FAMOUS FACTORY MEATLOAF
“You see what is going on in this picture? It’s a battleship in the middle of the ocean, moving along at cruising speed. Alongside it is an oil tanker. You see those tubes there? What do you think they’re doing? That’s right, the tanker is refilling the battleship in the middle of the ocean. You realize how difficult that is? Massive ships, moving fast, in the middle of the ocean. Thousands of gallons of fuel. A lot could go wrong. You know how many times they have crashed? Never. Never! How do they do it? Both ships are staffed with hundreds of young people, fresh out of high school. They are neither experienced nor skilled, but the ships have never crashed, because they follow a well-designed process.”
The basement speaker clicks to the next slide. “What about this? It’s a restaurant. Hundreds of meals every night. Each meal made from scratch. Each meal modified for the diner. You don’t like cilantro? They leave it out of the pad thai. Gluten-free? They make your salad without croutons. I like cilantro and croutons myself, but more than anything, I like my meal the way I want it, and this place does it, night in and night out. They have twenty chefs in this kitchen. None of these guys is famous, but they make hundreds of perfect meals every night. How do they do it? See those computers above their kitchen stations? They are following standard work.”
The speaker gestures to his assistant to pass out a packet of articles. As she circulates around the room, he continues. “Over the last two decades, we have sounded the alarm about error in healthcare. We have talked about how healthcare workers do not wash their hands, about fires occurring in operating rooms, about surgeons operating on the wrong side of a patient’s body, about how patients leave the hospital with the wrong medications. Despite a whole lot of effort, all of those things are still occurring. And patients are fed up with these ongoing errors in hospitals. So hospitals will have to figure out what battleships and big restaurants already know how to do, to be highly reliable organizations that never, never make errors.”
As the speaker continues, he flashes images of workers assembling airplanes, automobiles, and rockets on the screen behind him. It is like a wartime propaganda film. I lose interest and start flipping through the packet his assistant is distributing. Inside is a copy of one of Atul Gawande’s New Yorker essays, “Big Med,” about how healthcare will be saved by becoming like the aircraft carrier or the assembly-line restaurant. I always look forward to Gawande’s essays, so I tune out the speaker and start reading.
In the essay, Gawande described a trip to the Cheesecake Factory during which he ordered “a beet salad with goat cheese, white-bean hummus and warm flatbread, and the miso salmon.”1 Pleasantly surprised by the meal, he asked a line cook how the kitchen prepared the 308 items on the dinner menu and the 124 beverage choices. The line cook told him that each chef followed recipes displayed on a computer monitor at his or her station. Each chef could quickly produce any meal on the menu and tweak it to a diner’s specifications.
Gawande was impressed. The Cheesecake Factory had figured out how to provide delicious meals at affordable prices by training its chefs to produce them efficiently and to incorporate new items effectively into the restaurant’s ever-changing menu. He argued that medicine should follow suit. The training of today’s physicians is both inefficient—a disjointed series of lectures, apprenticeships, and continuing medical education conferences—and ineffective, resulting in inconsistent patient outcomes. Sometimes physicians are like chefs who make beautiful meals but do not know how to get the dinner to the table at the right time for the right price, and sometimes they are like chefs who hastily deliver economical but unappetizing slop.
As I sat pondering Gawande’s analogy, I wondered whether a restaurant that served beet salad with goat cheese offered the best analogy for the kind of medicine Gawande was advocating. Curious, I looked up the Cheesecake Factory’s menu. So many meals, garlanded with so many adjectives. Baja Chicken Hash. Giant Belgian Waffle. Jamaican Black Pepper Shrimp. Sunrise Fiesta Burrito. Famous Factory Meatloaf. It was this last that struck me as a more fitting representation of what Gawande and the basement speaker wanted for medicine. Ordering the more fashionable-sounding beet salad missed the fact that if contemporary medicine is a meal, they were insisting that it be produced through industrial processes perfected at factories.
