student was the first person in her family to go to college and got through college with a combination of loans and self-employment. When medical schools looked at these students’ applications, they saw a member of the historically disadvantaged black race and a historically privileged member of the white race, and gave preference to the black student, in large part because NEITHER student, to their everlasting credit, elected to describe their family circumstances in their applications.

    Some have argued that taking race into account is justified, in part because of studies suggesting that members of minority groups are better cared for and achieve better outcomes when under the care of health professionals who belong to the same groups. Hence, we need more black males, who are markedly underrepresented in medicine, to pursue medical careers, so they can care for patients like themselves. Yet those who make such arguments seem to be suggesting that we segregate patients and health professionals by race, ethnicity, religion, and so forth; and what moron really wants to invoke segregation as a policy?

    The issue is not as simple as meritocracy versus affirmative action, and any suggestion that persons be treated as members of categories rather than as distinct individuals should, again, give anyone with ANY sense of history serious pause. Even diseases such as sickle cell anemia are not so confined to specific racial and ethnic groups as once supposed. When people begin thinking that they can discern what they need to know to make a decision about a person from a photograph or a box checked on a form, they have positioned themselves in ethically perilous territory whose denizens include some of the most notorious and noxious figures of the twentieth century. Paging Dr. Josef Mengele, Please call your office... Yes, we always seem to come back to the Nazis. 

    Perhaps the deepest problem of all is the assignment of racial categories. Who counts as white, who as black, who as Hispanic, and who as an Asian/Pacific Islander? Should pre-med students, medical students, and physicians be subjected to genetic testing, and what threshold level should be established to qualify as a member of a particular race? For example, could one qualify as black with 50%, 25%, or 12.5% of the genes commonly found among people who self-identify as black? Would such genes need to be of African origin, or would genes common among dark-skinned people from other parts of the world count as well? If race is not defined genetically, should it be based on documented family trees, and if so, how would anyone establish the race of their parents, grandparents, great-grandparents, and so on? And if race cannot be established by either of these means, what alternative is there? Would self-identification be appropriate, and if so, how would medical school officials or health professionals handle individuals who appear to be self-identifying as members of a race to which they do not appear to belong? Perhaps Dr. Martin Luther King, Jr. was on to something when he longed for a world in which his children would be judged not by the color of their skin but by the content of their character. How quaint that sounds in today’s maelstrom of frighteningly stupid ideas. 

    Finally, the aforementioned medical students pledged “to honor all indigenous ways of healing that have been historically marginalized by Western medicine.” Really? How would this play out in practice? Would medical students and physicians caring for patients of Native American descent, for example, recognize taboo transgression, improper animal contact, inappropriate ceremonies, and contact with malignant entities as potential causes of their patient’s illnesses? When puzzled by a diagnosis or a lack of response to therapy, would they refer patients to medicine men or hand tremblers? Would they themselves resort to ceremonies, herbs, and sand paintings as means of treating patients?

    To be sure, practitioners of so-called Western medicine have adopted many practices not well supported by evidence, and no doubt many currently accepted diagnoses and therapies will be supplanted in the future. But there is a difference between saying that Western medicine is a work in progress and saying that it supplanted indigenous ways of healing through a power imbalance. Believe it or not, I have read many reputable articles that tell me things like microscopes, CT scanners, vaccines, and antibiotics REALLY WORK, while such evidence for many indigenous practices is simply, uhhh...how do I put this diplomatically... uh, lacking.

    Now, having typed ALL of the above, despite such objections to the student-crafted oath, more is called for than the mere rantings of a dope like me and my layman’s naïveté. To be fair, I truly believe that these students were engaged in a fundamentally laudatory activity, sketching out aspirations (however anti-intellectual I may find these aspirations) for themselves and their colleagues that extended beyond merely passing their examinations, obtaining the medical degree, avoiding malfeasance and malpractice litigation, and enjoying the fruits of a secure and well-paying career.

    Instead, the students were looking up from their books and computer screens long enough to consider the larger contributions they hoped to make as members of a learned and highly respected profession, gifted with first-rate minds and rich educations, and capable of making a real difference in their communities and society at large. They recognized that members of professions such as law, clergy, teaching, and medicine bear special responsibilities as bellwethers and guardians of standards of goodness and service, and they wanted to establish for themselves some sense of where such a profession’s aspirations should lie. Although their list of such aspirations was more than a little bit muddled, they were attempting, in their minds, to do good.

    Instead of simply condemning students of the professions for holding opinions that we regard as wrong-headed, naïve, or even the product of educational brainwashing, we would do better to take what steps we can to ensure their views are tested and challenged. No matter how good the scientific and technical aspects of medical education are, we are doing more harm than good if we allow medical students’ capacities to engage in serious ethical and political discourse—and to lead as human beings and citizens—to atrophy. Instead of merely dismissing students at the University of Minnesota and many other places, we should be inviting them out for coffee, and creating a dialogue.

Write to Peter: magtour@icloud.com