November 8, 2009

Making an Inhumane Science

In the theater of "health care reform," which late last night took a step toward final legislation, the phrase "best practices" has come to stand out as a defining concept of contemporary politics.

Last year, as a candidate, the President said that if we were to design health care from scratch a single-payer system was the preferred and logical model; it would be the supposed wide-spread public resistance to change that dictated smaller steps and compromised measures. The allure of a bi-partisan symbol was something else altogether. But as the minority party resisted any changes to how health care is distributed and paid for, polls repeatedly indicated support for the very idea Obama was in the process of turning from in the name of political realism: namely a single-payer system. Instead of leading, he chose a passive course of capitulation. His to a path of false realism brings into sharper relief the particularities of his technocratic ideology; one that is less about the efficient functioning of government than an avoidance of analysis, decision, or engagement.

Rather than an agonistic stance that eschews pre-packaged mantras for the sake of dialogue, persuasion and the battles of arguing positions, Obama's pattern is to posit as steadfast limits that are mere fictions, and continually promote his practical positions in terms ambiguous and ill-defined. This could seem like a typical third-way politics of opportunism (with the Keynesian elements of liberalism stripped away in our perpetual emergency to become only rhetorical moralizing), but the "best practices" provision of the health care bill reflects Obama's "philosophy" of governance as much as the drone strikes of Afghanistan and Pakistan: one accepts that there are no choices to be made so as to appear, to or to feel, victorious while simply enduring the time of choice.

Evidence-based practice is rooted in the idea that beliefs can be corrected by evidence and that practices can be authorized by the calculations of observing experts. Authority moves from a kind of faith (posited as almost mythic) in the physician to the aggregate determinations of the data. The assumption, or dream, is that a whole range of treatment modalities may be thus liberated from tradition and opened to new (already proven) methods.

The "best practices" language haunting the current health care legislation represents the economic and political leverage that can emerge from those assumptions. When physician Jerome Groopman describes this to the New York Review of Books, we hear how the benefits of clinical analysis quickly give way to an economic calculus that prescribes away the physician's most micro-level interactions with singular patients; patients whose histories, sensibilities, physical and psychological responses vary widely to treatment options. Where there is, and there can only be, conjecture in the face of the individual, the aphoristic, the bodily clue of symptom, there will be, the legislation promises, something more predictable, managed, enduring. Influenced to adhere to the legal fiction that there are no choices to be made, success will be measured in securing malpractice protection, and the idiosyncratic encounters of a humane "science" -- in that regard the tension unchanged from the time of Hippocrates -- made an inhumane gesture of mere endurance.