Dear Mr. Moore,
.PP
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Thank you for your letter.
I like your essay on poetry and madness.
It reminded me that forty-five years ago,
I was still in college,
I submitted an essay on just this topic,
with reference to Friedrich Nietzsche,
in a literary competition.
One of my teachers, F.O. Matthiessen,
liked the essay, and gave me the prize,
the only prize I ever have seen.
.PP
I am touched by your interest in
my undisciplined and unacademic observations.
So far as the possibility of publication is concerned,
the contents of letters belong not to their authors
but to the recipients,
and if on second reading what I have to say
still seems worthwhile to you, 
why don't you, if I might make the respectful suggestion,
paraphrase it as it sounds right to you
and submit it, perhaps in the style in which the
New Yorker's Talk of the Town used to report
the odd and unexpected. "The eye doctor, whose advice
I solicited concerning my glasses, launched, with but
minimal provocation, into an obviously well-rehearsed
obituary of his profession..."
.PP
We should all study political science, or perhaps,
in order to have something worthwhile to study,
improve on what is peddled as such in the colleges,
because the only perspective
from which I can offer a rational interpretation
for the fate that has befallen my profession is political
in the broad sense of that term.
The so-called sciences,
and medicine not least among them,
have for too long asserted their self-sufficiency,
their autonomy not only from the indivdual
whom they treat as their servant,
but from the society of which,
although they do not know it,
they are but a translated image.
Not only fictive prose and poetry,
but the purportedly objective sciences as well
reflect both in their structure and their content,
the exigencies of community
and of communication among human beings.
.PP
The Germans, in their better days, profited from their penchant,
not unlike that of the Greeks, 
to get to the bottom of things,
den Dingen auf den Grund zu gehen,
and to avail themselves of their
not insignificant intellectual prowess,
to search for the arche,
to derive the definitions,
and ultimately to invent the fictions
by which they succeeded to their own satisfaction,
if only transiently,
to explain what make the world go around.
A pale reflection
of Leibniz, Kant, Gaus, Schopenhauer,
Freud, Marx, Einstein,
he sits in his study, Faust-like,
with passionate determination,
"da~ ich erkenne, was die Welt, im Innersten zusammenh{lt."
.PP
In the spirit of Aristotle,
first things require first to be understood.
If science is the structure of knowledge,
and if mathematics is the foundation of sciences,
then, if Aristotle is right, 
and mathematics will explain science,
and science will explain the world
then the explanation of mathematics
might be the key to the derivative sciences.
And in one perspective,
this turns out to be the case.
.PP
To the tantalizing question, "What is mathematics?" 
I should like to offer the tentative explanation
that it is a communication with symbols
which creates functionally identical concepts
in the minds of its followers,
hence imbuing the social community
with a power of reason
that in the absence of mathematics
could be execised only by individuals in isolation.
That, as I understand it, is why mathematics
is indispensable to science,
and why in the absence of mathematics
scientific exposition becomes individualistic, subjective,
and turns into "literature", good or bad as the case may be;
and why creative souls who are less than exceedingly proficient
in mathematics are so offen offended and oppressed by it.
.PP
Medicine is a long way from mathematics,
and yet, it too, longs to become mathematical
so that it might assume a more dignified position
in the hierarchy of human accomplishments.
Paradoxically, the assessment of these accomplishments
is an historical judgment,
and as such, I believe, 
outside the realm of mathematics.
On behalf of his profession,
the contemporary physician rightly
boasts of many achievements,
of which perhaps the greatest
remains largely unrecognized.
It is the amoral interpretation of disease.
The physician distinguishes himself from the witch doctor
by refusing to believe that disease is an infestation with demons,
to be banished by punishment or threat or incantation.
He understands also that,
while many illnesses can be prevented or mitigated,
an ideal state of health is unattainable.
His ultimate task is to reconcile his patients,
as individuals and as society,
to the biological limitations of existence,
to help them create a tolerable,
if not indeed constructive relationship
to illness and death.
In the fulfillment of this
his most important task, the physician has failed.
It is not on account of his failure
to make his patients immortal
but on account of his failure
to reconcile them with their mortality
that he is being reprimanded.
.PP
The politicians who are presently presuming
to reform the "health care system"
are, if anything, worse,
comporting themselves
like the most ignorant of physicians.
Of the cause of the disorder they presume to cure,
they have no inkling,
and no conception of the consequences of
their prescriptions.
It seems unescapable that the unexpected side-effects
of the impending reforms
will dwarf any intended results.
My own experiences as
a physician contradict many of the presumptions,
both expressed and implicit,
from which the reformers proceed.
.PP
Perhaps the most fundamental of their assumptions
with which I cannot agree is that illness and death
are unconditionally repugnant to human nature.
