Francis Fukuyama1 famously declared that history ended on November 9, 1989. That was the date the Berlin Wall fell, the final victory of liberal democracy over every other form of government. The rest has been just a sorting through and biding time until all other governments come, in due course, to this realization.
According to Peter Sloterdijk,2 history ended on September 6, 1522. This was the day Ferdinand Magellan’s surviving crew, all 18 of them, sans Magellan, arrived back in Spain after circumnavigating the globe, thereby ushering in the era of “globalization” or the “post-history era.” Ever since, the rest has been a sorting out of the planet’s wealth by ruling oligarchies.
The nice thing about post-history is the opportunity it presents for a number of firsts. This is the first time there has been a broadly recognized health care crisis; this is the first time that health care has been referred to as an industry; in fact, this is the first time that medicine has been referred to as health care, with the implicit acknowledgment that medicine itself is a mere percentage of some greater enterprise. A medical megaplex—part physical structure, part ether—that by its very large-ness, its very enmeshment within an oligo-capitalist-informatic economy, has ceased to be an academic, philosophic, aesthetic, or noble endeavor.3 Insurers have ruled the day for less than a century, yet post-historically have come to dictate the practice of medicine: “Can you help me, Doc?” “Well, let me call your insurance company and see what we can do.”
So what is the role of the physician in this new post-historical age, this age of science, of neo-Enlightenment? Certainly in this age of cures, of solutions, the physician’s role is vastly different from that of his earlier counterparts. Before the age of cures—that is, when a physician was able to make and fulfill the odds-on promise of cure—he was bound to the patient’s bedside, as confessor and confidante, as a paternal figure of comfort and security. Indeed, the paternalistic model of the physician as authoritarian and dictator of patient care has long since fallen into disrepair—less through ineffectuality than semantic unkindness—in favor of a more insurance-friendly collaborative care model in which patient and physician agree upon a plan.
How might this work? The good post-historical doctor, with the advertising resources of the megalith at his or her disposal, above all must objectify the patient, must reduce him or her to an elemental story of biochemistry and pathology, must create only the slimmest measure of directed subjectivity within the patient. The real power of the post-historical physician is to grant the patient either a cherished or hated subjective experience.
Post-historical medicine of course is based on a legal-economic principle of autonomy, a principle without much historical basis, that views the individual as an isolated objective “unit” whose inner experience, once brought to said unit’s awareness, will allow the unit to make decisions in its own best self-interest. This model clearly only works in the context of a physician-patient relationship governed by the possibility of cure, where the physician actually holds something of value to the patient.
Still, there are many, if not a majority, of patients who wish nothing more than for their physicians to make medical decisions for them. Illness after all is a troubling subjective experience, mental illness near unbearable. It is little wonder the appeal of dissolution via narcotics or other drugs, meditation, death, or exotic religious experiences. Subjectivity is terrifying enough; more so in the face of disease. And subjectivity is certainly not to be equated with autonomy. One can act autonomously with little subjective experience. Similarly, one can maintain subjective experience in the midst of totalitarianism. The point here is that the subjectivity previously rendered by the physician now provides an illusion of autonomy against a perceived evil of paternalism.
The illusion of course is that of choice. Treatment options are presented with the full expectation that the patient will agree, similar to the illusion of choice in contractual agreements for other necessary services. In other words, a subjective experience common to all—if one needs such services, then one has no choice but to accept the proffered terms. Autonomy is after all a business concept, that aspect of an isolated objective unit that is targeted by media and is “open for business.” As a client is free to purchase the suggestions of a financial advisor, so a client purchases the suggestions of a physician. And given one’s inherent freedoms, one may well say “no thanks,” rendering the collaboration over—“see you later, no hard feelings.”
Dr. Martin reports no conflicts of interest concerning the subject matter of this article.
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2. Sloterdijk P. In the World Interior of Capital: For a Philosophical Theory of Globalization. Cambridge, UK: Polity Press; 2013.
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