Social Science & Medicine 383 (2025) 118428

Contents lists available at ScienceDirect

Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

On medical ideology and the production of docile doctors: The politics of

care in an age of authoritarianism
Eric Reinhart
Independent Scholar, Psychiatrist, and Psychoanalytic Clinician, Chicago, IL, United States

A R T I C L E I N F O A B S T R A C T

Handling Editor: Susan J. Elliott The United States is the only high-income nation that does not provide universal healthcare as a fundamental
public service to its citizens. Instead, it uses public funds to prop up a for-profit health system that enforces
Keywords: thousands of preventable deaths each year. By fueling public distrust, inequality, and resentment, this has played
Ideology a major role in the erosion of democracy and the rise of authoritarianism that is now posing direct threats to
Ethical disobedience
medical science and clinical care. To understand the persistence of this system despite the harm it causes requires
Moral injury
an account of ideology within the U.S. medical profession and medicine’s function as an ideological state
Burnout
Medical morality apparatus and disciplinary training ground for neoliberal subject formation for both doctors and patients. By
Depoliticization considering the wide-ranging effects of American medical ideology, its uses of morality, and the depoliticization
Health capitalism of health and care it instills, this essay challenges the discourses of “burnout” and “moral injury” as explanations
Medical fascism for growing demoralization among U.S. healthcare workers. Against this backdrop, the essay considers American
Social medicine medical training’s relation to systems justification, the production of docile bodies and docile doctors, the
suppression of dissent, and the political significance of immanent critique within medicine. It concludes with an
argument for the construction of a new medical ideology organized around the principles of social medicine
conjoined with applied practices of ethical disobedience, solidarity, and entwined clinical and political care.

Since the outbreak of the Covid-19 pandemic in 2020, the United universally indicted healthcare industry (Reinhart, 2023a, 2025a). How
States’ healthcare system has been subjected to unusually intense is this possible in a nation that just collectively witnessed the cata­
scrutiny. Investigative report after report from major news organizations strophic inadequacy of what is arguably its most important civic insti­
has documented rampant dysfunction, corruption, racism, exploitation, tution? Given the widespread material and social implications of
profiteering, and deadly systems-wide failures, putting into stark relief healthcare for a society, confronting the forces behind the reproduction
the fact that the U.S. is the only high-income nation that does not pro­ of U.S. health capitalism and the normalization of its harms is among the
vide universal healthcare as a fundamental public service to its citizens. most urgent tasks for public health and democratic political life writ
Instead, it uses public funds to prop up a for-profit healthcare industry large (Draper and Reinhart, 2025). This essay is an attempt to contribute
that has, for decades, overseen at least tens of thousands of preventable to that collective task by examining dominant professional medical
deaths each year due to the cost-prohibitiveness of care it enforces norms, their growing untenability, and the possibility now for a renewed
(Galvani et al., 2020; Yoon et al., 2014). As the pandemic – via hundreds concept and practice of care as necessarily both clinical and political.
of thousands of deaths among U.S. residents that could have been pre­ As the historian of authoritarianism Timothy Snyder notes, the
vented by universal healthcare (Galvani et al., 2022) – made undeniably United States’ corrupt and ineffective health care systems constitute “an
clear, this not only exacerbates inequalities and kills those who can’t invitation to tyranny” (Snyder, 2020) – one that played a key part in
afford to pay; it also undermines public health, financial security, trust, ushering Donald Trump back to the White House for a second term and
and safety for the entire population. Robert F. Kennedy Jr.’s associated ascent to control over the nation’s
Despite this, as deaths from Covid began to decline, healthcare ad­ health systems. Under the guise of their “Make America Healthy Again”
ministrators and policymakers from both major political parties urgently agenda, Trump and Kennedy are now exploiting justified anger at U.S.
pursued a “return to normal” without any substantive changes to a health systems to attack public trust in medical and environmental

This article is part of a special issue entitled: Beyond Hidden Curriculum published in Social Science & Medicine.
E-mail address: [email protected].

https://doi.org/10.1016/j.socscimed.2025.118428
Received 8 August 2024; Received in revised form 27 June 2025; Accepted 15 July 2025
Available online 16 July 2025
0277-9536/© 2025 Elsevier Ltd. All rights are reserved, including those for text and data mining, AI training, and similar technologies.
E. Reinhart Social Science & Medicine 383 (2025) 118428

