BRAVE NEW BIOCRACY: HEALTH CARE FROM WOMB TO TOMB
BY IVAN ILLICH http://www.davidtinapple.com/illich
http://ournature.org/~novembre/illich
http://www.salvationscience.com

Life, Death and the Boundaries of the Person
Ivan Illich

Source: NPQ: New Perspectives Quarterly, Winter94, Vol. 11 Issue 1

DNA maps and genetic cleansing; embryo cloning and euthanasia; organ
transplants and physician-assisted suicide--never before have the
traditional boundaries of life and death become so blurred. Never
before has science intruded so pervasively into the sanctuary of the
person. Where once only angels would tread, the medical
establishment now treats. Are we closer to the secret of life, or
just farther from God and nearer to the dust? In this symposium NPQ
takes an anxious look at the new frontiers of man's fate.

Life is not Sacred

BREMEN, GERMANY -- Physicians in the Hippocratic tradition were
pledged to restore the balance -- or "health" -- of their patient's
constitution but forbidden to use their skills to deal with death.
They had to accept nature's power to dissolve the healing contract
between the patient and his physician.

When the Hippocratic signs indicated to the physician that the
patient had entered into agony, the "atrium between life and death,"
he had to withdraw from what was now a deathbed. Both quickening --
coming alive in the womb -- and agony -- the personal struggle to
die -- defined the extreme boundaries between which a subject of
medical carecould be conceived.

In our world, these boundaries have been obliterated. By the early
20th century, the physician came to be perceived as society's
appointed tutor of any person who, having been placed in a patient
role, lost his own competence.

Physicians are taught today to consider themselves responsible for
lives from the moment the egg is fertilized through the time of
organ harvest. They have become the socially responsible
professional manager not of a patient, but of a life from sperm to
worm. Physicians have become the bureaucrats of the brave new
biocracy that rules from womb to tomb.

In societies confused by the technological prowess that enables us
to transgress all traditional boundaries of coming to life and
dying, the new discipline of big-ethics has emerged to mediate
between pop-science and law. It has sought to create the semblance
of a moral discourse that roots personhood in the "scientific
ability" of bioethicists to determine who is a person and who is not
through qualitative evaluation of the fetish, "a life. "

What I fear is that the abstract, secular notion of "a life" will be
sacralized, thereby making it possible that this spectral entity
will progressively replace the notion of a "person" in which the
humanism of Western individualism is anchored. "A life" is amenable
to management, to improvement and to evaluation in a way which is
unthinkable when we speak of "a person." The transmogrification of a
person into "a life" is a lethal operation, as dangerous as reaching
out for the tree of life in the time of Adam and Eve.

The churches -- one of the most important agencies for defining
moral issues in public life -- bear a particular responsibility as a
lost civilization turns to them for guidance on such issues as
abortion, euthanasia, organ transplants, embryo cloning and
eugenics.

"A life" is the most powerful idol the church has had to face in the
course of its history. More than the ideology of empire or feudal
order, more than nationalism or progress, more than gnosticism or
Enlightenment, the acceptance of "life" as a God given reality lends
itself to a new corruption of the Christian faith.

The Christian West has given birth to a radically other kind of
human condition unlike anything before it. Only within the matrix
which Jacques Ellul calls the "technological system" has this new
type of human condition come to full fruition. A new role opens for
mythmaking, moralizing, legitimating institutions, a role which
cannot quite be understood in terms of old religions, but which some
churches rush in to fill.

The new technological society is singularly incapable of generating
myths to which people can form deep and rich attachments. Yet, for
its rudimentary maintenance it needs agencies which create and
legitimate fetishes to which epistemic sentimentality can attach
itself.

We seem to need a Linus blanket, some prestigious fetish that we can
drag around to feel like defenders of sacred values. "Life" has
become this blanket: it has come to constitute an essential referent
in current ecological, medical, legal, political and ethical
discourse. Consistently, those who use it forget that the notion has
a history. It is a Western notion, ultimately the result of a
perversion of the Christian message.

When the Lord announced to Martha "I am Life," he did not say "I am
a Life." He says "I am Life" tout court. This Life has its
historical roots in the revelation that one human person, Jesus, is
also God. This one Life is the substance of Martha's faith. In the
Christian tradition, we hope to receive this Life as a gift; and we
hope to share it. We know that this Life was given to us on the
Cross and we cannot seek it except on the via crucis.

This Life is gratuitous, beyond and above having been born and
living. But, as Augustine and Luther constantly stress, it is a gift
without which being alive would be dust.

Life in the Christian tradition is personal to the point of being
one person, both revealed and promised in John 19. It is something
profoundly other than the life which appears as substantive in all
the headlines about abortion or euthanasia in American newspapers.

At first sight, the two have nothing in common. On the one side, the
Bible says: Emmanuel, Godman, Incarnation. On the other, the term is
used to impute substance to a process for which the physician
assumes responsibility, which technologies prolong and atomic
armaments protect; a substance which has standing in court, can be
wrongfully given, and about whose destruction without due process or
beyond the needs of national defense or industrial growth the so-
called pro-life organizations are incensed.

However, at closer inspection, life as a property, as a value, a
national resource, a right, is a Western notion which shares its
Christian ancestry with other key verities defining secular society.

The notion of a human life as a distinct entity which can be
professionally and legally protected has been torturously
constructed through a legal-medical-religious-scientific discourse
whose roots go far back into theology.

The emotional and conceptual connotations of life in Hindu, Buddhist
or Islamic traditions are utterly distinct from those evident in the
current debate on this subject in Western democracies.

In the United States, the politicized pro-life movements are
sponsored mainly by Christian denominations.

It is for this reason that it is mainly up to the churches to de-
mystify "life." The Christian churches now face an ugly temptation:
to cooperate in the social creation of a fetish which, in a
theological perspective, is the perversion of revealed Life into an
idol.

The History of a Life

Biblical scholars are well aware of the limited correspondence
between the Hebrew word for blood, dam, for breath, ruah, and the
Greek term we would render as soul, namely, psyche. Neither comes
anywhere near the meaning of the substantive, life. The concept of
life does not exist in Greco-Roman antiquity: bios means the course
of a destiny and zoe something close to the brilliance of aliveness.
In Hebrew, the concept is utterly theocentric, an implication of
God's breath.

Life as a substantive notion appears two thousand years later, along
with the science that purports to study it. The term biology was
coined early in the 19th century by Jean-Baptiste Lamarck. He was
reacting to the baroque progress in botany and zoology which tended
to reduce these two disciplines to the status of mere
classification. By inventing a new term, he also named a new field
of study, "the science of life."

Lamarck's genius confronted the tradition of distinct vegetable and
animal ensoulment, along with the consequent division of nature into
three kingdoms: mineral, vegetable and animal. He postulated the
existence of life that distinguishes living beings from inorganic
matter not by visible structure but by organization. Since Lamarck,
biology searches for the "stimulating cause of organization" and its
localization in tissue cells, protoplasm, the genetic code or
morphogenetic fields.

"What is life?" is, therefore, not a perennial question, but the pop-
science counterfoil to scientific research reports on a mixed bag of
phenomena such as reproduction, physiology, heredity, organization,
evolution and, more recently, feedback and morphogenesis.

Life appears during the Napoleonic wars as a postulate which is
meant to lead the new biologists beyond the competing descriptive
studies of mechanists, vitalists and materialists. Then, as
morphological, physiological and genetic studies became more precise
toward the middle of the 19th century, life and its evolution become
the hazy and unintended by-products reflecting in ordinary discourse
an increasingly abstract and formal kind of scientific terminology.

THE DEATH OF NATURE | A thread which runs back to Anaxagoras (500-
428 BC) links a number of otherwise profoundly distinct
philosophical systems: the theme of nature's aliveness. This idea of
nature's sensitive responsiveness found its constant expression well
into the 16th century in animistic and idealistic, gnostic and
hylomorphic versions. In these variations, nature is experienced as
the matrix from which all things are born. In the long period
between Augustine and Scotus this birthing power of nature was
rooted in the world's being contingent on the incessant creative
will of God.

By the 13th century, and especially in the Franciscan school of
theology, the world's being is seen as contingent not merely on
God's creation, but also on the graceful sharing of his own being,
his life. Whatever is brought from possibility (de potentia) into
the necessity of its own existence thrives by its miraculous sharing
of God's own intimacy, for which there is no better word than -- His
life.

With the scientific revolution, contingency-rooted thought fades and
a mechanistic model comes to dominate perception. Caroline Merchant
argues that the resulting "death of nature" has been the most far-
reaching event in changing men's vision and perception of the
universe. But it also raised the nagging question: How to explain
the existence of living forms in a dead cosmos? The notion of
substantive life thus appears not as a direct answer to this
question, but as a kind of mindless shibboleth to fill a void.

LIFE AS PROPERTY | The ideology of possessive individualism
progressively affected the way life could be talked about as a
property. Since the 19th century, the legal construction of society
increasingly reflects a new philosophical radicalism in the
perception of the self. The result is a break with the ethics which
had informed western history since Greek antiquity, clearly
expressed by the shift of concern from the good to values. Society
is now organized on the utilitarian assumption that man is born
needy, and needed values are by definition scarce. It becomes
axiomatic that the possession of life is then interpreted as the
supreme value. Homo economicus becomes the referent for ethical
reflection. Living is equated with a struggle for survival or, more
radically, with a competition for life. For over a century now it
has become customary to speak about the "conservation of life" as
the ultimate motive of human action and social organization.

Today, some bioethicists go even further. While up to now the law
implied that a person was alive, they demand that we recognize
that . . . there is a deep difference between having a life and
merely (sic!) being alive. The proven ability to exercise this act
of possession or appropriation is turned into the criterion for
personhood and for the existence of a legal subject.

During this same period, homo economicus was surreptitiously taken
as the emblem and analogue for all living beings. A mechanistic
anthropomorphism has gained currency. Bacteria are imagined to
mimic "economic" behavior and to engage in internecine competition
for the scarce oxygen available in their environment. A cosmic
struggle among ever more complex forms of life has become the
anthropic foundational myth of the scientific age.

LIFE AS ECOLOGY | Ecology can mean the study of correlations between
living forms and their habitat. The term is also and increasingly
used for a philosophical way of correlating all knowable phenomena.
It then signifies thinking in terms of a cybernetic system which. in
real time is both model and reality: A process which observes and
defines, regulates and sustains itself. Within this style of
thinking, life comes to be equated with the system: It is the
abstract fetish that both overshadows and simultaneously constitutes
it.

Epistemic sentimentality has its roots in this conceptual collapse
of the borderline between cosmic process and substance, and the
mythical embodiment of both in the fetish of life. Being conceived
as a system, the cosmos is imagined in analogy to an entity which
can be rationally analyzed and managed.

Simultaneously, this very same abstract mechanism is romantically
identified with life and spoken about in hushed tones as something
mysterious, polymorphic, weak, demanding tender protection.

In a new kind of reading, Genesis now tells how Adam and Eve were
entrusted with life and the further improvement of its quality. This
new Adam is potter and nurse of the Golem, his artificial creation.

In the sickening manufactured environment we have made for
ourselves, health in the Hippocratic tradition has become an
impossibility; balance has become hope-less.

The hope once symbolized in the mystery of the unborn has been
corrupted; now there is only the legal entity of the fetus monitored
on the sonogram. Agony, too, has been corrupted by the
medicalization of death.

Dignity will not be found in the universal health care now demanded,
but in hygienic autonomy and in a new found art of suffering and
dying. In modern sickness I see the occasion for this discovery.

A History of Health

The concept of health in European modernity represents a break with
the Galenic-Hippocratic tradition familiar to the historian. For
Greek philosophers, "healthy" was a concept for harmonious mingling,
balanced order. A rational interplay of the basic elements. He was
healthy who integrated himself into the harmony of the totality of
his world according to the time and place he had come into the
world.

For Plato, health was a somatic virtue, and spiritual health, too, a
virtue. In "healthy human understanding," the German language --
despite critiques by Kant, Hamann, Hegel and Nietzsche -- preserved
something of this cosmotropic qualification. But since the 17th
century, the attempt to master nature displaced the ideal of the
health of a people.

This inversion gives the a-cosmic health created in this way the
appearance of being engineerable. Under this hypothesis of
engineerability, "health as possession" has gained acceptance since
the last quarter of the 18th century. In the course of the 19th
century, it became common sense to speak of "my body" and "my
health."

