The 12 Rituals of Modern Medicine

An Essay on Confession, Divination, Sacrament, and Absolution in the Clinic

This essay is the companion to The 12 Screenings That Manufacture the Patients They Claim to Find.⁴ That piece examined the thresholds, the overdiagnoses, the cascades, and the markers that are not what they claim. This piece examines the ritual structure the screenings sit within, and extends the audit beyond screening into the daily prescription and the pharmacy counter. The anthropological lens is Robert Mendelsohn’s, from Confessions of a Medical Heretic (1979);³ he named modern medicine as a church and the physician as priest. The twelve rituals developed here are the sacraments of that church as it operates in 2026.

The essay engages material framed in establishment terms throughout: cholesterol, hypertension, osteoporosis, major depression, influenza, prostate cancer. Those terms appear in attribution, quotation, and the names of professional bodies. The terrain paradigm operates in the author’s own analytical voice when the question shifts to what the body is actually doing. The shifts are deliberate; the reader is asked to hold both registers and watch what each one obscures.

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The Cochrane Collaboration is the highest tier of evidence synthesis mainstream medicine recognizes. In 2012 the Nordic Cochrane Centre published a systematic review of general health checks in adults, pooling fourteen randomized trials with 182,880 participants and an average follow-up of nine years. The finding on overall mortality was null. The finding on cardiovascular mortality was null. The finding on cancer mortality was null.¹

The annual physical, the ritual that opens the door to every other ritual medicine performs, had no measurable effect on when people died. The authors updated the review in 2019 and the conclusion did not change.²

A finding of that scale, from a review of that quality, should have changed medical practice. It did not. Physicians continued to book the appointments. Insurers continued to cover them. Patients continued to attend. Health systems continued to describe the annual physical as the foundation of preventive care. In 2026, fourteen years after the original review and seven years after the update, the annual physical remains among the most common patient encounters in the Western clinical calendar.

Robert Mendelsohn, a Chicago pediatrician who taught at the University of Illinois Medical School, published Confessions of a Medical Heretic in 1979.³ Modern medicine, he argued, had become a religion. Doctors were its priests, hospitals its temples, pharmaceuticals its sacraments, medical school its seminary. He wrote the book as a confession because he had been ordained in that religion and had come to see what it was doing.

What he saw is now visible in a form he did not live to witness. The twelve rituals examined below are the sacraments of the Church of Modern Medicine as it operates in 2026. Three are confessions in which the patient produces data for the priest to judge. Four are divinations in which the priest reads signs the patient cannot see. One is the sacramental ceremony administered at a retail counter by a lay officiant. Four are the daily penances the patient takes until death.

Each ritual has been audited by the same tier of evidence that produced the Krogsbøll finding on the annual physical. The results of those audits accumulate below. The ritual persists, and the evidence against the ritual persists alongside it, in parallel, without the former being disturbed by the latter.

A practice that persists through the publication of evidence against it is operating on a logic other than the one it names. The anthropological lens makes that logic visible. Rituals are sustained by participation. The evidence is incidental.

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I. Confession

The confession is the ritual in which the parishioner produces material for the priest to examine and judge. In the Catholic sacrament the material is produced through speech. In the medical sacrament it is produced through speech, through breath, and through the drawn vial. The parishioner supplies the material; the officiant interprets it; the interpretation is pronounced over the parishioner and recorded in the file.

Three contemporary medical rituals follow this structure. The annual physical, in which the patient narrates recent symptoms, lifestyle, family history, and intimate function while the physician records and judges. The cholesterol screening, in which the drawn vial is examined for numeric values that will determine the patient’s status. The glucose tolerance test, in which the patient’s own metabolism, perturbed by a dose of pure sugar, produces the material that classifies the patient as prediabetic. The parishioner supplies the data in each case. The data is read against a threshold the parishioner did not set and did not consent to. The reading becomes a label the parishioner will carry.

The annual physical

The Krogsbøll Cochrane review found no mortality benefit. The review did find increased diagnosis. Participants in the health-check arm were diagnosed with more conditions and started on more medications than the control group, with no corresponding reduction in death from any cause.¹ The ritual produced patients. It did not produce survival.

The authors of the 2019 update were explicit about the mechanism. Finding a condition in an asymptomatic person does not, by itself, improve that person’s trajectory. The condition may have been one that would never have progressed. The medication started in response to the finding has risks of its own. The downstream appointments, the referrals, the specialist consultations, the imaging studies, generate harms the summary estimate must absorb.² The sum of those harms, offset against the gains from early detection of conditions that would otherwise have progressed, nets to zero on the mortality axis.

