You know those little jokes that centre around a person with a PhD being on a plane, and someone asks for a doctor, and they say they aren’t that kind of doctor but the emergency involves their field of study? I love those. If you don’t know what I am rabbiting on about I mean these:

Cute, right?

Anyway I saw one such example online the other day, but I think it was something about African textiles or something? IDK it was cute and funny and I had a sensible chuckle, and then, dear readers, then I scrolled down into the comments (by accident!) and saw something very silly indeed, which ruined it all for me. I didn’t take a screen shot of it, but basically the world’s most dull person was compelled to respond to said cute little joke by saying, ‘Don’t call yourself doctor then.’

Now, this is not the first time I have encountered such a sentiment. Very occasionally weirdo right wing people will attempt to rile me up by saying ‘I’m not going to call you doctor because you’re not an MD’ to me online. Which, like OK cool, I’m going to continue to never consider anything about you. You have fun.

What those weirdos have in common with the person yelling at a meme is this: they are being pretty confidently and loudly wrong, and today we are going to talk about why.

See the thing about the term ‘doctor’ is that for a long long (long long long long long) time it meant pretty exclusively people with PhDs.

It’s a nice and fun medieval thing because, well, so are universities. Universities were invented in Europe in the twelfth century as a convenient way to get annoying people to go yell at each other somewhere other than the local cathedral.

By this I mean, of course, that education over the medieval period had several stages. In the early medieval period, a great deal of philosophical and theoretical learning and education was centred in monasteries. During the Carolingian Renaissance, our good friend Charlemagne spent rather a lot of time and money making sure that this would continue, but also attracting people to court in order to nerd out. From there we then also had the rise of cathedral schools. See, to be in the Church you had to be literate, by which I mean you had to read and write in Latin. And if you were going to participate in the higher echelons of its legal structures you needed fancy Latin. So the place to go for that was a cathedral where people were already being high fallutin’ and had climbed the ranks of the Church so they knew what was needed to make that happen.

Universities came about in several different way from there. The very first university was at Bologna and it was started essentially by a student union. A bunch of nerds decided that they wanted more specialist education and did a call out for instructors who came to the city and would dole it out. Next came Paris, now the Sorbonne, which was much more of an instructor-led approach.  A lot of the biggest names in philosophy descended on the city and made it known they would be taking pupils, establishing the universitas magistrorum and scholarium Parisiensis. Then you got Oxford, where basically a lot of people who had been at Paris drifted back to England and eventually King Henry III (1207-1272) gave them a royal charter to try to convince everyone that England was fancy. 

No matter how they were founded, the universities all taught the same thing and awarded the same degrees based on the liberal arts curriculum. In this system, the first thing you had to master was the trivium of grammar, logic, and rhetoric. This was essentially three ways of dealing with the world in Latin. Grammar just means Latin, logic meant reading a bunch of classical history (in Latin) and then trying to argue like Plato or whatever. Rhetoric meant yelling at each other in Latin. I am being serious.

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Anyway, if you got good enough at being totally insufferable in varying Latin was then congratulations – you received your Bachelor of Arts, or BA. As a general rule of thumb this took around three or four years. From here, you could either go take up a literate job at court or in the Church or you could continue your studies. That meant that you had to move to what were known as the higher faculties of a university where you would begin to learn to the quadrivium or arithmetic, geometry, music, and astronomy. Completing these four subjects could take up to twelve years, and at the end you would be a Master of Arts and be awarded a doctorate, because the two things were synonymous.[1]  This is the very first way to use the term doctor.

OK but say you are a sick individual, such as myself, and you wished to torture yourself yet further with learning? Well you can do that! There were further degrees which could be taken in law, medicine, or theology. And you know what the most important one of these was? Theology. These faculties were tightly controlled and could only be found at Paris, Oxford, Cambridge, and Rome until my boy Charles IV started up one of my almae matres the University of Prague in 1374.[2] (It’s called Charles University now. Shout out!) Legal degrees could also be conferred at all of these places. In either case you would be known as a Doctor of Theology, or a Doctor of Law. Pretty cool.Similarly you could also train to be a doctor of medicine and get a degree saying that you were such a thing – and there were specialty schools like Salerno where people went to do just that.