In the American Declaration of Independence, the right to happiness
is affirmed. The right to health materialized in a parallel way. In
the same way as this happiness, modern-day health is the fruit of
possessive individualism. There could have been no more brutal and,
at the same time, more convincing way to legitimize a society based
on self-serving greed. In a similarly parallel way, the concept of
responsibility of the individual gained acceptance in formally
democratic societies. Responsibility then took on the semblance of
ethical power over ever more distant regions of society and ever
more specialized forms of "happiness-bringing" service deliveries.

In the 19th and early 20th century, then, health and responsibility
were still believable ideals. Today they are elements of a lost past
to which there is no return. Health and responsibility are normative
concepts which no longer give any direction. When I try to structure
my life according to such irrecoverable ideals, they become harmful -
- I make myself sick.

HEALTH IS A PLASTIC WORD | Health and responsibility have been made
largely impossible from a technical point of view. This was not
clear to me when I wrote Medical Nemesis, and perhaps was not yet
the case at that time. In hindsight, it was a mistake to understand
health as the quality of "survival," and as the "intensity of coping
behavior."

Adaptation to the misanthropic genetic, climatic, chemical and
cultural consequences of growth is now described as health. Neither
the Galenic-Hippocratic representations of balance, nor the
Enlightenment utopia of a right to "health and happiness," nor any
Vedic or Chinese concepts of well-being, have anything to do with
survival in a technical system.

"Health" as function, process, mode of communication; health as an
orienting behavior which requires management -- these belong with
those post-industrial conjuring formulas which suggestively connote
much, but denote nothing that can be grasped. And as soon as health
is addressed, it has already turned into a sense-destroying
pathogen, a member of a word family which Uwe Poerksen calls plastic
words, word husks which one can wave around, making oneself
important, but which can say or do nothing.

The situation is similar with responsibility, although to
demonstrate this is much more difficult. In a world which worships
an ontology of systems, ethical responsibility is reduced to a
legitimizing formality. The poisoning of the world is not the result
of an irresponsible decision, but rather of our individual presence,
as when traveling by airplane or commuting on the freeway, in an
unjustifiable web of interconnections. It would be politically
naive, after health and responsibility have been made technically
impossible, to somehow resurrect them through inclusion into a
personal project; some kind of resistance is demanded.

Instead of brutal self-enforcement maxims, the new health requires
the smooth integration of my immune system into a socioeconomic
world system. Being asked for responsibility is, when seen more
clearly, a demand for the destruction of sense and self And this
proposed self-assignment to a system stands in stark contrast to
suicide. It demands self-extinction in a world hostile to death.

Precisely because I favor those renunciations which an a-mortal
society would label suicide, I must publicly expose the idealization
of "healthy" self-integration.

To demand that our children feel well in the world which we leave
them is an insult to their dignity. Then to impose on them
responsibility for their own health is to add baseness to the
insult.

INCEDENT DEMANDS | In many respects, biological, demographic and
medical research of the last decade, focusing on health, showed that
medical achievements only contributed in an insignificant way to the
medically defined level of health in the population. Secondly,
studies have found that even preventive medicine is of secondary
importance in this respect. Further, we now see that a majority of
these medical achievements are deceptive misnomers, actually
prolonging the suffering of madmen, cripples, old fools and
monsters.

Therefore, I find it reprehensible that the self-appointed health
experts now emerge as caring monitors who, with their slogans, put
the responsibility of suffering onto the sick themselves. In the
last 15 years, propaganda in favor of hypochondria has certainly led
to a reduction in smoking and butter consumption among the rich and
to an increase in their jogging.

But throughout the world, propaganda for medically defined health
coincided with an increase in misery for the many. In India. Banerji
has demonstrated how the importation of Western thought undermined
the hygienic customs of the majority and solidified advancement of
elites.

Twenty years ago, Hakin Mohamed Said, the leader of the Pakistan
Unani, spoke about medical sickening through the imposition of a
Western concept of health. What concerned him was the corruption of
the praxis of traditional Galenic physicians, not by Western
pharmacopeia so much as by a Western concept of health which sees
death as the enemy. This hostility to death -- which is to be
internalized along with personal responsibility for health -- is why
I regard the slogan of "my body, my health" as indecent.

LIFE AS BLASPHEMY | In recent times, as I discussed earlier, the
representation of the substantive concept, "life," has prominently
emerged. The physician was required to take responsibility for life.
Around 1979, the quality of life was suddenly before us. Biomedicine
discovered its competence over "life."

Studying the history of well-being, the history of health, it is
obvious that with the arrival of life and its quality -- which was
also called health -- the thread which linked that which is called
health today with health in the past was broken. Health has become a
scale on which one measures an immune system's fitness for living.

The reduction of a person to an immune system corresponds to the
deceptive reduction of creation to a global system, Lovelock's Gaia.
And in this perspective, responsibility ends up being understood as
the self-steering of an immune system. As much as I would like to
rescue for future use the word "responsible" -- a word that, as a
philosophical concept, only appeared around 1920 -- to characterize
my actions and omissions, I cannot do it. And this is true, not
primarily because through this slogan for self-regulation of one's
own "quality of life" sense is extinguished, management transfigured
as beneficial, and politics reduced to feedback, but because God is
thus blasphemed.

I ask you to pay careful attention to my form of expression. I am a
Christian, but when I speak here about blaspheming God, I want to be
understood as an historian, not as a theologian.

I have outlined my thinking. Longing for that which health and
responsibility might have been in the recently arrived modernity I
leave to romantics and drop-outs. I consider it a perversion to use
the names of high-sounding illusions which cannot fit in the world
of computer and media for the internalization and embodiment of
systems and information theory.

Only if one understands the history of health and life in their
historical interconnection is there a basis for the passion with
which I call for the renunciation of "life." I completely agree with
T. S. Eliot:

Where is the Life we have lost in living? Where is the wisdom we
have lost in knowledge? Where is the knowledge we have lost in
information? The cycles of Heaven in twenty centuries Bring us
farther from God and nearer to the Drust.

The concept of a life which can be reduced to a survival phase of
the immune system is not only a caricature, not only an idol, but a
blasphemy And seen in this light, desire for responsibility for the
quality of this life is not only stupid or impertinent, it is a sin.

The Illusion of Responsibility

I can imagine no complex of controls capable of saving us from the
flood of poisons, radiations, goods and services which sicken humans
and animals more than ever before. What sickens us today is
something altogether new. What determines the epoch since
Kristallnacht is the growing matter-offact acceptance of a
bottomless evil which Hitler and Stalin did not reach, but which
today is the theme for elevated discussions on the atom, the gene,
poison, health, and growth.

These are evils and crimes which render us speechless. Unlike death,
pestilence, and devils, these evils are without meaning. They belong
to a non-human order. They force us into impotence, helplessness,
and powerlessness. We can suffer such evil, we can be broken by it,
but we cannot make sense of it, cannot direct it.

There is no way out of this world. I live in a manufactured reality
ever further removed from creation. And I know today what that
signifies, what horror threatens each of us.

A few decades ago, I did not yet know it. At that time, it seemed
possible that I could share responsibility for the remaking of this
manufactured world. Today, I finally know what powerlessness is. I
know that "responsibility" is an illusion.

In such a world, "being healthy" is reduced to a combination of the
enjoyment of techniques, protection of the environment, and
adaptation to the consequences of techniques, all three of which
are, inevitably, privileges.

In order to live today, I must decisively renounce health and
responsibility. Renounce, I say, not ignore or become resigned. I do
not use the word to denote indifference. What I mean is that I must
accept powerlessness, mourn that which is cone and renounce the
irrecoverable.

Renunciation can free one from the powerlessness which robs me of my
awareness. of my sense. But renunciation is not a familiar concept
today. We no longer have a word for courageous, disciplined, self-
critical renunciation accomplished in community -- but that is what
I am talking about. I will call it askesis.

I would have preferred another word, for askesis today brings to
mind Flaubert and Saint Antony in the desert -- turning away from
wine, women and fragrance. But the renunciation of which I speak has
very little to do with this.

The epoch in which we live is abstract and disembodied. The
certainties on which it rests are largely sense-less. And their
worldwide acceptance gives them a semblance of independence from
history and culture. What I want to call epistemological askesis
opens the path toward renouncing those axiomatic certainties on
which the contemporary world view rests. I speak of convivial and
critically practiced discipline. The so-called values of health and
responsibility belong to these certainties. Examined in depth, one
sees them as deeply sickening, disorienting phenomena. That is why I
regard a call to take responsibility for my health as senseless,
misleading, indecent, and, in a very particular way, blasphemous.

Hygienic Autonomy: A Manifesto

Many persons are confused today about something called "health."
Experts prate knowingly about "health care systems." Some persons
believe that without access to sophisticated and expensive
treatments, people will be sick. Everyone worries about increasing
costs. One even hears talk of a "health care crisis." I would like
to say something about these matters.

First, I believe it necessary to assert the truth of the human
condition: I suffer pain; I am afflicted with certain impairments; I
will certainly die. Some undergo greater pain, some more
debilitating disorders, but we all equally face death.

Looking around me, I see that we -- as people in other times and
places -- have a great capacity to care for one another, especially
in the moments of birthing, accidents and dying. Unless unbalanced
by historical novelties, our households, in close cooperation with
their surrounding communities, have been wonderfully hospitable,
that is, generally adequate to care for the real needs of living,
celebrating and dying.

In opposition to this experience, some of us today have come to
believe that we desperately need packages, commodities, all under
the label of "health," all designed and delivered by a system of
professionalized services. Some try to convince us that an infant is
born, not only helpless -- needing the loving care of household --
but also sick, requiring specialized treatment by self-certified
experts. Others believe that adults routinely require various drugs
and interventions in order to become old, while the dying need
medical treatment.

Many have forgotten -- or are no longer able to enjoy -- those
common-sense ways of living that contribute to one's well-being and
ability to recover from illness. Many have allowed themselves to
become dependent on a self-aggrandizing technological myth, against
which they nevertheless complain, because of the impersonal ways in
which it impoverishes many while enriching a few.

Sadly, I recognize that many of us are infected with a strange
illusion: a person has a "right" to something called health care.
Thus, one states a claim to receive the latest assortment of
technological therapies, based on some professional's diagnosis, to
enable one to survive longer in a situation which often ugly,
injuries,or depressing or just boring.

I believe it is time to state clearly that specific situations and
circumstances are "sickening," rather than that people themselves
are sick. The symptoms which modern medicine attempts to treat often
have little to do with the condition of our bodies; they are,
rather, signals pointing to the disorders and presumptions of modern
ways of working, playing and living.

Nevertheless. many of us are mesmerized by the glitter of high-
tech "solutions, " we pathetically believe in"fix-it" drugs, we
mistakenly think all pain is an evil to be suppressed, we seek to
postpone death at almost any cost.

I appeal to the actual experience of people, to the sensibleness of
the ordinary person, in direct opposition to professional diagnosis
and judgement. I appeal to people's memories, in opposition to the
illusions of progress. Let us look at the conditions of our
households and communities, not at the quality of "health care"
delivery; health is not a deliverable commodity and care does not
come out of a system.

I demand certain liberties for those who would celebrate living
rather than preserve "life":

* the liberty to declare myself sick;

* the liberty to refuse any and all medical treatment at any time;

* the liberty to take any drug or treatment of my own choosing;

* the liberty to be treated by the person of my choice, that is, by
anyone in the community who feels called to the practice of healing,
whether that person be an acupuncturist, a homeopathic physician, a
neurosurgeon, an astrologer, a witch doctor or someone else;

* the liberty to die without diagnosis.

I do not believe that countries need a national "health" policy,
something given to their citizens.
Rather, the latter need the courageous virtue to face certain
truths:

* we will never eliminate pain;

* we will not cure all disorders;

* we will certainly die.

Therefore, as sensible creatures, we must face the fact that the
pursuit of health may be a sickening disorder. There are no
scientific, technological solutions. There is the daily task of
accepting the fragility and contingency of the human situation.
There are reasonable limits which must be placed on
conventional "health" care. We urgently need to define anew what
duties belong to us as persons, what pertains to our communities,
what we relinquish to the state.

Yes, we suffer pain, we become ill, we die. But we also hope, laugh,
celebrate; we know the joy of caring for one another; often we are
healed and we recover by many means. We do not have to pursue the
path of the flattening out of human experience.