The ritual performs other work. It satisfies the patient’s intuition that attending medicine is itself a protective act. It satisfies the physician’s intuition that producing data is itself a competent act. It satisfies the insurer’s intuition that documented care is defensible care. None of these is the same as evidence that the ritual saves lives.

The confession is in form and in substance. The patient speaks the symptoms, confesses the diet, discloses the drinking, admits the stress. The physician absolves through reassurance or sentences through diagnosis. The next appointment is set. The sacrament is scheduled annually, as sacraments typically are. The parishioner leaves having performed a duty the evidence does not require them to perform, in a ceremony the evidence does not support, with instructions to return.

Cholesterol screening

The relationship between total cholesterol and all-cause mortality is not what the ritual presupposes. In the HUNT 2 study, a Norwegian population cohort of 52,087 adults followed for approximately a decade, women in the highest total cholesterol category (≥7 mmol/L) had lower all-cause mortality than women in the lowest category (<5 mmol/L).⁵ The relationship in men was essentially flat across most of the measured range. The inverse pattern at low cholesterol in older adults has been documented across multiple cohorts including Framingham, the Honolulu Heart Program, and the Leiden 85-plus study, and a 2016 systematic review by Ravnskov and colleagues found no association or an inverse association between LDL cholesterol and mortality in people over 60 across 19 cohort studies.⁶

The ritual continues to treat cholesterol as a dial on which lower is better and lowest is best. The LDL target for high-risk patients has been revised downward in successive guideline iterations across the past two decades. Each revision produced new patients from the same measured bodies. No molecule had changed; the dial on which the molecule was read had been moved.⁷

The confession runs as follows. The patient fasts, surrenders the vial, and waits. The number is produced. The number is compared to the threshold set by the guideline committee. A 2013 BMJ investigation by Jeanne Lenzer found that a majority of the panelists on the 2013 ACC/AHA cholesterol guideline, which rewrote the US treatment framework, had current or recent ties to drug manufacturers.⁸ The patient is informed of the number and the threshold, and offered the appropriate response, which is a lifetime prescription of a lipid-lowering medication the patient had not previously required.

The ritual’s structure survives even when the biochemistry is contested. The cholesterol hypothesis has been questioned by Ravnskov, Kendrick, Malhotra, de Lorgeril and others for three decades. The ritual’s response has been to lower the threshold again. A ritual that persists through revisions of its own underlying rationale is operating on a logic other than the one it names. The confession generates the number. The number generates the prescription. The prescription generates the refill.

Glucose tolerance test

The category of prediabetes was formalized by the American Diabetes Association in 2003 and expanded in 2010 to include HbA1c values between 5.7% and 6.4%.⁹ By the current definition, approximately one in three American adults is prediabetic.¹⁰ The majority will never progress to type 2 diabetes. Richard Kahn, former ADA chief scientific officer, and Mayer Davidson examined the natural history of the prediabetic state in a 2014 analysis in Diabetes Care and found that of patients meeting the criteria, only a minority progressed to diabetes over the ensuing decade, and a substantial fraction reverted spontaneously to normoglycemia.¹¹ The International Diabetes Federation and the World Health Organization have declined to adopt the ADA’s expanded criteria.¹²

The ritual produces the finding regardless. The patient drinks a dose of glucose solution, the blood is drawn at timed intervals, and the resulting number is compared to a threshold set by the professional society that counts prediabetes as a disease state requiring intervention. The intervention is pharmaceutical, dietary, or both. The appointments are recurring. The testing becomes a feature of the patient’s calendar for the remainder of their life.

The confession here is of metabolic sin. The parishioner has consumed too much sugar, carried too much weight, moved too little, eaten the wrong things. The number is the evidence of the sin. The absolution is a drug the patient did not previously need and a schedule of future monitoring that extends indefinitely. The patient leaves having been reclassified from well to pre-sick, with no detectable change in how they feel and no clear benefit from the intervention offered.

The ritual’s output is the label. The label changes the patient’s self-concept, the pharmaceutical relationship, and the position of the metabolic question in the patient’s life. The patient who entered as a person with a modestly elevated blood sugar leaves as a person whose body has been categorized as failing. The confession has produced its sinner.

II. Divination

Divination is the ritual in which the priest reads signs invisible to the parishioner and pronounces their meaning. The entrails of the sacrificial animal in Roman practice. The casting of lots. The reading of the stars. The parishioner cannot see what the priest sees. The authority of the pronouncement rests on the privileged access.