However, the term “doctor” wasn’t usually used to speak about those who subsequently went on to work with patients in the field of medicine. Why? Well, the term “doctor” comes from the Latin verb “docere” meaning to teach. So, if you were called a medical doctor it meant that you were teaching at Salerno, not that you were out in the field actually doing the stuff you were trained to do.

The people who got trained at Salerno, took their degree, and went out into the world to practice medicine needed a title which made it clear that they were not university professors, but university trained, so that people knew what their job was. And they had one – they were called physicians.

The term here comes, again, from Latin physicus which means things that relate to nature. In Old French and English this is then adopted as fisicien and physic, respectively, and in the thirteenth century we begin to see the Anglo-Norman word “physician” crop up. The word here is important because it was a means by which such men (and they were overwhelmingly men because women were often precluded from attending university because one had to take holy orders to do so) differentiated themselves from all of the other types of medical practitioners out in the world.

There were midwives who saw to pregnancy, birth, and well actually quite a lot of other medical issues if you lived in rural places where it would be difficult to thrive as a professional medical provider just due to population density. In cities it was easier to find other people to treat you as well. There were master surgeons, who were trained to, you know, cut you up and take things out by means of apprenticeship.[3] From 1308 onwards the Barber Surgeons were then established as guilds and you would go to them if you wanted some bleeding, or to treat minor wounds, or get your hair cut, and they soon overtook the Master Surgeons as the guys for all your cutting based needs.[4] There were also apothecaries, who were sort of like what we call chemists in the UK or pharmacists in America, who dispensed medicines.[5] In places like England, you needed all of these people to provide medical care because university-trained physicians were much more likely to be found where there were rich people that you could charge for your well-trained expertise.

Physicians were also much more likely to be found in places where there was a university training people up, like, say, in the Italian lands. But the Italian lands were weird because since Salerno was there, the universities would often oversee all sorts of medical practitioners, including midwives to make sure everyone was working as they should.[6] Because of this even places like Florence, which didn’t always have a university would have guilds which oversaw everyone.[7] The Italians were special like that though, so don’t go looking for this type of coverage in, say, rural Scotland.

All of this is to say that there were a lot of different ways to receive medical treatment in the medieval period – and a lot of different ways to address the people you were receiving them from – but none of those had a salutation of “doctor”.

In English the term “doctor” didn’t start being used to address people with medical degrees until the seventeenth century, and it began more particularly in Scotland. Funnily, the use of the term was meant to confirm respect to the doctor confirming that, yes, they were very smart indeed. Yes, that’s right – they were as smart as all the people with PhDs, bless them.[8] The medical people were trying to catch up with the humanities people because everyone knew that it’s really hard to get a PhD and it confers authority. This took off because everyone post-enlightenment absolutely loves to crank themselves about how important Science is, or whatever. The fact remains however, that it is a relatively new occurrence.

Here in the UK there is also resistance to the flattening of medical knowledge under the term “doctor”. Here, for example, it is a point of pride with surgeons that the retain the titles Mr/Miss/Ms/Mrs as appropriate. I think that is super cool.

The point of all this is that it is a historical fact that the term “doctor” is supposed to refer to people who have a PhD and teach, and we let medical practitioners start using it cuz we are not weirdo gate keepers. If you wanted to be a dick about it – which I do not – it technically makes more sense to prevent medical doctors from using the term because they have a professional degree, not a formal doctorate. So anyone trying to make some sort of point about the whole thing is simply wrong, and also annoying.

