Poor, unfortunate Machiavelli. As if he did not suffer enough in life, cast down from a position of prominence as a highly-placed official, tortured (rather brutally, apparently) and exiled from Florence, he has suffered as perhaps The Bogeyman, a stand-in for corruption and expedience in political discourse. Heck, he even became a paradigm at the hands of the Elizabethans; the term "Old Nick" as a cognomen for Satan is thought to be connected to Niccolo himself.
However, I daresay that most who sit down and actually take the time to read his most (in?)famous work, The Prince, let alone his Discourses, might well be surprised at the sophistication and nuance present in his work. You will not find an ethical defense of corruption in The Prince. Quite the contrary, in fact. To understand what Machiavelli was doing in The Prince, as well as to understand his importance for the modern day medical humanist, we have to know a little something about Machiavelli and about his objectives in writing The Prince.
Niccolo Machiavelli was born in his beloved Florence on May 3, 1469. He is reputed to have been descended from Florentine aristocracy, but his family was not wealthy. Little about his formal education is known other than that he was schooled in the studia humanitatis. Indeed, that he became a humanist in the most accurate sense of the term is generally accepted among historians. Machiavelli grew up, like Dante, in a Florence racked by political instability and strife: "notable events include the Pazzi conspiracy and its aftermath, the end of Medici rule, and the reign of the Dominican friar Girolamo Savonarola."
This was, unfortunately, to be a constant theme of Machiavelli's life. In 1498 he became the secretary of the Lower Chancery of the Ten, and was soon shuttling to various courts across Europe in diplomatic service (in the first decade of the sixteenth century): France, Rome, the Holy Roman Emperor, etc.
(As Bouwsma and Boutcher explain, the increasingly intercultural political economy of the Late Middle Ages was itself a factor in the studia humanitatis. If there was a emphasis on diplomacy and commerce, it only followed that some kind of vernacular was needed to ease cross-cultural communication. This shaped the importance of Latin in the humanist program. However, the seeds of humanism's own demise are evident here, as Valla's own humanist rigor demonstrated that classical Latin was archaic, and it began to be confined increasingly to universities, with the vernacular replacing Latin as a linchpin of the political economy).
After the defeat of the French king in Italy in 1512, the Medici regained control of Florence. Machiavelli was exiled from Florence (perhaps reminiscent of Cicero's exile?). Subsequently, upon the exposure of a plot against a prominent member of the Medici family, Machiavelli was accused of being an accomplice and was subsequently tortured.
He was eventually released, but his sentence of exile was not commuted, so he retired to a small property he owned at Strada, and settled down to read (mostly classical works) and write. He never ceased trying to convince the Medici that he merited officialdom in Florence, but he did not return until 1527, when the Medici had been overthrown. However, in a final grotesque irony, "his old political party turned against him as one who fawned on tyrants. He died soon afterwards."
Cheery stuff, yes?
But this background is actually crucial to understanding what Machiavelli was principally concerned with in writing The Prince. Consider that Machiavelli grew up amidst internecine strife, and he was exiled and subsequently tortured after the Medici's returned to power. It would be shocking if such a man would not be concerned principally with the survival and stability of the state, I tend to think.
Part of what made Machiavelli such a revolutionary thinker, as Hankins explains, is because he completely inverted the Ciceronian moral equivalence of honestum and utile that had been accepted in prior humanist thought. That is, Cicero posited (and humanists generally accepted) that what was morally good was civically useful, and what was civically useful was morally good. Machiavelli rejected this. He argued that what was politically useful (and the definition of utility here is what enhances the survival of the state) was not always coextensive with the good.
And who could disagree with him, really? What exactly is so controversial about this perspective to modern eyes? Machiavelli naturally endorsed the survival of the state as the most important objective of the prince, but it doesn't follow from that he would endorse such a move for any citizen. The Prince is nothing if not a handbook for governance sent to Lorenzo the Magnificent in the hope of earning Machiavelli some kind of leniency in his hope to return to his beloved Florence. It is a "how-to" manual for the prince who wishes to solidify his rule. There is little from The Prince that supports the notion that Machiavelli was sketching an account of private morality, rather than a guideline, applying classical histories (mostly Livy and Plutarch) to contemporaneous events to describe the characteristics of the successful prince (again, success being defined by survival of the state).
Even Machiavelli's most infamous passage is often quoted out of context:
From this arises the question of whether it is better to be loved more than feared, or feared more than loved. The reply is, that one ought to be both feared and loved, but as it is difficult for the two to go together, it is much safer to be feared than loved, if one of the two has to be wanting.
This passage is often interpreted to justify sweeping curtailment of political and social rights, but Machiavelli seriously qualifies his general assessment mere sentences later:
Still, a prince should make himself feared in such a way that if he does not gain love he at any rate avoids hatred: for fear and the absence of hatred may well go together, and will always be attained by one who abstains from interfering with the property of his citizens and subjects or with their women.
Machiavelli is obviously not recommending the kind of carte blanche, reckless repression that he is often taken to represent. Quite the contrary; a prince who is hated will not long survive. Even if a measure of fear is important to the prince's rule, repression that breeds hatred is ill-advised. Machiavelli even stresses that "above all [the prince] must abstain from taking the property of others, for men forget more easily the death of their father than the loss of their patrimony." Shades of Locke, perhaps?
So, what relevance does Machiavelli have for the modern medical humanist? (And no snide jokes about academic torture and exile, thank you!)
First, Machiavelli details the difficult tension between the useful and the good. What is good, he argues, is not always useful, and what is useful is not always good. That the tension between these two objectives underlies many issues in health care should be somewhat obvious (Indeed, it is at the heart of what makes notions of utilitarianism controversial). Providing free health care to all comers might be morally commendable, but if the hospital that does so enters insolvency (i.e., is unable to survive, in Machiavelli's terms), the ethical calculus obviously becomes more complicated. Attempting to disentangle the useful from the good strikes me as vital aspect of questions of justice, allocation of scarce resources, and health policy. This is not, of course, to endorse Machiavelli's conclusion that the useful must always take priority over the good when they conflict, but simply to suggest that taking account of the practical and its potential tension with the good is an unavoidable concern in assessing justice in health care. Machiavelli, if nothing else, is dogmatic about practices. If it doesn't work in practice, then its goodness is still important but not all-important.
Machiavelli is thus concerned with what works. And assessing "what works" in medical practices may be one important consideration for the medical humanist.
Second, Machiavelli reminds the humanist of the consequences of separating res (content or matter) from verba (form or language). The classical conception of rhetoric generally posited a close connection between the matter at issue and the specific language used to communicate about that matter. Rhetoric was not perceived as an end in itself, but was a good insofar as it enhanced understanding about the res. This fits with the early humanists' insistence on the use of rhetoric in the service of virtue. For the early humanists, res and verba ought not be separated. But, once the merits of rhetoric are excised from the merits of the matter at issue, then rhetoric becomes a (mere) means to political and economic ends.
The connection between rhetoric and the cultivation of virtue was arguably a preeminent part of the studia humanitatis. Part of the reason rhetoric is often viewed with suspicion today is because res has been entirely separated from verba. To the extent the medical humanist is or ought to be concerned with the cultivation of virtue in the culture of biomedicine, Machiavelli, poor, misunderstood figure that he is, is an important resource.