science, dismantle public care and regulatory systems, defund vital Given such distortions, to explain how ideology functions for doctors
medical research, and scapegoat gender and racial minorities (Coleman and healthcare today requires a brief byway through the history of the
and Reinhart, 2025; Reinhart, 2025b). But even amid this rise of what I concept.
have elsewhere called medical fascism (Reinhart, 2025c), one thing Ideology was first coined in the late 1790s as a “science of ideas” by
remains stable: the prioritization of healthcare industry interests and the the aristocratic French philosopher Antoine Destutt de Tracy, who
essential collaborating role and obedience of physicians within it. Even imagined it would provide a defense of rational thinking against what he
those within the medical and public health professionals who are, regarded as mob mentalities (Kennedy, 1979). For Destutt de Tracy,
rightly, decrying the Trump administration’s cruelty and unjust policies ideology was a means by which to protect liberal principles like private
are overwhelmingly doing so by appealing for a return to the pre-Trump property, free markets, individual liberty, and constitutional limits to
status quo – while ignoring its role in fueling authoritarianism’s appeal – state power.
rather than insisting upon an alternative vision for genuine systems A half-century later, the term found its current usage when it was
transformation to provide care to all. adopted by Karl Marx and Friedrich Engels to explain how capitalism
To explain the remarkable persistence of American health capitalism successfully justifies and reproduces itself despite the harm it does to
despite the obvious harm it causes requires a key concept: ideology. workers who far outnumber the capitalists whose profits depend on
Recognizing the significance of ideology and its depoliticizing uses of exploiting the masses. An essential feature of ideology is that it absorbs
morality in U.S. medicine also allows for a reframing what has been us into its operation without our awareness, producing a “false con­
widely discussed as “burnout” and “moral injury” (Yong, 2021; Press, sciousness” that keeps us from seeing both the world and our position in
2023). It helps us to see that what is now burning out is not healthcare it as they truly are.
workers’ ability to work but rather our faith in the traditional stories The concept of ideology has since gone through many complex
that American medicine has told about itself, including about our sup­ permutations as the subject of endless philosophical debate (Butler et al.,
posed moral virtue, that have for so long sustained what should have 2000; Wolff and Leopold). What remains consistent across these debates
been an unsustainable system (Reinhart, 2023a). is this: ideology names a near-totalizing belief system made up of
As Rachael Bedard wrote about her decision to quit her job as a jail interlinking political, economic, and cultural ideas upon which we
doctor at New York City’s Rikers Island, "For me, doctoring in a broken depend to make sense of our social world and the unequal distribution of
place required a sustaining belief that the place would become less power in it. Simply put, it generates the plotlines and tropes for the
broken as a result of my efforts. After what I had seen … I couldn’t stories we tell ourselves about ourselves.
sustain that belief any longer” (2022). Thousands of U.S. healthcare Ideology provides explanations for why specific parts of the world,
workers, including those working not just in under-resourced jails but which might appear wrong or confusing when examined in isolation, are
also in the wealthiest hospitals in America, increasingly echo similar the way they are. It does this by connecting particular phenomena to an
perspectives. overarching meaning-making system in which everything appears to be
When we as caregivers believe that we are effectively helping our in its right or natural place. The whole explains the parts and, in turn, the
patients and that we are part of a collective movement that is making parts – which no longer provoke questions but instead come with ready-
society more just and caring, then morale improves and we are buoyed made answers – testify to the truth of the whole.
by our faith in the value of our work, even when it’s exhausting. But if By removing the need to think for oneself or to wrestle with dis­
we no longer believe that our profession and everyday labor are tressing realities that make little sense and feature widespread suffering
contributing to repairing an injured society but are instead complicit that we as individuals feel powerless to stop, ideology provides comfort,
with its cruel inequalities and profit-over-people policies, then morale especially to those who benefit from existing inequalities. It lightens the
plummets. People quit. One in five doctors recently reported that they burden of responsibility we might otherwise feel for the state of the
planned to leave practice in the coming years (Abbasi, 2022). Many world around us. But this comfort comes at a price: an inability to
more would if they could afford to (Whang, 2022). Those who remain perceive the fact of our reliance on ideology and the ways it oppresses,
are frustrated. And to try to explain it, many have reached for this term, the interests it serves, and our power to make the systems governing our
“burnout,” that pop psychology has supplied to name the consequences lives differently than they currently exist.
of overwork (Lepore, 2021). Nearly two-thirds of physicians now report It is in response to this that the tradition of ideology critique, or what
they are experiencing symptoms of burnout (Berg, 2022). since the Frankfurt School has been called “critical theory,” seeks to
But what if rising discontent among healthcare workers is not simply, make visible the dominant ideology in a given context (Jay, 1973; Geuss,
or even primarily, due to overwork, exhaustion, or poor labor condi­ 1981). Such critique – a kind of thinking that seeks to expose the con­
tions? What if what has been identified as occupational burnout is in fact ditions, assumptions, and social forces that shape thinking itself – is
ideological burnout driven by a growing awareness, augmented by the motivated by a relentless optimism. It wagers that the practice of
Covid pandemic, that neither our healthcare system nor our work inside revealing the status quo as historically contingent and thus modifiable,
of it are designed to provide care or to counteract the inequalities upon as opposed “just the way things are and have always been,” will enable
which disease preys? Might we be witnessing the death of American change toward a more just, less violent society.
medical ideology? If so, this may be a moment ripe for the construction a But there’s a catch – one that traditional Marxists and critical theo­
new ideological paradigm organized around careful critique rather than rists have sometimes been accused of failing to acknowledge: there is no
automatic compliance, genuine ethics rather than self-serving moralism, position from which one can practice ideology critique that is not also
and a vision of responsibility in which clinical care and political care are under the influence of another ideology. This does not mean that the
entwined. project of critique is useless or misguided. Instead, it means that it re­
mains an always-unfinished project. As a consequence, it requires per­
1. The origins of our ideas about ourselves petual self-criticism and ethical dissent against oppressive power to
avoid falling into the very same violence-normalizing position it seeks to
This term, ideology, is thrown around so frequently in both popular counteract.
and scientific discourse and in such idiosyncratic ways that many people
are understandably confused as to what it means. One common 2. Medicine as ideological state apparatus
impression is that, whatever ideology may be, it applies to one’s political
opponents’ beliefs and not to one’s own. This idea – itself reflective of Resistance to self-criticism and recognition of the field’s ideological
ideology’s pervasive power – is a fundamental misunderstanding that foundations has long been a hallmark of the U.S. medical profession and
short-circuits our ability to appreciate the role of ideology in our lives. the healthcare industry it has shaped. This resistance can be traced in

