MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH

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This is a very good book about

the fraud of orthodox medicine.

It offers solutions. Buy it and

read it or find it online.

 

Paul

 

--

 

IVAN ILLICH

 

MEDICAL NEMESIS

THE EXPROPRIATION OF HEALTH

 

 

PANTHEON BOOKS, NEW YORK

 

 

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 \brk. Originally published in

Great Britain by Calder & Boyars, Ltd., London. Copyright© 1975 by

Ivan Illich.

 

Library of Congress Cataloging in Publication Data

 

Illich, Ivan, 1926

Medical nemesis.

Includes bibliographical references and indexes.

1. Social medicine. 2. Medicine—Philosophy

3. Medical care. 4. latrogenic diseases. I. Title. [DNLM: 1.

Delivery of health care. 2. Ethics, Medical. 3. latrogenic disease.

4. Philosophy, Medical. 5. Politics. 6. Social medicine.

WA 30129m 1976a]

[RA418.I441982] 362.1 82-47952

ISBN 0-394-71245-5 (pbk.) AACR2

 

Manufactured in the United States of America

 

 

 

 

 

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; Andre 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 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

 

 

PART I. Clinical latrogenesis

 

1. The Epidemics of Modern Medicine

Doctors' Effectiveness—an Illusion

Useless Medical Treatment

Doctor-Inflicted Injuries

Defenseless Patients 32

 

 

PART II. Social latrogenesis

 

2. The Medicalization of Life

Political Transmission of Iatrogemc Disease

Social latrogenesis

Medical Monopoly

Value-Free Cure?

The Medicalization of the Budget

The Pharmaceutical Invasion

Diagnostic Imperialism

Preventive Stigma

Terminal Ceremonies

Black Magic

Patient Majorities

 

 

PART III. Cultural latrogenesis

 

Introduction

 

3. The Killing of Pain

 

4. The Invention and Elimination of Disease

 

5. Death Against Death

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

 

7. Political Countermeasures

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

Industrialized Nemesis

From Inherited Myth to Respectful Procedure

The Right to Health

Health as a Virtue

 

 

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 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 .

 

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. It uses a model of social assessment

of technological progress that I have spelled out elsewhere1 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

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 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 environment 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-consuming

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 specific 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 undertaken 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 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 acceptable 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.

 

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.,

administered) 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