So to close out let’s try our hand at a medieval version of the joke we started with. If you said “doctor” to people in the middle ages, they would assume that you were talking about the doctors of the Church because it was just the common understanding. For medieval people, then, the version of the doctor joke would be being on, say, a boat to Rome, when someone calls for a doctor on board. The Physician trained at Salerno with a medical degree would then say, “Oh no there must be a misunderstanding, I can’t help.” Then the people would say, “This woman’s humors are unbalanced!” So the physician says, “I’m here.” Yes, they are technically a doctor (if they also finished their trivium and quadrivium before their medical training), but it’s just not what anyone was thinking about.

Trust me. It’s hilarious.

[1] A great overview on all of this, if you want to go further, is Olaf Pederson, The First Universities: Studium Generale and the Origins of the University Education in Europe, (Cambridge: Cambridge University Press, 1997).
[2] Walter Rüegg, Asa Brigg, Geschichte der Universität in Europa 1: Mittelalter, (München: Beck, 1993), p. 33.
[3] Vern L. Bullough, ‘Training of the Nonuniversity-Educated Medical Practitioners in the Later Middle Ages’, Journal of the History of Medicine, 14 (1959), p. 447.
[4] Carole Rawcliffe, Medicine & society in later medieval England (Stroud: Alan Sutton: 1995), p. 218.
[5]  H. Rolleston, ‘The Historical Relations of Pharmacy and Physic’, The Pharmaceutical Journal 139 (1937).
[6] Bullough, ‘Training of the Nonuniversity-Educated Medical Practitioners’, p. 446.
[7] Carole Rawcliffe, Urban Bodies: Communal Health in Late Medieval English Towns and Cities, (Woodbridge: Boydell and Brewer, 2013), p. 294.
[8] AA Asfour, JP. Winter, ‘Whom should we really call a “doctor”?’, Canadian Medical Association Journal. 2018 May 28;190(21):E660. doi: 10.1503/cmaj.69212. PMID: 29807940; PMCID: PMC5973890.

For more on medicine and myths about the medieval period, see:
On medical milestones, being racist, and textbooks, Part 1
On medical milestones, the myth of progress, and textbooks, Part 2

For more on medieval education, see:
Podcast alert: a medieval education

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My book, The Once And Future Sex: Going Medieval on Women’s Roles in Society, is out now.

© Eleanor Janega, 2023

Take a deep breath, center, and focus

George Takei shares what politics has taught him in 86 years:

A Democrat was in the White House when my family was sent to the internment camps in 1941. It was an egregious violation of our human and civil rights.

It would have been understandable if people like me said they’d never vote for a Democrat again, given what had been done to us.

But being a liberal, being a progressive, means being able to look past my own grievances and concerns and think of the greater good. It means working from within the Democratic party to make it better, even when it has betrayed its values.

I went on to campaign for Adlai Stevenson when I became an adult. I marched for civil rights and had the honor of meeting Dr. Martin Luther King. I fought for redress for my community and have spent my life ensuring that America understood that we could not betray our Constitution in such a way ever again.

Bill Clinton broke my heart when he signed DOMA into law. It was a slap in the face to the LGBTQ community. And I knew that we still had much work to do. But I voted for him again in 1996 despite my misgivings, because the alternative was far worse. And my obligation as a citizen was to help choose the best leader for it, not to check out by not voting out of anger or protest.

There is no leader who will make the decision you want her or him to make 100 percent of the time. Your vote is a tool of hope for a better world. Use it wisely, for it is precious. Use it for others, for they are in need of your support, too.

That advice would seem unremarkable if not for the fact that so many with less patience speak with louder voices. How many disagreements have you had with your spouse without moving out and filing for divorce?

Writing a review is an exercise in free will. Not only can I tell you what I want about the book and whether I liked it or not, but I also get to choose how to begin. If I decide to start with a personal anecdote, that’s what you will get. And I have the ability—the freedom—to start in other ways instead. These facts may seem too obvious to mention. But they are denied by Robert Sapolsky, a professor of biology at Stanford whose new book, Determined, argues, “We have no free will at all.”