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part to American doctors’ organized efforts – via our professional or­ medicine or healthcare in his elaboration of ideological state appara­
ganizations, hospitals and academic medical centers, and lobbying tuses. Nonetheless, in the U.S. today, health institutions are among the
groups from at least the 1930s to the present – to suppress the specter of most important vehicles for both the material reproduction and ideo­
“socialized medicine” (Reagan, 1961; Brickman, 2013; Topol, 2019; logical inculcation of unequal economic systems and their morality.
Reinhart and Brauner, 2020; Marks, 2022). Making use of widespread Most obviously, “the economy” as we know it relies on medicine, psy­
anti-communist rhetoric and the “red scare” in U.S. popular culture, chiatry, and public health to maintain a supply of able bodies and
doctors set out at midcentury to defend healthcare as a business venture willing workers while also − in the absence of universal healthcare –
against the threat that it might become a public institution oriented using employer-contingent access to health insurance as a means by
around rights rather than revenue. which to compel submission to exploitative labor conditions. And the U.
Professional leaders rallied their peers by warning them that if S. healthcare industry itself constitutes nearly a fifth of gross domestric
healthcare were made a public institution, then, although it was true product, the largest single sector of the post-industrial American econ­
that the availability of care to patients would likely dramatically omy, and the largest employer in many regions of the country (Winant,
improve, doctors would lose their professional autonomy to a sea of 2021). But, even more significantly for the reproduction of existing
bureaucracy and paperwork. We were also repeatedly told that medicine norms and systems, medical and psychiatric interactions also function as
as a public institution would mean that we would make far less money, a key moral training ground for imparting the sense of individual re­
perhaps no more than our working-class patients. sponsibility that, by deflecting state responsibility to care for its citizens,
In a 1957 issue of the Journal of the American Medical Association, is so central to American capitalism.
for example, an excerpt on “The Doctor in Russia” from Mark G. Field’s There are few better systems for teaching the importance of uncrit­
Problems of Communism observed the following: “In the course of a ically adopting belief in individual responsibility for one’s body, psychic
recent trip to the Soviet Union, this author was struck by the low salaries states, and life – and not looking to assign responsibility to systems or
ordinary physicians received as compared to the salaries of the people public policy for one’s situation – than in clinical medical interactions
they treated.” Fields also observed that “the position and prestige of the (Reinhart, 2024). Every day as doctors, we sit beside our patients as we
medical profession is somewhat lower than that of most other pro­ counsel them on their personal responsibility to counteract the risks of
fessions. The Soviet hero is not the healer but the man who builds ma­ obesity, heart disease, and diabetes tied to poor food quality and
chinery for industry or the one who fights for the cause” (1957). For an disease-causing environments; anxiety, depression, and other so-called
American medical profession that had, as Paul Starr details in The Social psychiatric disorders in the context of financial, environmental, and
Transformation of American Medicine (1982), fought hard for a century to social insecurity; inadequate sleep as they work multiple jobs to make
leave its modest origins behind and to achieve elite social status and ends meet; “irresponsible” substance use or sexual behavior in an effort
highest-in-the-world physician incomes, lines like these hit home. to manage stress and to find pleasure in a life largely deprived of it; or, in
In reaction, the U.S. medical profession was expressly organized, the face of the Covid-19 pandemic, modulating their social behavior to
trained, and primed to defend itself against criticism of America’s for- reduce their individual risk in the face of dismal public health systems.
profit healthcare system and to dismiss as unfortunate but unavoid­ U.S. healthcare trains doctors into ways of thinking and practicing
able the fatal exclusion it enforced. The profession learned to lean medicine that make it difficult for us to recognize – let alone address –