If Osler created a ladder for medical training—medical student to intern to resident to attending—then it was his contemporary, the legendary chef Auguste Escoffier, who created the comparable ladder for kitchens. It was Escoffier who codified the famous brigade de cuisine that characterizes a French haute cuisine kitchen. At the large hotels where Escoffier perfected the brigade system, a maître de cuisine oversaw several teams. Each team was headed by a chef who oversaw a particular portion of the meal: a chef pâtissier took charge of desserts, a chef rôtisseur the meat dishes, a chef saucier the sauces, a chef entremetier the soups and vegetable dishes, and a chef poissonnier the seafood. He even assigned a chef garde-manger to manage the pantry and a chef de nuit to operate the kitchen overnight.
In Escoffier’s kitchen, each chef held his particular position for a time. A chef would spend months or years managing the pantry before learning to roast meats, prepare soups, or make sauces. Like Osler, Escoffier modernized his discipline by encouraging specialization and training. Through the process, a chef mastered the skills specific to each technique before becoming maître de cuisine of his own kitchen. Every chef learned every role. A person who invested time and energy in the kitchen departed with skills and with a new social role: master chef. In this way, Escoffier’s kitchen was invested in transmitting the traditions of French cuisine by training apprentice chefs to be master chefs.
In addition to passing on the traditions of French cuisine and developing apprentices into masters, the brigade system was designed to enable the cooks to quickly prepare the meals ordered by a patron. According to Kenneth James’s biography, Escoffier’s “aim was for speed with quality. He achieved this by a production line technique where processes were carried out in parallel instead of sequentially, and each by a cook well-practised in his allocated procedure. [Escoffier] was able then to reduce the customers’ waiting time to a minimum and to serve a quality dish at the right temperature.”2 Like Osler, Escoffier encouraged efficiency and effectiveness through the repetitive performance of a particular task.
The attending physician and the maître de cuisine were both men (or mostly men) who clambered up their professions’ respective ladders by apprenticing themselves to more experienced practitioners. As they learned skills in these apprenticeships, they acquired the habits of the profession, and then, once they had completed their training, they transmitted those habits to students.
At first blush, the Cheesecake Factory sounds like a contemporary version of Escoffier’s brigade. The Cheesecake Factory shares Escoffier’s goal “to reduce the customers’ waiting time to a minimum and to serve a quality dish at the right temperature.” But the Cheesecake Factory is not a unique restaurant; it is a chain. The recipes at the Cheesecake Factory do not come from either the master chef or his or her subordinates in the brigade. The recipes come from corporate headquarters. Every six months, corporate headquarters introduces a new menu to match the fluctuating prices of food and the changing tastes of diners. For each dish, headquarters creates a script and then trains line chefs to follow the scripts. Less than a month after the new recipes are transmitted, line chefs are following the recipes and uniformly producing the meal designed at headquarters. The line chefs in this kitchen follow a corporate script rather than the counsel of a learned maître de cuisine.
Indeed, although the recipes are created by the corporation’s chefs, the individual kitchens have no real maîtres de cuisine. In their place are kitchen managers looking over the shoulder of each line chef. If Escoffier’s maître de cuisine was concerned with the quality of the meal, the Cheesecake Factory kitchen manager, according to Gawande, looks for waste and lost profit. For the kitchen manager to achieve the efficient results demanded by the Cheesecake Factory requires, in Gawande’s words, “control, and they’d figured out how to achieve it on a mass scale.”3
Control on a mass scale.
Quality-improvement advocates such as the basement speaker and Atul Gawande believe that the only way to fix healthcare is through controlling the practice of medicine on a mass scale. Healthcare is the largest industry in the United States, so we must use economies of scale to drive down costs and improve quality.
Most contemporary healthcare reform debates thus revolve around who controls healthcare, and the controllers are always conceived as some version of the market or the state. One side argues that government payers should mandate the care provided to patients. The other side argues that the market should determine what care is provided to patients. The genius of Gawande is that he split the difference, finding, in the kitchen of a casual dining restaurant, a happy synthesis of government regulations and market forces that he believed could work in healthcare. Just as the government regulates the production, preparation, and sale of food to ensure safety, it can regulate industrialized healthcare to protect patient safety. The market would determine what should be served, and the state would regulate its safety.