The challenge to the cherished notion of free will comes from what philosophers call “causal determinism.” This is the idea that everything that happens is the product of prior causes, stretching back into a past that was not up to us. We do not originate our choices ex nihilo; instead, they are determined by our history. As Sapolsky puts it, bluntly:

The intent you form, the person you are, is the result of all the interactions between biology and environment that came before. All things out of your control. Each prior influence flows without a break from the effects of the influences before. As such, there’s no point in the sequence where you can insert a freedom of will that will be in that biological world but not of it.

The upshot, for him, is that “there can be no such thing as blame, and that punishment as retribution is indefensible.” It’s a shocking conclusion. Imagine a murder committed in cold blood by a ruthless killer, pursuing personal gain; the murder is premeditated, carefully planned, entirely in character. Now imagine that the victim is someone you love. For many of us, this scenario, even when hypothetical, provokes feelings of resentment and blame, a desire to punish the killer. For Sapolsky, none of these responses can be justified.

In making his case, Sapolsky distances himself from a recently fashionable critique of free will inspired by the neuroscientist Benjamin Libet, whose brain-imaging studies suggest to some that our “decisions” are epiphenomenal, a superficial side effect of the real decisions made by the unconscious brain. Sapolsky is not convinced. He believes that our intentions make a difference in the world. What concerns him is instead a question he sets in italics, and asks more than once: “Where did that intent come from in the first place?” What Sapolsky argues, in hundreds of pages of neurobiology, genetics, Darwinian selection, chaos theory, and quantum mechanics—all explained with diagrams and effervescent prose—is that, however unpredictable our actions are in practice, our intentions are caused by factors that were caused in turn by conditions that existed before we were even born. Ergo, free will is a myth.

That is Sapolsky’s argument in a nutshell. And if the last step—from determinism to the total absence of free will—went by quickly in my telling, it goes by very quickly in his book. Before he gets to the evidence for determinism, Sapolsky spends about a page on what it would mean to say that we are free: “Show me a neuron (or brain) whose generation of a behavior is independent of the sum of its biological past,” he writes, “and for the purposes of this book, you’ve demonstrated free will.”  

Now, it’s no surprise that, if you define free will as a violation of determinism, the truth of determinism is not compatible with free will. What’s frustrating is that Sapolsky knows that the majority of philosophers—he himself estimates 90 percent—do not accept that definition. They are what are called “compatibilists,” thinkers who defend the existence of free will not by denying that events outside of our control determine our actions, but by giving philosophical accounts of freedom, blame, and punishment that don’t require Sapolsky’s miraculous neuron: accounts that are compatible with determinism.

Perhaps the most influential compatibilist in history is the Scottish philosopher David Hume, who helped invent the science of the mind. “By liberty,” he wrote in 1748, “we can only mean a power of acting or not acting, according to the determinations of the will; that is, if we choose to remain at rest, we may; if we choose to move, we also may.” Hume called this “hypothetical liberty” because it has an “if-then” structure. If I choose to type this sentence, then I’ll press the appropriate keys and the words I’ve decided to type will appear on my computer screen. If I decided to type other words, my fingers would move differently. For Hume, that’s all it takes for me to have the freedom, or liberty, to do otherwise: My actions depend on my decisions. This is an instance of causality at work, not a violation of causal law. It involves the determination of what I do by what I intend, given a hospitable environment, not a failure of determinism. Nor does it turn on the prior history of my intentions. If Hume is right, Sapolsky’s question—“Where did that intent come from in the first place?”—is irrelevant to free will.

Sapolsky doesn’t mention Hume or the many philosophers influenced by him. (The closest we get is a reference to the 20th-century compatibilist Peter Strawson that confuses him with Galen Strawson, his incompatibilist son.) Nor does Sapolsky engage with the idea of hypothetical liberty: If I decide to do A, I’ll do it; if I decide not to, I won’t. So we have to read between the lines.