heavily on ready-made answers drawn from dominant liberal-capitalist both the root political causes of disease and the origins of much of what
ideology that designated many as “undeserving” of care, used “work we do and the interests these activities serve. For example, a system of
ethic” to explain away inequality, and preached personal (not public) billing codes invented by the American Medical Association as part of a
moral responsibility for one’s health (Sher, 1983; Brandt and Rozin, political strategy to protect its vision of for-profit health care now dic­
2013). In the process, healthcare institutions emerged during the Cold tates nearly every single aspect of U.S. medical practice, producing not
War as a key ideological ally of U.S. capitalism and the ascent of just our endless paperwork burdens but also seeping into our training,
neoliberalism and associated market fundamentalism, including its clinical reasoning, diagnostic categories, and treatment choices
mythologies of meritocracy and individualism and its accompanying (Reinhart, 2022). We are simply taught that this is how things must be
norms of profound economic inequality, exploitation, criminalization of done. And, in medicine, we learn by doing – that is, via apprenticeship in
poverty, and racial exclusion (Stevens, 1999; Brickman, 2013). which we repeat what’s modeled for us in medical school, residency,
American medicine began to increasingly function as what the fellowship, and still into practice as an attending physician when
French philosopher Louis Althusser called an “ideological state appa­ learning new techniques.
ratus” (1971), with consequences not just for its relationship to broader We constantly hear and follow the mantra, "see one, do one, teach
U.S. politics but also for medicine’s own internal culture. As an ideo­ one." Medical training is explicitly organized around reproduction of the
logical apparatus, U.S. healthcare functions as a system for making sense existing way of doing things and “trusting the system.” This is, to a
of and naturalizing existing political arrangements so that they are degree, a necessary aspect of training in an applied technical field; it is
hidden from view. This then supports the unquestioned reproduction of also a fundamentally conservative model for learning that trains us to
the status quo. It also limits our ability to imagine alternatives to our suppress critical thinking while working inside a system that has, at its
dysfunctional system. foundation, perverse incentives. This decontextualizing style of thought,
Althusser famously described two kinds of institutions that assist the or “clinicism” (Reinhart, 2023b), reduces health and patients’ life ex­
state in the reproduction of exploitation and inequality under contem­ periences to individualistic biomedical paradigms while normalizing the
porary capitalism: repressive and ideological state apparatuses. social conditions behind them. This clinicist tendency has historically
Repressive state apparatuses are used by the ruling class to overtly spilled over into physicians’ engagements with matters beyond clinical
control the working class via both violent and non-violent means of practice, including hospital administration, health policy, and general
coercion. These consist of the police, military, courts, legislative bodies, political perception, producing what has long been a notably politically
etc. Ideological state apparatuses serve the same function – that is, conservative U.S. medical profession – although there are some signs
perpetuation of the status quo – but are typically informal extensions of this may be beginning to change (Adamy and Overberg, 2019).
state power that operate via civil society and without direct force. These In our training-by-doing, we are often discouraged, typically in the
consist of schools, heteronormative family structures, religion, media, name of efficiency and professionalism, from asking why something is
trade unions, culture, and political parties. done the way it is. This is particularly true when the answer to a ques­
Writing in a far less medicalized era than our own (and perhaps tion, as is frequently the case in medicine, is one that ultimately boils
because medicine was by that point the established terrain of his down to bureaucracy and authority rather than robust scientific evi­
contemporary Michel Foucault), Althusser left out any mention of dence. The truth is that doctors in senior teaching roles often don’t