In this analogy, hospitals learn from chain restaurants to deliver innovative care to the most people possible for the least amount of money. Hospitals, like the Cheesecake Factory, could be improved if administrators studied best practices, standardized those practices, and then implemented them. Gawande argued that while physicians often know what the best practices are (such as those vetted by the Cochrane Collaboration), and even how to standardize them, they struggle when it comes to implementing them. It often takes physicians decades to introduce innovative practices into medicine; the Cheesecake Factory line chefs can master new recipes in days. Medicine, claimed Gawande, must be similarly standardized.
To illustrate the benefits of standardization, Gawande described how a private investment firm transformed six faltering hospitals by implementing “large-scale, production-line medicine” in their Intensive Care Units by combining bedside care with remote monitoring.4 In these units, physicians and nurses at the bedside were like line chefs, while the physicians and nurses who remotely monitored the units were the kitchen managers. Describing a physician who remotely oversaw the units, Gawande wrote: “Ernst believes that his job is to make sure that everyone is collaborating to provide the most effective and least wasteful care possible.” Ernst watched for errors—disconnected tubes, improper bed angles—and corrected them through video communication with the bedside staff. In Gawande’s description, Ernst sounded less like one of Escoffier’s maîtres de cuisine and more like a drone strike operator, a technician working at a bloodless remove from a deadly situation. The system Gawande described required bedside practitioners to perform, and remote practitioners to enforce, evidence-based standards of care. If this is what the future of medicine looks like, there will be bedside and remote physicians, just as there are kitchen managers and line chefs, but both kinds of physicians will work for the corporation that mandates the care the physicians do (and do not) deliver.
When we compare medicine to a standardized meal, we should ask what is lost in the process. Surely a meal can offer a very different experience to the patron even if it is prepared using the same ingredients, recipes, and techniques. Eating a beet salad prepared by a chef for restaurant patrons is a different experience from eating the same dish prepared for a potluck supper, a romantic meal shared by lovers, or an institutional meal served to prisoners, let alone a ritual meal like a familial Seder, a communal Iftar, or a prasada offering. The meals we eat have different meanings for us based on the occasions for which we prepare them and the people with whom we share them. When we focus on technique and outcomes, without concern for who prepares the meal for whom, the experience of the meals is neglected. Food becomes fuel.
When we extend this approach to the hospital and the clinic, the body is reduced to a collection of parts.
. . .
A neurosurgery resident is on the phone, apologizing for the call. He is requesting an ethics consult, and, as a member of our hospital’s ethics committee, I answer his page. For the past decade, I have served on the ethics committees of the hospitals at which I have trained and worked. Sometimes we are consulted about difficult moral dilemmas, but most consults stem from a conflict between practitioners and patients, or their representatives, over when or whether to perform a medical intervention. The issues concern who controls the body, often a body in an Intensive Care Unit like those Ernst supervises.
“You can’t do anything, I know, but my attending made me call,” the neurosurgery resident says wearily. “It’s hopeless. She is brain-dead on a blower, but I’ve talked to the family and they just don’t understand. We’re going to have to do the procedure anyway.” I reassure him that he was right to call, and I ask the patient’s name.
Tihun.
Tihun is a fifty-nine-year-old grandmother and Ethiopian immigrant. Several months before the consult, she was at home, watching three of her grandchildren while her daughters worked. Tihun suffered from a dull headache, but then the ache enveloped her. She began sweating and breathing heavily. She told her granddaughter she was struggling to stay awake. When the ambulance arrived, the paramedics found Tihun unconscious on her daughter’s couch. Indeed, since the moment she lay down on the couch, Tihun had never regained full consciousness.
Sometime that afternoon, Tihun had suffered a hemorrhage of her pons, a portion of the brain that bridges the cerebrum and cerebellum. When the pons is damaged, it is a struggle to breathe, hear, move, sleep, and taste. For Tihun, the damage left her in a persistent vegetative state, a euphemism for a condition in which a person is awake but not aware.
The neurosurgery resident believed Tihun would die soon. How soon? He could not say, but he believed that further treatment would be meaningless. Tihun’s daughters, on the other hand, wanted the neurosurgeons to place a permanent shunt, a sterile plastic drain, in the ventricles of Tihun’s brain. When cerebrospinal fluid built up in her brain, the shunt would relieve the excessive fluid her body could no longer remove on its own. When I asked the resident about the shunt, he told me, “It’s futile. The shunt won’t affect her function. She has zero chance at meaningful further existence.”
