This article appears in the February 1999 edition of the Catholic Medical Quarterly
How does Ivan Illichs view of medical dominance square with the actual history of medicine since Greek times?Andrew Papanikitas
Medical Nemesis (1974, 1978) *5, or the Limits to Medicine*6, by the Austrian-born former Catholic Priest Ivan Illich (b. 1926), is a thesis with apocalyptic pretentions: The medical establishment has become a major threat to health and, Hospitals have become monuments narcissistic scientism. Medicalisation of life, pre-Galen and Renaissance has grown with the advance of capitalism and of medicine and medical language. Illich attempts to highlight the passivity with which individuals have relinquish control over their own bodies. He divides his argument into two main parts: Clinical iatrogenesis and Social, cultural and structural iatrogenesis, followed by a set of guidelines to limit medicine.
First, he argues that clinical iatrogenesis (doctor-induced disease) is increasing. In being subjected to investigations and treatments for a relatively minor health problem, a patient runs the risk of gaining a worse problem than the original. Clinicians have been aware of this simplistic argument since medicine became an establishment, and when Illich proposed the idea, medicine was starting to take account of it. Some increase in iatrogenic disease may, paradoxically, represent therapeutic advances that enable some patients to either live longer or more satisfying lives despite having a serious disease. In the end they suffer from the therapy rather than the disease which has been kept at bay, and they become a case of iatrogenic disease. Illich picks the example most in his favour, in stating that Consultants sanctimoniously select one in every five of those Englishmen who are afflicted with kidney failure and condition him to desire the sacred privilege of dying in protracted torture on dialysis. Depression as a result of limitations imposed by life-prolonging treatment is a documented phenomenon be it renal dialysis or amputation of a gangrenous limb.
Far from taking up the harder argument of death versus amputation Illich builds up a picture of the physician as a villainous charlatan that preys on the healthy; They tend to gather where the climate is healthy... and where the patients can pay for their services. Hospitals are monuments of narcissistic scientism in which, Negligence becomes random human error. In The Greatest Benefit to Mankind Roy Porter summarises the view that, it (medicine) was driven not by concern for the patients health needs but by collective professional ambition, corporate financial pressures, and deluded imperatives - not least an itch to intervene.*9 The idealism which inspires most people to study and practise medicine is quite overlooked.
Illich's second argument is more expansive, and concerns the wider iatrogenic effects of medicine developing to an extent that: The medical establishment has become a major threat to health. *5,6
The argument that medicine might harm resonates with further developments relating the notion of social control specifically to modern medicine. Far from control being-exercised for patient welfare and well-being, medicine seemed to be extending its interest to infinite minutiae of social life: not only are medical resources more available for the ill, but the healthy are persuaded that they could still be at risk and usefully follow medical advice. The net effect is the increasing medicalization of everyday life.
Illich argues that the general availability of health care for the population has resulted in increasing dependence on doctors. Generous provision of health-care services (and indeed any welfare programme) has undermined the ability of individuals to cope with illnesses as they presumably did in the past. In an iatrogenic Health service, people depend increasingly on the system to sustain them through all life's minor tribulations. Illich argues that providing health services to meet apparent need is counter-productive and harmful. Increasing the quantity of health services creates more need (by reducing peoples thresholds) and encourages greater use, which in turn is met by increasing resources and so on. A positive feedback of need generating demand and requiring yet more resources is created, eventually leading to disaster.
Some support for this model can be found in the apparent exponential growth in health services in the Western world over the last few decades, while subjective feelings of being healthy, such as can be measured by self-assessment of health status or sickness absence rates, seem to deteriorate. This analysis is the opposite of the Inverse Care Law*11, i.e. that non-availability of health services is detrimental to the health of sections of the population. For Illich it is the converse: too great an availability of health services is unhealthy. Liberal health service provision actually encourages people to use the health service more than they really need. Over time they gradually become dependent on this over-use, feeling it is a necessary part of being healthy. But, claims Illich, this dependence is itself a form of sickness that undermines the good health of autonomous human beings.
Illichs net effect of modern medicine is that people feel themselves to be less healthy than before largely because modern medicine persuades the population that they can attain unrealistic standards of health (a state of complete physical, mental and social well-being according to the World Health Organisation in the 1960s). By this definition very few people can be healthy most of the time, but many might be persuaded that they could be healthier. As an important part of a feeling of well-being is the size of the gap between how healthy people think they are and how healthy they think they should be then a widening of that gap will produce feelings of ill-health.
