Medicine Against Reality
Sanctified falsehood and the affirmation of delusion
Physicians should tell the truth. This was once an uncontroversial statement, from a time when the physician’s role was understood to be both diagnostic and corrective. A patient came seeking clarity, and the physician, trained to discern the normal from the pathological, spoke plainly. This was not always easy, but it was essential. Diagnosis is the first step toward healing, and it was understood as an honest and accurate account of the cause of the patient’s problem, not a label to be worn like a fashion accessory or a badge of identity. The physician’s duty was not to reflect the patient’s worldview but to correct it when necessary, even when the truth was painful.
That ethic has eroded. Medicine has now absorbed the broader cultural impulse to elevate my truth over the truth, treating personal perception as more authoritative than objective reality. In this view, validating a patient’s self-conception is deemed more compassionate than confronting it. What was once pathological is now affirmed, and what was once regarded as disorder is now not only accepted as a legitimate choice but often actively celebrated as braver and more authentic than the norm. The consequence of this shift is that modern medicine has begun to abandon its most basic purpose out of a misguided commitment to emotional affirmation over clinical reality.
Personal perception, it goes without saying, is not infallible. “My truth” often means nothing more than “my wish.” People reject the parts of reality they find unpleasant and replace them with an imagined version they can better tolerate. A man may wish he were a woman and declare it his truth. A pregnant woman who wishes she were not may claim that ending the pregnancy is her truth, and may further insist that what she is killing is not her human child but a clump of cells with no moral or personal significance. A patient who is academically or professionally unsuccessful may declare it his truth that his failings are the result of a psychiatric disorder beyond his control. In each case, the subjective “truth” is a shield, protecting the individual from shame, fear, or regret, but it is not reality.
In the era of “my truth,” the physician’s role is to supply post hoc legitimization for the disordered life a patient is choosing to live, rather than therapeutically guiding the patient toward better, healthier choices, thoughts, and actions. The clinical encounter becomes less about uncovering and correcting the cause of suffering and more about furnishing a medical rationale for a predetermined course of action.
Consider the most extreme example: Medical Assistance in Dying (MAID). In jurisdictions like Canada, the already ethically perverse practice of euthanasia is no longer limited to the terminally ill. It is increasingly offered to patients suffering from depression, poverty, or loneliness.1 A patient who says he wants to die is now met not with suicide prevention, but with state-sanctioned death. The physician’s rightful role is to help the patient recover the will to live; instead, he affirms the existential despair, agrees that the patient’s life is not worth living after all, and proceeds to help end it. That this is done in the name of mercy only underscores how thoroughly the ethic of affirmation has replaced respect for truth and reverence for life.
A similar transformation has taken place in the realm of gender. A man who identifies as a woman is no longer encouraged to accept his true sex. He is affirmed in his delusion. He is prescribed estrogen. His genitals may be surgically removed. To question this course of action, even on scientific or ethical grounds, is to risk professional sanction. Despite the apparent certainty of the guidelines published by central medical authorities, the outcome of gender-affirming intervention remains highly dubious. Longitudinal data show persistent psychological morbidity, including high rates of suicide attempts post-transition.2 This has not slowed the advance of so-called gender affirmation, for affirmation has become its own justification. If the patient desires it, it must be therapeutic.
The male patient is not female nor can he ever be, no matter how intensely he desires it or how extensively he alters his body in pursuit of this unattainable goal. That depression and suicidality persist despite continuous affirmation is no mystery: there is simply no amount of pharmacological or surgical self-deceit that can make the patient believe, deep down, that he is something he knows in his soul that he is not. No matter how language is contorted to protect the patient’s self-conception, there are no pronouns and no euphemisms that can transform artifice into authenticity. The notion that one is living an “authentic self” while sustained by a regimen of synthetic hormones and surgically constructed genitalia is a contradiction in terms. Nothing could be less authentic than manufacturing outward signs of an identity one does not in fact possess. To speak this immutable truth aloud and to maintain therapeutic focus on it is now considered bigotry.
In psychiatry, the same dynamic takes the form of pathologizing what were once understood as normal human failings. Boredom in the classroom becomes ADHD. Adolescent moodiness, misbehavior, and rebellion are relabeled as Oppositional Defiant Disorder or Disruptive Mood Dysregulation Disorder. Sadness or grief, even when appropriate and proportionate to circumstance, is called depression. PTSD, once reserved for major and sustained traumas like combat or prolonged abuse, is now applied after ordinary misfortunes. Anxiety, which every human being has experienced since the beginning of time, is treated as a distinct disease state rather than a universal part of the human condition. Even ordinary personality traits, such as social awkwardness, idiosyncrasies, or intense interests, are increasingly reclassified as autism spectrum disorder.