I asked to meet with the daughters. Through an interpreter, we sat down together in the break room on the surgical floor. They had never talked with their mother about what she would want done in this situation, but they did recall that Tihun would comment, “As long as there is life, there is hope,” which they took to mean that she would want to remain alive. Neither daughter had much medical experience or had ever seen anyone die. What they had seen was the effects of a shunt. The daughters said that earlier in the week the neurosurgery team had proposed a permanent shunt to replace a temporary shunt that had reduced Tihun’s agitation and pain. Throughout the conversation, they used the word pressure again and again, saying, “We want her to feel less pressured.” To her daughters, the shunt relieved pressure on Tihun’s brain. That was, after all, what the physicians had told them it would do. Her daughters also claimed that Tihun seemed different when the shunt was placed. They said she was “less pressured,” and thus more able to be comforted by her family. They found this change meaningful.
They had known Tihun’s maternal attention and affection, and they told me, “We want to care for her as she cared for us.” I asked if they could recognize a difference between Tihun’s maternal care and our invasive medical treatments. They could not.
I could sympathize with Tihun’s daughters, who loved their mother and wanted to repay her affection by caring for her. But I could also sympathize with the neurosurgeon. I wished he had not suggested a procedure he believed would be futile. He had recognized, belatedly, a difference between caring for someone and performing a meaningless surgical procedure.
Seeing Tihun reminded me of when I was a medical student on the surgery services. I was forever getting caught up in the existential questions raised by illness, the disparate ways a person was altered by entering, through injury or illness, into the kingdom of the ill. Most of the surgeons I met were devoted, disciplined, and disinclined to take up such questions. They focused on body parts and wanted to talk about procedures—how to close a patent ductus arteriosus or to complete a living donor liver transplant, not what to meant to close a hole in one person’s heart or to take a portion of one person’s liver and place it another person’s abdomen.
Quality-improvement experts can tell us the best way to complete both procedures. This, the accumulation of a century of learned effort, is a mighty achievement. Using the scientific spirit Osler summoned, the epidemiological rigor Cochrane championed, and the operational efficiency Deming routinized, today’s quality-improvement experts design protocols and techniques for operationalizing our best practices from evidence-based documents like Cochrane reviews, turning several-hundred-page summaries into processes as clear as those displayed on the computers of line chefs at the Cheesecake Factory.
In their inability to answer the questions of either the neurosurgery resident or Tihun’s daughters, though, we find a limit to what quality-improvement experts can do, to their claims to improve patient outcomes by displacing the subjective judgment of physicians with objective, evidence-based guidelines. In Tihun’s case, those guidelines would help the surgical team place the shunt as efficiently and effectively as possible. But the quality-improvement experts cannot explain what it means for Tihun, her family, and those who care for her to keep her in a persistent vegetative state. This kind of life/nonlife is possible only through contemporary medicine’s technological control of the body, and no one knows how to define the meaning of such a life. Or how we can reconcile our furious efforts to keep Tihun alive with our anger at her daughters for wanting the very medical procedures we offer them.
Gawande characterized the meals at the Cheesecake Factory as “sweeter, fattier, and bigger” than necessary, but he and other quality-improvement advocates insist that Cheesecake Factory–style standardization is the solution to the healthcare system’s ills.5 Medicine, they say, is a series of procedures, scientifically informed techniques, that physicians provide to healthcare consumers. The pressing problems with medicine are not that it cannot answer the questions of Tihun’s daughters or her physicians but that it is unable to deliver technical advances reliably enough. The solution therefore lies in delivery models that increase the medical profession’s ability to innovate, to provide ever-better procedures ever more efficiently.
In this model, each physician becomes a technician, with a specific role to play in an industrial process. If we accept Gawande’s analogy, we accept that we renew hospitals and clinics by turning them into factories where the physicians do not so much use a tool to encourage a patient’s healing as engage a patient in an entire system of healthcare. I learned about this shift from tool to system from an interview with the philosopher Ivan Illich. I had not read Illich’s work since medical school, when a professor recommended his landmark Medical Nemesis, which criticized contemporary medicine for medicalizing human existence.6 Years later, in the last interviews he gave, Illich observed that what he had failed to recognize earlier in his career was that we have entered an era of “systems.” Whereas we once used tools that were separate from their user, Illich said, we now engage with systems from which we perceive ourselves as inseparable. “In a system the user . . . becomes part of the system.”7 Instead of encouraging patients’ ability to heal themselves, like a Hippocratic physician, or wielding a tool to affect the healing of a patient, like a nineteenth-century physician, the physicians of today, Illich concluded, are technicians who are inseparable from the systems in which they engage their patients.