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E. Reinhart Social Science & Medicine 383 (2025) 118428

themselves actually know why things are done the way they are. They Foucault’s focus in describing the effects of disciplinary power is
were, after all, trained in the same system. In a very hierarchical medical primarily on the pupil, imprisoned, and patient rather than on the
culture in which the ostensible basis for this social hierarchy is superior teacher, guard, or doctor. But the production of docility and the self-
knowledge earned over grueling years of training, many doctors don’t policing subject who willingly gives to the institution and the state
like to be asked questions – especially not by those beneath them on the what it requires even prior to any demand is no less important for
career ladder – to which we don’t have definitive, confident answers. disciplinary power’s relatively privileged administrative agents than it is
And doctors, like the administrators for whom we work, don’t for those under their ‘care.’ The docility we as doctors unwittingly train
generally appreciate it when trainees question the standard operating into our patients, who we expect to passively submit to our authority
procedures upon which we rely for our belief that we are providing best- and to thereby earn the sick role, is inseparable from that which we too
quality care to our patients. This belief in what we do as doctors is not have absorbed and reproduce in relation to our profession and em­
based on rational judgment. It is grounded in an ideological belief in our ployers, to whom we in turn render ourselves docile in order to enjoy the
status as virtuous individuals who are part of a noble, moral profession privileges accorded to the physician. Similarly, the “medical gaze” about
that exists to serve others and alleviate suffering. To acknowledge the which Foucault writes in The Birth of the Clinic (1973) as a means by
ways in which we as physicians within a racist and capitalist health which doctors learn to transform people into biomedical objects is not
system routinely cause suffering, assist the police state, or take advan­ simply constitutive of the patient but so too of the physician whose
tage of vulnerable patients to generate profits, for example, undermines perception of self, power, and responsibility undergoes a parallel
this idealized image of ourselves. It shouldn’t be surprising, then, that transformation. As the historian Carl Elliott has noted in his work on
doctors are often defensive in reaction to criticism of either our indi­ academic medicine’s intolerance for ethical dissent, “a central aim of
vidual practice or of the systems that largely determine it. medical training is to transform your sensibility” and to elicit an auto­
Displays of loyalty to one’s teachers and abstention from criticism of matic thought that, regardless of whatever horrible acts we may watch
our medical institutions and professional guild are not just unwritten our colleagues and superiors commit, “this is the way it is done” (202
norms if one desires to build a good reputation and achieve professional 4a). Moreover, if this is the way that our profession does something, it
advancement as a doctor. They are often explicitly written into our must be morally good, because at the foundation of the medical pro­
employment contracts and even make up the opening lines of the Hip­ fession is a belief that it is underpinned by moral virtue.
pocratic oath: In most instances, this internalized belief alone is enough to ensure
compliance with established norms. But as Foucault noted in his
I swear before my gods, my ancestors, my teachers, my fellow healers
1977–78 lectures published as Security, Territory, Population (2007)
and apprentices, and by all the arts and knowledge I was privileged
regarding the interplay of sovereign and disciplinary power, including
to learn, that I will stand by these words: I will love those who taught
his clarification that their historical relation is not one of simple suc­
me these arts as I love my parents and I will offer my skills to the
cession but of layered overlap, when the smooth flow of disciplinary
young with the same generosity that they were given to me. And I
power is disrupted by a failure or refusal to perform the roles it assigns to
will never ask them for gold, but demand that they stand by this
us, the force of sovereign power often returns to shore it up. It is in these
covenant in return. I also swear that if I earn fame and wealth, I will
moments that typically taken-for-granted disciplinary power becomes
share it with my masters and my students.
most visible. As illustrations of how this manifests in everyday in­
Against this backdrop, we as a profession are conditioned to receive teractions within the medical field, consider three examples below taken
criticism of our work and workplaces as a direct attack on our moral and from my own training experiences.
social identity, which in turn often elicits responses that reinforce the While as a resident I was working on a hospital service for a month
status quo. The psychologist John Jost has written about a related psy­ under an attending physician, they searched for information about me
chological tendency towards “systems justification” – an inclination to on the internet, reading articles I had published and coming across a
perceive the social and epistemic systems in which one lives or works as passing comment I had made on social media: “Physicians, especially
normal, necessary, and proper, and to defend them against criticism psychiatrists: ‘the law says my duty is’ and ‘if this happens and they sue’
regardless of their merits (2004). While Jost argues that this tendency are not, in fact, principles of ethical practice. law ∕ = ethics.” (This
manifests across human contexts, the U.S. medical profession in happened to be prompted by an article I was then revising with a legal
particular has honed it over many decades through its selection in scholar on the relationship between policing and medicine.) The
medical school admissions, cultivation in training, and promotion into attending physician took personal offense. They believed that this was
leadership roles of what we might call docile doctors defined in large part an unprofessional comment and, furthermore, was certain – although
by a dedication to systems justification. incorrect – that it was meant as an attack on their personal clinical
I draw here on Foucault’s concept of “docile bodies” that he describes practice.
as the result of a process of subject-formation through disciplinary I learned of this when, without ever speaking to me about it or raising
training administered in part by institutions like prisons, schools, hos­ any concerns to me directly, the attending reported their discovery of
pitals, and asylums (Foucault, 1977). By leveraging control and manu­ my public views to the training program’s then-directors (all of whom
factured dependence upon them, such institutions take bodies as have since assumed other positions), who called me into a disciplinary
something “that can be made” such that “out of a formless clay, an inapt meeting. I was told to stop engaging in public writing, to restrict my
body, the machine required can be constructed” (Foucault, 1977: 135). publications to peer-reviewed academic medical articles, and to delete
The machine required, as Foucault puts it, is the eagerly obedient subject any social media accounts. I had a larger public profile than faculty in
prepared to fulfill their designated functions in regard to profit and the the department, my training supervisors explained, and I should
state not because of external coercion (ie, the exercise of “sovereign appreciate that this made them uncomfortable. Then, as the two other
power”), as in times past, but rather as a consequence of the internali­ training directors looked on in silence, I was told the following by the
zation of social norms and associated surveillance of the self (ie, the senior training director: “Eric, no one here fucking cares about what
operation of “disciplinary power”). The effects of this training are pro­ you’ve done before residency. And no one here is concerned about your
found and far-reaching, Foucault argues: “posture is gradually cor­ ability to take care of patients. That’s not the issue and, for you, that’s
rected; a calculated constraint runs slowly through each part of the not what residency is about. For you, residency is about becoming a
body, mastering it, making it pliable, ready at all times, turning silently totally different person: You need to learn to talk like us, to think like us,
into the automatism of habit” (1977: 135). Obedience becomes not a to look like us, to walk like us. And you need to have the humility to
deliberative choice but rather an often-unrecognized, automatic accept that." Although no formal disciplinary process had been initiated
response at the most elementary level of the body. and no allegation of any specific wrongdoing had been made against me,

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E. Reinhart Social Science & Medicine 383 (2025) 118428