I invite all to shift their gaze, their thoughts, from worrying
about health care to cultivating the art of living. And, today, with
equal importance, to the art of suffering, the art of dying.
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IVAN ILLICH The philosopher and theologically trained historian Ivan
Illich published his seminal and highly controversial study op
health care, medical nemesis: The Expropriation of Health, in 1976.

In his first major essay on this subject in the nearly 20 years
since Medical Nemesis Illich argues here that the modern social
construction of "a life" into an abstract, disembodied and dis-
integrated entity -- a "fetish" -- prepares the way for
depersonalized manipulation and management of our existence from
womb to tomb.

Going beyond his argument in 1976 that the medical establishment
itself had become a threat to health through doctor-induced
suffering, Illich here renounces as an indecent demand the very idea
of "responsibility" for one's health in a sickening environment.
Instead, he takes a radical leap and calls for the only "decent"
alternative: hygienic autonomy from any system of health care.

http://www.davidtinapple.com/illich
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Medical Nemesis: The Expropriation of Health by Ivan Illich
[Includes acknowledgements, introduction and Part1 - Clinical
Iatrogenesis]
http://www.mindfully.org/Health/Medical-Nemesis-Illich1976.htm

IVAN ILLICH / Random House 1976
Ivan Illich, Pantheon Books, A Division of Random House, New York.
First American Edition. Copyright 1976 by Random House, Inc. All
rights reserved under International and Pan-American Copyright
Conventions. Published in the United States by Pantheon Books, a
division of Random House, Inc., New York. Originally published in
Great Britain by Calder & Boyars, Ltd., London. Copyright © 1975 by
Ivan Illich. Manufactured in the United States of America. Library
of Congress Catalog Card Number: 75-38118 ISBN: 0-394-40225-1

Acknowledgments

My thinking on medical institutions was shaped over several years in
periodic conversations with Roslyn Lindheim and John McKnight. Mrs.
Lindheim, Professor of Architecture at the University of California
at Berkeley, is shortly to publish The Hospitalization of Space, and
John McKnight, Director of Urban Studies at Northwestern University,
is working on The Serviced Society. Without the challenge from these
two friends, I would not have found the courage to develop my last
conversations with Paul Goodman into this book.

Several others have been closely connected with the growth of this
text: Jean Robert and Jean P. Dupuy, who illustrated the economic
thesis stated in this book with examples from time-polluting and
space-distorting transportation systems; André Gorz, who has been my
principal tutor in the politics of health; Marion Boyars, who with
admirable competence published the draft of this book in London and
thus enabled me to base my final version on a wide spectrum of
critical reaction. To them and to all my critics and helpers, and
especially to those who have led me to valuable reading, I owe deep
gratitude.

This book would never have been written without Valentina Borremans.
She has patiently assembled the documentation on which it is based,
and refined my judgment and sobered my language with her constant

v

criticism. The chapter on the industrialization of death is a
summary of the notes she has assembled for her own book on the
history of the face of death.

IVAN ILLICH
Cuernavaca, Mexico January 1976

Contents

Introduction 3

PART I. Clinical Iatrogenesis

The Epidemics of Modern Medicine 13

Doctors' Effectiveness—an Illusion
Useless Medical Treatment
Doctor-Inflicted Injuries
Defenseless Patients

PART II. Social Iatrogenesis

2. The Medicalization of Life 39

Political Transmission of Iatrogenic Disease
Social Iatrogenesis
Medical Monopoly
Value-Free Cure?
Medicalization of the Budget
The Pharmaceutical Invasion
Diagnostic Imperialism
Preventive Stigma
Terminal Ceremonies
Black Magic
Patient Majorities

vii

PART III. Cultural Iatrogenesis

Introduction 127

3. The Killing of Pain 133

4. The Invention and Elimination of Disease 159

5. Death Against Death 179

Death as Commodity
The Devotional Dance of the Dead
The Danse Macabre
Bourgeois Death
Clinical Death
Trade Union Claims to a Natural Death
Death Under Intensive Care

PART IV. The Politics of Health

6. Specific Counterproductivity 211

7. Political Countermeasures 221

Consumer Protection for Addicts
Equal Access to Torts
Public Controls over the Professional Mafia
The Scientific Organization—of Life
Engineering for a Plastic Womb

8. The Recovery of Health 261

Industrialized Nemesis
From Inherited Myth to Respectful Procedure
The Right to Health
Health as a Virtue

Index 279

About the Author 289

viii

Introduction

The medical establishment has become a major threat to health. The
disabling impact of professional control over medicine has reached
the proportions of an epidemic. Iatrogenesis, the name for this new
epidemic, comes from iatros, the Greek word for "physician," and
genesis, meaning "origin." Discussion of the disease of medical
progress has moved up on the agendas of medical conferences,
researchers concentrate on the sick-making powers of diagnosis and
therapy, and reports on paradoxical damage caused by cures for
sickness take up increasing space in medical dope-sheets. The health
professions are on the brink of an unprecedented housecleaning
campaign. "Clubs of Cos," named after the Greek Island of Doctors,
have sprung up here and there, gathering physicians, glorified
druggists, and their industrial sponsors as the Club of Rome has
gathered "analysts" under the aegis of Ford, Fiat, and Volkswagen.
Purveyors of medical services follow the example of their colleagues
in other fields in adding the stick of "limits to growth" to the
carrot of ever more desirable vehicles and therapies. Limits to
professional health care are a rapidly growing political issue. In
whose interest these limits will work will depend to a large extent
on who takes the initiative in formulating the need for them: people
organized for political action that challenges status-quo
professional power, or the health

3

professions intent on expanding their monopoly even further.

The public has been alerted to the perplexity and uncertainty of the
best among its hygienic caretakers. The newspapers are full of
reports on volte-face manipulations of medical leaders: the pioneers
of yesterday's so-called breakthroughs warn their patients against
the dangers of the miracle cures they have only just invented.
Politicians who have proposed the emulation of the Russian, Swedish,
or English models of socialized medicine are embarrassed that recent
events show their pet systems to be highly efficient in producing
the same pathogenic—that is, sickening—cures and care that
capitalist medicine, albeit with less equal access, produces. A
crisis of confidence in modern medicine is upon us. Merely to insist
on it would be to contribute further to a self-fulfilling prophecy,
and to possible panic.

This book argues that panic is out of place. Thoughtful public
discussion of the iatrogenic pandemic, beginning with an insistence
upon demystification of all medical matters, will not be dangerous
to the commonweal. Indeed, what is dangerous is a passive public
that has come to rely on superficial medical housecleanings. The
crisis in medicine could allow the layman effectively to reclaim his
own control over medical perception, classification, and decision-
making. The laicization of the Aesculapian temple could lead to a
delegitimizing of the basic religious tenets of modern medicine to
which industrial societies, from the left to the right, now
subscribe.

My argument is that the layman and not the physician has the
potential perspective and effective power to stop the current
iatrogenic epidemic. This book offers the lay reader a conceptual
framework within which to assess the seamy side of progress against
its more publicized benefits.

4



It uses a model of social assessment of technological progress that
I have spelled out elsewhere' and applied previously to education2
and transportation,3 and that I now apply to the criticism of the
professional monopoly and of the scientism in health care that
prevail in all nations that have organized for high levels of
industrialization. In my opinion, the sanitation of medicine is part
and parcel of the socio-economic inversion with which Part IV of
this book deals.

The footnotes reflect the nature of this text. I assert the right to
break the monopoly that academia has exercised over all small print
at the bottom of the page. Some footnotes document the information I
have used to elaborate and to verify my own preconceived paradigm
for optimally limited health care, a perspective that did not
necessarily have any place within the mind of the person who
collected the corresponding data. Occasionally, I quote my source
only as an eyewitness account that is incidentally offered by the
expert author, while refusing to accept what he says as expert
testimony on the grounds that it is hearsay and therefore ought not
to influence the relevant public decisions.

Many more footnotes provide the reader with the kind of
bibliographical guidance that I would have appreciated when I first
began, as an outsider, to delve into the subject of health care and
tried to acquire competence in the political evaluation of
medicine's effectiveness. These notes refer to library tools and
reference works that I have learned to appreciate in years of single-
handed exploration. They also list readings, from technical
monographs to novels, that have been of use to me.

Finally, I have used the footnotes to deal with my own

_______________________________________________
1 Tools for Conviviality (New York: Harper & Row, 1973).
2 Deschooling Society, Ruth N. Anshen, ed. (New York: Harper & Row,
1971).
3 Energy and Equity (New York: Harper & Row, 1974).



parenthetical, supplementary, and tangential suggestions and
questions, which would have distracted the reader if kept in the
main text. The layman in medicine, for whom this book is written,
will himself have to acquire the competence to evaluate the impact
of medicine on health care. Among all our contemporary experts,
physicians are those trained to the highest level of specialized
incompetence for this urgently needed pursuit.

The recovery from society-wide iatrogenic disease is a political
task, not a professional one. It must be based on a grassroots
consensus about the balance between the civil liberty to heal and
the civil right to equitable health care. During the last
generations the medical monopoly over health care has expanded
without checks and has encroached on our liberty with regard to our
own bodies. Society has transferred to physicians the exclusive
right to determine what constitutes sickness, who is or might become
sick, and what shall be done to such people. Deviance is
now "legitimate" only when it merits and ultimately justifies
medical interpretation and intervention. The social commitment to
provide all citizens with almost unlimited outputs from the medical
system threatens to destroy the environmental and cultural
conditions needed by people to live a life of constant autonomous
healing. This trend must be recognized and eventually be reversed.

Limits to medicine must be something other than professional self-
limitation. I will demonstrate that the insistence of the medical
guild on its unique qualifications to cure medicine itself is based
on an illusion. Professional power is the result of a political
delegation of autonomous authority to the health occupations which
was enacted during our century by other sectors of the university-
trained bourgeoisie: it cannot now be revoked by those who conceded
it; it can only be delegitimized by popular

6

agreement about the malignancy of this power. The self-medication of
the medical system cannot but fail. If a public, panicked by gory
revelations, were browbeaten into further support for more expert
control over experts in health-care production, this would only
intensify sickening care. It must now be understood that what has
turned health care into a sick-making enterprise is the very
intensity of an engineering endeavor that has translated human
survival from the performance of organisms into the result of
technical manipulation.

"Health," after all, is simply an everyday word that is used to
designate the intensity with which individuals cope with their
internal states and their environmental conditions. In Homo
sapiens, "healthy" is an adjective that qualifies ethical and
political actions. In part at least, the health of a population
depends on the way in which political actions condition the milieu
and create those circumstances that favor self-reliance, autonomy,
and dignity for all, particularly the weaker. In consequence, health
levels will be at their optimum when the environ-ment brings out
autonomous personal, responsible coping ability. Health levels can
only decline when survival comes to depend beyond a certain point on
the heteronomous (other-directed) regulation of the organism's
homeostasis. Beyond a critical level of intensity, institutional
health care—no matter if it takes the form of cure, prevention, or
environmental engineering—is equivalent to systematic health denial.

The threat which current medicine represents to the health of
populations is analogous to the threat which the volume and
intensity of traffic represent to mobility, the threat which
education and the media represent to learning, and the threat which
urbanization represents to competence in homemaking. In each case a
major institutional endeavor has turned counterproductive. Time-con-

7

suming acceleration in traffic, noisy and confusing communications,
education that trains ever more people for ever higher levels of
technical competence and specialized forms of generalized
incompetence: these are all phenomena parallel to the production by
medicine of iatrogenic disease. In each case a major institutional
sector has removed society from the specific purpose for which that
sector was created and technically instrumented.

Iatrogenesis cannot be understood unless it is seen as the
specifically medical manifestation of specfic counterproductivity.
Specific or paradoxical counterproductivity is a negative social
indicator for a diseconomy which remains locked within the system
that produces it. It is a measure of the confusion delivered by the
news media, the incompetence fostered by educators, or the time-loss
represented by a more powerful car. Specific counterproductivity is
an unwanted side-effect of increasing institutional outputs that
remains internal to the system which itself originated the specific
value. It is a social measure for objective frustration. This study
of pathogenic medicine was under-taken in order to illustrate in the
health-care field the various aspects of counterproductivity that
can be observed in all major sectors of industrial society in its
present stage. A similar analysis could be undertaken in other
fields of industrial production, but the urgency in the field of
medicine, a traditionally revered and self-congratulatory service
profession, is particularly great.