Four contemporary medical rituals follow this structure. The mammogram, in which radiographic images of breast tissue are interpreted by a specialist whose reading the patient cannot verify. The colonoscopy, in which a camera is passed through the colon and the specialist describes what the camera showed. The PSA test, in which a serum level is compared to a threshold the patient did not set. The bone density scan, in which radiation is passed through the skeleton and a T-score is calculated against a reference population the patient has no way to evaluate. In each case the patient is passive, the priest reads, and the pronouncement is made. The reading determines what the patient is next required to do.

Mammogram

The Nordic Cochrane group’s 2013 systematic review of randomized trials of screening mammography reported that for every 2,000 women screened over ten years, one would avoid dying from breast cancer, around ten healthy women would be overdiagnosed and treated unnecessarily, and 200 would experience false alarms with psychological consequences.¹³ The overall mortality benefit was not statistically significant. The authors concluded that it was no longer reasonable to attend screening without being told that the balance of benefits and harms had not been established in the woman’s favor.

Bleyer and Welch, in a 2012 New England Journal of Medicine analysis of three decades of US screening mammography, estimated that approximately 1.3 million American women had been overdiagnosed with breast cancer over that period. Cancers had been detected and treated that would never have progressed to cause symptoms or death if left alone.¹⁴ The late-stage incidence of breast cancer, which screening was supposed to reduce, was essentially unchanged. The reduction in breast cancer mortality observed over the same period was largely attributable to improvements in treatment.

The defense of mammography has shifted ground as the evidence has accumulated. The current argument is that the Cochrane trials were old, uptake was imperfect, and modern imaging has caught up with its own earlier failures. The argument misreads what the trials measured. If screening were catching the cancers that would otherwise have killed women, late-stage disease would have declined over the three decades of expanded US screening that Bleyer and Welch analyzed. It did not. The population-level test of a screening program is whether the dangerous end of the disease moves. In breast cancer, it has not moved.

The divination structure is intact. The patient enters the imaging suite, is positioned by a technician, and the plates are produced. The patient cannot read the plates. The specialist reads them in a separate room. The pronouncement is returned by letter, phone call, or portal message. If the pronouncement is suspicious, the ritual escalates to biopsy, which escalates to pathology, which escalates to treatment. The pathology report, like the mammogram, is a specialist reading the patient cannot verify. The patient is told what has been seen in her body, what it means, and what must be done about it. She is in no position to question any step of the sequence.

Peter Gøtzsche, who co-founded the Nordic Cochrane Centre and spent two decades auditing mammography, concluded that the apparatus should be dismantled.¹⁵ He was removed from the Cochrane board in 2018 after disputes with the organization’s leadership. The letters still arrive. The pronouncements are still made. The divination’s accuracy was never the point of its persistence.

Colonoscopy

The NordICC trial, published in the New England Journal of Medicine in October 2022, randomized 84,585 adults in Poland, Norway, Sweden, and the Netherlands to invitation for a single screening colonoscopy or to usual care, and followed them for ten years.¹⁶ The reduction in colorectal cancer incidence was 18% in the intention-to-screen analysis. The reduction in colorectal cancer death was not statistically significant. The reduction in all-cause mortality was zero.

The result landed in the gastroenterology literature with visible discomfort. US guidelines had treated screening colonoscopy as settled since the 1990s on the basis of case-control and cohort studies. NordICC was the first large randomized trial of invitation to screening with mortality endpoints. The response from the specialty was to argue that compliance in the trial was low (42% of those invited attended) and that per-protocol analyses, limited to those who actually attended, showed benefit. The move was not credible. Screening programs invite everyone; some fraction attends; the ones who attend are self-selected on health behavior and health anxiety. The intention-to-screen result is the only result that measures what the policy does at the level the policy operates. The per-protocol result measures the self-selected attenders and cannot be generalized back to the invited population. The gastroenterology response was to prefer the result that could not answer the question over the result that could.

The divination runs as follows. The patient fasts for a day, drinks a preparation that evacuates the colon over the following hours, presents to the facility, is sedated, and the camera is passed. The patient cannot see what the camera sees. The physician describes what was found. If polyps are identified they are removed in the same session. The pathology report is returned later and the patient is informed. The next appointment is scheduled, typically in five to ten years. The ritual recurs through the remainder of the patient’s life.

The procedure carries non-trivial risk. Perforation, bleeding, and sedation complications occur at rates measured in the single digits per thousand, applied to tens of millions of procedures per year.¹⁷ The NordICC finding of no mortality benefit means those harms have been absorbed without corresponding gain at the population level. The divination’s authority rests on access the patient does not have. The patient cannot see the colon. The physician describes what was seen. The pronouncement is accepted. The authority is in the specialized vision.