I was nonetheless informed that if I did not modify my performance in make your life miserable. You have to understand that the medical side
accordance with this direction, then dismissal from the program could of the university is not like the arts and sciences. Criticism is not valued.
be a future repercussion. Ideas are welcomed, but only if they further the business model, and the
When I recounted this to the former, then-retired department chair fact is that – as you know – yours do not.” He then reflected that there is
who had recruited me and had since continued informally advising me, a notable exception that I should consider for my own career prospects.
he noted he was disappointed but not surprised this had happened and "Now, if you do this in global health, if you apply these ideas to poor
that it was reflective of regrettable problems in the department and countries elsewhere like many of your mentors have done, then that’s a
academic medical training. By way of consolation, he added that I – as different matter. It doesn’t threaten the institution, doesn’t threaten
an anthropologist – could perhaps one day write about it. I would of what people do here or how they seem themselves. In fact, in many
course, for career reasons, have to wait many years until I was in a senior ways, it supports it." He lamented this state of affairs, assured me it was
position before I could think about doing so, he added. He then advised not his own views but those of the institution that forced his hand, and,
me not to protest nor to bring this interaction to the attention of an then, in a classic turn of medical professionalism (that, I should add,
ombudsman or office of graduate medical education, as, “in my expe­ appeared conjoined with sincere kindness), noted that although he could
rience within academic medicine, resisting in these kinds of situations – not hire me, he would be eager to mentor me.
even when you are completely in the right – simply provokes the whole As each of these instances reflect, U.S. medicine as an ideological
weight of the institution to fall down upon you. I’ve seen it happen many apparatus interweaves economic and moral self-interest. It takes
times before. Even if it seems like the right thing to do, it almost always advantage of the necessarily institutional basis of effective modern
backfires for trainees and junior faculty. The best thing for you to do is to healthcare to align doctors with existing systems and with the perpet­
just go along with it: Tell the program directors you are sorry and then uation of America’s for-profit healthcare industry, despite the harm it
ask one of them specifically to be your mentor, to teach you how to be inflicts. And, as reflected in my friend’s expression above of offense that
like them.” I – someone without a position of institutional authority – would pub­
As a second illustration, take the reaction of a friend of mine – a licly voice criticisms of our shared profession, American medical ideol­
nationally well-respected, liberal-identifying senior physician – to an ogy does this in part by discouraging both critique of and ethical dissent
essay parallel to this one in which I argued that U.S. physicians have an against the economic systems and moral norms upon which the pro­
ethical responsibility to our patients to dissent against our corrupt in­ fession is based.
stitutions and to collectively address the political determinants of
health. This friend has been my single best clinical teacher and is one of 3. Medical morality and ethical dissent
the kindest, most supportive, and most thoughtful physicians I know.
They are the first physician to whom I refer those I love. Noting that they In recent years, the rhetoric of “moral injury” has gained popularity
found my criticisms of the medical field offensive, particularly given my as an alternative to the discourse of burnout to explain increasing levels
lack of professional status, they offered the following comments on the of discontent and frustration among U.S. physicians (Press, 2023). This
essay, which I share with their permission: discourse emphasizes that doctors’ pain arises not simply from over­
work, but from being compelled by unjust systems to act against our
I’ll be honest, I kind of hate it … The vast majority of docs are people
personal moral convictions. But despite its use in attempts to highlight
who know everything you say, know that the illnesses in patients
injustice and the widespread psychic effects of structural violence, the
they treat are just symptoms of societal inequities, but knowingly
framework of moral injury in the context of the U.S. medical profession
choose to focus on the individual. They do this because it is right, it
often serves a conservative function. It foregrounds clinicians’ individ­
has been what physicians always have done and do because no so­
ual feelings of betrayal without interrogating the structural causes of
ciety has ever not left people behind. Medicine does more to help the
harm or the medical profession’s historical and ongoing role in perpet­
ills of society than just about any other profession.
uating systems that cause harm.
This moral defense of the medical profession is drilled into us as Moral injury diagnoses distress, but it stops short of linking it to an
doctors from at least the time we begin pre-medical courses in college analysis of power. Rather than inciting political responsibility and ac­
and continues until the last eulogies have been told at our funerals. It is tion, it fosters an egocentric therapeutic focus. It soothes and reassures
an essential part of medical ideology on both individual and collective rather than radicalizes. It offers doctors a story of suffering in which the
levels. And it serves a key function: dogmatic belief in our status as tragedy lies in our own victimization, bad feelings, and loss of confi­
morally good actors helps suppress lurking suspicions that our in­ dence in our own virtue, rather than in the widespread preventable
stitutions and much of our work inside them primarily serve a money- death and disability we oversee or the policies that cause them. The
making machine, often at the cost of our patients’ health, dignity, and result is a subtly narcissistic orientation that privileges the coherence of
economic well-being and also at the cost of our own working conditions, the physician’s moral self-image and its repair over the political con­
health, and personal ethics. ditions that harm both physicians and patients. It makes doctors’ sense
A third example of how medical ideology reproduces itself and in­ of our own morality, not public accountability or effective and equitable
sulates existing norms from critique arose from my few inquiries while care, the metric by which we assess ourselves and our institutions. By
briefly considering potential jobs in academic psychiatry after the doing so, it shores up rather than challenges the depoliticizing ideo­
conclusion of my training. On more than one occasion, chairs at well- logical foundations of the profession and its beliefs about its own
regarded institutions kindly held long, wide-ranging interviews with fundamental virtue.
me before ultimately sharing the same essential conclusion, which they To question the self-proclaimed moral integrity of the profession and
conceded – upon my questioning – they had arrived at before meeting its daily practices, and especially to do this from a position internal to
me: although they valued my research and believed that my clinical and the profession itself, represents one of the most ‘unprofessional’ offenses
teaching abilities were of high quality, to their regret, they could not a physician can commit. As illustrated by vitriolic responses to those
offer me a position in their department. Why? Because, as one chair who who dare to act as whistleblowers within the field (Elliott, 2024b), for
was particularly frank with me put it, it would “hurt morale” among example, ethical dissent is often regarded as a betrayal of the Hippo­
their faculty due to my “controversial” political writing and public cratic oath that commands us as physicians to love our professional
criticism of psychiatric norms, policing, and U.S. medical institutions. teachers as parents and to demonstrate fidelity to our guild, its economic
“I’ll have them coming to me and saying,” he told me, “if this young guy interests, and its reputation.
is out there criticizing what we’re doing, then why the hell is he here? As a consequence, egregiously unethical practices – such as routin­
And in the end,” he added, “you won’t be happy here, because they’ll ized rape via unconsented, medically unindicated vaginal exams