Built-in iatrogenesis now affects all social relations. It is the
result of internalized colonization of liberty by affluence. In rich
countries medical colonization has reached sickening proportions;
poor countries are quickly following suit. (The siren of one
ambulance can destroy Samaritan attitudes in a whole Chilean town.)
This process, which I shall call the "medicalization of life,"
deserves articulate political recognition. Medicine could

8

become a prime target for political action that aims at an inversion
of industrial society. Only people who have recovered the ability
for mutual self-care and have learned to combine it with dependence
on the application of contemporary technology will be ready to limit
the industrial mode of production in other major areas as well.

A professional and physician-based health-care system that has grown
beyond critical bounds is sickening for three reasons: it must
produce clinical damage that outweighs its potential benefits; it
cannot but enhance even as it obscures the political conditions that
render society unhealthy; and it tends to mystify and to expropriate
the power of the individual to heal himself and to shape his or her
environment. Contemporary medical systems have outgrown these
tolerable bounds. The medical and paramedical monopoly over hygienic
methodology and technology is a glaring example of the political
misuse of scientific achievement to strengthen industrial rather
than personal growth. Such medicine is but a device to convince
those who are sick and tired of society that it is they who are ill,
impotent, and in need of technical repair. I will deal with these
three levels of sickening medical impact in the first three parts of
this book.

The balance sheet of achievement in medical technology will be drawn
up in the first chapter. Many people are already apprehensive about
doctors, hospitals, and the drug industry and only need data to
substantiate their misgivings. Doctors already find it necessary to
bolster their credibility by demanding that many treatments now
common be formally outlawed. Restrictions on medical performance
which professionals have come to consider mandatory are often so
radical that they are not accept-able to the majority of
politicians. The lack of effectiveness of costly and high-risk
medicine is a now widely discussed fact from which I start, not a
key issue I want to dwell on.

9

Part II deals with the directly health-denying effects of medicine's
social organization, and Part III with the disabling impact of
medical ideology on personal stamina: under three separate headings
I describe the transformation of pain, impairment, and death from a
personal challenge into a technical problem.

Part IV interprets health-denying medicine as typical of the
counterproductivity of overindustrialized civilization and analyzes
five types of political response which constitute tactically useful
remedies that are all strategically futile. It distinguishes between
two modes in which the person relates and adapts to his environment:
autonomous (i.e., self-governing) coping and heteronomous (i.e., ad-
ministered) maintenance and management. It concludes by
demonstrating that only a political program aimed at the limitation
of professional management of health will enable people to recover
their powers for health care, and that such a program is integral to
a society-wide criticism and restraint of the industrial mode of
production.

10


---------------------------------------------------------------------
-----------

PART I
Clinical Iatrogenesis


1
The Epidemics
of Modern Medicine

During the past three generations the diseases afflicting Western
societies have undergone dramatic changes.' Polio, diphtheria, and
tuberculosis are vanishing; one shot of an antibiotic often cures
pneumonia or syphilis; and so many mass killers have come under
control that two-thirds of all deaths are now associated with the
diseases of old age. Those who die young are more often than not
victims of accidents, violence, or suicide.2

These changes in health status are generally equated with a decrease
in suffering and attributed to more or to better medical care.
Although almost everyone believes that at least one of his friends
would not be alive and well except for the skill of a doctor, there
is in fact no evidence of any direct relationship between this
mutation of sickness and the so-called progress of medicine.3 The
changes are

13

dependent variables of political and technological trans-formations,
which in turn are reflected in what doctors do and say; they are not
significantly related to the activities that require the
preparation, status, and costly equipment in which the health
professions take pride.4 In addition, an expanding proportion of the
new burden of disease of the last fifteen years is itself the result
of medical intervention in favor of people who are or might become
sick. It is doctor-made, or iatrogenic.5

After a century of pursuit of medical utopia,6 and contrary to
current conventional wisdom,7 medical services

14

have not been important in producing the changes in life expectancy
that have occurred. A vast amount of contemporary clinical care is
incidental to the curing of disease, but the damage done by medicine
to the health of individuals and populations is very significant.
These facts are obvious, well documented, and well repressed.



Doctors' Effectiveness—An Illusion

The study of the evolution of disease patterns provides evidence
that during the last century doctors have affected epidemics no more
profoundly than did priests during earlier times. Epidemics came and
went, imprecated by both but touched by neither. They are not
modified any more decisively by the rituals performed in medical
clinics than by those customary at religious shrines.8 Discussion of
the future of health care might usefully begin with the recognition
of this fact.

The infections that prevailed at the outset of the industrial age
illustrate how medicine came by its reputation.9 Tuberculosis, for
instance, reached a peak over two generations. In New York in 1812,
the death rate was estimated to be higher than 700 per 10,000; by
1882, when Koch first isolated and cultured the bacillus, it had
already declined to 370 per 10,000. The rate was down to 180 when
the first sanatorium was opened in 1910, even though "consumption"
still held second place in the mortality tables.10 After World War
II, but before antibi-

15

otics became routine, it had slipped into eleventh place with a rate
of 48. Cholera," dysentery,12 and typhoid similarly peaked and
dwindled outside the physician's control. By the time their etiology
was understood and their therapy had become specific, these diseases
had lost much of their virulence and hence their social importance.
The combined death rate from scarlet fever, diphtheria, whooping
cough, and measles among children up to fifteen shows that nearly 90
percent of the total decline in mortality between 1860 and 1965 had
occurred before the introduction of antibiotics and widespread
immunization.13 In part this recession may be attributed to improved
housing and to a decrease in the virulence of micro-organisms, but
by far the most important factor was a higher host-resistance due to
better nutrition. In poor countries today, diarrhea and upper-
respiratory-tract infections occur more frequently, last longer, and
lead to higher mortality where nutrition is poor, no matter how much
or how little medical care is available.14 In England, by the middle
of the nineteenth century, infectious epidemics had been replaced by
major malnutrition syndromes, such as rickets and pellagra. These in
turn peaked and vanished, to be replaced by the diseases of early
childhood and, somewhat later, by an increase in duodenal ulcers in

16

young men. When these declined, the modern epidemics took over:
coronary heart disease, emphysema, bronchitis, obesity,
hypertension, cancer (especially of the lungs), arthritis, diabetes,
and so-called mental disorders. Despite intensive research, we have
no complete explanation for the genesis of these changes.15 But two
things are certain: the professional practice of physicians cannot
be credited with the elimination of old forms of mortality or
morbidity, nor should it be blamed for the increased expectancy of
life spent in suffering from the new diseases. For more than a
century, analysis of disease trends has shown that the environment
is the primary determinant of the state of general health of any
population.16 Medical geography,17

17

the history of diseases,18 medical anthropology,19 and the social
history of attitudes towards illness20 have shown that food,21
water,22 and air,23 in correlation with the level of



sociopolitical equality24 and the cultural mechanisms that make it
possible to keep the population stable,25 play the

19

decisive role in determining how healthy grown-ups feel and at what
age adults tend to die. As the older causes of disease recede, a new
kind of malnutrition is becoming the most rapidly expanding modern
epidemic.26 One-third of humanity survives on a level of
undernourishment which would formerly have been lethal, while more
and more rich people absorb ever greater amounts of poisons and
mutagens in their food.27

Some modern techniques, often developed with the help of doctors,
and optimally effective when they become part of the culture and
environment or when they are applied independently of professional
delivery, have also effected changes in general health, but to a
lesser degree. Among these can be included contraception, smallpox
vaccination of infants, and such nonmedical health measures as the
treatment of water and sewage, the use of soap and scissors by
midwives, and some antibacterial and insecticidal procedures. The
importance of many of these practices was first recognized and
stated by doctors—often courageous dissidents who suffered for their
recommendations28

20

—but this does not consign soap, pincers, vaccination needles,
delousing preparations, or condoms to the category of "medical
equipment." The most recent shifts in mortality from younger to
older groups can be explained by the incorporation of these
procedures and devices into the layman's culture.

In contrast to environmental improvements and modern nonprofessional
health measures, the specifically medical treatment of people is
never significantly related to a decline in the compound disease
burden or to a rise in life expectancy.29 Neither the proportion of
doctors in a population nor the clinical tools at their disposal nor
the number of hospital beds is a causal factor in the striking
changes in over-all patterns of disease. The new techniques for
recognizing and treating such conditions as pernicious anemia and
hypertension, or for correcting congenital malformations by surgical
intervention, re-define but do not reduce morbidity. The fact that
the doctor population is higher where certain diseases have become
rare has little to do with the doctors' ability to control or
eliminate them.30 It simply means that doctors

21

deploy themselves as they like, more so than other professionals,
and that they tend to gather where the climate is healthy, where the
water is clean, and where people are employed and can pay for their
services.31



Useless Medical Treatment

Awe-inspiring medical technology has combined with egalitarian
rhetoric to create the impression that contemporary medicine is
highly effective. Undoubtedly, during the last generation, a limited
number of specific procedures have become extremely useful. But
where they are not monopolized by professionals as tools of their
trade, those which are applicable to widespread diseases are usually
very inexpensive and require a minimum of personal skills,
materials, and custodial services from hospitals. In contrast, most
of today's skyrocketing medical expenditures are destined for the__
kind_ of diagnosis and treatment whose effectiveness at best
doubtful.32 To make this point I will distinguish between infectious
and noninfectious diseases.

In the case of infectious diseases, chemotherapy has played a
significant role in the control of pneumonia, gonorrhea, and
syphilis. Death from pneumonia, once the "old man's friend,"
declined yearly by 5 to 8 percent after sulphonamides and
antibiotics came on the market. Syphilis, yaws, and many cases of
malaria and typhoid can be cured quickly and easily. The rising rate
of venereal

22

disease is due to new mores, not to ineffectual medicine. The
reappearance of malaria is due to the development of pesticide-
resistant mosquitoes and not to any lack of new antimalarial
drugs.33 Immunization has almost wiped out paralytic poliomyelitis,
a disease of developed countries, and vaccines have certainly
contributed to the decline of whooping cough and measles,34 thus
seeming to confirm the popular belief in "medical progress." 35 But
for most other infections, medicine can show no comparable results.
Drug treatment has helped to reduce mortality from tuberculosis,
tetanus, diphtheria, and scarlet fever, but in the total decline of
mortality or morbidity from these diseases, chemotherapy played a
minor and possibly insignificant role.36 Malaria, leishmaniasis, and
sleeping sickness indeed receded for a time under the onslaught of
chemical attack, but are now on the rise again.37

23

The effectiveness of medical intervention in combatting
noninfectious diseases is even more questionable. In some situations
and for some conditions, effective progress has indeed been
demonstrated: the partial prevention of caries through fluoridation
of water is possible, though at a cost not fully understood.38
Replacement therapy lessens the direct impact of diabetes, though
only in the short run.39 Through intravenous feeding, blood
transfusions, and surgical techniques, more of those who get to the
hospital survive trauma, but survival rates for the most common
types of cancer—those which make up 90 percent of the cases—have
remained virtually unchanged over the last twenty-five years. This
fact has consistently been clouded by announcements from the
American Cancer Society reminiscent of General Westmoreland's
proclamations from Vietnam. On the other hand, the diagnostic value
of the Papanicolaou vaginal smear test has been proved: if the tests
are given four times a year, early intervention for cervical cancer
demonstrably increases the five-year survival rate. Some skin-cancer
treatment is highly effective. But there is little evidence of
effective treatment of most other cancers.40 The five-year survival
rate in breast-can-

24

cer cases is 50 percent, regardless of the frequency of medical
check-ups and regardless of the treatment used.41 Nor is there
evidence that the rate differs from that among untreated women.
Although practicing doctors and the publicists of the medical
establishment stress the importance of early detection and treatment
of this and several other types of cancer, epidemiologists have
begun to doubt that early intervention can alter the rate of
survival.42 Surgery and chemotherapy for rare congenital and
rheumatic heart disease have increased the chances for an active
life for some of those who suffer from degenerative conditions.43
The medical treatment of common cardiovascular disease44 and the
intensive treatment of heart

25

disease,45 however, are effective only when rather exceptional
circumstances combine that are outside the physician's control. The
drug treatment of high blood pressure is effective and warrants the
risk of side-effects in the few in whom it is a malignant condition;
it represents a considerable risk of serious harm, far outweighing
any proven benefit, for the 10 to 20 million Americans on whom rash
artery-plumbers are trying to foist it.46