So the line chef at a computer monitor or Ernst at his command center engage with the meal or the ICU patient only through the computer, and the computer is an instrument not of the chef or the physician but of the total system, the casual-dining restaurant or the chain hospital. Neither the chef nor Ernst can perform his or her task apart from the system. Unlike the earlier professionals who advanced through the hierarchies established by Escoffier and Osler, the chef and Ernst learn skills valued only within the system. The authority that was once localized in the physician is dispersed throughout the healthcare system.
In such systems, Illich says the patient is conceptualized as “a system, that is, as an extraordinarily complex arrangement of feedback loops.” The physician-technician perceives the patient as an inanimate, albeit complex, object to be controlled.
Illich’s comment made me flip back through Gawande’s essay. I wrote down all the things to which Gawande compared an ill person—a house on fire, a car, a solar panel, and a variety of meals—all inanimate objects. The restaurant analogy was actually harder to apply to medicine than it appeared: to the extent a patient requests a medical intervention, she or he is like a restaurant patron, but to the extent a patient is an object produced by a medical intervention, she or he is like the meal itself. Is an ill person the “product” of healthcare the way a meal is the product of a chef’s work in the kitchen? A chef can manipulate the ingredients of a meal to whatever degree his or her skills allow, but by what should a physician’s manipulation of the body be limited? How does this analogy take into account the needs of the patient and the ethical responsibilities of the physician? When we compare the ill to objects and declare the central question of medicine to be one of control, we reinforce the domination that Illich feared medicine exerts over them.
When we focus on outcomes—the ordered meal, prepared effectively and efficiently—over how and why the meal is prepared, we neglect the ways a process has meaning independent of its outcomes. That is another way in which restaurants are unlike hospitals. In a restaurant, you can always send back your overcooked plate of Famous Factory Meatloaf, and the kitchen will replace it with a new serving. In a hospital, the patient cannot ask for a new body. Patients have to live with the bodies with which they enter the hospital. Human bodies can be tinkered with, repaired sometimes, even improved on occasion, but cannot, finally, be fixed. We do a disservice to patients and their families when we suggest otherwise, when we encourage them to place their final hopes in medicine. The neurosurgery resident can either place or not place the shunt within Tihun’s ventricles, he can relieve pressure or not, but the eventual outcome will still be her death. So sometimes how and why we care for the ill matters more than outcomes in hospitals.
Quality improvement enjoys support from hospitals, insurers, and regulators, but also from venture capitalists, tech evangelists, and corporate America.8 The quality-improvement movement speaks to our technological utopian moment—how cool is it that we can refuel battleships in the ocean or that Ernst can monitor critically ill patients from thousands of miles away? But in turn it forces physicians and other practitioners to understand themselves as technicians instead of artisans. They are Ernst rather than Osler, line chefs rather than Escoffier, users of a system rather than wielders of a tool. So physicians have to abandon traditional ethical models intended for artisans and embrace the ethics of technicians. The ethical model of artisans is often called “virtue ethics,” which makes it sound like training for Victorian-era prudery. But virtue ethics is not about sex, it is about how we form habits through relationships. In a virtue ethics account of medicine, a physician learns virtues like curiosity, humility, and patience through apprenticeships to excellent, experienced physicians. In today’s ethical account of physicians, they are first and foremost efficient and effective technicians, inseparable from the system under which they work. So we develop systems and scripts with reliable outcomes instead of virtuous people who care for patients.