[Read: To get happier, choose to read this column]

To be fair to Sapolsky, he is not alone in giving short shrift to the sort of freedom that is compatible with determinism. In his 1788 Critique of Practical Reason, Immanuel Kant called this conception of liberty a “wretched subterfuge … the freedom of a turnspit.” (A turnspit was a wind-up rotisserie.) But Hume’s interpretation of free will has real force. When we talk in ordinary terms about what we are free, or able, to do, we aren’t talking about failures of determinism or violations of causal law. For all I know, it’s physically possible for me to vanish in a fluke of quantum mechanics. But if I told you “I am able to vanish,” I’d be lying. Hume’s sensible thought is this: Freedom means being able to perform an action if and when I decide to try. That’s why the fact that I would never choose to run a marathon doesn’t mean that I’m not free to run one. So long as “running” very slowly counts, I’m pretty sure I could.

When philosophers doubt that hypothetical liberty is liberty enough—and many do—they point to cases of addiction or compulsion, in which one’s decision is caused by an urge so powerful, it diminishes one’s freedom. If the alcoholic is compelled to choose another drink, he’s not free to go sober. Hume is therefore wrong, the reasoning goes: Even if the alcoholic would refrain if he decided to—he enjoys hypothetical liberty—the fact that he’d never make that decision, because of factors beyond his control, means that he lacks free will. Sapolsky would agree: The relevant question is not whether the addict’s decision is efficacious, or whether he would act differently if he decided otherwise, but why he makes the decision he does. If addiction is the cause, he is not free.

Ironically, the neuroscience in Sapolsky’s book suggests that the truth about compulsion may support Hume’s view. The prefrontal cortex (PFC) plays a central role in the regulation of behavior, our power to resist temptation. As Sapolsky writes, the efficacy of one’s PFC is sensitive to one’s upbringing and to temporary influences of all sorts. This plays out in the exercise of self-control. Sapolsky gives a low-key example: “Place a bowl of M&M’s in front of someone dieting. ‘Here, have all you want.’ They’re trying to resist. And if the person has just done something frontally demanding”—which exhausted their prefrontal cortex—“the person snacks on more candy than usual.”

What Sapolsky doesn’t note is that his dieter is unable to resist, and lacks the freedom to do so, in Hume’s sense. For Hume, I am free to perform an action if and when I would successfully perform it if I decided to try. The dieter tries to resist—they’ve decided not to snack too much—but their decision isn’t efficacious: They act against it or change their mind. What they lack is hypothetical liberty, the “power of acting or not acting, according to the determinations of the will.” In other words, we don’t need to ask about the origins of their intentions—Sapolsky’s question, “Where did that intent come from in the first place?”—in order to explain why the dieter lacks free will. They lack free will because their decision not to snack is ineffective. Hume’s analysis gets this right. To generalize from here: The inability to resist temptation characteristic of addiction, and dependent on the PFC, is not a problem for Hume’s view but an illustration of it. When the alcoholic cannot help but drink, he’ll end up drinking even if he intends to stay sober. His intention not to drink won’t be effective. That’s why he doesn’t have the freedom not to drink.

At other times, we manage to resist temptation. Sapolsky quotes the psychologist James Cantor on the neurobiology of pedophilia: “One cannot choose to not be a pedophile, but one can choose to not be a child molester.” Sapolsky finds this position absurd: If pedophilic desire is out of our control, so is the pedophilic action that results from it. But Cantor’s claim makes sense. Deciding not to be a pedophile won’t eliminate pedophilic desire. But deciding not to act on that desire might work. That depends on one’s biology and environment, including one’s level of self-control. It’s true that one’s strength of will is not, itself, under one’s direct control. But so what? If one has sufficient willpower, one can exercise it. If one doesn’t, one’s freedom is diminished—not by determinism or the fact that one’s decision has prior causes, but by a lack of hypothetical liberty.

If we think of freedom as the ability to do otherwise, understood in Hume’s way—if I decide to do A, I will; if I decide otherwise, I won’t—then it is perfectly compatible with determinism: Freedom turns on how effective we are in executing our intentions, no matter what caused them.

