The metric, the dialectic, and the chart electric

There is no document of civilization which is not at the same time a document of barbarism.                      -Walter Benjamin, Theses on the philosophy of history

It is 1940 and the Nazi horror is bearing down on Europe.  France has fallen, and refugees are streaming out, fleeing to safety through neutral states and America.  Walter Benjamin, a Jew and a German philosopher, joins a small group being guided through southern Spain with the hope of making it to Portugal and safety.  He has just completed his manuscript that would reverberate through modernity with its insight into how rationality brought us civilization and Nazism at the same time.

“Enlightenment was supposed to involve the use of reason to help humans free themselves from myth and superstition.” Scientific thought abolished foolish superstition, yet somehow the over-reliance on measurement and mechanization also had a downside.  The Enlightenment project, dominant in Western thought since the Medieval Age, created a new scientific future where mechanization and measurement improved innumerable lives.  Yet, the elimination of magical thinking also created a sterility of thought that enabled Nazism in Europe.

Benjamin’s colleague Theodor Adorno, a German Jew who succeeded in escaping to America, later expanded the ideas on the duality of development in The Dialectic of Enlightenment.  Here he details how the enlightenment project “has always aimed at liberating men from fear and establishing their sovereignty… the dissolution of myths and the substitution of knowledge for fancy.” But the other side of the dialectic also ends up with “men paying for their increase in power with alienation from that over which they exercise their power.”  For example, as we control the natural environment by building cities, we become alienated from authentic communion with our natural world.  As we harness social media to stay connected with people, we may become alienated from authentic human interaction.  So goes the dialectic of enlightenment and progress.

Western scientific medicine epitomizes the enlightenment process as it replaces superstition with rational diagnosis and treatment.  As modern medicine measured more and more with the goal of improving health, we also created the “quality metric”.  Rather than being subject to the vagaries of non-standard care, rather than individual doctors perpetuating treatment myths, we created the temple of evidence-based medicine, and measured the dimensions of the temple with quality metrics.  The electronic record then burst open the dam of myth in medicine and allowed us to measure, well… everything.  We now know what being a good doctor means because we measure blood pressures, and we know if patients have less than 140/90.  We know if you are talking to your patients about flu shots because it is in the electronic chart.

And yet… Benjamin’s eerily prescient warning about progress has also come to pass.  “For the Enlightenment, whatever does not conform to the rule of computation and utility is suspect.”  The art of medicine, whatever that might mean, is not measurable, and teeters on the verge of extinction.  Increased control over the body ended up bringing about domination over bodies: paternalism, futile end-of-life care, polypharmacy… and pay-for-performance. Pay-for-performance promises the quantification of the entire patient-physician relationship and then its optimization as providers become rational profit-maximizers.  Rather than the comforting hand of the healer, the invisible hand of the market will guide improved patient care.  So goes progress.

Adorno famously died before writing his views on the possibility of synthesis between progress and domination.  Perhaps he never meant to write such an essay, not believing it was possible to become civilized without also losing the humanistic values of civilization.  The ability to measure “quality” practically defines what it means to be “scientific”; science is that branch of human knowledge which measures things.  I fear that pay-for-performance represents the enlightenment run amok, “scientism” rather than science, with the loss of the realization that medicine is ultimately a humanistic profession, and not scientific.

My medical school each year granted a “Humanism in medicine” award to some deserving students.  The rich irony of the need for this award has only now, years later, begun to sink in for me.  The criteria for winning must have been more than simply being human, or even being A human.  I would forlornly hope that we would all have won this award, or even better, that there would be no need for such an award at all.  I recall that I won the award, by what criteria I know not, or have long forgotten, but I write this as a humanist, as a recognition of the potential barbarism of pay-for-performance everywhere.  

The day is not far off when the economic problem will take the back seat where it belongs, and the arena of the heart and the head will be occupied or reoccupied, by our real problems — the problems of life and of human relations, of creation and behaviour and religion.

-John Maynard Keynes

I have not heard a better apology for the “real problems” that preoccupy doctors than what the economist Keynes describes, and we might do well to heed his warning about economics taking the back seat. Is not medicine by definition “humanist”?  Will we succeed in merging the scientific and the relational, or will medicine end up separating patients and their healers?

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