Doctor-Inflicted Injuries

Unfortunately, futile but otherwise harmless medical care is the
least important of the damages a proliferating medical enterprise
inflicts on contemporary society. The pain, dysfunction, disability,
and anguish resulting from technical medical intervention now rival
the morbidity due to traffic and industrial accidents and even war-
related activities, and make the impact of medicine one of the most
rapidly spreading epidemics of our time. Among murderous
institutional torts, only modern malnutrition injures more people
than iatrogenic disease in its various manifestations.47 In the most
narrow sense, iatrogenic disease includes only illnesses that would
not have come

26

about if sound and professionally recommended treatment had not been
applied.48 Within this definition, a patient could sue his therapist
if the latter, in the course of his management, failed to apply a
recommended treatment that, in the physician's opinion, would have
risked making him sick. In a more general and more widely accepted
sense, clinical iatrogenic disease comprises all clinical conditions
for which remedies, physicians, or hospitals are the pathogens,
or "sickening" agents. I will call this plethora of therapeutic side-
effects clinical iatrogenesis. They are as old as medicine itself,49
and have always been a subject of medical studies.50

Medicines have always been potentially poisonous, but their unwanted
side-effects have increased with their power51 and widespread use.52
Every twenty-four to thirty-

27

six hours, from 50 to 80 percent of adults in the United States and
the United Kingdom swallow a medically prescribed chemical. Some
take the wrong drug; others get an old or a contaminated batch, and
others a counterfeit;53 others take several drugs in dangerous
combinations;54 and still others receive injections with improperly
sterilized syringes.55 Some drugs are addictive, others mutilating,
and others mutagenic, although perhaps only in combination with food
coloring or insecticides. In some patients, antibiotics alter the
normal bacterial flora and induce a superinfection, permitting more
resistant organisms to proliferate and invade the host. Other drugs
contribute to the breeding of drug-resistant strains of bacteria.56
Subtle kinds of poisoning thus have spread even faster than the
bewildering variety and ubiquity of nostrums.57 Unnecessary surgery
is a standard procedure.58 Disabling nondiseases

28

result from the medical treatment of nonexistent diseases and are on
the increase:59 the number of children disabled in Massachusetts
through the treatment of cardiac non-disease exceeds the number of
children under effective treatment for real cardiac disease.60

Doctor-inflicted pain and infirmity have always been a part of
medical practice.61 Professional callousness, negli-

29

gence, and sheer incompetence are age-old forms of malpractice.62
With the transformation of the doctor from an artisan exercising a
skill on personally known individuals into a technician applying
scientific rules to classes of patients, malpractice acquired an
anonymous, almost respectable status.63 What had formerly been
considered an abuse of confidence and a moral fault can now be
rationalized into the occasional breakdown of equipment and
operators. In a complex technological hospital, negligence
becomes "random human error" or "system break-down," callousness
becomes "scientific detachment," and incompetence becomes "a lack of
specialized equipment." The depersonalization of diagnosis and
therapy has changed malpractice from an ethical into a technical
problem.64

loss of the master's income during his protracted sickness. Citizens
were not covered by these statutes, but could avenge malpractice on
their own initiative.

30

In 1971, between 12,000 and 15,000 malpractice suits were lodged in
United States courts. Less than half of all malpractice claims were
settled in less than eighteen months, and more than 10 percent of
such claims remain unsettled for over six years. Between sixteen and
twenty percent of every dollar paid in malpractice insurance went to
compensate the victim; the rest was paid to lawyers and medical
experts.65 In such cases, doctors are vulnerable only to the charge
of having acted against the medical code, of the incompetent
performance of prescribed treatment, or of dereliction out of greed
or laziness. The problem, however, is that most of the damage
inflicted by the modern doctor does not fall into any of these
categories.66 It occurs in the ordinary practice of well-trained men
and women who have learned to bow to prevailing professional
judgment and procedure, even though they know (or could and should
know) what damage they do.

The United States Department of Health, Education, and Welfare
calculates that 7 percent of all patients suffer compensable
injuries while hospitalized, though few of them do anything about
it. Moreover, the frequency of reported accidents in hospitals is
higher than in all industries but mines and high-rise construction.
Accidents are the major cause of death in American children. In

31

proportion to the time spent there, these accidents seem to occur
more often in hospitals than in any other kind of place. One in
fifty children admitted to a hospital suffers an accident which
requires specific treatment.67 University hospitals are relatively
more pathogenic, or, in blunt language, more sickening. It has also
been established that one out of every five patients admitted to a
typical research hospital acquires an iatrogenic disease, sometimes
trivial, usually requiring special treatment, and in one case in
thirty leading to death. Half of these episodes result from
complications of drug therapy; amazingly, one in ten comes from
diagnostic procedures.68 Despite good intentions and claims to
public service, a military officer with a similar record of
performance would be relieved of his command, and a restaurant or
amusement center would be closed by the police. No wonder that the
health industry tries to shift the blame for the damage caused onto
the victim, and that the dope-sheet of a multinational
pharmaceutical concern tells its readers that "iatrogenic disease is
almost always of neurotic origin." 69



Defenseless Patients

The undesirable side-effects of approved, mistaken, callous, or
contraindicated technical contacts with the medical system represent
just the first level of pathogenic medicine. Such clinical
iatrogenesis includes not only the damage that doctors inflict with
the intent of curing or of exploiting the patient, but also those
other torts that result from the doctor's attempt to protect himself
against the

32

possibility of a suit for malpractice. Such attempts to avoid
litigation and prosecution may now do more damage than any other
iatrogenic stimulus.

On a second level,70 medical practice sponsors sickness by
reinforcing a morbid society that encourages people to become
consumers of curative, preventive, industrial, and environmental
medicine. On the one hand defectives survive in increasing numbers
and are fit only for life under institutional care, while on the
other hand, medically certified symptoms exempt people from
industrial work and thereby remove them from the scene of political
struggle to reshape the society that has made them sick. Second-
level iatrogenesis finds its expression in various symptoms of
social overmedicalization that amount to what I shall call the
expropriation of health. This second-level impact of medicine I
designate as social iatrogenesis, and I shall discuss it in Part II.

On a third level, the so-called health professions have an even
deeper, culturally health-denying effect insofar as they destroy the
potential of people to deal with their human weakness,
vulnerability, and uniqueness in a personal and autonomous way. The
patient in the grip of contemporary medicine is but one instance of
mankind in the grip of its pernicious techniques.71 This cultural
iatrogen-

33

esis, which I shall discuss in Part III, is the ultimate backlash of
hygienic progress and consists in the paralysis of healthy responses
to suffering, impairment, and death. It occurs when people accept
health management de-signed on the engineering model, when they
conspire in an attempt to produce, as if it were a commodity,
something called "better health." This inevitably results in the
managed maintenance of life on high levels of sublethal illness.
This ultimate evil of medical "progress" must be clearly
distinguished from both clinical and social iatrogenesis.

I hope to show that on each of its three levels iatrogenesis has
become medically irreversible: a feature built right into the
medical endeavor. The unwanted physiological, social, and
psychological by-products of diagnostic and therapeutic progress
have become resistant to medical remedies. New devices, approaches,
and organizational arrangements, which are conceived as remedies for
clinical and social iatrogenesis, themselves tend to become
pathogens contributing to the new epidemic. Technical and managerial
measures taken on any level to avoid damaging the patient by his
treatment tend to engender a self-reinforcing iatrogenic loop
analogous to the escalating destruction generated by the polluting
procedures used as antipollution devices.72

I will designate this self-reinforcing loop of negative
institutional feedback by its classical Greek equivalent and call it
medical nemesis. The Greeks saw gods in the forces of nature. For
them, nemesis represented divine vengeance

34

visited upon mortals who infringe on those prerogatives the gods
enviously guard for themselves. Nemesis was the inevitable
punishment for attempts to be a hero rather than a human being. Like
most abstract Greek nouns, Nemesis took the shape of a divinity. She
represented nature's response to hubris: to the individual's
presumption in seeking to acquire the attributes of a god. Our
contemporary hygienic hubris has led to the new syndrome of medical
nemesis.73

By using the Greek term I want to emphasize that the corresponding
phenomenon does not fit within the explanatory paradigm now offered
by bureaucrats, therapists, and ideologues for the snowballing
diseconomies and disutilities that, lacking all intuition, they have
engineered and that they tend to call the "counterintuitive behavior
of large systems." By invoking myths and ancestral gods I should
make it clear that my framework for analysis of the current
breakdown of medicine is foreign to the industrially determined
logic and ethos. I believe that the reversal of nemesis can come
only from within man and not from yet another managed (heteronomous)
source depending once again on presumptious expertise and subsequent
mystification.

Medical nemesis is resistant to medical remedies. It can be reversed
only through a recovery of the will to self-care among the laity,
and through the legal, political, and institutional recognition of
the right to care, which imposes limits upon the professional
monopoly of physicians. My final chapter proposes guidelines for
stemming medical nemesis and provides criteria by which the medical
enterprise can be kept within healthy bounds. I do not suggest any
specific forms of health care or

35

sick-care, and I do not advocate any new medical philosophy any more
than I recommend remedies for medical technique, doctrine, or
organization. However, I do propose an alternative approach to the
use of medical organization and technology together with the allied
bureaucracies and illusions.

http://www.mindfully.org/Health/Medical-Nemesis-Illich1976.htm
----------------------------------------------------------------

Chapter 7 of Medical Nemesis by Ivan Illich
http://www.soilandhealth.org/03sov/0303critic/030313illich/Frame.Illi
ch.Ch7.html

Political Countermeasures

Fifteen years ago it would have been impossible to get a hearing for
the claim that medicine itself might be a danger to health. In the
early 1960s, the British National Health Service still enjoyed a
worldwide reputation, particularly among American reformers.1 The
service, created by Albert Beveridge, was based on the assumption
that there exists in every population a strictly limited amount of
morbidity which, if treated under conditions of equity, will
eventually decline.2 Thus Beveridge had calculated that the annual
cost of the Health Service would fall as therapy reduced the rate of
illness.3 Health planners and welfare economists never expected that
the service's redefinition of health would broaden the scope of
medical care and that only budgetary restrictions would keep it from
expanding indefinitely. It was not predicted that soon, in a
regional screening, only sixty-seven out of one thousand people
would be found completely fit and that 50 percent would be referred
to a doctor, while according to another study, one in six people
screened would be defined as suffering from one to nine serious
illnesses.4 Nor had the health planners forecast that the threshold
of tolerance for everyday reality would decline as fast as the
competence for self-care was undermined, and that one-quarter of all
visits to the doctor for free service would be for the untreatable
common cold. Between 1943 and 1951, 75 percent of the persons
questioned claimed to have suffered from illness during the
preceding month.5 By 1972, 95 percent of those surveyed in one study
considered themselves unwell during the fourteen days prior to
questioning, and in another study6 in which 5 percent considered
themselves free of symptoms, 9 percent claimed to have suffered from
more than six different symptoms in the two weeks just past. Least
of all did the health planners make provision for the new diseases
that would become endemic through the same process that made
medicine at least partially effective.7 They did not forecast the
need for special hospitals dedicated to the soothing of terminal
pain, usually suffered by the victims of unsound or ineffective
surgery for cancer,8 or the need for other hospital beds for those
affected by medicine-induced disease.9

The sixties also witnessed the rise and fall of a multinational
consortium for the export of optimism to the third world which took
shape in the Peace Corps, the Alliance for Progress, Israeli aid to
Central Africa, and in the last brush-fires of medical-missionary
zeal. The Western belief that its medicines could cure the ills of
the nonindustrialized tropics was then at its height. International
cooperation had just won major battles against mosquitoes, microbes,
and parasites, ultimately Pyrrhic victories which were advertised as
the beginning of a final solution to tropical disease.10 The role
that economic and technological development would play in spreading
and aggravating sleeping sickness, bilharziasis, and even malaria
was not yet suspected.11 Those who saw world hunger and new
pestilence on the horizon were treated like prophets of doom12 or
romantics;13 the Green Revolution was still considered the opening
phase of a healthier and more equitable world.14 It would have
seemed unbelievable that within ten years malnutrition in two forms
would become by far the most important threat to modern man.15 The
new high-caloric undernourishment of poor populations was not
foreseen,16 nor was the fact that overfeeding would be identified as
the main cause for the epidemic diseases of the rich.17 In the
United States the new frontiers had not yet been obstructed by
competing bureaucratic schemes.18 Hopes for better health still
focused on equality of access to the agencies that would do away
with specific diseases, Iatrogenesis was still an issue for the
paranoid.

