Medicina via negativa
Or, the highest form of medicine, or, taking the Hippocratic Oath seriously
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"Via negativa," also known as the "negative way", is a theological concept and philosophical approach that seeks to describe God, the divine, or other ineffable concepts by specifying what they are not, rather than attempting to define what they are. This approach acknowledges the limitations of human language and cognition in grasping the full essence of such concepts. By eliminating attributes or qualities that are not appropriate for the subject, it helps to clear away misconceptions and create a more precise understanding, even though this understanding remains incomplete.
In the context of theology, via negativa is often used to describe the divine by negating attributes that are seen as inadequate or inappropriate when applied to a transcendent being. For example, one might say that God is not limited, not changeable, not confined to time, etc.
Via negativa is also used more broadly in philosophy, where it’s applied to various concepts that are difficult to pin down or define positively. This approach is especially popular in certain Eastern philosophical traditions, such as Zen Buddhism, where it is used to point towards a direct experience of reality that transcends linguistic or conceptual categories. To put it more simply, via negativa is a way to approach ideas or systems of extreme complexity. Second and third order effects of altering a complex system can be difficult, or even impossible, to predict.
In the context of health and medicine, we are always dealing complex systems with complex interactions. It is impossible to fully grasp the overwhelming interconnectedness of processes that go on in the human body and relation to their immediate environment. Thinking it can all be completely understood is utter hubris.
To sustain life, billions of cells and all their component parts must interact with each other and maintain an appropriate balance. This balance is called homeostasis. Homeostasis is not static, but dynamic. So while the body as a whole must maintain an equilibrium, the variables are always changing and moving through various levels of imbalance. Ideas in ancient medicine, such as “humors” in Western Medicine and “qi” in Eastern, tried to encapsulate this idea of a dynamic balance.
As a quick and simple example, think about energy availability. Throughout the day, sources of fuel (food) are intermittently added to the system. First, the food needs to be broken down and turned into a fuel the cells can use, and that fuel needs to be regulated so that it can be available over the next few hours or longer to continue to maintain necessary cellular functions. There’s a constant imbalance of fuel availability, but your body is able to maintain an appropriate balance so that all organs can continue functioning properly.
In general, the body does a fantastic job of maintaining this constant imbalanced balance through countless methods of cell signaling and response. Some cell signals are meant for those in the immediate vicinity and induce immediate action, while other signals are meant for cells far away within the body with responses that take months to years to enact. Think of all the conversations that may be had across New York City in a typical business day and how complicated it would be to try and track them all.
Our bodies are resilient and able to handle the varying imbalance caused by both internal and external stressors, but the balance is delicate. Medicine has always tried to help maintain this balance, and most of the time this involves intervening in some way. Obviously if you see something wrong, you should fix it. If an artery has been cut and is gushing blood, it should be sewn back together. If a bacteria has spread systemically through the body and is causing septic shock, antibiotics are necessary to push the body back into balance. For serious, acute problems, intervention is necessary, and modern medicine is better at this than it’s ever been. Rapid imbalances can be fixed with rapid intervention.
Chronic diseases have to be managed differently. Chronic diseases include heart disease, hypertension, type 2 diabetes, etc. These diseases are the result of imbalances that developed over months to years, not overnight. As with all imbalances, the initial impulse is to intervene in a way to fix the problem, and with the current paradigm of modern medicine, this is usually with a medicine. There are countless medicines that can be used to lower cholesterol, blood pressure, or blood sugar and restore a semblance of balance. All these medications, though, cause greater disruption to the dynamic balance of the human body. By adding a medication, you are adding an extra variable that needs to be integrated into the balance, and the variable is often a foreign, synthetic substance that the body has no prior experience or reference about how to properly manage. Adding a medicine disrupts the immense complexity of all the cellular interactions, the second and third order side effects cannot be predicted. Medication doesn’t cure the cause of the imbalance, it just gives the illusion of balance while the actual cause of the imbalance continues to progress and strengthen.
