In the popular column “Diagnosis” in The New York Times Magazine, the author once described an illness that confounded doctors for weeks. After a sudden collapse at home, the patient began a mysterious decline, marked by spiking fevers and unexplained organ dysfunction. Almost offhandedly, we were told that he was a widow in his mid-seventies; moreover, he cared alone for an adult son with intellectual disability. Writing in, a woman from the Midwest suggested exhaustion as the culprit: This man, she insisted, is clearly worn down from the sole pressure of caregiving.

You could hear the snickers of enlightened readers from several states away. And yet, as we discovered when we turned to the column’s last page, while the medical problem was a rare disorder caused by a still-rarer virus, it’s almost always triggered by stress and a prolonged lack of sleep.

I recalled this column while listening to physician Peter Attia in September on the art and science of longevity. In a wide-ranging conversation about how to achieve a longer healthspan—the measure of how well we live—he explains that a funny thing happened on the way to “Medicine 2.0,” his name for the current era of managing chronic disease. In our focus on treating illness, he says, we’ve forgotten the person in whom illness lives. A person whose environment, lifestyle, and psychological state all affect his physiology.

This is a recurring theme in many of this year’s episodes, which featured a range of guests from the front lines of healthcare. While their theaters of battle are different, they all share a common enemy: the narrowing of medicine’s focus to the pinprick of disease. For example, oncologist Vinay Prasad, who kicked off 2023 with a critique of cancer drugs, argued that the relentless pace and prioritization of cancer-drug development isn’t translating into better outcomes. Rather, it’s simply forcing our sights on survival, with little regard for that survival’s quality. Along with randomized trials and more rigorous testing, Prasad calls for giving patients choices in how their healthcare dollars are spent. He also suggests diverting funds to the sorts of holistic treatments that see patients as people, too.

Psychiatrist Marco Ramos echoes this argument in his conversation about misunderstanding mental illness, which—despite billions spent on research and drug development—is still far from being understood. He believes that his field’s insistence on the biological basis for psychiatric disease has not only failed to yield more effective treatments. It has also prevented us from making structural changes that mentally-ill patients need.

Of course, if medicine is bad at admitting failure, it’s arguably even worse when it comes to bowing out gracefully. Physician Lydia Dugdale ups Prasad’s stakes in her episode on the lost art of dying, in which she argues that our denial of death negatively affects our quality of life. And like Ramos—and most Christians way back in the Middle Ages—she believes that it takes a village to help a person end her life well.

If all these guests are advocating for less pharmaceutical and technological intervention, does that mean that medicine’s next move is simply to swing the pendulum back? Or, to use Attia’s metaphor, should Medicine 3.0 look more like the old-school Macintosh, and less like the sleek MacBook Pro?

Maybe, says Attia, if by Macintosh you mean not so much floppy disks but an emphasis on exercise, diet, and developing emotional well-being. In other words, the things that can’t cure a rare disorder, but may well prevent it in the first place.

And therein lies the opportunity—and the challenge, too. All these guests’ prescriptions for a better life (and death) call not only for more early screening and effective medication, but also more rucking, more vegetables, and more probing self-reflection. They challenge us to have difficult conversations, as individuals and societies.

In short, when it comes to health, we may be more powerful than we realize. But with great power comes rucksack-heavy responsibility.

Who among is strong enough to take it up?

Marla Braverman, editor at EconTalk

Mining the Conversation

A selection of past EconTalk episodes that relate to health, medicine, and the practical and philosophical problems they raise:

Vivian Lee on the Long Fix: Arguing that America’s healthcare system incentivizes doctors to provide services, rather than to keep patients healthy, physician and healthcare CEO Vivian Lee proposes a radical new approach to doing medicine: prevention. While recognizing that it won’t be easy—nor will it be quick—Lee suggests adopting technologies, business models, and lessons from different sectors that can both save the public’s purse and help patients live better lives.

D.G. Myers on Cancer, Dying, and Living: In a conversation held just months before he died quietly of cancer, the iconoclast literary critic D.G. Myers embodied a courageous paradox: He spoke with bitter yet undeniable humor about the terrible injustice of his fate, and both raged against the waning light while facing it with proud grace. Most of all, with the time that remained to him, he sought to share a hard-earned lesson: namely, the bitter truth of opportunity costs, and the need to use our time wisely.

Adam Cifu on the Case for Being a Medical Conservative: We tend to think of medical knowledge as decisive, yet reversal—or the overturning of previous thinking about a medical service—happens more often than you think. Worse, once a practice has been established as the norm, it’s incredibly hard to change clinicians’ behavior—and patients’ expectations. For this reason, University of Chicago physician Adam Cifu urges caution before implementing new procedures or tests, and suggests skepticism in the face of industry influence and hype about “breakthroughs.”

Jacob Stegenga on Medical Nihilism: Already in ancient Greece, Heraclitus claimed that the way doctors torture their patients is “just as bad as the diseases” themselves. University of Cambridge philosopher Jacob Stegenga brings that argument up to date, arguing for a critical approach to not only particular medical interventions, but also the very theoretical framework on which all medical interventions are based. Pointing out that “facts and values are inextricably linked,” he recommends a less exciting but more realistic understanding of what medicine can and cannot do.

Gary Greenberg on the Placebo Effect: What if the placebo effect isn’t a trick? Diving into new research on the phenomenon’s biochemical basis, psychotherapist Gary Greenberg explores what this knowledge means for a cornerstone of modern medicine—the placebo-controlled double-blind drug trial—and how the effect can be harnessed to improve healthcare.

Conversation Starters

An eclectic selection of books, films, and podcasts for enhancing your own conversations on the topic.

So Much for That, by Lionel Shriver: Between scathing critiques of the American healthcare system and unflinching looks at chemotherapy, Shriver’s darkly comic novel tells the story of Shep Knacker’s slow march to financial ruin, one co-payment at a time. The worst part? Shep knows the terminal cancer he’s treating will kill his wife, anyway. An infuriating, horrifying, yet wildly entertaining read that manages to raise some provocative questions, from how much a life is really worth to what makes life worth living, anyway.

Podcast: Art of Manliness #852: The Brain Energy Theory of Mental Illness: After decades of research and clinical practice as a Harvard psychiatrist, Dr. Christopher Palmer believes he knows the root cause of mental illness—and it’s not bio-psychosociology, genetics, or a chemical imbalance. Called the Brain Energy Theory, it posits that metabolic problems can greatly affect the mind, and that changes in diet and exercise are just as critical as medication. Talk about a mind-blowing shift in the prevailing paradigm.

“The Big Loser,” a poem by Max Ritvo: Before he lost his struggle with cancer at the age of just 25, poet Max Ritvo produced a powerful meditation on the relationship between growth and death, collected in his work Four Reincarnations. In “The Big Loser,” dead things grow and promising things wish to die, and distress provides a brilliant lyricist with beautiful insights into life.

In Defense of Food: An Eater’s Manifesto by Michael Pollan: Arguing that the more we worry about nutrition, the less healthy we Westerners have become, food journalist Michaell Pollan offers a deliciously simple rule to live—and eat—by instead: “Eat food. Not too much. Most plants.” And for those of us who can’t imagine a world without dessert, take heart: According to Pollan’s prescription, you can have your cake and eat it, too.

Have the last word.