But by 1975 much of this had changed.19 A generation ago,
children in kindergarten had painted the doctor as a white-coated
father-figure.20 Today, however, they will just as readily paint him
as a man from Mars or a Frankenstein.21 Muckracking feeds on medical
charts and doctors' tax returns, and a new mood of wariness among
patients has caused medical and pharmaceutical companies to triple
their expenses for public relations.22 Ralph Nader has made the
consumers of health staples money-and quality-conscious. The
ecological movement has created an awareness that health depends on
the environment—on food and working conditions and housing—and
Americans have come to accept the idea that they are threatened by
pesticides,23 additives,24 and mycotoxins25 and other health risks
due to environmental degradation. Women's liberation has highlighted
the key role that the control over one's body plays in health
care.26 A few slum communities have assumed responsibility for basic
health care and have tried to unhook their members from dependence
on outsiders. The class-specific nature of body perception,27
language,28 concepts,29 access to health services,30 infant
mortality,31 and actual, specifically chronic, morbidity32 has been
widely documented, and the class-specific origins33 and prejudices34
of physicians are beginning to be understood. The World Health
Organization, meanwhile, is moving to a conclusion that would have
shocked most of its founders: in a recent publication WHO advocates
the deprofessionalization of primary care as the most important
single step in raising national health levels.35

Doctors themselves are beginning to look askance at what doctors
do.36 When physicians in New England were asked to evaluate the
treatment their patients had received from other doctors, most were
dissatisfied. Depending on the method of peer evaluation used,
between 1.4 percent and 63 percent of patients were believed to have
received adequate care.37 Patients are told ever more frequently by
their doctors that they have been damaged by previous medication and
that the treatment now prescribed is made necessary by the effects
of such prior medication, which in some cases was given in a life-
saving endeavor, but much more often for weight control, mild
hypertension, flu, or mosquito bite or just to put a mutually
satisfactory conclusion to an interview with the doctor.38 In 1973 a
retiring senior official of the U.S. Department of Health,
Education, and Welfare could say that 80 percent of all funds
channeled through his office provided no demonstrable benefits to
health and that much of the rest was spent to offset iatrogenic
damage. His successor will have to deal with these data if he wants
to maintain public trust.39

Patients are starting to listen, and a growing number of
movements and organizations are beginning to demand reform. The
attacks are founded on five major categories of criticism and are
directed to five categories of reform: (1) Production of remedies
and services has become self-serving. Consumer lobbies and consumer
control of hospital boards should therefore force doctors to improve
their wares. (2) The delivery of remedies and access to services is
unequal and arbitrary; it depends either on the patient's money and
rank, or on social and medical prejudices which favor, for example,
attention to heart disease over attention to malnutrition. The
nationalization of health production ought to control the hidden
biases of the clinic. (3) The organization of the medical guild
perpetuates inefficiency and privilege, while professional licensing
of specialists fosters an increasingly narrow and specialized view
of disease. A combination of capitation payment with institutional
licensing ought to combine control over doctors with the interest of
patients. (4) The sway of one kind of medicine deprives society of
the benefits competing sects might offer. More public support for
alpha waves, encounter groups, and chiropractic ought to countervail
and complement the scalpel and the poison. (5) The main thrust of
present medicine is the individual, in sickness or in health. More
resources for the engineering of populations and environments ought
to stretch the health dollar.

These proposed remedial policies could control to some degree the
social costs created by overmedicalization. By joining together,
consumers do have power to get more for their money; welfare
bureaucracies do have the power to reduce inequalities; changes in
licensing and in modes of financing can protect the population not
only against nonprofessional quacks but also, in some cases, against
professional abuse; money transferred from the production of human
spare parts to the reduction of industrial risks does buy
more "health" per dollar. But all these policies, unless carefully
qualified, will tend to reduce the externalities created by medicine
at the cost of a further increase of medicine's paradoxical
counterproduct, its negative effect on health. All tend to stimulate
further medicalization. All consistently place the improvement of
medical services above those factors which would improve and
equalize opportunities, competence, and confidence for self-care;
they deny the civil liberty to live and to heal, and substitute
promises of more conspicuous social entitlements to care by a
professional.

In the following five sections I will deal with some of these
possible countermeasures and examine their relative merits.


Consumer Protection for Addicts

When people become aware of their dependence on the medical
industry, they tend to be trapped in the belief that they are
already hopelessly hooked. They fear a life of disease without a
doctor much as they would feel immobilized without a car or a bus.
In this state of mind they are ready to be organized for consumer
protection and to seek solace from politicians who will check the
high-handedness of medical producers.40 The need for such self-
protection is obvious, the implicit dangers obscure. The sad truth
for consumer advocates is that neither control of cost nor assurance
of quality guarantees that health will be served by medicine that
measures up to present medical standards.

Consumers who band together to force General Motors to produce an
acceptable car have begun to feel competent to look under the hood
and to develop criteria for estimating the cost of a cleaner exhaust
system. When they band together for better health care, they still
believe— mistakenly—that they are unqualified to decide what ought
to be done for their bowels and kidneys and blindly entrust
themselves to the doctor for almost any repair. Cross-cultural
comparison of practices provides no guide. Prescriptions for
vitamins are seven times more common in Britain than in Sweden,
gamma globulin medication eight times more common in Sweden than in
Britain. American doctors operate, on the average, twice as often as
Britons; French surgeons amputate almost up to the neck. Median
hospital stays vary not with the affliction but with the physician:
for peptic ulcers, from six to twenty-six days; for myocardial
infarction, from ten to thirty days. The average length of stay in a
French hospital is twice that in the United States. Appendectomies
are performed and deaths from appendicitis are diagnosed three times
more frequently in Germany than anywhere else.41

Titmuss42 has summed up the difficulty of cost-benefit accounting
in medicine, especially at a time when medical care is losing the
characteristics it used to possess when it consisted almost wholly
in the personal doctor-patient relationship. Medical care is
uncertain and unpredictable; many consumers do not desire it, do not
know they need it, and cannot know in advance what it will cost
them. They cannot learn from experience. They must rely on the
supplier to tell them if they have been well served, and they cannot
return the service to the seller or have it repaired. Medical
services are not advertised as are other goods, and the producer
discourages comparison. Once he has purchased, a consumer cannot
change his mind in mid-treatment. By defining what constitutes
illness the medical producer has the power to select his consumers
and to market some products that will be forced on the consumer, if
need be, by the intervention of the police: the producers can even
sell forcible internment for the disabled and asylums for the
mentally retarded. Malpractice suits have mitigated the layman's
sense of impotence on several of these points,43 but basically, they
have reinforced the patient's determination to insist on treatment
that is considered adequate by informed medical opinion. What
further complicates matters is that there is no "normal" consumer of
medical services. Nobody knows how much health care will be worth to
him in terms of money or pain. In addition, nobody knows if the most
advantageous form of health care is obtained from medical producers,
from a travel agent, or by renouncing work on the night shift. The
family that forgoes a car to move into a Manhattan apartment can
foresee how the substitution of rent for gas will affect their
available time; but the person who, upon the diagnosis of cancer,
chooses an operation over a binge in the Bahamas does not know what
effect his choice will have on his remaining time of grace. The
economics of health is a curious discipline, somewhat reminiscent of
the theology of indulgences which flourished before Luther. You can
count what the friars collect, you can look at the temples they
build, you can take part in the liturgies they indulge in, but you
can only guess what the traffic in remission from purgatory does to
the soul after death. Models developed to account for the
willingness of taxpayers to foot rising medical bills constitute
similar scholastic guesswork about the new world-spanning church of
medicine. To give an example: it is possible to view health as
durable capital stock used to produce an output called "healthy
time."44 Individuals inherit an initial stock, which can be
increased by investment in health capitalization through the
acquisition of medical care, or through good diet and
housing. "Healthy time" is an article in demand for two reasons. As
a consumer commodity, it directly enters into the individual's
utility function; people usually would rather be healthy than sick.
It also enters the market as an investment commodity. In this
function, "healthy time" determines the amount of time an individual
can spend on work and on play, on earning and on recreation. The
individual's "healthy time" can thus be viewed as a decisive
indicator of his value to the community as a producer.45

Orientation on policy and theories on the dollar value
of "health" production divide the adherents of squabbling academic
factions much as realism and nominalism divided medieval divines.46
But to the point that concerns the consumer, they just state in a
roundabout way what every Mexican bricklayer knows: only on those
days when he is healthy enough to work can he bring beans and
tortillas to his children and have a tequila with his friends.47 The
belief in a causal relationship between doctor's bills and health—
which would otherwise be called modernized superstition—is a basic
technical assumption for the medical economist.48

Different systems have been used to legitimize the economic value
of the specific activities in which physicians engage. Socialist
nations assume the financing of all care and leave it to the medical
profession to define what is needed, how it must be done, who may do
it, what it should cost, and who shall get it. More brazenly than
elsewhere, input/output calculations of such investments in human
capital seem to determine Russian allocations.49 Most welfare states
intervene with laws and incentives in the organization of their
health-care markets, although only the United States has launched a
national legislative program under which committees of producers
determine what outputs offered on the "free market" the state shall
approve as "good care." In late 1973 President Nixon signed Public
Law 92-603 establishing mandatory cost and quality controls (by
Professional Standard Review Organizations) for Medicaid and
Medicare, the tax-supported sector of the health-care industry,
which since 1970 has been second in size only to the military-
industrial complex. Harsh financial sanctions threaten physicians
who refuse to open their files to government inspectors searching
for evidence of over-utilization of hospitals, fraud, or deficient
treatment. The law requires the medical profession to establish
guidelines for the diagnosis and treatment of a long list of
injuries, illnesses, and health conditions, mandating the world's
most costly program for the medicalization of health, production
through legislated consumer protection.50 The new law guarantees the
standard set by industry for the commodity. It does not ask if its
delivery is positively or negatively related to the health of people.

Attempts to exercise rational political control over the
production of medical health care have consistently failed. The
reason lies in the nature of the product now called "medicine," a
package made up of chemicals, apparatus, buildings, and specialists,
and delivered to the client. The purveyor rather than his clients or
political boss determines the size of the package. The patient is
reduced to an object—his body—being repaired; he is no longer a
subject being helped to heal. If he is allowed to participate in the
repair process, he acts as the lowest apprentice in a hierarchy of
repairmen.51 Often he is not even trusted to take a pill without the
supervision of a nurse.

The argument that institutional health care (remedial or
preventive) ceases after a certain point to correlate with any
further "gains" in health can be misused for transforming clients
hooked on doctors into clients of some other service hegemony:
nursing homes, social workers vocational counselors, schools.52 What
started out as a defense of consumers against inadequate medical
service, will, first, provide the medical profession with assurance
of continued demand and then with the power to delegate some of
these services to other industrial branches: to the producers of
foods, mattresses, vacations, or training. Consumer protection thus
turns quickly into a crusade to transform independent people into
clients at all cost.

Unless it disabuses the client of his urge to demand and take
more services, consumer protection only reinforces the collusion
between giver and taker, and can play only a tactical and a
transitory role in any political movement aimed at the health-
oriented limitation of medicine. Consumer-protection movements can
translate information about medical ineffectiveness now buried in
medical journals into the language of politics, but they can make
substantive contributions only if they develop into defense leagues
for civil liberties and move beyond the control of quality and cost
into the defense of untutored freedom to take or leave the goods.
Any kind of dependence soon turns into an obstacle to autonomous
mutual care, coping, adapting, and healing, and what is worse, into
a device by which people are stopped from transforming the
conditions at work and at home that make them sick. Control over the
production side of the medical complex can work towards better
health only if it leads to at least a very sizable reduction of its
total output, rather than simply to technical improvements in the
wares that are offered.