Medical capitalism persuades governments and patients that health is something to do with consuming services. For a government to improve the health of the nation they must invest more money and persuade people to consume; for individuals to be healthier, they must become greater consumers. Medicine seems to have been very successful in this strategy, in that most Western governments have devoted an increasing proportion of gross national product (about 10%) to health care. Even when the gross national product is static or in decline Health keeps getting money. Even so, costs and demands on the system are still rising inexorably (in Illich's terms), because the extra amounts spent on the health care system are themselves generating further demand.
Among the commonest groups of drugs prescribed are minor analgesics, and mood altering drugs. According to Illich in 1974, In the U.S. central nervous system agents are the fastest growing sector of the pharmaceutical market, making up 31% of total sales. He also describes how the prescribed tranquilliser and medicalised addiction outgrows self-chosen forms. It is only recently that some of the side effects and long-term addictive properties of these drugs have been established. For many years, patients have been persuaded to take tranquillisers, sedatives, hypnotic and stimulants in a vain attempt to make them feel healthier.
Not only has medicine seemed content to persuade ill people to consume health services, but also in its attempts to extend illness prevention and health promotion in the last few decades, medicine has tried to persuade everyone that even the healthy are still at risk. Thus, they can be persuaded to consume health education and health promotion messages together with screening for various illnesses. In America, annual check-ups are extremely popular despite the lack of evidence as to their overall value. Illich would argue that even if there were benefits, these are heavily outweighed by the negative consequences of medicalizing people's lives.
Something in the educational, medical and bureaucratic world leads to an inevitable contradiction of promise. Longer painless lives are espoused, which are not always delivered. Illness and pain are part of the human condition, and empty promises of relief, and inducements to consume, only exacerbate the situation. Illich believes that pain and old age aquaint us with absolute human truths. If we resist the medicalisation of the state, a life unclouded by excessive medical intervention will better prepare us for the ultimate truth i.e. death. Medical enterprise saps the will of the people to suffer their reality. The freedom to suffer pain is the definition of freedom and autonomy, a rite of passage involving a persons own will, such as dying fully conscious. An image that Illich dwells on is that of laughing at the grave, the recognition of death as part of life rather than the end of it. Interestingly he talks of the Churchs attempts to stop the pagan festivals of the dead, before narrating how, in his estimation, the policing of untimely death was appointed to the medical profession. He points out that the French Revolution resulted in a brief hiatus during which it was believed that untimely death would not visit the Utopian republic. With some regret he also notes that when this did not work they set up a powerful medical establishment with expropriated church funds. Similarly in the planning of the British National Health Service (NHS), Illich is too keen to remind that Beverage assumed that there was a limited amount of morbidity, and that the NHS would have a limited half-life. This may have been proven inaccurate, but the growth of medicine appears to be self limiting, as the NHS is forced to ration life-saving treatment and withdraws the unnecessary, such as tattoo-removal, and the impotence drug Viagra.
Illichs first solution is to remove the medical establishments monopoly on health and restore personal responsibility, as was, no doubt, common until the advent of state welfare. Almost immediately (1975) he is criticised by writers such as Navarro*8 for blaming the medical establishment and a gullible public for aspects of health best understood as ideologues of a capitalist economy. Unemployment is the unavoidable product of capitalist society and a certainty in economic systems. Some employments are regarded as pathological or unnecessary by Illich. In Douglas Adams Hitch-hikers Guide to the Galaxy, a society exiles all its telephone-sanitisers into outer space, only to be wiped out by a plague contracted from a dirty telephone *1.
In The Power of Life or Death, Fabian Tassano *10 accuses Illichs solutions of being as collectivist as the ideologies that drive current medical authoritarianism. Whereas evidence about increases in health service provision and consumption has always been praised as signs of improving health standards, Illich turns the tables and points to their negative implications. In favouring the diversion of resources away from individual treatment towards the engineering of populations and environments and arguing that nationalisation should remove the hidden biases of the clinic, Illich ignores the fact that nationalisation in this way represents and increase in power to the medical bureaucracy. Perhaps this is preferable to the Medical Mafia He would seem to want the population to return to a Utopian state of total self-sufficiency. This is clearly impracticable in modern society, even if desirable and has even been attempted historically: The French Revolution closed the medical school in Paris on the pretext that Physicians had been part of the corrupt ancien regime. Within the year the failure of their Liberte Egalite and Fraternite to produce Utopian health and the Napoleonic Wars led to their reopening with more influence than before. Illich simply states that Medicine was seen to be replacing the role of the church and the law in policing the boundary between normal and abnormal especially with respect to the cause of death.