PSA

Richard Ablin discovered prostate-specific antigen in 1970 at Roswell Park. In 2010 he published an op-ed in the New York Times titled “The Great Prostate Mistake.”¹⁸ “I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster,” he wrote. Prostate cancer, he argued, may be America’s most over-diagnosed and over-treated malignancy, and the test was the engine of it. He developed the point in a 2014 book, The Great Prostate Hoax, co-authored with Ronald Piana.¹⁹

The PLCO trial, published in the New England Journal of Medicine in 2009, randomized 76,693 American men to annual PSA screening versus usual care, and found no reduction in prostate-cancer mortality after seven to ten years of follow-up.²⁰ The European ERSPC trial, with a different protocol, reported a small reduction in prostate-cancer mortality in the screened arm, offset by overdiagnosis and overtreatment at rates sufficient to make the net benefit contested.²¹ The US Preventive Services Task Force gave PSA screening a “D” recommendation in 2012, meaning the harms outweighed the benefits, then softened to a “C” in 2018 after specialty pushback, meaning the decision should be individualized.²²

The divination structure is unchanged by the controversy. The serum level is drawn, the number is produced, the number is compared to a threshold the professional societies have revised downward over time. A number above the threshold triggers biopsy, which carries post-procedural complication risks including bleeding and sepsis measured in the low single-digit percentages per procedure.²³ The biopsy produces tissue; the tissue is read by a pathologist; the pathologist assigns a Gleason score; the Gleason score triggers treatment. Treatment is typically prostatectomy or radiation, both of which carry well-documented incontinence and erectile dysfunction rates measured in the double digits.

Ablin, the man who found the antigen, has spent the fifteen years since his New York Times op-ed trying to dismantle the apparatus his discovery enabled. The apparatus continues. The number is still drawn. The thresholds are still read. The biopsies are still ordered. The specialist’s privileged access to the serum level and its interpretation is what makes the ritual a divination.

Bone density scan

The World Health Organization defined osteoporosis in 1994 as a T-score of −2.5 or lower on dual-energy X-ray absorptiometry (DEXA), using young healthy women as the reference population.²⁴ The 1994 working group’s deliberations proceeded with support from the pharmaceutical and bone-density scanning industries, a conflict developed in subsequent critiques of the diagnostic category.²⁵ The threshold has not been revisited despite extensive critique of the reference-population choice and the clinical implications of applying young-adult norms to older patients.

Teppo Järvinen and colleagues, writing in the BMJ in 2015 under the title “Overdiagnosis of bone fragility in the quest to prevent hip fracture,” argued that the diagnostic threshold had produced systematic overdiagnosis of bone fragility and that the bisphosphonate medications prescribed in response had marginal benefit on fracture risk and non-trivial adverse effects, including atypical femur fractures, osteonecrosis of the jaw, and esophageal injury.²⁵ The paper did not alter the screening recommendations.

The divination runs as follows. The patient is positioned on the scanning bed; X-rays are passed through the lumbar spine and hip; the machine calculates a T-score; the T-score is pronounced. The pronouncement determines classification as normal, osteopenic, or osteoporotic. The classification determines whether a bisphosphonate is prescribed. The prescription is typically weekly or monthly oral dosing, continued for years, with pharmacovigilance checklists advising the patient to remain upright for thirty minutes after each dose to avoid esophageal erosion.

The patient cannot see the T-score as it is calculated. The patient has no way to evaluate whether the reference population is appropriate to her own body, bone structure, ethnicity, or weight-bearing history. The specialist reads the machine’s output and pronounces the finding. The patient is told what her bones are. The medication follows. The medication is taken for the remainder of life, as absolution rituals typically are, and the divination recurs at intervals set by the specialist, as divinations typically do.

III. Sacrament

Sacrament is the ritual in which a substance is administered on an appointed day as the physical conveyance of invisible benefit. The Catholic Eucharist. The baptismal water. The anointing oil. The sacrament’s efficacy is not demonstrated by evidence; it is affirmed by participation. The parishioner receives the substance from the officiant on the specified day in the specified setting, and the reception itself is the ritual.

One medical practice has this structure in its contemporary form. The annual flu shot administered at the pharmacy counter is the only medical procedure a person is likely to undergo in a public retail setting, delivered by a lay officiant who is not the patient’s physician, with no appointment, no case history, no examination, and no follow-up. The sacrament is seasonal. The appointed days arrive each autumn. The signage goes up at the drugstore, the supermarket, the shopping mall. The parishioner presents to the counter, bares the shoulder, receives the substance, and is given a sticker.

