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reproduce… one consequence is that selfish genes evolved through individual-level selection processes to promote social preferences and group processes, including reciprocal social behaviors, that can extend beyond kin relationships

The concept of inclusive fitness helps to explain why humans care for the young when they are sick, and even why they care for those who when healthy are able to contribute to caring for the young. In addition, it may be that hunter-gatherers were more likely to survive and reproduce when they cared for a wounded or sickened member of the clan—thereby establishing an expectation of reciprocity that would contribute to social cohesion, collective effort, and defense of other group members. These provide at least the rudiments of an evolutionary rationale for the practice of medicine.

Yet, medicine does not involve caring merely (or even primarily) for the young, much less for those who are most genetically fit. Rather, medicine in large measure involves caring for those who either have no capacity to contribute to the gene pool because they are aged and otherwise infertile, or whose contributions to that pool will reduce population fitness because they are genetically predisposed to sickness and disability. Concern about the latter led Francis Galton and many of his American and European contemporaries to embrace social Darwinism and to champion efforts to keep the diminished and infirm from reproducing. In the United States, the eugenics movement was memorialized in the infamous words of Supreme Court justice Oliver Wendell Holmes, who justified the constitutionality of the forced sterilization of mentally ‘unfit’ women in the case of Buck v. Bell by writing, “Three generations of imbeciles are enough.” Sterilization rates under eugenic laws in the United States increased following this ruling until the Skinner v. Oklahoma case in 1942, after which point they declined.

The practice of medicine expresses more than a straightforward social instinct for protecting the young. To borrow from Browning, it may be that medicine builds on and extends the dynamic of inclusive fitness much like in Catholic moral theology caritas (love) builds on and extends eros (desire). Browning writes, “[Aquinas] held – and Christianity has always taught – that Christian love includes more than kin altruism and the care of our familial offspring; it must include the love of neighbor, stranger, and enemy, even to the point of self-sacrifice.” The theological concept of God as creator and Father of all “made it possible for Christians to build on yet analogically generalize their kin altruism to all children of God, even those beyond the immediate family, their own children and their own kin.” Even those beyond the reasonable hope of reproducing or helping others to reproduce.

Notably, the self-conscious commitments that animate medicine do not include promoting population fitness or ensuring survival of offspring to the point of reproduction. Rather, physicians discipline themselves to practices that make possible the commitment of medicine: to preserve and restore the health of patients, notwithstanding patients’ other characteristics. Religions ground this care for the sick in sacred and transcendent obligations to God and neighbor, and it is not incidental that the hospital began when Christian monastic

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