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E. Reinhart Social Science & Medicine 383 (2025) 118428

performed under anesthesia as part of medical education – are rendered retaliation, discrimination, and dismissal, often under the guise of
banal and routine (Elliott, 2024a). Profit-driven institutional policies discipline for lack of so-called professionalism. This, in turn, supports an
that exclude people from care, even as hospitals (including tax-exempt, intensely hierarchical, conformist professional culture characterized by
‘non-profit’ academic medical centers) and healthcare companies very little tolerance for deviation from professional norms, let alone
generate enormous profits and cash reserves (Jenkins and Ho, 2023), are open criticism of them (Reinhart, 2023c; Elliott, 2024a). Many doctors
accepted as inevitable or even actively defended by many doctors as fear their careers will be harmed if they speak against injustices in which
necessary. Racist and classist personality policing of trainees, including their colleagues and institutions are complicit. And institutional leaders
by one another, to enforce homogeneity in the profession – and to are wary of upsetting the philanthropists, corporate board members, and
manage perceived threat from those who would criticize it – under the wealthy alumni upon whom their personal careers typically depend. In
guise of upholding professionalism is normalized (Reinhart, 2023c). And an era of growing oligarchic power and associated authoritarianism, this
not only do we as doctors become willing participants in such practices; has left the medical profession and our institutions distinctly vulnerable
we also progressively lose the capacity to even discern their violent to fascist capture (Reinhart, 2025c,f ).
nature. The reality that doctors in the U.S. face is that, without a collective
The institutionalization of medical ethics, by which ethics as a political movement with which to overcome the suppression of ethical
practice of critically questioning the good is instead replaced by a pro­ dissent and to force fundamental changes to our care systems, our work
fessional morality that gives us ready-made answers to assure us of our doesn’t do what we were told it did. It doesn’t serve the people we were
goodness, plays a central role in this suppression of critical perception at told it serves. Our research doesn’t in fact translate to the alleviation of
the core of medical ideology (Reinhart, 2021). From the earliest days of suffering – unless it also yields increased profits. Our healthcare in­
medical school, we are trained to repeat by heart the keywords of stitutions and our administrators who are paid millions each year as
medical ethics – autonomy, non-maleficence, beneficence, justice – as a executives of even non-profit hospitals (Saini et al., 2022; Jenkins and
means of shoring up our sense of ourselves and our profession as ethical Ho, 2023), let alone for-profit healthcare companies, are part of the
actors. This decontextualizing, keyword approach to ethics, which was problem rather than the solution. And when we as doctors begin to
expressly designed to be unobjectionable to physicians regardless of worry that we too, as complicit and well-paid cogs in these lucrative
“personal philosophy, politics, religion, moral theory, or life stance,” machines, might be more aligned with perpetuation of suffering rather
pervades medical training (Gillon, 1994). And in the context of a U.S. than with genuine care, then what burns out isn’t our ability to work but
healthcare industry that systematically prioritizes profits over people – rather our belief that our work matters.
such that medical debt is the leading cause of personal bankruptcy and a Having cracked under the weight of mass death during the Covid
major contributor to poverty, which in turn drives poor health, medical pandemic, well-worn American medical ideology is no longer sufficient
need, and premature mortality – while perversely medicalizing poverty, to disguise the brutality of our healthcare reality. Without dramatic
one of professional medical ethics’ core functions today is to separate changes not just to doctors and nurses’ working conditions but also to
doctors’ concept of ethics from political economy and any sense of an the fundamental organization of intertwined U.S. healthcare, economic,
ethical obligation to engage the political struggles that so profoundly and welfare systems, many more healthcare workers will leave their jobs
determine the lives and deaths of our patients. in the coming years. This will intensify dysfunction in our already
This depoliticizing concept of ethics and associated disavowal of the flailing system, exacerbate inequalities, and further undermine public
intrinsically political nature of medicine and public health is pivotal to health, safety, and trust. And as this transpires, it will once again be
the suppression of critical self-reflection and ethical dissent within the poor, racialized, disabled, and otherwise marginalized communities
profession (Reinhart, 2021). Proponents of frameworks like the social who will be pushed to the front of the line to be sacrificed on the altar of
determinants of health, causes of the causes, cultural competency, a dying ideology.
structural competency, and structural racism, for example, have
attempted to disrupt this. But as each of these terms has gradually been 4. Repoliticizing care
accommodated by the medical profession and welcomed into training
curricula, each has been granted nominal institutional endorsement in To prevent this, healthcare workers need to be given reason to
connection with dilution of its more critical and actionable believe that our systems are worthy of our labor and emotional invest­
political-economic implications. In their watered-down forms, these ment. We need, in short, both a new ideological paradigm and accom­
frameworks are frequently appropriated for repetitive description of panying material changes to support its viability. To date, healthcare
unjust realities that are then used as a substitute for political pre­ industry leaders and policymakers have failed to provide this. Not only
scriptions by which to change them. As a consequence, as the pro­ are they making clear that they have no intent to make any of the
genitors of these various frameworks themselves have repeatedly transformative changes needed to produce a healthcare system that
lamented, the successive discursive shifts they have provoked have not cares more for people than for profit, but, in the face of rising authori­
been accompanied by meaningful material changes in the distribution of tarian interference in clinical care, medical research, and education,
care, institutional practices, or health outcomes (Lavizzo-Mourey et al., most powerful medical institutions have put up notably little resistance.
2021; Singh and Hickel, 2023; Reinhart, 2024). Many have even voluntarily complied with the Trump administration’s
Explicitly political medical education and associated political orga­ wishes by shutting down gender-affirming care programs; scrubbing
nizing remain foreign to the field, and it continues to be commonplace to websites and training curricula of terms like racism, gender, and
decry the “politicization” of medicine, science, and public health as inequality; and disciplining students and staff who speak out or protest
threats to the integrity of our work. By selectively appealing to the against U.S. support for Israeli war crimes against Palestinians,
simplistic idea that medicine and public health are not political, both including the systematic destruction of hospitals and killing of health
institutional leaders and rank-and-file doctors can deny any ethical re­ workers (Reinhart 2025c; 2025d).
sponsibility beyond the bedside whenever convenient – all while our It is in this glaring ethical vacuum and associated ideological gap
lobbying groups carry on with explicitly political projects focused on that social medicine has an opportunity and obligation to now speak
maximizing the field’s profitability (Berwick, 2023; Reinhart and Bas­ with renewed urgency and with a voice guided not by fear of offending
sett, 2024). professional norms but rather by the imperatives of mass political
For those doctors who see this ideological ruse for what it is and seek mobilization. The tradition of social medicine is rooted in the observa­
to protest, they must navigate another obstacle to dissent: the relative tion that medicine and public health are intrinsically political – that is,
vulnerability of physicians in the overwhelmingly private U.S. health they are in large part the product of policy such that effective care must
industry. Few doctors are unionized and most are thus subject to risk of therefore include political struggle to change the social conditions