No other pharmaceutical is distributed this way. Prescription medications require a prescriber relationship, pharmacist review, and documentation. Over-the-counter medications are selected by the consumer and purchased in the aisle. The flu shot stands alone in combining the public setting, the lay administrator, the seasonal timing, the absence of medical examination, and the ceremonial return. In a society that has abandoned religious ceremony, the one surviving public ceremony administered by a lay officiant to a stranger in a retail setting is the autumn vaccination.

Flu shot at the pharmacy counter

The Cochrane Collaboration’s 2018 systematic review of inactivated influenza vaccines in healthy adults pooled 52 clinical trials with over 80,000 participants and reported that approximately 71 adults would need to be vaccinated to prevent one case of what the authors defined as influenza, and 29 would need to be vaccinated to prevent one case of what the authors defined as influenza-like illness.²⁶ The review found no measurable effect on working days lost, no measurable effect on hospitalization, and no evidence of effect on complications. Tom Jefferson, a senior author on the Cochrane influenza vaccine reviews across two decades, has written repeatedly that the evidence base for mass influenza vaccination does not support the public health policy built around it.²⁷

The sacrament continues to be administered. In the United States, approximately half of adults receive the shot annually, with higher rates in people over 65 and in healthcare workers.²⁸ The retail setting has grown steadily; pharmacy-based administration surpassed physician-office administration during the 2010s and is now the dominant mode. The shot is covered by insurance without copay in most plans. The administration takes under a minute. The sticker is applied. The transaction is complete.

The terrain reading of the seasonal pattern the shot is said to address is simple. Winter brings reduced sunlight exposure, reduced vitamin D synthesis, more time indoors in heated and dry air, more consumption of holiday foods high in sugar and alcohol, more exposure to indoor heating systems, more disruption of sleep and routine. Seasonal illness in that context is a predictable terrain response to a predictable terrain shift. The body’s cleansing responses, which medicine calls flu-like illness, are the response to the burden the season imposes.

The terrain reading has history behind it. Daniel Roytas’s Can You Catch a Cold? catalogs approximately 200 human transmission experiments conducted between 1798 and the present, in which investigators attempted to induce respiratory illness in healthy volunteers using the mucus, blood, and nasal secretions of the sick.⁴⁶ The pattern in the record is striking. Milton Rosenau’s 1918 Boston experiments during the Spanish influenza outbreak used Navy volunteers at Deer Island, Angel Island, and Gallups Island; mucus, blood, and throat washings from the acutely ill were introduced into the healthy by every route Rosenau could devise. None of the volunteers became ill. Rosenau’s conclusion, published at the time, was that medicine was not quite sure what it knew about the disease.⁴⁷ The British Common Cold Research Unit at Salisbury ran similar experiments for four decades from 1946 and found that transmission from the sick to the healthy was difficult to produce and often failed outright. The experiments are not in the standard medical education of the twenty-first century. The sacrament continues as if they had never been run.

The sacrament is administered on the premise that the illness is caused by a particle the body must be primed to repel. The terrain reading holds that the illness is caused by the burden the body is attempting to cleanse. The pharmacist is not asked which view is correct. The customer is not asked. The shot is given. The sticker is applied. The parishioner leaves having performed the autumn ritual as it has become. What sustains the sacrament is its sociology.

IV. Absolution

Absolution is the ritual in which the parishioner is pronounced forgiven and assigned a penance to perform in continuing recognition of the sin. In Catholic practice the penance is a prescribed number of prayers. In medical practice the penance is a daily pill. The sin is not spiritual; it is biochemical. The parishioner has been found to have an elevated number, a reduced bone, an acidic stomach, a prolonged grief. The absolution is the diagnosis itself: the condition has been named and accepted into the clinical system. The penance is the pharmaceutical regimen that proceeds from the diagnosis and does not stop until the parishioner dies.

Four pharmaceutical regimens dominate the absolution function in Western clinical life. The statin, prescribed in response to the cholesterol confession, taken daily to lower the number the confession produced. The antihypertensive, prescribed in response to a reading above a threshold a committee lowered in 2017, taken daily thereafter. The proton pump inhibitor, prescribed in response to reflux symptoms, taken daily to suppress gastric acid, continued often for years beyond the labeled duration. The selective serotonin reuptake inhibitor, prescribed in response to a symptom pattern that includes bereavement, taken daily to adjust a serotonergic process whose connection to the symptom pattern has never been established. The penance in each case is daily and lifelong. The penance in each case cannot be stopped without clinical sequelae that function to anchor the parishioner to the regimen.

