As I explored in two recent posts (“The Managerialist Revolution in Medicine” and “Why We Are Sick“), our medical institutions—from hospitals and licensing boards to medical schools and professional societies—are failing us. The complex of problems in many of these institutions makes reform or repair, in the short term at least, impractical and perhaps impossible. Too many vested financial or other interests will not readily relinquish their territory.
Still, I want to suggest here a rough blueprint for a way forward. Any short-term hopes for the medical system’s fundamental reform or even moderation appear futile. I believe a better strategy involves, to the extent possible, ignoring the medical regime’s official structures and building new ones—small-scale initiatives where decentralized medical care can be restored and patients can be empowered to take responsibility for their own health. We need what the Czech dissidents of the 1970s called a “parallel polis” for medical institutions.[i]
These would supplement the beneficial and necessary functions that are missing in the existing structures, and wherever possible, would use those existing structures to humanize them. These initiatives need not lead to a direct conflict with mainstream medical institutions. At the same time, this strategy harbors no illusions that cosmetic changes to mainstream medicine can make any meaningful difference.
This involves occupying the spaces that medicine has temporarily abandoned or which it never occupied in the first place. These parallel institutions need not constitute a ghetto or an underground; they are not a black-market system hiding in the shadows. The purpose of these institutions is to eventually renew the entire healthcare system, not to retreat from it entirely.[ii]
Admittedly, every institution of the parallel polis will be a David facing the Goliath of a massively powerful and totalizing medical system. Any one or another of these institutions could be crushed by the state machinery, working as the enforcement arm of institutional and corporate medicine, if the state specifically targeted it for liquidation. Our task, therefore, is to create so many of these parallel structures and institutions that the captured state would finally be limited in its reach: while it could crush any one institution at any time, there would eventually be too many such institutions for the state to target them all simultaneously.
At the behest of governments, medical institutions during Covid demanded we become disempowered and isolated. People globally ceded their sovereignty and abandoned social solidarity. By contrast, the new parallel institutions of medicine must return sovereignty to individuals, families, and communities and strengthen social solidarity. These institutions must help people take responsibility for their health and must always support the doctor-patient relationship, minimizing external intrusions on this relationship.
In these new medical models, physicians need to be able to exercise individualized clinical judgment and appropriate discretionary latitude. Doctors should work primarily for patients and only secondarily for institutions. During Covid, governments weaponized fear to coerce individuals, families, and communities to cede their sovereignty and even make them forget they once had it. To help individuals, families, and small communities reclaim their ability to self-govern we must help people overcome their fear and find their courage.
Markets, communications, and governing structures within medicine have become increasingly centralized at a national and global level, robbing individuals, families, and local communities of legitimate authority, privacy, and medical freedom. Thus, the new medical institutions must be grounded in technologies and models of decentralized communications and information sharing, dispersed authority, and localized markets. To name just one example among many, subscription-based models of direct primary care, which bypass Medicare and other third-party payers, are springing up around the country and in many cases proving financially viable—delivering better health outcomes at lower costs by eliminating the expensive and superfluous bureaucratic middlemen.
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Individuals, families, and local communities have been robbed of their legitimate authority. To rectify this, the new medical institutions must support the principle of subsidiarity and empower practical efforts at the local level. New cooperatives as an alternative to traditional health insurance are one example of recent creative thinking in the domain of healthcare reimbursements that respect this principle of subsidiarity and help individuals and families maintain legitimate authority over healthcare payments.
The Homeschooling Parallel
We need to plant seeds that might not fully germinate in our lifetimes, thinking in 50- to 100-year increments. Consider the homeschooling movement in the United States. In 1973, just over fifty years ago, there were 13,000 homeschoolers; today there are 5 million. A generation ago parents would get a visit from social services for not sending their children to “approved” public or private schools. It was considered déclassé, if not borderline criminal, to attempt to educate one’s children oneself.
Undeterred by suspicion and outright persecution, the homeschool movement created a parallel polis, reappropriating the idea of self-education and autonomous learning that had been monopolized by those with advanced degrees in education. While not every homeschooler succeeded, many thrived, demonstrating that their children could get a superior education—winning the spelling bees, acing standardized exams, and earning admission to prestigious universities—for a fraction of the cost of other schools. These pioneers formed co-ops, and often later founded private or charter schools, thereby influencing directly or indirectly the mainstream educational landscape. This movement eventually changed the face of institutional education. Homeschooling is now part of the mainstream and the resources to facilitate it have multiplied.
Medicine today needs its own equivalent of the homeschool movement. Ordinary people need to reappropriate the idea of self-care and autonomous healing that has been monopolized by physicians and other healthcare professionals. Just as homeschooling deinstitutionalized education, so we need to demedicalize healthcare, at least to some extent. Medical professionals have our role—just as professional teachers continued to have a role, influencing and sometimes assisting the pioneers of homeschooling. But doctors and nurses need not be the only game in town. Over time, perhaps in fifty years, this decentralized healthcare movement will positively influence, directly and indirectly, the practice of institutionalized medicine.