6
E. Reinhart Social Science & Medicine 383 (2025) 118428

inflicting disease, despair, and death upon our patients. To deny this those physicians who wield most power within it and who benefit most
reality today is itself a political act in service of the indefensible status from its corruption. We should also expect fierce opposition from
quo of U.S. health capitalism that is fueling inequality, inflicting thou­ powerful industry actors and their lobbies who are loath to see policies
sands of preventable deaths each week, and contributing to the erosion implemented that might cause healthcare profits decline, even when
of democratic trust and community. they are clearly necessary to improve health outcomes and equity.
Proponents of social medicine should push for a central role in This resistance to confronting the politics of care underlines several
medical education and political debates about how to remake a U.S. basic tenets of the new ideology of social medicine that we must now
medical profession and capitalist health system that is now caught in a build. Because meaningful political positions must address the distri­
death spiral. But to make social medicine effective and to be faithful to bution of resources, rights, and opportunity that so overwhelmingly
its most elementary lessons, we must move it beyond academic determines health, life, and death, they do not generate universal
discourse and research paradigms into everyday practice both inside and agreement. And because those benefiting from unjust systems rarely use
beyond hospitals and clinics. In the process, given the past appropriation their broad power to invite structural changes that would compel more
by capitalist medical ideology of ‘the social determinants of health’ and equitable distribution of influence and resources, genuine care neces­
its various permutations so as to render them politically inert, we must sarily requires political commitments and collective struggle. It is only
not allow social medicine to be stripped of explicit political-economic when we as caregivers, workers, and patients bind together with one
critique, specific intra-institutional and broader political demands, another and take direction from those most harmed by our existing
dependence upon effective collective organizing, and commitments to systems that we will be able to effectively demand and realize the
ethical disobedience in the face of fascist violence (Reinhart 2025c; changes upon which our lives depend.
2025e). To do so, we must attach the teaching, learning, and practice of
social medicine to pragmatic vehicles for forcing material changes to Declaration of competing interest
intertwined health, safety, and economic policy. The labor movement,
which is now resurgent within U.S. healthcare, offers one possible means The author declares that they have no competing financial interests
by which to do so. relevant to this submission.
While our lawmakers – including and perhaps especially those who
are physicians – and medicine’s institutional leaders continue to fail us, Data availability
doctors hold an enormous amount of collective power to force changes
to health policy through labor organizing. And when clinical care is No data was used for the research described in the article.
estimated to account for only 10–20 % of modifiable factors shaping
health in the U.S., with the remaining 80–90 % of factors hinging on References
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