Statin at fifty

The 2022 JAMA Internal Medicine systematic review by Byrne, Demasi and colleagues pooled 21 randomized controlled trials of statins against placebo and examined the relationship between LDL-cholesterol reduction and all-cause mortality.²⁹ The authors found that the association between the magnitude of LDL reduction and the reduction in all-cause mortality, cardiovascular mortality, myocardial infarction, and stroke was “inconsistent and weak.” The absolute risk reductions, averaged across the trials, were small. The number needed to treat for several years to prevent one death was in the triple digits.

The pharmaceutical class generates revenue measured in the tens of billions of dollars annually and sits among the most-prescribed drug families in medical history.³⁰ Roughly one in four American adults over 40 is on a statin.³¹ The prescription is typically initiated at age 50 for men and somewhat later for women. Discontinuation is discouraged clinically; the physician warns the patient of elevated cardiovascular risk if the drug is stopped, and the patient resumes.

The adverse-effect profile of long-term statin use includes muscle pain and weakness (common), new-onset diabetes (increased risk documented in trial meta-analyses), cognitive effects (reported in post-marketing surveillance and some observational studies), liver enzyme elevation (routinely monitored), and rhabdomyolysis (rare but serious).³² The muscle complaints are frequent enough that some patients are shifted between statin molecules in search of one they can tolerate, a process that is itself a ritual of adjustment within the broader penance.

The absolution structure is explicit. The patient confessed the cholesterol number. The number exceeded the threshold the committee set. The patient was absolved by being formally diagnosed with what medicine calls hyperlipidemia and assigned a penance. The penance is a pill taken each morning. The pill does not resolve the underlying metabolic condition; it suppresses one measured marker of it. The patient is told to continue indefinitely. The absolution has removed the parishioner’s moral responsibility for the number. The number remains elevated in the absence of the pill. The pill is therefore required for the remainder of life.

Blood pressure medication at 130/80

On November 13, 2017, the American Heart Association and the American College of Cardiology jointly released a guideline that redefined hypertension as a reading of 130/80 or higher, down from the previous threshold of 140/90.³³ The redefinition increased the US adult population classified as hypertensive by approximately 31 million people overnight.³⁴ No pathophysiology had changed. No bodies had been altered. The dial on which blood pressure was read had been moved.

The SPRINT trial, published in the New England Journal of Medicine in 2015, was the primary evidence cited for the lower threshold.³⁵ The trial compared intensive blood pressure control (target under 120 systolic) to standard control (target under 140 systolic) in high-risk adults and reported a reduction in composite cardiovascular events and all-cause mortality in the intensive arm. Critics noted that SPRINT used unattended automated blood pressure measurements, which typically read 5 to 15 mmHg lower than conventional office readings. The SPRINT “intensive” target was closer to a conventional target of 130 to 135 than to 120.³⁶ The guideline committee applied to office readings a trial-measured target derived from a lower-reading methodology.

The 2017 guideline paper’s own disclosure section documents extensive financial relationships between committee members and the manufacturers of antihypertensive medications.³³ The threshold revision immediately expanded the eligible patient population for those medications. The sequence from guideline revision to prescription expansion was mechanical.

The penance follows. The patient receives the diagnosis of hypertension at the new threshold, is prescribed one or more antihypertensive medications, and is monitored at recurring intervals thereafter. The medications carry well-documented adverse-effect profiles including fatigue, dizziness, erectile dysfunction, electrolyte disturbance, cough (ACE inhibitors), and cognitive effects in the elderly. The medications are taken for the remainder of life. The patient’s blood pressure, which was within the normal range as defined before November 2017, has become a condition requiring daily pharmaceutical management. The absolution has been granted. The penance will not end.

Proton pump inhibitor for reflux

The FDA approved proton pump inhibitors for short-term use (typically four to eight weeks) in gastroesophageal reflux disease. The approved labeling specifies limited duration because of safety signals that have accumulated since the drug class was introduced in the late 1980s. Long-term use measured in years and decades is common. A 2008 editorial in the BMJ titled “Overprescribing proton pump inhibitors” documented widespread prolonged prescribing of these drugs well beyond the labeled duration, often without evidence of continuing benefit and without clinical reassessment.³⁷

The adverse-effect literature is substantial. Lazarus and colleagues, in JAMA Internal Medicine in 2016, found a 20 to 50 percent increased risk of chronic kidney disease in PPI users compared to non-users, with a dose-response relationship.³⁸ Gomm and colleagues, in JAMA Neurology in 2016, found an increased risk of dementia in older adults on PPIs.³⁹ The FDA added a warning for increased fracture risk in 2010 after multiple studies documented the association with osteoporotic fracture.⁴⁰ PPIs reduce absorption of vitamin B12, magnesium, calcium, and iron over long-term use.