This kind of democratizing movement, empowering ordinary people to act autonomously in their own self-care, is not without historical precedent in American medicine. In the 19th century, practical books for the domestic practice of medicine enjoyed wide popularity. According to Pulitzer Prize-winning historian of medicine Paul Starr, “Written in lucid, everyday language, avoiding Latin or technical terms, the books set forth current knowledge on disease and attacked, at times explicitly, the conception of medicine as a high mystery.”[iii]
The most popular of these works was Dr. William Buchan’s Domestic Medicine, which carried the subtitle, “an attempt to render the Medical Art more generally useful, by showing people what is in their own power both with respect to the Prevention and Cure of Diseases.” The book went through more than thirty editions in America between 1781 and the mid-1800s.
Although the author was a member of the Royal College of Physicians in Edinburgh, the most prestigious medical institution of the day, he was highly critical of the medical profession’s monopolistic elitism, writing that “no discovery can ever be of general utility while the practice of it is kept in the hands of a few.” As Starr notes, “Though Buchan did not dismiss the value of physicians when they were available, he upheld the view that professional knowledge and training were unneeded in treating most diseases…Most people, he assured readers, ‘trust too little to their own endeavors.’”[iv]
Buchan maintained a general skepticism toward the value of drugs, preferring like the Hippocratic physicians to focus on diet and preventive measures. In his words, “I think the administration of medicines always doubtful, and often dangerous, and would much rather teach men how to avoid the necessity of using them, than how they should be used.” As Starr describes, “He counseled repeatedly that exercise, fresh air, a simple regimen, and cleanliness were of more value in maintaining health than anything medicine could do.”[v] This remains as true today as when Buchan wrote in the nineteenth century.
Today, the specific medical content of these books is less instructive than the fact of their enormous popularity, which indicated a culture that generally embraced a model of autonomous self-care, with lay medical wisdom cultivated in the context of the family. This was likewise a period of intense iatrogenic medical injuries, when “mainstream” medicine’s mainstays included harmful bloodletting and emetic purges for most diseases. Through these popularized works of domestic medicine, medical knowledge—such as it was at the time—and less aggressive medical interventions were democratized, decentralized, and made widely available to the broadest possible audience. Common sense was trusted to accomplish much of the necessary work, with physicians available when necessary for situations that the lay public could not manage.
The Hippocratic Society
In the realm of organized medicine, I’ll mention just one example of a parallel, alternative medical society that I recently helped establish along with three other doctors from Duke, Harvard, and Stanford. The Hippocratic Society, which as of this writing has chapters for pre-medical and medical students at eight universities, exists to form and sustain clinicians in the practice and pursuit of good medicine.[vi] “HippSoc,” as we nicknamed it, focuses on helping medical students and practicing physicians cultivate the virtues that characterize good medical practice. Today’s medical ethics often asks doctors to set aside clinical judgment in service to the expectations of third parties or to patient “autonomy” arbitrarily defined. In contrast, Hippocratic Society physicians seek to discern and do what good medicine requires, thereby fulfilling our healing profession.
As I discussed in a recent post, today’s corporatization of healthcare treats practitioners as interchangeable “providers” who are expected to “just do your job”—i.e., do what the managerial elites dictate—which contributes to a crisis of medical morale. The Hippocratic Society embraces medicine as a sacred profession in the service of the patient’s genuine good. In our age of medical censorship, HippSoc also sponsors fair, serious, and open discourse about the most important questions facing medical practitioners in our time. Against the tendency in academia to ignore or suppress disagreement and dissent, this new medical society promotes public dialogue and debate about difficult questions in medicine. We are confident that by reasoning together, medical practitioners can discern better how to serve our patients and fulfill our profession.
If we succeed, by 2035 every major academic medical center will have an active chapter of the Hippocratic Society. A dense network of senior clinicians will serve as mentors to medical trainees, and a parallel network of clinician chapters will support practitioners across the United States and beyond. The success of this enterprise will be measured not only by the number of chapters created or symposia held, but especially by the character and flourishing of the practitioners who participate in this community. HippSoc members will be recognized by their peers and patients alike as exemplars of the medical profession—trustworthy healers characterized by knowledge and skill, wisdom and compassion, courage and integrity.
This is just one example among the hundreds of new medical institutions that we need to begin building. If we fail to make the necessary reforms, young talent will be misdirected and their energies mismanaged. Iatrogenic harms from managerialized medicine will continue to multiply. The loss will be incalculable. This sobering and sometimes severe assessment of medicine’s current crisis need not be the last word. There is hope. If we succeed in building parallel institutions than can help restore medicine, the gains will be worth every effort. Renewal is possible if we put our hand to the plow and do the work.
[i] The concept of a Parallel Polis was elaborated by the Czech dissident, Vaclav Benda, who along with Vaclav Havel (later the first president of the Czech Republic following the fall of communism) and other collaborators opposed the Soviet Communist regime in the 1970s. See Benda’s essay on the parallel polis in Václav Benda, F. Flagg Taylor, and Barbara Day, The Long Night of the Watchman : Essays by Vaclav Benda, 1977-1989 (South Bend, Indiana: St. Augustine’s Press, 2017).
[ii] See my essay, “Rebellion, Not Retreat,” The American Mind, June 27, 2023.
[iii] Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982), 32.
[iv] Ibid., 33.
[v] Ibid., 34.
[vi] For more information, including information on how to start a new chapter, go to https://hippsoc.org.
Republished from the author’s Substack
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