Equal Access to Torts

The most common and obvious political issue related to health is
based on the charge that access to medical care is inequitable, that
it favors the rich over the poor,53 the influential over the
powerless. While the level of medical services rendered to the
members of technical elites does not vary significantly from one
country to another, say from Sweden and Czechoslovakia to Indonesia
and Senegal, the value of the services rendered to the typical
citizen in different countries varies by factors exceeding the
proportion of one to one thousand.54 In many poor countries, the few
are socially predetermined to get much more than the majority, not
so much because they are rich as because they are children of
soldiers or bureaucrats or because they live close to the one large
hospital. In rich countries members of different minorities are
underprivileged, not because, in terms of money per capita, they
necessarily get less than their share,55 but because they get
substantially less than they have been trained to need. The slum
dweller cannot reach the doctor when he needs him, and what is
worse, the old, if they are poor and locked in a "home," cannot get
away from him. For these and similar reasons, political parties
convert the desire for health into demands for equal access to
medical facilities.56 They usually do not question the goods the
medical system produces but insist that their constituents have a
right to all that is produced for the privileged.57

In the poor countries, the poor majorities clearly have less
access to medical services than the rich:58 the services available
to the few consume most of the health budget and deprive the
majority of services of any kind. In all of Latin America, except
Cuba, only one child in forty from the poorest fifth of the
population finishes the five years of compulsory schooling;59 a
similar proportion of the poor can expect hospital treatment if they
become seriously ill. In Venezuela, one day in a hospital costs ten
times the average daily income; in Bolivia, about forty times the
average daily income.60 Everywhere in Latin America, the rich
constitute the 3 percent of the population who are college
graduates, labor leaders, political party officials, and members of
families who have access to services either through money or simply
through connections. These few receive costly treatment, often from
the doctors of their choice. Most of the physicians, who come from
the same social class as their patients, were trained to
international standards on government grants.61

Notwithstanding unequal access to hospital care, the availability
of medical service does not inevitably correlate with personal
income. In Mexico about 3 percent of the population has access to
the Institute de Seguridad y Servicios Sociales de las Trabajadores
del Estado (ISSSTE), that special part of the social security system
which still holds a record for combining personal nursing care with
advanced technological sophistication. This fortunate group is made
up of government employees who receive truly equal treatment,
whether they are ministers or office boys, and can count on high-
quality care because they are part of a demonstration model. The
newspapers, accordingly, inform the schoolmaster in a remote village
that Mexican surgery is as well endowed as its counterpart in
Chicago and that the surgeons who operate on him measure up to the
standards of their colleagues in Houston. When high-level officials
are hospitalized, they may be annoyed because for the first time in
their lives they have to share a hospital room with a workman, but
they are also proud of the high level of socialist commitment their
nation shows in providing the same for boss and custodian. Both
kinds of patient tend to overlook the fact that they are equally
privileged exploiters. Providing the 3 percent with beds, equipment,
administration, and technical care takes one-third of the public-
health-care budget of the entire country. To be able to afford to
give all of the poor equal access to medicine of uniform quality in
poor countries, most of the present training and activity of the
health professions would have to be discontinued. However, delivery
of effective basic health services for the entire population is
cheap enough to be bought for everyone, provided no one could get
more, regardless of the social, economic, medical, or personal
reasons advanced for special treatment. If priority were given to
equity in poor countries and service limited to the basics of
effective medicine, entire populations would be encouraged to share
in the demedicalization of modern health care and to develop the
skills and confidence for self-care, thus protecting their countries
from social iatrogenic disease.

In the rich countries, the economics of health are somewhat
different.62 At first sight, concern for the poor appears to demand
further increases in the total health budget.63 Yet the more people
come to depend on care by service institutions, the more difficult
it is to identify equity with equal access and equal benefits.64 Is
equity realized when equal numbers of dollars are available for the
education of rich and poor? Or does it require that the poor get the
same "education" although more will have to be spent on their
account to achieve equal results? Or must the educational system, in
order to be equitable, assure that the poor are not humiliated and
hurt more than the rich with whom they compete on the academic
ladder? Or is equity in learning opportunities provided only when
all citizens share the same kind of learning environment? This
battle of equity versus equality in the access to institutional
care, already being waged in education, is now shaping up in the
medical field.65 In contrast to education, however, the issue in
health can easily be resolved on available evidence. The per capita
expenditure on health care, even for the poorest sector within the
United States population, indicates that the base line at which such
care turns iatrogenic has long since been passed. In rich countries,
the total budget of services for the poor, if used for that which
reinforces self-care, is more than ample. More access, even though
restricted to those who now receive less, would only equalize the
delivery of professional illusions and torts.

There are two aspects to health: freedom and rights. Above all,
health designates the range of autonomy within which a person
exercises control over his own biological states and over the
conditions of his immediate environment. In this sense, health is
identical with the degree of lived freedom. Primarily the law ought
to guarantee the equitable distribution of health as freedom, which,
in turn, depends on environmental conditions that only organized
political efforts can achieve. Beyond a certain level of intensity,
health care, however equitably distributed, will smother health-as-
freedom. In this fundamental sense, health care is a matter of well-
ordered liberty. Implicit in this concept is a preferred position of
inalienable freedoms to do certain things, and here civil liberty
must be distinguished from civil rights. The liberty to act without
restraint from government has a wider scope than the civil rights
the state may enact to guarantee that people will have equal powers
to obtain certain goods or services.

Civil liberties ordinarily do not force others to carry out my
wishes; a person may publish his or her opinion freely as far as the
government is concerned, but this does not imply a duty for any one
newspaper to print that opinion. A person may need to drink wine in
his kind of worship, but no mosque has to welcome him to do so
within its walls. At the same time, the state as a guarantor of
liberties can enact laws that protect equal rights without which its
members would not enjoy their freedoms. Such rights give meaning to
equality, while liberties give shape to freedom. One sure way to
extinguish freedom to speak, to learn, or to heal is to delimit them
by transmogrifying civil rights into civic duties. The freedoms of
the self-taught will be abridged in an overeducated society just as
the freedom to health care can be smothered by overmedicalization.
Any sector of the economy can be so expanded that for the sake of
more costly levels of equality, freedoms are extinguished.

We are concerned here with movements that try to remedy the
effects of socially iatrogenic medicine through political and legal
control of the management, allocation, and organization of medical
activities. Insofar as medicine is a public utility, however, no
reform can be effective unless it gives priority to two sets of
limits. The first relates to the volume of institutional treatment
any individual can claim: no person is to receive services so
extensive that his treatment deprives others of an opportunity for
considerably less costly care per capita if, in their judgment (and
not just in the opinion of an expert), they make a request of
comparable urgency for the same public resources. Conversely, no
services are to be forcibly imposed on an individual against his
will: no man, without his consent, shall be seized, imprisoned,
hospitalized, treated, or otherwise molested in the name of health.
The second set of limits relates to the medical enterprise as a
whole. Here the idea of health-as-freedom has to restrict the total
output of health services within subiatrogenic limits that maximize
the synergy of autonomous and heteronomous modes of health
production. In democratic societies, such limitations are probably
unachievable without guarantees of equity—without equal access. In
that sense, the politics of equity is probably an essential element
of an effective program for health. Conversely, if concern with
equity is not linked to constraints on total production, and if it
is not used as a countervailing force to the expansion of
institutional medical care, it will be futile.66


Public Controls over the Professional Mafia

A third category of political remedies for unhealthy medicine
focuses directly on how doctors do their work. Like consumer
advocacy and legislation of access, this attempt to impose lay
control on the medical organization has inevitable health-denying
effects when it is changed from an ad hoc tactic into a general
strategy.

Four and a half million men and women in two hundred occupations
are employed in the production and delivery of medically approved
health services in the United States. (Only 8 percent are
physicians, whose net income after deductions for rent, personnel,
and supplies represents 15 percent of total health expenditures and
whose average income in 1973 was $50,000.67) The total does not
include osteopaths, chiropractors, and others who might have
specialized university training and require a license to practice,
but who, unlike pharmacists, optometrists, laboratory technicians,
and similar physicians' underlings, do not produce health care of
the same prestige.68 Even further removed from the establishment,
and therefore excluded from these statistics, are thousands of
purveyors of nonconventional health care, ranging from mail-order
herbalists and masseurs to teachers of yoga.69

Of the many claimants to competence who are more or less
integrated into the official establishment, about thirty categories
are licensed in the United States.70 In no state of the union is a
license required for fewer than fourteen kinds of practitioners.71
These licenses are issued on completion of formal educational
programs and sometimes on the evidence of a successful examination;
in rare instances, proficiency or experience is a prerequisite for
admission to independent practice.72 Competent or successful work is
nowhere a condition for continuing in practice. Renewal is
automatic, usually upon payment of a fee; only fifteen out of fifty
states permit a physician's license to be challenged on grounds of
incompetence.73 While claims to specialist standing come and go on
the fringes, the specialties recognized by the American Medical
Association have steadily increased, doubling in the last fifteen
years: half the practicing American physicians are specialists in
one of sixty categories, and the proportion is expected to increase
to 55 percent before 1980.74 Within each of these fields a fiefdom
has developed with specialized nurses, technicians, journals,
congresses, and sometimes organized groups of patients pressing for
more public funds.75 The cost of coordinating the treatment of the
same patient by several specialists grows exponentially with each
added competence, as does the risk of mistakes and the probability
of damage due to the unexpected combination of different therapies.
As the number of patient relationships outgrows the elements in the
total population, the occupations dealing with medical information,
insurance, and patient defense multiply unchecked. Of course,
physicians lord it over these fiefs and determine what work these
pseudo-professions shall do. But with the recognition of some
autonomy many of these specialized groups of medical pages, ushers,
footmen, and squires have also gained some power to evaluate how
well they do their own work. By gaining the right to self-evaluation
according to special criteria that fit its own view of reality, each
new specialty generates for society at large a new impediment to
evaluating what its work actually contributes to the health of
patients. Organized medicine has practically ceased to be the art of
healing the curable, and consoling the hopeless has turned into a
grotesque priesthood concerned with salvation and has become a law
unto itself. The policies that promise the public some control over
the medical endeavor tend to overlook the fact that to achieve their
purpose they must control a church, not an industry.

Dozens of concrete strategies are now being discussed and
proposed to make the health industry more health-serving and less
self-serving: decentralization of delivery; universal public
insurance; group practice by specialists; health-maintenance
programs rather than sick-care; payment of a fixed amount per
patient per year (capitation) rather than fee-for-service;
elimination of present restrictions on the use of health manpower;
more rational organization and utilization of the hospital system;
replacement of the licensing of individuals by the licensing of
institutions held to performance standards; and the organization of
patient cooperatives to balance or support a professional medical
power.

Each of these proposals would indeed improve medical efficiency,
but at the cost of a further decline in society's effective health
care. To increase efficiency by upward mobility of personnel and
downward assignment of responsibility could not but tighten the
integration of the medical-care industry and with it social
polarization.

As the training of middle-level professionals becomes more
expensive, nursing personnel in the lower ranks is becoming scarce.
Poor salaries, growing disdain for servant and housekeeping roles,
an increase in chronic patients (and consequent growing tedium in
their care), disappearance of the religious motivation for nuns and
deacons, and new opportunities for women in other fields all
contribute to a manpower crisis. In England nearly two-thirds of all
low-level hospital personnel come from overseas, usually from former
colonies; in Germany, from Turkey and Yugoslavia; in France, from
North Africa; in the United States, from racial minorities. The
creation of new ranks, titles, curricula, roles, and specialties at
the bottom level is a doubtfully effective remedy. The hospital only
reflects the labor economy of a high-technology society:
transnational specialization on the top, bureaucracies in the
middle, and at the bottom, a new subproletariat made up of migrants
and the professionalized client.76

The multiplication of paraprofessional specialists further
decreases what the diagnostician does for the person who seeks his
help, while the multiplication of generalist auxiliaries tends to
reduce what uncertified people may do for each other or for
themselves.77 Institutional licensing78 would indeed permit a more
efficient deployment of personnel, a more rational health-manpower
mix, and greater opportunity for advancement: it would no doubt
greatly improve the delivery of medical staples such as dental work,
bonesetting, and the delivery of babies. But if it became the model
for over-all health care, it would be equivalent to the creation of
a medical Ma Bell.79 Lay control over an expanding medical
technocracy is not unlike the professionalization of the patient:
both enhance medical power and increase its nocebo effect. As long
as the public bows to the professional monopoly in assigning the
sick-role, it cannot control hidden health hierarchies that multiply
patients.80 The medical clergy can be controlled only if the law is
used to restrict and disestablish its monopoly on deciding what
constitutes disease, who is sick, and what ought to be done to him
or her.81

Misdirection of blame for iatrogenesis is the most serious
political obstacle to public control over health care. To turn
doctor-baiting into radical chic would be the surest way to defuse
any political crisis fueled by the new health consciousness. If
physicians were to become conspicuous scapegoats, the gullible
patient would be relieved from blame for his therapeutic greed.
School-baiting did save the institutional enterprise when crisis
last hit in education. The same strategy could now save the medical
system and keep it essentially as it is.