Illich is happy to quote Pliny Secundus in stating the Roman contempt for Hippocratic medicine, but it is clear that Pliny is criticising an unrestrained medical free market. It is the dominant institution which Illich intends to criticise. He does not mention that a prime tenet of the Hippocratics was to leave alone what could not be helped, something which he heavily criticises in western tradition. Writers describe him as a drop-out from society, and as such disgruntled with it. Having left the Roman Catholic Church, he is very quick to assign it an anthropological role in the policing of death. He almost bitterly states medicines new church-like role with respect to ritual, hospital birth and death being the two prime examples, and even uses different sects of Christianity to illustrate attitudes towards different health systems within a country.
Illich's arguments have resonances in political movements over the last decades that stress individual responsibility and autonomy and the deleterious of various forms of welfare provision effects on those same aspects of individuality. There is an intentional dragooning into dependency leading to the production of humans without autonomy. He talks from personal experience of the arrival of social security in many a small village in Mexico. For a generation people continue in their traditional beliefs; they know how to deal with death, dying and grief. The new nurse and doctor, thinking they know better, teach them about a Pantheon of evil clinical deaths, each one of which can be banned for a price. Illichs dark claim is that even with the growth of the number of languages the hospitals/insurance medical system remains a menace to society because rather than encouraging independence it only attracts consumers. Without limitation by fiscal policy, behaviour or reasoning, it may become the Leviathan of the late 20th / early 21st Century. Patients must grown up and take responsibility to limit both Medical paternalism and endless public demand. There is a certain nostalgia for the peasant hardship / scepticism and the Latin-American strength of purpose.
Illich argues that there ought to be limits to medicine, and that an ideal world contains optimally healthy individuals with a minimum of medical intervention. Although contradictory in parts, his perspective has added an alternative to complaints about the unhealthy effects of resource shortages. The assumption of many that more means better is not necessarily supported by the available evidence.
Moreover, it is a useful tool by which to analyse health service provision. 2 for example, rather than asking whether a particular screening programme identifies pathology, or saves lives, it helps focus on the possible negative effects of medical intervention. Does screening have iatrogenic effects, even on those people shown to be healthy? Does attendance at a screening programme in some way undermine the autonomy and independence of individual patients? According to Armstrong, Illich's critique has taught that health services can be damaging as well as helpful, and that these negative effects should be closely looked for.
However, critics of Illich have a valid point in that he vents his hatred of institutions in an inappropriate manner. And since medicine is a sacred cow, its slaughter would have a vibration effect: people who face suffering and death without need for magicians and mystagogues are free to rebel against other forms of expropriation now practised by teachers, engineers, lawyers, priests and party officials.
In this sweeping condemnation Illich ignores the idea that society constructed by the above individuals requires the medical establishment, and is analogous to forcing a heroin addict to go cold turkey. He also ignores that any expansion or advance has come to humanity as a result of corporate endeavour. His real aim appears to be (as in the title of his previous work) Deschooling Society, to advocate a regression to a pastoral existence in a life regulated by natural laws, waiting for an inevitable natural Armageddon, rather than an uncertain human one. Medical Nemesis does not square with the history of medicine since the Greeks because of the whiggish way in which it looks at yesterday through todays problems. It does not acknowledge that the institution, be it a scholarly medieval monastery or the Royal Society, represents any positive progress, but demands that world regresses back to an idealised past instead.
