Medicine is a good in Western society. Those of us who are engaged in the practices of the good of medicine—especially in light of the status that medicine has achieved—think of ourselves as practicing a good that is virtually unqualified. So, when critiques come, we, the practitioners of medicine, tend to have one of two responses: either outright dismissal of the criticism or a quick attempt to resolve the problem. What follows in this book is another critique of medicine, particularly in its mode of caring for the dying. By “the dying,” I mean those who are in the ICU and in palliative care. I have no doubt that there will be those who will dismiss my critique outright. As for the second group, those who hear the critique and accept it as, at least in part, accurate, they will no doubt attempt a quick remedy, one that fixes the problems that affect a broken medicine. Those remedies will range from a call for better scientific data in order to know better how to care for the dying, to a call for a good dose of humanism in order to solve the problem. The former will emphasize the science of medicine; the latter will emphasize the art of medicine. The former will say that medicine needs better science in order to become, once again, humane; the latter will call for a therapeutic course of humanistic education, a humanities pill to fix what ails us. Yet it seems to me that we have been attempting both fixes for so long that we do not even know where the problem lies. It is virtually impossible to think about how to solve any problem in medicine without our thinking becoming almost immediately mechanical and instrumental. We already live inside a way of thinking that prevents us from thinking differently; not that thinking differently is impossible, it is just difficult. If we are to prevent all practices in medicine from becoming thoughtless doing, we must once again turn to how we think about what it is that we do. In order to achieve this, however, we must, paradoxically perhaps, realize that all thinking is also a kind of doing. The strict line between theoria and praxis, so prominent in the West, and the strict division between subject and object are, in a way, false ones, but they continue to flourish in our practices. These lines (theory vs. practice, subject vs. object) sit at the very heart of the West, if we are to believe thinkers such as Nietzsche and Heidegger; or perhaps these lines are just an aberration of late Western Scholasticism, or are lines drawn at the Enlightenment. If we accept Foucault’s position—which does not preclude accepting any one of these possible readings on the history of Western thought—we know that there are various kinds of practices implicit in all theoretical endeavors, and at the same time there are implicit theoretical stances in all that we do. Thus, we must think, once again, about what it is that we do by examining critically what we do. Medicine as a discipline is mostly concerned with doing and with the effects it brings about in the world. Medicine concerns itself with how to pragmatically produce or cause those effects in the world. Or, as Carl Elliott points out, medicine collapses into an unthinking pragmatism, an inane “practice in order to be practical.” Medicine is a practice ordered toward and by its own practicality. Medical information is justified as medical knowledge if one can do something with it in the world. Medicine’s metaphysical stance, then, is a metaphysics of material and efficient causation, concerned with the empirical realm of matter, effects, and the rational working out of their causes for the purposes of finding ways to control the material of bodies; that is to say, medicine’s metaphysics of causation is one of material and efficient causation at the expense of final causes or purposes. Among Aristotle’s four causes, early modern science—including medical science—historically repudiated or, at the very least, minimized formal and final causation and elevated material and efficient causation. Efficient causality reigns supreme in all technological thinking, such that even matter comes to be thought of not so much as a cause, but as the stuff that stands in reserve of power, awaiting knowledge to mold it into what we desire it to be. On this view, matter—the body—has no integrity, except that it is driven by an automaticity and can be bent to our desires. At least since Bacon, it has been understood that knowledge is power gained to relieve the human condition. That is to say, true knowledge can do things with the world. The purpose of knowing—the end of knowing—is to bring about desired effects in a world of immanent cause and effect. Medicine gives no thought to its metaphysics; it might even deny having one. And it gives no thought to its practices, because medicine is about doing and not about thinking. For Western medicine, and perhaps for all of scientific and technological thinking, the important problem in the medical world is how to manipulate the body or the psyche in order to get the effects that we desire. Bodies have no purpose or meaning in themselves, except insofar as we direct those bodies according to our desires. In this sense Eric Krakauer has said that medicine is the standard-bearer of Western metaphysics. The world—the body—stands before us as a manipulable object, and all thinking about the world or the body becomes instrumental doing; thus, to do good we must manipulate the world and show our effects toward some measureable outcome.