Quite suddenly in the 1970s the schools lost their status as
sacred cows. Driven by Sputnik, racial conflict, and new frontiers,
the school bubble had outgrown all nonmilitary budgets and had
burst. For a short while, the hidden curriculum of the school system
lay exposed. It became conventional wisdom that after a certain
point in its expansion, the school system inevitably reproduces a
meritocratic class society and neatly arranges people according to
levels of highly specialized torpor for which they are trained in
graded, age-specific, competitive, and compulsory rituals.
Frustration of an expensive dream had led many people to grasp that
no amount of compulsory learning could equitably prepare the young
for industrial hierarchies, and that all effective preparation of
children for an inhuman socio-economic system constituted systematic
aggression against their persons. At this point a new vision of
reality could have grown into a radical revolt against a capital-
intensive system of production and the beliefs that bolster it. But
instead of blaming the hubris of pedagogues, the public conceded to
pedagogues more power to do precisely as they pleased. Disgruntled
teachers focused criticism on their peers, the methods, the
organization of schooling, and the financing of institutions, all of
which were defined as obstacles to effective education.

School-baiting enabled liberal schoolmasters to mutate into a new
breed of adult educators. School-baiting not only saved but—
momentarily—upgraded the salary and prestige of the teacher. Whereas
before the crisis point the schoolmaster had been restricted in his
pedagogical aggression to an age-specific group below sixteen years
of age, which was exposed to him during class hours in the school
building to be initiated into a limited number of subjects, the new
knowledge-merchant now considers the world his classroom. While the
curricular teacher could disqualify only those nonstudents who dared
to learn a curricular matter on their own, the new manager of
lifelong and recurrent "education," "conscientization," "sensitivity
training," or "politicization" presumes to degrade in the eyes of
the public any behavioral patterns that he has not approved. The
school-baiting of the sixties could easily set the pattern for the
coming medical war. Following the lead of the teachers who declare
that the world is their classroom, some chic crusading physicians82
now jump onto the bandwagon of medicine-baiting and channel public
frustration and anger at curative medicine into a call for a new
elite of scientific guardians who would control the world as their
ward.83


The Scientific Organization—of Life

Belief in medicine as an applied science generates a fourth kind
of countermeasure to iatrogenesis which inevitably increases the
irresponsible power of the health profession—and thereby the damage
medicine does. The proponents of higher scientific standards in
medical research and social organization argue that pathogenic
medicine is due to the overwhelming number of bad doctors let loose
on society. Fewer decision-makers, more carefully screened, better
trained, more tightly supervised by their peers, and more
effectively in command over what is done for whom and how, would
ensure that the powerful resources now available to medical
scientists would be applied for the benefit of the people.84 Such
idolatry of science overlooks the fact that research conducted as if
medicine were an ordinary science, diagnosis conducted as if
patients were specific cases and not autonomous persons, and therapy
conducted by hygienic engineers are the three approaches which
coalesce into the present endemic health-denial.

As a science, medicine lies on a borderline. Scientific method
provides for experiments conducted on models. Medicine, however,
experiments not on models but on the subjects themselves. But
medicine tells us as much about the meaningful performance of
healing, suffering, and dying as chemical analysis tells us about
the aesthetic value of pottery.85

In the pursuit of applied science the medical profession has
largely ceased to strive towards the goals of an association of
artisans who use tradition, experience, learning, and intuition, and
has come to play a role reserved to ministers of religion, using
scientific principles as its theology and technologists as
acolytes.86 As an enterprise, medicine is now concerned less with
the empirical art of healing the curable and much more with the
rational approach to the salvation of mankind from attack by
illness, from the shackles of impairment, and even from the
necessity of death.87 By turning from art to science, the body of
physicians has lost the traits of a guild of craftsmen applying
rules established to guide the masters of a practical art for the
benefit of actual sick persons. It has become an orthodox apparatus
of bureaucratic administrators who apply scientific principles and
methods to whole categories of medical cases. In other words, the
clinic has turned into a laboratory. By claiming predictable
outcomes without considering the human performance of the healing
person and his integration in his own social group, the modern
physician has assumed the traditional posture of the quack.

As a member of the medical profession the individual physician is
an inextricable part of a scientific team. Experiment is the method
of science, and the records he keeps—if he likes it or not—are part
of the data for a scientific enterprise. Each treatment is one more
repetition of an experiment with a statistically known probability
of success. As in any operation that constitutes a genuine
application of science, failure is said to be due to some sort of
ignorance: insufficient knowledge of the laws that apply in the
particular experimental situation, a lack of personal competence in
the application of method and principles on the part of the
experimenter, or else his inability to control that elusive variable
which is the patient himself. Obviously, the better the patient can
be controlled, the more predictable will be the outcome in this kind
of medical endeavor. And the more predictable the outcome on a
population basis, the more effective will the organization appear to
be. The technocrats of medicine tend to promote the interests of
science rather than the needs of society.88 The practitioners
corporately constitute a research bureaucracy. Their primary
responsibility is to science in the abstract or, in a nebulous way,
to their profession.89 Their personal responsibility for the
particular client has been resorbed into a vague sense of power
extending over all tasks and clients of all colleagues. Medical
science applied by medical scientists provides the correct
treatment, regardless of whether it results in a cure, or death sets
in, or there is no reaction on the part of the patient. It is
legitimized by statistical tables, which predict all three outcomes
with a certain frequency. The individual physician in a concrete
case may still remember that he owes nature and the patient as much
gratitude as the patient owes him if he has been successful in the
use of his art. But only a high level of tolerance for cognitive
dissonance will allow him to carry on in the divergent roles of
healer and scientist.90

The proposals that seek to counter iatrogenesis by eliminating
the last vestiges of empiricism from the encounter between the
patient and the medical system are latter-day crusaders of an
inquisitorial kind.91 They use the religion of scientism to devalue
political judgment. While operational verification in the laboratory
is the measure of science, the contest of adversaries appealing to a
jury that applies past experience to a present issue, as this issue
is experienced by actual persons, constitutes the measure of
politics. By denying public recognition to entities that cannot be
measured by science, the call for pure, orthodox, confirmed medical
practice shields this practice from all political evaluation.

The religious preference given to scientific language over the
language of the layman is one of the major bulwarks of professional
privilege. The imposition of this specialized language upon
political discourse about medicine easily voids it of effectiveness.

The deprofessionalization of medicine does not imply the
proscription of technical language any more than it calls for the
exclusion of genuine competence, nor does it oppose public scrutiny
and exposure of malpractice. But it does imply a bias against the
mystification of the public, against the mutual accreditation of
self-appointed healers, against the public support of a medical
guild and of its institutions, and against the legal discrimination
by, and on behalf of, people whom individuals or communities choose
and appoint as their healers. The deprofessionalization of medicine
does not mean denial of public funds for curative purposes, but it
does mean a bias against the disbursement of any such funds under
the prescription or control of guild members. It does not mean the
abolition of modern medicine. It means that no professional shall
have the power to lavish on any one of his patients a package of
curative resources larger than that which any other could claim for
his own. Finally, it does not mean disregard for the special needs
that people manifest at special moments in their lives: when they
are born, break a leg, become crippled, or face death. The proposal
that doctors not be licensed by an in-group does not mean that their
services shall not be evaluated, but rather that this evaluation can
be done more effectively by informed clients than by their own
peers. Refusal of direct funding to the more costly technical
devices of medical magic does not mean that the state shall not
protect individual people against exploitation by ministers of
medical cults; it means only that tax funds shall not be used to
establish any such rituals. Deprofessionalization of medicine means
the unmasking of the myth according to which technical progress
demands the solution of human problems by the application of
scientific principles, the myth of benefit through an increase in
the specialization of labor, through multiplication of arcane
manipulations, and the myth that increasing dependence of people on
the right of access to impersonal institutions is better than trust
in one another.


Engineering for a Plastic Womb

So far I have dealt with four categories of criticism directed at
the institutional structure of the medical-industrial complex. Each
gives rise to a specific kind of political demand, and all of them
become reinforcements for the dependence of people on medical
bureaucracies because they deal with health care as a form of
therapeutic planning and engineering.92 They indicate strategies for
surgical, chemical, and behavioral intervention in the lives of sick
people or people threatened with sickness. A fifth category of
criticism rejects these objectives. Without relinquishing the view
of medicine as an engineering endeavor, these critics assert that
medical strategies fail because they concentrate too much effort on
sickness and too little on changing the environment that makes
people sick.

Most research on alternatives to clinical intervention is
directed towards program engineering for the professional systems of
man's social, psychological, and physical environment. "Non-health-
service health determinants" are largely concerned with planned
intervention in the milieu.93 Therapeutic engineers shift the thrust
of their interventions from the potential or actual patient towards
the larger system of which he is imagined to be a part. Instead of
manipulating the sick, they redesign the environment to ensure a
healthier population.94

Health care as environmental hygienic engineering works within
categories different from those of the clinical scientist. Its focus
is survival rather than health in its opposition to disease; the
impact of stress on populations and individuals rather than the
performance of specific persons; the relationship of a niche in the
cosmos to the human species with which it has evolved rather than
the relationship between the aims of actual people and their ability
to achieve them.95

In general, people are more the product of their environment than
of their genetic endowment. This environment is being rapidly
distorted by industrialization. Although man has so far shown an
extraordinary capacity for adaptation, he has survived with very
high levels of sublethal breakdown. Dubos96 fears that mankind will
be able to adapt to the stresses of the second industrial revolution
and overpopulation just as it survived famines, plagues, and wars in
the past. He speaks of this kind of survival with fear because
adaptability, which is an asset for survival, is also a heavy
handicap: the most common causes of disease are exacting adaptive
demands. The health-care system, without any concern for the
feelings of people and for their health, simply concentrates on the
engineering of systems that minimize breakdowns.

Two foreseeable and sinister consequences of a shift from patient-
oriented to milieu-oriented medicine are the loss of the sense of
boundaries between distinct categories of deviance, and a new
legitimacy for total treatment.97 Medical care, industrial safety,
health education, and psychic reconditioning are all different names
for the human engineering needed to fit populations into engineering
systems. As the health-delivery system continually fails to meet the
demands made upon it, conditions now classified as illness may soon
develop into aspects of criminal deviance and asocial behavior. The
behavioral therapy used on convicts in the United States98 and the
Soviet Union's incarceration of political adversaries in mental
hospitals99 indicate the direction in which the integration of
therapeutic professions might lead: an increased blurring of
boundaries between therapies administered with a medical,
educational, or ideological rationale.100

The time has come not only for public assessment of medicine but
also for public disenchantment with those monsters generated by the
dream of environmental engineering. If contemporary medicine aims at
making it unnecessary for people to feel or to heal, eco-medicine
promises to meet their alienated desire for a plastic womb.

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Chapter 8 of Medical Nemesis by Ivan Illich
http://www.soilandhealth.org/03sov/0303critic/030313illich/Frame.Illi
ch.Ch8.html

The Recovery of Health

Much suffering has been man-made. The history of man is one long
catalogue of enslavement and exploitation, usually told in the epics
of conquerors or sung in the elegies of their victims. War is at the
heart of this tale, war and the pillage, famine, and pestilence that
came in its wake. But it was not until modern times that the
unwanted physical, social, and psychological side-effects of so-
called peaceful enterprises began to compete with war in destructive
power.

Man is the only animal whose evolution has been conditioned by
adaptation on more than one front. If he did not succumb to
predators and forces of nature, he had to cope with use and abuse by
others of his own kind. In his struggle with the elements and with
his neighbor, his character and culture were formed, his instincts
withered, and his territory was turned into a home.

Animals adapt through evolution in response to changes in their
natural environment. Only in man does challenge become conscious and
the response to difficult and threatening situations take the form
of rational action and of conscious habit. Man can design his
relations to nature and neighbor, and he is able to survive even
when his enterprise has partly failed. He is the animal that can
endure trials with patience and learn by understanding them. He is
the sole being who can and must resign himself to limits when he
becomes aware of them. A conscious response to painful sensations,
to impairment, and to eventual death is part of man's coping
ability. The capacity for revolt and for perseverance, for stubborn
resistance and for resignation, are integral parts of human life and
health.

But nature and neighbor are only two of the three frontiers on
which man must cope. A third front where doom can threaten has
always been recognized. To remain viable, man must also survive the
dreams which so far myth has both shaped and controlled. Now society
must develop programs to cope with the irrational desires of its
most gifted members. To date, myth has fulfilled the function of
setting limits to the materialization of greedy, envious, murderous
dreams. Myth assured the common man of his safety on this third
frontier if he kept within its bounds. Myth guaranteed disaster to
those few who tried to outwit the gods. The common man perished from
infirmity or from violence; only

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