What all of these diagnoses have in common is that they describe feelings, behaviors, and reactions that every person will experience at some point. We have all felt sad, defiant, angry, anxious, or socially awkward. These are not evidence of permanent defect, but part of the ordinary struggle of self-mastery. The proper aim of medicine should be to help patients overcome and master negative emotions, controlling their behavior in spite of them. Instead, these diagnoses confer an identity with a built-in excuse not to try. Patients are encouraged to see themselves as powerless over their impulses and emotions, and in doing so are subtly relieved of the responsibility to grow beyond them. These diagnoses, while not always entirely invalid, become exculpatory tools. They absolve patients of responsibility for their behavior. The extent of this phenomenon cannot be overstated; every day, criminals are brought not to the jail but to the emergency department, their violence recast as a symptom of Conduct Disorder or Antisocial Personality Disorder instead of criminal intent. No longer do we say the patient is misbehaving; we say he is ill.
One of the earliest and most consequential examples of medicine’s slide from truth-telling to affirmation can be found in abortion. Reproductive rights were among the first “healthcare” causes to be recast in euphemism, transforming a grave and irreversible act into a protected personal choice, and then into something to be celebrated. In decades past, abortion was regarded even by its defenders as a shadowy, tragic, and shameful necessity, to be kept “safe, legal, and rare.” Now, it is extolled as a sacrament of women’s rights, with public campaigns urging women to “shout your abortion.”3 In this rhetorical shift, medicine’s role has changed from weighing the moral and clinical gravity of ending a human life to affirming the patient’s desire to do so, and to furnishing the language that makes it sound not only permissible, but empowering.
A woman who becomes pregnant and feels distressed is now told that her suffering entitles her to terminate the pregnancy. No effort is made to help her reframe her situation, to see her child as a gift or a moral responsibility. Instead, abortion is presented as therapeutic. The humanity of the unborn is bracketed. The capacity of the mother to rise to the occasion is doubted in advance. A transient emotional state becomes sufficient justification for the most permanent act of all. The modern physician does not help her envision a future in which she meets the challenge and preserves the life within her; instead, he confirms that her life will be better if she ends another’s.
What ties all these cases together is not merely the politicization of medicine, but the systematic divorce of choice and consequence. Modern medicine, like the modern welfare state, seeks to shield individuals from the natural fallout of poor decisions. The social safety net insulates against unemployment, homelessness, and family dissolution. Medical practice now does the same, but under the language of diagnosis. Patients are no longer encouraged to make different choices, and instead they are offered a label that excuses them from having to.
Nowhere is this more visible than in the treatment of obesity. Despite its role as a leading contributor to chronic disease, obesity has increasingly been treated as an identity. To suggest that weight loss is desirable is labeled “fatphobia.” The phrase “health at every size” is uttered without irony, even as Type 2 diabetes and cardiovascular disease proliferate. Physicians are urged to focus on “weight-neutral care.” The implication is clear: the physician’s duty is not to help the patient improve, but to help the patient feel better about staying the same. (This movement is now in retreat, but not because its premises have been rejected; Ozempic now permits thinness without the renunciation of gluttony and sloth, making obesity less of a visible symbol of these sins and therefore less in need of affirmation.)
The result of all this is a therapeutic model that discourages change, undermines responsibility, and ultimately abandons the patient. This drift owes much to the self-esteem movement, which prized the protection of feelings above the cultivation of character. The remedy was not to cultivate the virtues that earn justified, authentic self-respect. Instead we learned to bend reality and language so that no one need endure the truth: that he is less than he ought to be.
It is not cruel to tell the truth. It is not stigmatizing to name a disorder for what it is. The physician’s obligation is not to affirm the patient’s self-conception, but to help to realign it with reality. Healing begins with the recognition that something is wrong, and that it can be made right through effort, discipline, and in many cases, sacrifice. Without that, there is no medicine. There is only appeasement. The patient deserves better. The patient deserves the truth.
Pitter J. Canadians with non-terminal conditions sought assisted dying for social reasons. The Guardian. October 17, 2024. https://www.theguardian.com/world/2024/oct/17/canada-nonterminal-maid-assisted-death
Straub JJ, Paul KK, Bothwell LG, Deshazo SJ, Golovko G, Miller MS, Jehle DV. Risk of Suicide and Self-Harm Following Gender-Affirmation Surgery. Cureus. 2024 Apr 2;16(4):e57472. doi: 10.7759/cureus.57472.
Erlangsen A, Jacobsen AL, Ranning A, Delamare AL, Nordentoft M, Frisch M. Transgender Identity and Suicide Attempts and Mortality in Denmark. JAMA.2023;329(24):2145–2153. doi:10.1001/jama.2023.8627
Shout Your Abortion. Shout Your Abortion website. https://shoutyourabortion.com/. Accessed August 13, 2025.
Solnit R. Can #ShoutYourAbortion turn hashtag activism into a movement? The New Yorker. October 21, 2015. https://www.newyorker.com/news/news-desk/can-shoutyourabortion-turn-hashtag-activism-into-a-movement. Accessed August 13, 2025.