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From the archives

Carbon Copy

In equal balance justly weighed

Slouching toward Democracy

Where have all the wise men gone?

By Populist Demand

When urban and rural voters went separate ways

Second Opinion

Just what did the doctor order?

Viviane Fairbank

Medicine and Morality: Crises in the History of a Profession

Helen Kang

UBC Press

168 pages, hardcover, softcover, and ebook

Most of us have a delicate relationship with health care. We appreciate its availability, of course, but we prefer not to acknowledge its existence until it’s necessary. We like to think of the healing arts only when we are already in danger — and then they serve not as a threatening reminder of mortality but rather as a comfort, a promise to try to delay suffering, if only for a while. Until the start of the COVID‑19 pandemic, it was possible for a relatively healthy person to maintain a calculated distance from the everyday activities of the medical world. But by the start of last summer, as more and more lockdown rules were implemented, evidence of that world had seeped uncomfortably into the fabric of quotidian life. In Montreal, hand sanitizing stations were nailed to every wall, neon signs reminded us to wear masks inside every building, and garbage bags covered every other sink in public washrooms. Even as lockdowns have lifted, those measures remain in place, here as elsewhere. We’ve always been potential patients, but, until 2020, rarely were we so explicitly reminded of it everywhere we turned.

I’ve been mulling over this new reality as I’ve read countless news briefings and op‑eds about how our doctors are failing us — either by not doing enough to protect the public or by doing too much. The medical profession has simultaneously gained the respect of some, who feel protected and cared for during a dangerous time, and lost the trust of others, who feel betrayed or pushed around by masks, Plexiglas, and social distancing. We hold doctors and public health officials to a high moral standard, yet we don’t necessarily feel comfortable with the level of authority their profession affords them.

Even as some people joined their neighbours in clanging pots to thank essential workers, others marched through our streets to protest mask requirements. Bonnie Henry, British Columbia’s provincial health officer, was profiled in the New York Times for her cool-headed response to the pandemic, but she also received a mountain of abuse and death threats from unhappy citizens. And throughout this ordeal, some newspapers have devoted entire sections to the work of essential workers across the country — our anointed “pandemic heroes.” Others, however, have taken a different tack. This past spring, for example, the Toronto Sun ran a provocative cover: “DOCTATORSHIP,” in red capital letters. “When this is all over, public health doctors’ powers must be curbed,” the paper tweeted.

No book has helped me understand these divisions as well as Medicine and Morality, a slim volume by Helen Kang about the history of the medical profession in Canada. Kang completed her manuscript well before the first documented case of COVID, so she makes no direct reference to the pandemic; instead, she teases out the roots of the discomfort we’re now experiencing. The volatility of our attitudes toward clinicians and nurses may be more visible now than before, but Medicine and Morality shows that the problem has been growing for decades — symptomatic of our thorny relationship with professionals whose work we mostly don’t understand but on whom we place a huge amount of responsibility and expectation.

A mishmash of medical practices and practitioners.

Science Museum, London; Wellcome Collection

Citing old medical journals, legislative proceedings, and correspondence, Kang writes in lucid, readable prose about the past 300 years. She structures her book in four parts. The first is, unexpectedly, an introduction to the work of Pierre Bourdieu, the French sociologist who invented the term “invested disinterestedness.” As Kang puts it, the nineteenth-century bourgeoisie had “the luxury to move away from a focus on immediate life necessities and instead to contemplate the universal, common welfare, aesthetics, and the pursuit of knowledge.” But they could do this only if they preserved their power, which made their declared interest in universality and the rest pretty hypocritical.

Kang applies Bourdieu’s ideas to doctors, whom she describes as similarly positioned: the profession, she writes, is precariously balanced “between its bureaucratic imperatives (the pursuit of individual livelihood and professional autonomy) and its ‘purely’ disinterested pursuit of knowledge and the common good.” Doctors as a whole “repress this contradiction, as something that can be tolerated because something greater is being achieved.” Their efforts to ignore the contradictory motivations of their work aren’t always effective, however, and this is the problem that Kang then describes.

