Abstract
This is a rich and beautiful volume on medical ethics in the form of a deeply personal reflection. The author, Aaron Kheriaty—psychiatrist, writer, and professor of psychiatry—shares the joys and suffering of medical practice while confronting the serious problems facing medicine and physicians today.
Kheriaty, who majored in philosophy and is well-versed in literature, diagnoses the illness of modern medicine: a faulty conception of the human being and a loss of trust in the patient–doctor relationship. He shows how patients are too often reduced to body parts rather than encountered as whole persons.
The analysis is not only penetrating but rings true for those of us who are physicians and who were once medical students and residents. The stories of patients’ suffering and the unequal relations within the medical hierarchy are rendered with honesty and recognition.
In a chapter titled, “Their Exits,” Kheriaty offers a diagnosis of the crisis in our society's and medicine's understanding of death. In my view, it is one of the finest chapters on death I have read. It exposes two opposite errors: “extreme artificial life prolongation” due to the denial of death's reality on one side, and the embrace of euthanasia on the other. The chapter closes: “Medicine must likewise learn to yield modestly before this mystery of human mortality. For in the face of death, medicine finds itself out of its depth. Instead of trying to master death, medicine needs to acquire the ability to stand aside when the time comes” (p. 99).
The problem of brain death criteria is addressed in the chapter, “Heal with Steel.” The author rightly decries the dualistic, mechanistic vision of the person in which the body becomes a mere repository of harvestable parts. He is equally critical of opt-out approaches to organ retrieval, which treat organs as commodities rather than as deliberate and personal gifts.
In another chapter, “Minds on Fire,” Kheriaty calls for understanding and compassion toward the mentally ill. He questions the wholesale removal of patients from mental health institutions—a concern underscored by estimates that 10%–25% of incarcerated persons suffer from mental illness. Later in the book, the author offers us a glimpse into the humanity and talents of such patients with a vivid and unexpected description of an impromptu music jam session with patients on a ward.
Throughout the book, Kheriaty draws on deep personal experience, including the loss of a close friend to suicide. He reflects on the suffering of both patients and physicians, and discusses three risk factors that erode the physician's capacity to encounter the patient as a whole human being. The physician–philosopher Karl Jaspers identified these three dispositions as skepticism, naturalism, and atheistic nihilism. Skepticism, a thoroughgoing doubt about truth itself, undermines the physician's capacity for committed, compassionate action. Naturalism, the reductive view that the human person is nothing more than biological processes, causes the doctor to treat patients as cases rather than persons, stripping away awareness of human dignity and transcendence. Atheistic nihilism, the most radical of the three, denies any ultimate meaning to existence, leaving the physician without the moral resources that sustain genuine care of patients through years of suffering and death.
Among the most striking chapters is “Diagnosing the Disease,” in which the author mounts a forceful critique of managerial medicine—its endless guidelines, its erosion of the patient–doctor relationship, and its displacement of the physician's judgment. He also unmasks the false claims of evidence-based medicine and randomized controlled trials, instruments designed and deployed largely by and for the pharmaceutical industry. The author offers some proposals for addressing managerial medicine, though one might wish for fuller development of the subject. Nevertheless, in this chapter and throughout the book, Kheriaty's commitment to his patients and to the integrity of medicine is unmistakable. Beyond his personal care for numerous patients, he has been part of initiatives such as the Center for Medical Humanities (at the University of California at Irvine) and The Hippocratic Society.
One dimension somewhat underrepresented in the book is patient spirituality and religion. It is a dimension the author clearly values, yet he treats it only lightly. Much the same could be said of his discussion of euthanasia, which invites more sustained engagement than the book provides. Topics on the beginning of life are also hardly discussed, although, for the most part, the author is presenting his experience as a psychiatrist.
Dr. Kheriaty conveys the hard realities of contemporary medical practice but does not leave the reader without hope. In the same vein as his mentor, Dr. Edmund Pellegrino, this volume is a recognition of the noble role of a physician, and an invitation to great respect for, acceptance of, compassion toward, and dedication to the patients in his care. In the book's closing pages, he expresses gratitude toward his teachers, patients, and family.
Ultimately, Making the Cut: How to Heal Modern Medicine is about re-discovering the patient as a whole being—body and soul, as a member of family and society—with a transcendent end. When we lose sight of this, medicine becomes a simple transaction and replacement of body parts. This book reminds us that the physician is a committed and vulnerable healer, dedicated to patient and family alike. This is the noble view of the physician that needs to be restored. Such a view of the patient, his family, and the physician rests on medicine as the art enshrined in the Hippocratic Oath.