But Sapolsky has a second argument, which is more about morality than the nature of free will. How can it be fair to blame or punish someone who acts wrongly if their doing so is a consequence of factors beyond their control? Something—some combination of genetics, upbringing, and environment—made that ruthless murderer ruthless, the sort of person who plans a murder and is able to follow through. If we can’t blame him for those past causes, how can we blame him for what he does? How can we justify the punishment we so desire?

When it comes to blame, I think the rhetorical question can be answered. Let’s grant, as Sapolsky does, that your character is fixed by facts that are not up to you. Still, when you act with indifference to the rights and needs of others, we can blame you for what you do—unless you have a good excuse. What counts as an excuse is a question of morality, not metaphysics. We excuse wrongful action when it’s the product of manipulation or coercion, when you don’t know what you’re doing (provided your ignorance is not willful or negligent), and perhaps when you’re unable to do otherwise. These excuses mitigate blame by showing that your behavior is not reflective of your moral character; whether or not you are to blame for the character you have is irrelevant. Nor is there pressure to acknowledge an additional excuse—that one’s behavior is determined by the past—because we do not need it to account for the excuses we accept in everyday life.

It’s ironic, again, that Sapolsky’s reasoning tends to support, not undermine, this view. For Sapolsky, “all that came before, with its varying flavors of uncontrollable luck, is what came to constitute you.” But if my present psychology, even if formed by forces outside my control, constitutes me, and my behavior reflects who I am—not ignorance or compulsion—then it issues from me and I should take responsibility for it. My wrongdoing is expressive of my moral character and therefore subject to moral blame. What is my excuse?

[Read: Why TV is so worried about free well]

Sapolsky goes on to draw a comparison between his project and the way in which medical conditions like epilepsy and schizophrenia, along with the behaviors they cause, came to be exempted from blame. We learned to say, “It’s not him. It’s his disease.” Which is progress. But these diseases interfere with the efficacy of one’s intentions, that hypothetical liberty, and with what Sapolsky elsewhere calls “the consistency of behavior that constitutes our moral character.” When it’s me, not my disease, acting with the consistency of behavior that constitutes my character—again, not out of ignorance or compulsion—I don’t see what gets me off the hook.

Punishment is something else. Sapolsky is appalled by our ruthless urge to see the guilty suffer. “If there’s no free will,” he writes, “there is no reform that can give retributive punishment even a whiff of moral good.” Hence his public-policy proposal: to replace the punitive carceral system with “quarantine,” the comfortable confinement of those who are a danger to others, until they aren’t.

But there are problems here. First, Sapolsky’s view implies that the perpetrator of a one-off crime—so long as we are sure it’s one-off—should go scot-free: If there’s no risk that they’ll reoffend, then there’s no benefit in quarantining them. Second, his view neglects the crucial role of punishment in deterrence: not physically preventing future crimes but giving us incentives not to commit them. Third, the moral challenge to retribution has nothing to do with freedom or determinism. Those who believe that punishment is of value even if nothing good will come of it simply want to see the guilty suffer. Sapolsky is one of many who recoil from this impulse. Unless it has some deterrent or preventative function, how can the suffering of the guilty make the world a better place? If you struggle to see an answer, debates about determinism won’t help.

Sapolsky has a lot to teach about the science of decision making and about empathy for the unfortunate. But Hume remains a better guide to the philosophy of free will. I suppose that verdict makes this a negative review, and I don’t feel great about that. Books require a lot of work, and authors have feelings. Still, I take comfort in the fact that, although I wrote these words of my own free will, Sapolsky doesn’t think I did—or that it’s fair to blame me for their potential ill effects.

Star forts, or bastion forts, are a type of fortification that first emerged more than 500 years ago in response to the growing power of cannons on the battlefield, with sloped walls and angled bastions that allowed defenders better coverage above any attackers. These polygonal or star-shaped defensive structures were built in locations around the world by kingdoms, revolutionaries, colonial forces, commercial entities, and more. Although most have outlived their military usefulness, dozens of these forts still survive, now renovated as museums, tourist attractions, hotels, or city parks.

Last Wednesday the