Richard Smith: The faults and dangers of an iatrocracy

The first thing that struck Bernard-Henri Lévy, arguably France’s leading public intellectual, about the covid-19 pandemic was the rise of “medical power.” In his short, enjoyable, and provocative book The Virus in the Age of Madness he explains why such power is both undeserved and dangerous.

Now aged 71, Lévy is one of the Nouveaux Philosophes inspired by among others Michel Foucault, and he reminds us that Foucault observed that governments have learnt as much from the hospital as the prison. In The Birth of the Clinic Foucault described the management of outbreaks of plague in the 18th century: in Lévy’s words, “exile to an island or a ghetto on the outskirts of the city, as was the practice with lepers and the insane, gave way to confinement of entire cities, where all citizens were under house arrest and neighborhood watch patrols wrote up holdouts. Once night fell, everyone was out on their balcony, not to applaud the caregivers but to enable the sanitary authorities to tally up the dead, the dying, and the living.”

“But,” observes Lévy, “until now, never had things gone quite this far.” He emphasises the uniqueness of how we have responded to this latest in a long line of pandemics, including to the “Hong Kong Flu” of 1968 that killed a million people. “Never had we seen, as we did in Europe, heads of state surrounding themselves with scientific councils before daring to speak.”

After praising the health professionals who put themselves at risk by treating those sick with covid-19, Lévy writes “but to make physicians into supermen and superwomen and to endow them with extraordinary powers requires a leap that can be taken only with the help of several misconceptions.” He then explains those misconceptions.

Firstly, doctors and scientists do not always know more than others. Lévy, who is equally comfortable quoting Plato and Youtube, tells us that the French philosopher Gaston Bachelard observed that “scientific truth” is never more than a “corrected mistake.” The British philosopher of science Karl Popper also argued that the only “truth” in science is the hypothesis that has not yet been falsified, with the implication that one day it may well be falsified. Lévy supports his argument by quoting just some of the many doctors who have made statements like the “coronavirus is way less serious than influenza” that have proved badly wrong.

Secondly, doctors and scientists do not speak with one voice, as even the most casual reader of The BMJ knows well. Having been “fortunate enough to have arrived at philosophy through the door of epistemology,” Lévy notes that “the ‘community’ of scholars is no more communitarian than any other…is riven with fault lines, divergent sensibilities and interests, petty jealousies, esoteric disputes, and, of course, fundamental differences. I know that the research world is a Kampfplatz, a battlefield, a free-for-all no less messy than the one Immanuel Kant bemoaned in metaphysics.”

“The emperor has no clothes, even if he is a physician,” concludes Lévy. “Especially [his emphasis],” he continues, “if he is a physician. The renowned doctor, the big shot, however formidable and learned he may be, is naked under his white coat. And in that he reconnects with and shares the fate of the rest of humanity.”

Lévy’s third anxiety is the most worrying. He warns against what he calls “hygienics.” He defines it thus: “health becomes an obsession; all social and political problems are reduced to infections that must be treated; and the will to cure becomes the paradigm of political action.” We all know, he writes, where such a doctrine can lead, arguing unphilosophically it seems to me that one example will suffice. He tells the story of eugenics, which gripped France and other countries in the 1930s before being taken to its hideous extreme in Nazi Germany.

I’ve heard several philosophers say that the history of philosophy is essentially a matter of understanding Plato, and Lévy describes how in his dialogue The Statesman Plato considers a country run by physicians. After advancing several reasons in favour of an iatrocracy, Plato abandons the idea: in Lévy’s words, “Politics, he says, is an art that, since the retreat of the gods, deals with a chaotic, changing world, swept by storms and rudderless. But, in a storm, what is the point of a Hippocratic nosology of ‘cases’? Do not the difficult times call instead for citizen-guardians possessing the audacity and strength to think through, carve into stone, and proclaim legal ‘codes’?”

Doctors have important roles to play in a pandemic—primarily in treating the sick and advising on prevention—but they cannot become rulers, and politicians cannot hide behind them. And we, the people, must never succumb to the idea that a world run by doctors would be a better world.

Richard Smith was the editor of The BMJ until 2004.

Competing interests: None declared.