Systems work best in a world of quickly assembled (and disassembled) teams, and they encourage transient connections between these teams. If you work in one of today’s medical factories, you often do not know which patients you will see on a given day. If you are superstitious, you might believe that full moons draw, like ill tides, waves of peculiar patients. If you are cynical, you might believe that the waning days of the month bring dependents whose government checks have been drunk away. If you are exhausted, you might believe that your very presence attracts the most demanding drug-seekers. Whatever you believe, you care for the patients on your clinic schedule, census sheet, and sign-out list, along with whoever else gets added to the queue.
If you work in one of today’s medical factories, you also often do not know who will work alongside you. Some days, I work with students from two or three disciplines, professionals from four or five disciplines, and multiple physicians. Even on days when I see patients alone, I speak with social workers, nurses, various therapists, and consulting physicians. We build and disassemble teams throughout a hospital day.
And just as the kitchen staff and the dining room patrons are strangers to each other, so too in hospitals, where teams of strangers prepare treatments for patients who are mostly unknown to us. We know our patients as the MI in five, the UTI in seven, and the SI in nine. They know us only because the nurses write our names on the board above their beds. We know the patients as a myocardial infarction, a urinary tract infection, or a suicide attempt. Even our names written above the bed are a kind of deceit: in a single day in a contemporary hospital, the physician responsible for a patient’s care can change with each shift. So to stay organized, physicians are learning to follow processes perfected by restaurants that have learned to handle the problem of strangers preparing food for strangers.
Of course, complex processes rely upon an individual practitioner’s ability to tinker in the face of unanticipated events. The chef needs to be able to tinker with a recipe when the tomatoes are overripe or the fruit is sour. Physicians likewise need to tinker with evidence-based scripts, and they have to be trained to figure out when and how to do so. The ability to tinker, to adapt to changing circumstances, is hard to account for in industrial processes focused on consistency, but in virtue ethics tinkering is easily accounted for through the virtuous habits of attentiveness to detail and flexibility, habits we cultivate through life in a community. Even the best-engineered processes depend on these habits in their practitioners. But quality-improvement advocates claim that well-engineered industrial processes actually cultivate virtuous habits—they describe the wisdom of group rationality as embodied in industrial processes. And so physicians and other practitioners are being asked to learn not only our skills but also our ethics from participating in industrial-scaled systems.
But when the neurosurgeon resident pages me about Tihun, it is an implicit acknowledgment that the ethics of this system are inadequate. The neurosurgeons had done everything they were supposed to do according to the quality-improvement literature. They took a careful history from Tihun’s daughters. They used an interpreter. When they finally agreed to the surgery on which the daughters insisted, they completed two separate checklists before making an incision. During the operation, they counted surgical instruments and pads to ensure they left none behind in Tihun’s body. The operation was as efficient and as effective as the preparation of a meal in a corporate kitchen, but the surgeons operated with gritted teeth. Afterward, the resident again characterized the procedure as “meaningless” and Tihun’s chances of “meaningful recovery at zero.”
When I met with Tihun’s daughters again after the permanent shunt was placed, they were pleased at the relief Tihun exhibited with less cerebrospinal fluid bearing down upon her brain, but they too were frustrated. They distrusted the surgeons. I asked whether they or Tihun trusted anyone to advise them about her health. They named the priest at their Ethiopian Orthodox church. They said he knew Tihun and understood what she wanted. They described Tihun as devout, making frequent appeals to God, as well to the Kidusan, a multitude of saints and angels who intercede with God on behalf of the faithful. I asked whether the physicians had ever spoken to the priest. The daughters shook their heads.
Tihun had a ladder as well, but it extended not up the line of a kitchen or the wards of a hospital but to her God. The neurosurgeons had involved Tihun’s daughters, but not her priest, the Kidusan, or her God. They never figured out what being ill and receiving medical care meant to Tihun and her family.
Quality-improvement advocates rarely entertain the possibility that traditions outside the restaurant might have something to say about what we should eat and why—the possibility that instead of avoiding unwanted fuels, carbs, sugar, fat, or gluten, someone might want to avoid food that is treif or haram or contains the five pungent spices, food prohibited, respectively, in Judaism, Islam, and Buddhism. Similarly, the industrial hospital rarely considers that the traditions of health and illness and medicine embodied in Judaism, Islam, or Buddhism, with their millennia of wisdom, might teach us about processes relevant to good medical care. But this is perhaps more of a coup than an oversight. Foucault observed that in Western society, medicine replaced the cultural role of the church—displacing salvation with health and priests with physicians—but maintained its moral obligation. In the medieval era, we sought salvation; in the modern era, we are obligated to seek constant improvements in medical performance. We now believe suffering is bad itself, so we are morally obligated to eliminate pressure and pain. We physicians reduce pain simply to minimize it.
