Credibility-Goods, Scripts, and Sacramental Cost Disease

(A continuation of a dangerously overgrown blog-comment that will now veer sharply away from the empirical questions answered by RCADFMtowards a hypothesis about the economic implications of religion masquerading as technological progress.)

I left off yesterday with the claim there are not one but (at least) two ways to understand the claim that healthcare (or for that matter education) sells credibility-goods. To understand the second candidate, we must start with the observation that human life contains many phases marked by special tensions, in particular dependence, conflict of interest, honor (debts, promises, favors repaid in kind), transfer of authority, and entry into groups (particularly, where this involves coordination, conformity, and cooperation in addition to mere coexistence) or departure from them.

Because these phases of tensions involve so many uncertainties, irreconcilable interests and conflicting incentives – difficulties that place complex pressures on the families that navigate them – societies often develop stable cultural scripts for individual members to follow, and castes of ethical authorities (often priestly, sometimes martial) to propagate, supervise, notarize, and troubleshoot the performance of their library of scripts.

Death is one example. As the state of a dying man deteriorates, his chance of recovery grow dim. His likely future contributions to those around him plummet to zero as his dependence on their care grows more absolute. Questions arise about what extraordinary measures to save the dying man, or to relieve him of his pain, could be worth the price — especially given the rapidly diminishing probability of success. The transfer of any property and privileges to his heirs draws nearer. The ability of the dying man to project social authority falters just at the moment the desire to protect and perfect family and friends even after his own death becomes most real.

For this harrowing phase of life, the medieval Church prescribed the sacrament of extreme unction as a script for the laity to follow. It identified the most vital concern of the dying man as his entry into the Kingdom of Heaven, and prepared for him the soteriological equivalent of TSA pre-flight safety announcements. Reaffirming his faith, purging his anxieties, turning his eyes to the heavenly crown in his final days on Earth, the gravely ill believer can rest peacefully — with hope as his balm, and his family’s. Whatever powerlessness or confusion they feel about their prospects for saving the man’s life are put in proper perspective by their clear and easy responsibility for arranging the one final safety-check on his soul. They are absolved from their inevitable limitations by their attention to a small task that has communally-recognized priority and yet is within reach for even the most humble.

We have a different script for this phase of life today: it is called “end of life care,” broadly construed to include everything from the decision to spend the final months of life reeling with nausea from aggressive chemotherapy or convalescing rom some sort of multi-stage surgery, through colorful end-game variants like rib-cracking and (typically irreversible) intubation, or multiple colors of opium dream, before finally arriving at the medical team’s open-ended invitation to order them to withhold fluids.

The early Christians, eager to save the soul but resigned to the frailty of the body, could do little for the dying but give them water to drink. Yet even with so little to offer, and despite confidence that failure to save the patient would lead him directly to heavenly joy, they were indefatigable and sometimes valiant in continuing to succor the dying man until the bitter end. (Through this valor the early Christians inadvertently discovered that measles is not a death sentence, so long as someone cares for the patient while he is too weak to drink.) There is a macabre irony in the fact that now, after promethean efforts to keep the corpse pulsing, the hospitals raised up on the rubble of Christian civilization inflict dehydration as the most convenient way to finish off the bodies their machines will not allow to die. We have exchanged one version of last rites for another, hope for eternal life replaced with hope for indefinite prolongation of terminal illness, the credibility of Christ’s ministers with the credibility of a sales-pitch for experimental chemo or equivalent.

The old priesthood demanded a tenth of the harvest for its troubles. The new priesthood is up to 17.9% and climbing — and its temples, admittedly monumental, are not even beautiful. Whipsawing the mortally ill between feelings of invincibility and gnawing despair with exotic machinery and biochemical compounds it transpires, is, compared to infinite, unmerited grace, a more expensive way to establish the credibility of the shared scripts that bring resolution to life’s most dismaying moments.

The last rites provide a striking comparison, for our purposes, because a large fraction of all medical costs are incurred in the final months of life, but if I have dwelled on this example it was not with the intention to speak narrowly of societal scripts for managing grief and responsibility for death. At nearly every phase of life, one finds important decisions and transitions brought under the jurisdiction of one variety or another of credibility-merchant: if not professors or media celebrities, then usually doctors. Future societies will, I suspect, find the concentration of late-imperial America’s societal scripts in hospitals rather funny, and too idiosyncratic to even try to investigate rigorously.

And I should be clear that I am not trying to insinuate the hospitals are medicalizing human life; on the contrary, what is simultaneously embarrassing and unfathomably expensive is that they are trying to clericalize medicine.

To observe that clinical psychology is auricular confession with a more aggressive billing structure will probably not be news to anyone. Freud explicitly modeled the psychoanalysis movement militant on the hierarchy of the Roman Catholic church (even down to apostolic succession in the ordination of new psychoanalysts). As psychologists gradually, quietly get rid of Freud’s pseudoscientific justifications for secular confession, fewer and fewer differences will remain between the sacrament and the knock-off. If we want to be more technical, we might say that the sort of kenosis that Freud expected to follow a truly adequate and salvific confession has affinities with the ultra-protestant conception of introspection and inspiration held by Quakers and Baptists. Every move away from Freud’s peculiar interior intimo meo brings latter-day psych’s conception of the goals of “therapy” closer to the attitude of medieval papism: 30 Hail Marys or 30 milligrams of poorly understood pharmaceuticals, a penance is a penance.

A Christian child must be baptized before he can be received into the Church; what does an American child have to do before he can enroll in kindergarten? A young Christian, before leaving the family home and starting a new independent, productive life, is ritually bound to a suitable partner for life in front of the eyes of the entire community; what is the ritual that now guides the children of the American elite as they leave their parents’ home, and to whom (or what) are they joined to accompany them on this adventure?

Wherever there is a phase of life marked my turmoil, there will be tension and confusion; where there is tension and confusion, there will be societal scripts to follow; where there are such scripts, there will be a priestly caste responsible for the production and distribution of credence. The demand they seek to meet is insatiable, the confidence they create priceless. The price the priesthood can extract for this service is constrained only by their integrity or by the limits of the caste’s power. A priesthood run on techno-scientific principles may benefit from the illusion that the technological marvels its clergy are taught to produce are a means to an end, that each marvel provides the final solution to a single well-defined, self-contained problem — but however efficacious this perception is at producing faith in the laity, throwing finite means at an infinite end is a piss-poor recipe for cost-control.

2 thoughts on “Credibility-Goods, Scripts, and Sacramental Cost Disease

  1. “A Christian child must be baptized before he can be received into the Church; what does an American child have to do before he can enroll in kindergarten? A young Christian, before leaving the family home and starting a new independent, productive life, is ritually bound to a suitable partner for life in front of the eyes of the entire community; what is the ritual that now guides the children of the American elite as they leave their parents’ home, and to whom (or what) are they joined to accompany them on this adventure?”

    I assume the answers are ‘vaccination’ and ‘college.’

    Liked by 1 person

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