Rebound acid hypersecretion, demonstrated in Reimer and colleagues’ 2009 trial in Gastroenterology, means that PPI discontinuation in healthy volunteers who had never previously had reflux produced a surge of acid secretion above baseline and symptoms resembling the original condition the drug is prescribed to treat.⁴¹ The rebound mechanism is a pharmacological absolution lock. The drug produces, upon cessation, the condition it was prescribed to treat.

The ritual structure is characteristic. The patient reports reflux. The physician prescribes a PPI. The patient’s symptoms resolve. The patient takes the drug for weeks, months, years. Occasionally the patient tries to stop and the symptoms return, often worse than before. The patient resumes the drug and is told the reflux was more severe than previously appreciated. The patient takes the drug for life. The terrain reading of the original reflux is distinct from the pharmaceutical one. Stomach acid rises when the sphincter is relaxed, the stomach is overfull, the diaphragm is distended, or the diet is irritating. Each of those has a non-pharmaceutical response. The ritual does not pursue the non-pharmaceutical response. The pill is simpler. The absolution is granted.

Selective serotonin reuptake inhibitor for grief

In 2013, the American Psychiatric Association removed the bereavement exclusion from the diagnostic criteria for major depressive disorder in the DSM-5.⁴² Prior to 2013, the diagnostic criteria specifically excluded depressive symptoms in the first two months after the death of a loved one from counting toward a diagnosis of major depression. The removal of the exclusion meant that normal bereavement, if its symptoms exceeded a two-week duration and met the symptom checklist, could now be diagnosed as major depression and treated with antidepressant medication from the second week forward.

Allen Frances, who chaired the DSM-IV task force and had spent his career inside the apparatus, opposed the change in writing. He argued that it would convert ordinary human grief into clinical pathology and open the diagnostic door to pharmaceutical treatment of an experience as old as mourning.⁴⁸ The objection was published. The revision proceeded.

The SSRI class, originally approved for severe depression and anxiety, now accounts for one of the most frequently prescribed drug families in Western medicine. Approximately one in eight American adults is on an antidepressant at any given time, with substantially higher rates in women and in people over 60.⁴³ The 2017 BMC Psychiatry meta-analysis by Jakobsen and colleagues pooled 131 randomized placebo-controlled trials of SSRIs and reported that the mean difference in depression scores between drug and placebo was small, below the threshold considered clinically meaningful, and was accompanied by elevated risk of serious adverse events in the drug arms.⁴⁴ The authors concluded that the use of SSRIs did not appear to justify the harms.

The serotonin hypothesis of depression, which the drug class was developed around, has been formally retired by prominent researchers in the field. Moncrieff and colleagues’ 2022 umbrella review in Molecular Psychiatry concluded that there was no consistent evidence of an association between serotonin and depression, and no evidence that depression was caused by lowered serotonin activity.⁴⁵ The mechanism the drug class was built around does not appear to exist. The drug class is still prescribed in the volumes it has reached.

The absolution operates on grief as it does on cholesterol. The patient reports sadness after a loss. The physician applies the symptom checklist. The checklist meets the threshold. The diagnosis is made. The prescription follows. The patient is informed that grief has become depression and that depression requires a daily pill. The pill is taken thereafter, often for years, with discontinuation syndromes that functionally anchor the patient to the regimen. The absolution is permanent. The penance is daily. The grief, which was always a terrain response to loss, has been reclassified as a disease that requires lifelong pharmaceutical management.

V. The audit

The Cochrane finding on the annual physical is one point in a pattern. Each of the twelve rituals examined above has been audited by evidence of equivalent tier, and the audits produce consistent results. The annual physical does not reduce mortality. The cholesterol relationship is not what the ritual presupposes. The prediabetes category does not predict progression in the majority of those labeled. The mammogram does not reduce overall mortality and overdiagnoses on a scale measured in the hundreds of thousands per decade. The colonoscopy does not reduce overall mortality in randomized trial. The PSA does not reduce prostate-cancer mortality in the largest trials, and the man who discovered the antigen has spent fifteen years asking that the apparatus be dismantled. The bone density scan uses a diagnostic threshold set in 1994 by a working group that operated with industry support and whose criterion has not been revisited despite extensive critique. The flu shot’s own Cochrane review reports a number needed to vaccinate of 71 for the illness the shot is named to prevent. The statin’s absolute mortality benefit is small. The hypertension threshold was moved in November 2017 and 31 million Americans became hypertensive without having changed. The PPI produces upon cessation the condition it was prescribed to treat. The SSRI’s mechanism was formally retired in 2022 and the drug class continues to be prescribed in historic volumes.