The notion that they should be avoided at all costs,
has literally driven our society to the edge of bankruptcy.
The expulsion from the Garden of Eden occurred not,
as my Sunday School teachers would have had me believe,
because Adam and Eve ate of the tree of knowledge,
although it was knowledge that made them miserable and mortal.
Jealousy, not love, was the most conspicuous characteristic
of the Old Testament God.
It was from the jealous concern that his creatures
should not become immortal like him
in order to frustrate their lust for the tree of life,
that he banished them from his paradise.
The cherubim and the flaming sword at the gate of Eden
serve to protect the tree of life against human incursion.
.PP
In modern parlance,
the tree of life is called preventive medicine.
The dramatic changes which technology has wrought
in the style of our lives has created an illusion.
We have become convinced
that all disorders of body and mind are curable.
We pretend that death has been vanquished.
The mistake is plausible.
Environmental, pharmacological and surgical efforts
have eliminated or controlled so many disorders
that the question, why not the rest?
is altogether logical.
At the same time disease control has 
created ecological, social, and I might say, psychological
issues with which no one has even begun to come to terms.
In an arithmetic dimension it is surely true to say
that mankind has partially conquered death.
This partial conquest has failed to solve the old problems
and has created new ones as yet unrecognized.
.PP
I derive a certain satisfaction from tracing the paths
on which medicine has evolved to its present state.
We have transformed education,
the protected growth
by which an individual reaches the limits of his personality,
into training,
which makes of him an intellectual slave,
compelled to the endless repetition of sterile rituals.
Thus in the medical schools
physicians are drilled,
manufactured if you will,
to standard specifications,
set forth by the most explicit of regulations,
and controlled interminably by examination.
It is not difficult to understand,
why, under these circumstances,
it is almost a miracle
that a physician should survive his medical education at all.
.PP
The role of the doctor, it seems to me,
arises spontaneously out of the human condition,
not unlike those of the farmer, the fisherman,
the carpenter, the mason, the merchant,
the midwife, the nurse, the teacher, the mortician.
For each of them
the process of human life has provided a function.
It is the unspoken assumption of our contemporaries,
that the physicians function is to prevent, heal, and repair
the injury wrought by disease,
and the complexity of technologies creates illusions
particularly among the unsophisticated public,
that this is possible to a far greater extent than is actually the case.
The technological frenzy in which we are caught up
obscures other function of the physician,
which at one time was so impressively
displayed in the practice of psychiatry:
the physicians duty and privilege
to share the patients experience of his illness.
I must confess although this notion occurred to me
when I was a second or third year medical student,
I have never discussed it with any of my colleages.
Sometimes, when I wish to get some bearings
on the alienation that separates me from my colleagues
I imagine explaining myself to them at a staff meeting.
I feel giddy then,
as if I were standing at the edge of an abyss,
and the ground under my feet were crumbling.
.PP
Listen, how our speech betrays us.
For all the talk about "sympathetic" physicians,
have you ever encountered one
who shared in the suffering of his patient
in anything other than a trivial, frivolous sense
and with anything more than an actor's deceptive demeanor?
Genuine sympathy has vast potential for healing.
But the sympathy must be real,
not feigned, and real sympathy is delicate
and can flourish only in a protected environment.
It springs like an ephemeral flower
secretely in the garden of our emotions;
by comparison the medical schools and teaching hospitals
are parade grounds of indifference and cruelty,
and the process of medical education 
is like the pouring of concrete or asphalt, -
your choice, - extinguishing the sensibilities
of the budding health care providers.
The mindless pedagogic ordeal
by which physicians in training are stripped
of their moral and intellectual decency is conventionally justified
with the complexity of technology
and the profusion of (mostly spurious) knowledge.
It takes decades to reacquire our decency,
and many of us learn to do without.
.PP
The belief that this week, or month or year
will prove to be a turningpoint
in the history of the medical profession,
most likely reflects an illusuion,
if only because history itself is almost invariably
contrived, a story with which we deceive ourselves.
The most truthful statement we can make about the past
is that its reality is beyond our grasp,
and that we do not understand it.
Pre-eminently, history is the repository of our dreams,
of our hopes, of our fears, our nightmare, our vanieties.
Seldom, if ever is it a museum of truths.
Medicine is changing indeed;
but then so does everything else,
and we know neither from what
nor to what this change occurs.
And the pronouncements of change emanating from the government
are themselves propaganda,
calculated to weaken our reliance on
and our defense of the past.
.PP
Depending then on our consitution,
or perhaps on the state of our digestion,
we are optimistic,
and assume that the future is better than the past,
or we are pessimistic, and assume the converse.
Unavoidably our estimates both of the future and of the past
will be in error.