Foucault showed that we no longer allow alternative interpretations of the body. The body is interpreted by medicine or by the powers of modernity that it serves—the market or the state—not by the family or members of the synagogue, mosque, or temple. So the quality-improvement movement proposes to renew medicine within itself, by reducing adverse events, improving outcomes, and saving lives, without ever pausing to ask why we pursue health or to what end we seek to prevent death. When alternative interpretations of the body are disallowed, medicine circumscribes morality because it controls the only goods that we pursue: the elimination of suffering and the perfection of the body. Health is the good, so our pursuit of health for its own sake becomes the focus of our lives. Indeed, our lives become the avoidance of death. We resist death to resist death.9 Or, returning to the restaurant analogy, we eat to eat.
In our new world of medicine, life consists of parts in motion, and medicine’s job is to keep those parts moving. We die when a clot ruptures and occludes blood supply to our brain. That is all physicians can see. When we see the body today, it becomes an object that can be controlled and disciplined by medicine for the benefit of the market or the state. We see what happened to our bodies, not what our bodies mean as we live, love, and labor with our family, friends, and communities. We can no longer see the deep patterns of our bodies or their ultimate meaning.
I am not sure Tihun’s daughters could, either. While they invoked Tihun’s faith, they were also the ones who requested the shunt. They were pursuing the relief of Tihun’s pain with limited regard for what it would mean to Tihun’s life. Tihun’s daughters seemed obviously distinct from the neurosurgeon—by gender, ethnicity, and faith—but they were already part of the system. They wanted to order off the hospital’s menu. They wanted to decide for Tihun.
In contemporary medicine, ethical conflicts are reduced to considerations of who decides, who chooses, and who orders what for whom. Someone has to choose, so questions of choosing, of control, are the only questions we ask. The Cheesecake Factory offers many options, but the limitation is that you have to pick something from the menu, and you are not encouraged to ask why you should eat it or what it means to eat all that food.
Of course, the most recent trend in restaurants is to emphasize the authentic, local, and particular. The garlic scapes are grown behind the restaurant. The chef forages for the morels. The eggs were laid that morning by the restaurant’s prize hens. The particularity of each ingredient, each chef, is celebrated. Every time I go to work, though, the hospital is celebrating the consistency of its production. The infection rate beats the national average. The surgical suite is set up according to international guidelines. The physicians are assessed through Press Ganey scores. The uniformity of each procedure, each provider, is celebrated. I wonder why we are moving away from standardization in our restaurants and toward it in our hospitals.
Instead of altering medicine so it can serve the complex meals only an industrial process can produce, we could call on medicine to serve simple suppers. Instead of calling on physicians to become line chefs or kitchen managers in an industrial process, we could call on them to be, like farm-to-table chefs, rooted in the particularities, the terroir, of a local community. We could reinvigorate the guild model and its model of the physician as an artisan who carefully passes on accumulated wisdom. Just as some food writers suggest teaching people to cook at home rather than to eat out, we could empower patients to choose healthy habits as a way to practice self-care.
The American government currently has more than a dozen different agencies measuring the quality of medical care. Insurers, accrediting agencies, and licensing boards have their own measures as well. Together, they are pushing medicine toward uniform outcomes, with little acknowledgment of the particularities of people and places. The goal of standardization does not recognize that excellence can be achieved in many different ways—Ethiopian cuisine should not be like the food at the Cheesecake Factory. It took us decades to pivot away from the standardization of food, and someday we may shift our focus away from the standardization of medicine.
For now, though, we are eating Famous Factory Meatloaf. It is efficiently and effectively prepared fuel, but it is not a meal. For a true meal, you need other people with whom to share the food and a culture of preparing, serving, and sharing food. Beyond bare quality improvement, we need to cultivate a culture of health that addresses the analogous questions of what it means to be well, to be ill, and to seek and provide medical assistance. We need a way out of the factory.