Written in about the 5th century BCE (2,500 years ago), the Hippocratic Oath has been reduced to a very simplified form of “Do No Harm.” Many inconvenient parts, such as medical education being free and abortion being antithetical to the purpose of medicine, have been taken out. We barely even pay lip service to what little remains of the Oath. Every additive intervention (ie medication) will cause harm. We justify it, though, because the idea is it does less harm than the disease process it’s trying to fix. As we’ve extensively discussed in other essays, it doesn’t fix the problem, but masks it.
While sometimes necessary for severe acute issues, prescribing medications to manage chronic diseases is the lowest form of medicine. It often actually would be better to have an inattentive, lazy doctor that did nothing than one that over-prescribes medications to micromanage even the smallest lab abnormality. The doctor that prescribes a statin as soon as your calculated 10 year ASCVD risk (risk of severe cardiovascular event, like a heart attack or stroke) equals 7.5% or prescribes an anti-hypertensive when your blood pressure is 136/90 at two separate occasions is not the best doctor if your goal is to live a long and healthy life. (Both of these interventions would be the recommended management based on medical society guidelines.) Even worse, it has become somewhat fashionable among “longevity doctors” to prescribe statins, metformin, and other drugs in a completely prophylactic manner, regardless of any signs of disease progression.
The highest form of medicine is to understand that the body is perfectly well equipped (barring significant genetic incapacity) to maintain an appropriate balance, or self-sustained equilibrium, and that chronic disease simply represents a persistent imbalance. The doctor’s job, then, is to identify what substance or practice is disrupting the balance, and help to remove it. This is Medicina via negativa, or medicine by removal. This is also the only way to practice medicine and truly follow the Hippocratic Oath, since adding medication or other intervention will cause harm.
There are appropriate times and places for medication, such as when the chronic condition has gotten so acutely severe that it poses an immediate threat to life. Short-term medication in this case would be warranted. (But even acute illnesses, such as those caused by viruses, are often overly and inappropriately treated with antibiotics. Even in acute cases, use of medicine needs to be thoroughly evaluated.) Also, some people may have sustained damage to an organ or other regulation mechanism, either from a traumatic event or due to persistence of a chronic disease, that is beyond repair and prevents the body from properly regulating itself. Medication may also be necessary here as well.
As you can see, this highest form of medicine, Medicina via negativa, involves the patient making appropriate lifestyle changes to heal themselves. As with all chronic diseases, they are not healed by the doctor, but by the patient. Intervention by the doctor is more likely than not to lead to greater harm down the road. This seems to minimize the doctor’s role, and in a sense it’s not a bad thing. This style of medicine actually makes the physician’s job much, much harder. Rather than taking five seconds to write a prescription, it involves thoroughly discussing the patient’s lifestyle, identifying the problem, and working with the patient to develop a plan to make appropriate changes. It involves emotionally investing in the patient and persistently encouraging them. It involves identifying unhealthy habits and disease processes early, because the earlier it is addressed, the easier it is to fix. It involves dealing with setbacks, monitoring even the slowest of improvements, and developing the mental fortitude to accept increased short-term risks for the benefit of long-term reward.
In Hippocrates’ time, food was considered medicine. Different herbs or soups were recommended at different times based on the patient’s physical condition. More importantly, certain foods were often abstained from during times of illness. In our current culture, food has become a poison. The vast majority of chronic disease is due to our diet, or an imbalance of persistent excessive energy availability. This means the intervention is often dietary change, or removing the type or amount of food causing the imbalance. This is difficult because of habit, addictive qualities of the food, and a cultural paradigm that promotes indulgence.
The body positivity movement has been extremely damaging to population health. While it may have had some good intentions, the results are devastating. Celebrating obesity is a uniquely western thought, developed to coddle the most fragile egos. In most Asian or South American countries, people won’t hesitate to mention if you’ve been putting on weight. In America that is considered hate speech. When a Taiwanese a’ma (grandmother) asks if you’ve been eating too much rice lately, it’s not fat shaming, it’s a gentle reminder that she is concerned about your health and that you should practice some medicina via negativa, and remove excesses from your diet.