In the following chapters, Kang details three key moments from the nineteenth century until today — moments when the profession’s claims to scientific and moral legitimacy were questioned, either by competitors, by the government, or by patients. Each time, as doctors struggled to maintain their collective authority, they were forced to renegotiate their relations with the public. Kang’s analysis illuminates our current anxiety about the proper place of health care in public life. Each case study exposes how our relationship to the field has been shaped as much by cultural, political, and social factors as by practical health needs — and shows that shifts in this relationship are usually unexpected, painful, and consequential.

One thing we often learn from history books is that events might have happened differently; they didn’t need to end up the way they did. The situation we find ourselves in today, in which our experience of the medical profession is mediated by a complex structure of public relations managers, ethics boards, accounting departments, and other players, has a complicated past. Of course, this backstory is more than any one book can capture, but it’s clear even from Kang’s short retelling that things are far more complicated than we usually take them to be. Although the medical profession may seem united, organized, and well regulated, Kang shows this has never really been the case. Look more closely and you’ll find that, just like any other system, it is and has long been full of disorder, disagreements, and vulnerabilities.

“In the eyes of our sickly patients we may be demigods,” a Halifax physician wrote in the Canadian Medical Association Journal in 1961. But “in the eyes of the collective public we seem to be a group of monopolistic money-grubbers, bloated with self-importance, intolerant of intrusion in to our private domain and martyred in pseudo-sacrificial devotion to our indigent brethren.” In the mid-twentieth century, as today, such contradictory attitudes toward medicine were reflective of deep tensions within the medical system itself — notably the discord between the need to serve individual patients and the need to protect the collective public. These imperatives carry different, and sometimes conflicting, interpretations of a doctor’s responsibilities. When it comes to treating individual patients, a physician needs to be adaptable, delicate, intimate. The public as a whole, however, demands cool efficiency when prescribed care — everyone expects to be taken care of. That puts those who devote their lives to patient care in a delicate position, forced to navigate such different realms while simultaneously protecting their own professional interests. Kang describes doctors as caught in a “moral paradox” at the heart of their vocation. This, she argues, has motivated the evolution of the profession.

Take, for example, Medicine and Morality ’s first case study, set in Upper Canada after the British victory against the French in 1759. In the early colonial days, “medical men,” as they were known, were a diverse group of professionals with “a mishmash of practices based on diverse theories of disease.” While some learned the new methods of anatomy, others advocated bloodletting and purging. For the most part, medical men from Britain dominated the field simply because they were the only ones available to serve the small colonial population. (Of course, Indigenous people had their own practices, some of which still exist today, and their health was dramatically worsened by the violent arrival of newcomers, though Kang does not mention any of these details in her book.)

The landscape changed throughout the nineteenth century, as non-medical “healers” and graduates of new North American schools began to arrive. Self-taught homeopaths, chiropractors, and Thompsonians, who practised a kind of botanical medicine, also began to soar in popularity. British doctors accused their new competitors of quackery (a favoured insult at the time), but because they had no coherent set of practices of their own — indeed, their own medical knowledge was hardly better than, or even very different from, that of their rivals — there was no proven reason for patients to favour a licensed doctor over an eclectic botanist.

Besides, people of lesser means could not afford licensed care, and many immigrants resented the colonial-imperialist symbolism of the British medical class, choosing to rely instead on newly arrived American-schooled doctors who were eager to gain recognition. British-trained medical men resented the loss of trade; Kang references journal articles and public meetings in which they expressed disdain for the public as “an unruly, irrational mob that acted against its own interests by regularly turning to unlicensed and non-medical practitioners.”

British doctors were seeing their dominance fade; they needed some way of convincing the public that they deserved political and financial protection. So they joined forces. Instead of seeing and selling themselves as individual entrepreneurs, as they had previously done, they began to claim collective moral authority, citing a special relationship that existed between British physicians (the right medical practitioners, who belonged to a respectable, scientific class) and their deserving patients (the vulnerable colonial population). For the first time, it was in doctors’ interest to articulate a moral and scientific ideal for medicine — one that could be upheld only by reputable gentlemen.