Each ritual has been audited by the gold-standard apparatus that mainstream medicine itself uses to adjudicate practice. The audits have returned null or negative results across the twelve. The practice has not changed.

A practice that persists through the publication of evidence against it is operating on a logic other than the one it names. Mendelsohn named that logic in 1979. The twelve rituals are the sacraments of a church that does not understand itself as a church. The confession is scheduled. The divination recurs at the specified intervals. The sacrament is administered on the appointed day. The absolution anchors the parishioner to the regimen for the remainder of life.

Two auditors stand as markers of what the apparatus does with its most careful critics. Robert Mendelsohn had been ordained in the apparatus and spent his career inside it before publishing Confessions of a Medical Heretic and the “People’s Doctor” newsletters that followed. His profession responded by marginalizing him. Peter Gøtzsche co-founded the Nordic Cochrane Centre, built the mammography review that produced the 2013 finding at the center of this essay, and later turned the same methods on the HPV vaccine review. The Cochrane Collaboration removed him from its board in 2018. The institution that defines itself by evidence has a durable record of ejecting the auditors who produce the evidence it cannot absorb.

Each ritual has an off-ramp. The appointment can be declined. The vial can be refused. The scan can be skipped. The pill can be set down. Each off-ramp is a decision the patient has always been able to make. The ritual depends on participation and participation has always been voluntary.

The evidence base that was supposed to validate the apparatus has become the record of its failure. The Cochrane library is where that record is kept. The library is open. The record is readable. The ritual persists in parallel with the record. That parallel is the apparatus.

How to Explain It to a Six-Year-Old

In a village there is a temple, and once a year everyone must visit. The priest listens to each person tell him about their life, then takes a little of their blood and reads it. Then the person goes to another room where a different priest looks through a special window at their insides. The priests write things in a book and sometimes they say, “You have a small sickness we have found. From now on you must carry this stone in your pocket every single day. If you ever stop carrying it, you will get much sicker than you are right now.”

The years go by. The village is careful about remembering who died and when. One day some careful people from another village look at the records and notice something. The people who went to the temple every year did not live any longer than the people who did not. The people with stones in their pockets did not live longer than the people without stones. The careful people wrote this down in a big book and showed everyone.

The villagers read the book. Then they went back to the temple the next year, and the year after, and the year after. The priests kept finding small sicknesses. The villagers kept carrying their stones. New kinds of stones were handed out. More kinds of sicknesses were found.

Everyone could read the book. Everyone kept going to the temple anyway. That is the strange part.

In Print

The Unbekoming library is available in paperback, printed to order through Lulu and shipped worldwide. The shelf begins with the paradigm question underneath everything else — No Virus, the isolation problem, the collapse of virology’s foundational claims, and a disease-by-disease reappraisal — and moves through the suppressed compounds mainstream medicine set aside: The DMSO Book, Chlorine Dioxide: The Forbidden Remedy, The Iodine Book, and The Hydrogen Peroxide Book. Two more recover what’s still on the kitchen shelf: Baking Soda and The Castor Oil Book. Two more recover the minerals modern soil, water, and processing quietly stripped from the diet: The Magnesium Handbook and The Boron Book. Sitting alongside these is No Contagion, co-authored with Jamie Andrews — the case against germ theory itself, catalogued through 258 failed contagion experiments.

The critique books cover what medicine, dentistry, psychiatry, and veterinary practice have become. The Unvaccinated treats the completely unvaccinated as a comparison group across twenty chapters and five appendices. Medicalized Motherhood follows a woman through 123 documented interventions from teenage pill to postpartum discharge. Drilling for Profit treats cavities, gum disease, and crooked teeth as the dietary problem they are. What Your Vet Can’t Tell You applies the same critique to pets. Escape from Psychiatry documents the fabrication of the DSM and the specific damage of every major psychiatric drug class. The Vitamin K Injection covers what happens in the first hours of a newborn’s life.

The full shelf is at lulu.com/spotlight/unbekoming. A physical book reaches the person a Substack post never will — the skeptical relative, the friend who won’t click a link but might open a book, the visitor whose eye lands on a coffee table. Buy one to keep, and one to give away.

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