Adams D. The Restaurant at the End of the Universe, Chapter 25, Heinemann, London 1993
Armstrong D. Evaluating Health Care, p.130 - 132 Outline of Sociology as Applied to Medicine, Butterworth London 1995,
Medicine and Sociology, Vol. 2, p.1653 - 1654, Companion Encyclopedia to The History of Medicine, (eds Bynum & Porter, London: Routledge 1993
Fitzpatrick R.M. Society and changing aspects of disease, p.15, Sociology as applied to medicine (ed. G.Scambler), Saunders, London 1991
Illich, I. (1974) Medical Nemesis, Caldar Boyars, London
Illich, I. ( 1978) Limits to Medicine, Caldar Boyars, London
McKeown, T. (1979) The Role of Medicine, Dream Mirage or Nemesis, Blackwell Science, Oxford
Navarro V. The industrialisation of fetishism or the fetishism of industrialisation: a critique of Ivan Illich, Int. J. Health Serv., vol 5, 351-371, 1975.
Porter R. Medicine and the people, p. 687,The greatest benefit to mankind, Harper Collins, London 1997
Tassano F. Patients: Passive victims, P 42-43 The Power of Life or Death, Duckworth, London 1995
Tudor Hart, J. (1971) The inverse care law. Lancet, i, 405-12
I happened to be in Rio de Janeiro and Lima when Dr Christian Barnard was touring there ... he was able to fill the major football stadium twice in one day with crowds who hysterically acclaimed his macabre ability to exchange human hearts Illicc shows the irony of people applauding progress from which they will never benefit, and on the same page demonstrates one way in which it could cause endless suffering: 'Shortly afterwards I saw well documented evidence proving that the Brazilian police so far have been the first to use life extending equipment and techniques in the torture chamber Medical Nemesis (p.54)
David Armstrong (1995) crystallises an allegorical example of Illichian iatrogenesis and Medicalisation: A patient goes to the doctor with a tension headache; the doctor prescribes a month�s course of morphine. The therapy is effective because the patient gets better but the patient is now addicted to morphine. The patient benefited from the therapy in one way, but the cost was overwhelming in another. The cost of the health care to this patient is an iatrogenic, that is doctor-induced, disease. This is an unrealistic allegory, as the Doctor is more likely to abuse the morphine him or herself, than prescribe it to a patient. This is simply because: though conceivable to a 19th century doctor, to prescribe in such an extreme manner in the latter half of the twentieth century would be considered scandalous (in western countries at least).
'They want to be taught, moved, treated or guided, rather than learn, heal and find their own way' (p.61). Thus Illich describes the passivity of individuals resulting from over-industrial society.
According to Armstrong (1995) this means that people in the work-force in those countries spend about six weeks in every year of their working lives creating the resources which they will then consume to make them healthy. 'And with further increases in health care costs, will the proportion of people�s lives spent creating resources which can then be consumed to make them feel healthy keep on rising?
lIlich criticises the identification of the sick role with the patient role, in that the sick person is obliged to comply with technical help in order to get better (p.57). This is seen as attempt to medicalise all the sick rather than to eliminate malingerers from the system.
A new myth about the social value of the old was developed. Primitive hunters, gatherers and no mads had usually killed them, and peasants had put them into the back room (p. 137). Illich contrasts this attitude in a disturbingly nostalgic manner with today s situation: 'Society felt threatened that the man on death row might use his tie to hang himself. Authority might be challenged if he took his life before the appointed hour (p.149). He even goes one step further and compares this and the campaign for medical euthanasia to the nuclear deter rent of the Superpowers: 'An uncanny analogy exists between atomic and cobalt bombs: both are deemed necessary for the good of mankind, both are effective in providing man with control over the end. (p.146).
Having said this, Illich studied theology and philosophy at the Gregorian University in Rome before obtaining a PhD in history at the University of Salzburg. After serving as an assistant pastor he organised an intensive training centre for American priests in Latin-American culture. He was the co-founder of the controversial Centre for Intercultural Documentation (CIDOC) in Cuernavaca, Mexico, and since 1964 has directed research seminars on 'Institutional Alternatives in a Technological Society , with special focus on Latin America.
Fitzpatrick (1991) provides a concise summary of Illich�s criticism. Medicine:-
raised public expectations of wonder cures which in reality are ineffective.
extended too far the kinds of problem thought to be medical.
was responsible for large amounts of medicallyinduced illness.
decreased the individual�s ability to cope with their own illness, fostering a debilitating dependency on the expert.
Leviathan is the great monster of the Jewish faith, representing an aggregation of evil and bad intentions.
See footnote 2
Mr Papanikitas is a 3rd year medical student currently studying an intercalated BSc, in the History of Medicine, and President of the Guy's and St. Thomas's Medical Ethics Group.