In medical journals, physicians began strategically presenting themselves as guardians of health — organized professionals with distinguished expertise, the only ones on whom the public could safely rely. At the same time, they pushed for new licensing standards that excluded lower-class or foreign-educated doctors, and they petitioned the government to discredit American, French, and “alternative” practitioners. Thompsonians and homeopaths were, as one medical man protested in 1849, “a set of ignorant and despicable pretenders [who] are to be allowed, by lawgivers, to prey upon society, and sport with human life.”

But medical men knew their claims of moral authority alone wouldn’t protect them; they also needed to demonstrate their superiority. This realization prompted a change in behaviour. In the past, they had often fought publicly and aggressively among themselves, but now they began to develop what Kang calls “a genuine feeling of brotherliness.” Doctors understood that “even legitimate scientific debates could be misunderstood as dishonourable and could ‘degrade the profession in the eyes of the public,’” and so disagreements needed to stay more or less hidden.

This prioritization of doctors over patients, but under the guise of quite the opposite, can be seen in the publication of the Canadian Medical Association’s first code of ethics, in 1868, which was devoted mostly to professional etiquette. How doctors were seen to act — whether the public would consider them worthy of financial and political protection — mattered much more than how they actually behaved behind closed doors. The result of this attitude is that, from the nineteenth century onward, doctors have mostly excluded the general public from professional matters, and they have expected to be paid and respected for their work with little justification or competition.

Medicine and Morality is the kind of book that lingers on such details, making it feel longer than it really is. Abstracted from historical minutiae, the first case study’s central message is its most compelling: the reign of the modern, university-educated medical professional, whom we all take for granted in health care today, is a relatively new development. It emerged, in large part, thanks to the coordinated efforts of the old British elite, some of whom had much less regard for the public than for their own well‑being.

We can recognize these origins in our attitudes today; in fact, Kang’s whole book feels eerily familiar in the context of the pandemic. Unless we know better, most of us — doctors and patients alike — still believe in the ideal of the rational, scientific, moral expert in a lab coat. Consequently, many of us think that elitism in medicine is a good and necessary thing: it leads to the public being served by only the best. Really, that’s not so bad a goal; it’s our understanding of “served” and “best” that might be worth elaborating, now that Kang has shown us their unfortunate historical context.

Although slightly less relatable to our present moment, Kang’s next two chapters are interesting in their own right. One is about doctors’ protests against the implementation of universal health insurance in Saskatchewan in the 1950s and ’60s, and the other is about the controversial dismissal of the top editors of the Canadian Medical Association Journal in 2006. In her conclusion, Kang argues that one storyline unites her three case studies: despite their differences, they all represent moments in which the inherent tensions and contradictions of medical practice bubbled over, in part because doctors struggled to find the right balance between helping their patients and helping themselves.

In the nineteenth century, medical men beat their financial competitors by standing together and claiming the moral high ground — and by using this elevated position as a justification for payment. But the same claim worked against doctors in Saskatchewan a century later, when their financial demands clashed with the government’s proposed reforms. They were shamed in the press for putting their own interests above the public’s welfare. To fix their image, doctors started working more closely with media organizations, but half a century later this effort led to complications related to balancing financial and ethical priorities in medical publishing.

Kang’s argument is a sophisticated one, and her defence of it isn’t always convincing; a reader could reasonably question whether the three crises, which are so disconnected in time and geography, really had the same cause. But there’s also some intuitive truth to her hypothesis: generally, any quick fix to get out of a moral dilemma will come back to bite you. The same line of thinking could be applied today. The pandemic has shined too bright a light on an unsustainable situation. Because we often resent and mistrust doctors when we see imperfections in their practice, and because ambiguity is ­difficult to explain, they usually keep the uncertainties of their work to themselves, which leads to a widening divide between our expectations of the medical world and what it can actually do for us. The closed-door attitude that helped the profession codify its monopoly 200 years ago is now working against it.