This cultural perception doesn’t make the doctor’s job easy, especially when the American Heart Association’s approval is stamped on countless sugary cereal boxes. The body positivity movement has persisted, not because of its positive effects on mental health, nor despite its extreme negative effects on public health, but because it involves increasing profits to pharmaceutical and large food manufacturers whose marketing budgets allow for bribing governmental and medical institutions and providing much more appealing commercials to eat their literal poison. As always, the poison is in the dose, but many of our foods today (mostly highly processed carbohydrates and oils) are literal slow-acting poisons that gradually destroy our organs.
In a culture that celebrates excess, it is a doctor’s job to preach austerity. It is easy to get caught up in various movements, and simply parrot lines of body positivity and self-acceptance. There is a strong belief in “nutrition” circles that patients shouldn’t be told to avoid foods, and that there’s no such thing as unhealthy foods. This outrageous claim also has the support of Presidentially-appointed health experts. It is almost unbelievable how promotion of dangerous practices can be so widespread and supported and it leaves physicians fighting a Sisyphean uphill battle. But doctors that don’t point out this blatant misinformation are doing their patients a disservice.
Health is valuable, maybe the most valuable attribute a person may have, and as such it is not cheap. In a world where so many influences push towards unhealth, or disease, the price for health is even higher. Good health comes at a price, and not just a higher bill at the grocery store. Yes, there is an abundance of cheap unhealthy foods, but being healthy doesn’t have to be costly just in the monetary sense. The poorest communities in the world often have the fewest chronic diseases.
In Bitcoin, “proof of work” is a prominent concept. It is also a lightning rod for haters and governments trying to cling to their authoritarian fiat currencies. Proof of work refers to the fact that in order to mine a block, obtain the block reward (a certain amount of bitcoin that varies from block to block), and further secure the blockchain ledger, an input of capital is required. There is no reward without first spending the money to purchase bitcoin miners (computers that solve the algorithm to mine a block) and supplying the electricity for them to run. Compare this to the US Dollar, or any other government fiat currency, in which the supply of available money can be increased dramatically with a vote or sometimes just by the decision of unelected officials. Fiat currency rapidly and consistently loses value because it can be created without any input or sacrifices. It can essentially appear out of thin air, and when currency is cheap, the things it is used to buy become expensive. If there is an unlimited amount of dollars, goods and services that are limited due to time or other natural constraints then become expensive. We call this inflation, and we’re told it’s a good thing. Proof of work, or the input of scarce resources, is what gives bitcoin its value. Anything that requires sacrifice is going to be more valuable than that which doesn’t, but the application of this principle is more stark, apparent, and controversial in Bitcoin than other areas of life.
Obtaining good health is the same in that it requires proof of work, or sacrifice of resources. It’s not cheap, and it requires physical, emotional, and mental inputs. You won’t achieve long term health through over-indulgence. There must be a balance. If a doctor’s job is to promote health and help ensure the long-term vitality of their patients, they must also fight against the cultural tidal wave of extravagance and help patients realize the true keys to health. Yes, it hard, but it is necessary. Obesity and other chronic diseases run rampant through our population, and continuing to uphold the current paradigm of masking symptoms of disease with medication without fixing the underlying problem will only propagate the current problems and create greater and greater profits for the corporations that benefit. Health requires sacrifice – there’s no other way about it. The doctor’s job is to help their patients know what appropriate sacrifices need to be made and support them in that path. Sacrifice can include types of food, amounts of food, not immediately ceding to hunger and eating, and increasing activity and exercise. Waiting a couple hours to eat when you feel hungry doesn’t, and isn’t going to, make you anorexic. The lowest form of medicine is to simply prescribe a medication, while the highest form, Medicina via negativa, involves insightful diagnosis and persistent persuasion, and is far harder, but the only true way to do the job well.
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