In the recent past, public health strategies were often based on the belief that doctors should present an appearance of agreement and confidence in their judgments so that their patients would trust and listen to them — so that they would stay indoors when told to. As we’ve struggled with managing the pandemic, however, this appearance of coordination and unity has crumbled. Across the country, doctors have disagreed, errors have been made, recommendations have changed. (The Centers for Disease Control and Prevention, in Atlanta, was originally mistaken, for example, about the coronavirus spreading in the form of droplets instead of aerosols, and, as Michael Lewis demonstrates so persuasively in The Premonition, it was incredibly slow in admitting its errors.) We’re not used to seeing experts arguing, and it’s made the public deeply uncomfortable. We don’t know how to deal with ambiguity in care; for the most part, we haven’t had the opportunity to learn how.

No matter how thought-provoking, Medicine and Morality would be stronger if we heard more from patients, either as individuals or as a collective, about how they’ve felt about medicine throughout Canadian history. Fittingly enough, this omission is exactly the kind of mistake made by a large part of the medical world: the public has rarely been considered a group worth engaging with; individual patients are treated as simply the bodies that receive care. And despite the book’s title, Kang does not mention doctors’ most problematic behaviours over the years, including a litany of unethical experiments, ­sexual abuse, and discriminatory practices.

Medical professionals today need to build a relationship with the public based on mutual trust and respect — not the kind established by British physicians centuries ago. It will require some soul-searching by doctors, who will have to admit that despite their best efforts, they are not always as moral and rational as they claim to be. We now know, for example, that a patient’s relationship to the health care system is mediated by class, identity, and a variety of other social, political, and cultural factors. Just think of medical trials, many of which do not include women or people of colour, meaning the resulting products or procedures haven’t been adapted for different physiologies. Or think of the unequal impacts of the coronavirus itself: in 2020, Black Canadians were nearly three times more likely than the general population to know someone who had died of COVID‑19. Or think of Joyce Echaquan, the thirty-seven-year-old Atikamekw woman who died of pulmonary edema in a Quebec hospital last year, right after posting a Facebook video showing nurses mocking and insulting her as she cried out in pain. It’s no wonder some people don’t trust the system.

Such considerations have pushed me to think about what a healthy, more transparent relationship between doctors and patients might consist of. To even imagine it is a difficult task; it’s not clear what the boundaries of such a relationship should be. For example, in the context of a pandemic, worsened by the online spread of disinformation, do we believe it is the medical profession’s responsibility to ensure that accurate information is conveyed to (and accepted by) the public? If we do, then there may be times when being too transparent about the imperfections of their field might work against them and even be weaponized to foster distrust — for example, when trolls accuse labs of having intentionally created the virus as a biological weapon. It may also be impossible for doctors to clearly explain everything that’s going on to their patients, given that they may not have a clear understanding yet themselves.

This is painful for some people to admit: we just don’t know all we would like to know, including in medicine. And admitting the limitations of one’s knowledge can make it seem difficult to preserve an aura of gravitas. To act as a doctor is precisely to ask patients to defer to the authority of the system — to ask them to say, “My body is in your hands, and I don’t quite understand what you’ll do with it, but I trust that you do.” How can doctors expect people to be faithful to the medical world, then, including its vaccinations and lockdown restrictions, if practitioners admit that they don’t know exactly what will happen? And that sometimes they make the wrong decisions?

Now that the medical world has become a bigger part of our everyday lives, its flaws visibly out in the open, doctors will need to articulate why trust in the public health care system is nevertheless the best way forward. Kang points out that “we all have a stake in having medicine aspire to be as objective and ethical as possible.” But for that to be a tenable goal, we first need to agree on what objective and ethical medical behaviour actually looks like.

Viviane Fairbank writes from Montreal.