Limits to Medicine E-Book

Ivan Illich

• Herausgeber: Marion Boyars
• Kategorie: Fachliteratur
• Sprache: Englisch
• Veröffentlichungsjahr: 1976

Beschreibung

The medical establishment has become a major threat to health'. So begins Ivan Illich's spirited and reasoned attack upon the mythic prestige of contemporary medicines, examining the customs and rituals conducted by the medical profession. Relentlessly and with full documentation taken from recognized medical sources Illich proves the impotence of medical services to change life expectancy, the insignificance of most clinical care in curing disease, the magnitude of medically inflicted damage to health, and the futility of medical and political counter measures.

Leseprobe

IVAN ILLICH

LIMITS TO MEDICINE

Medical Nemesis: The Expropriation of Health

With a New Introduction by the Author

Marion Boyars London • New York

Contents

Title Page

Preface

Introduction

PART I. Clinical Iatrogenesis

1. The Epidemics of Modern Medicine

Doctors’ Effectiveness—an Illusion

Useless Medical Treatment

Doctor-Inflicted Injuries

Defenseless Patients

PART II. Social Iatrogenesis

2. The Medicalization of Life

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

PART III. Cultural Iatrogenesis

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

Subject Index

Index of Names

About the Author

By the Same Author

Copyright

Preface to the 1995 edition

Pathogenesis, Immunity and the Quality of Public Health

A Lecture given at the Qualitative Health Research Conference, Hershey, Pennsylvania. June 13th, 1994

Professor Janice Morse:

I am honoured by your invitation to address this second assembly of nurses who have organized themselves to act as learned watchdogs over the quality of Health Care. I have been invited as the author of LimitstoMedicine – MedicalNemesis, a book that was published some twenty years ago. I am not a nurse and, emphatically, I do not care about health. I teach about the history of friendship and the history of the art of suffering.

I am trained as a medieval historian and philosopher. I come here because Professor Carl Mitcham encouraged me. We are associated in research on the symbolic effects of technique: we study what technique says rather than what it does. The predicament which you are facing at this second meeting of your association seems to both of us relevant to our theme.

You study the quality of health care. What is it you focus on: is it the delivery of services or of messages? I would like to distinguish between those among you who want more, better, cheaper and less degrading services for more people, and others who want to do research on pathogenic myths and certainties that result from financing and organizing health care rituals. To accomplish this delicate task, I will tell you my own story. I will tell you about my intellectual growth beyond MedicalNemesis, presenting my story as a cautionary tale.

I welcome this occasion to make public amends for something I did when I wrote that book. I wrote MedicalNemesis as one of four essays which examined the symbolic power inherent in modern techniques to shape our basic certainties. In each essay, I used a different method to examine four major institutions, each serving as a screen on which to project my observations. In Nemesis, I took 1970s medicine and studied it with a method which demonstrated the paradoxically counterproductive effectiveness implicit in disproportionate techniques. With my description uncovering clinical, social and cultural iatrogenesis, namely, the production of multiple misery, I did not target the medical establishment for reform. I used medicine as a paradigm for any mega-technique that promises to transform the conditiohumana, I examined it as a model for any enterprise claiming, in effect, to abolish the need for the art of suffering by a technically engineered pursuit of happiness. I analyzed the ‘development’ of health care parallel to that of education, transportation, human garaging, and so on, conscious that in the case of institutionalized hygiene, the pursuit of happiness is translated into the pursuit of ‘health’.

After nearly a quarter of a century, I am still satisfied with the substance and rhetoric of Nemesis. The book opened up a discussion on counterproductivity and the history of needs. But it did something else also: it brought medicine back into the realm of philosophy. My focus on the culture of suffering was the appropriate antidote to the emerging epidemic of bioethics. By reducing each person to ‘a life’, bioethics is helpless to prevent total management of the person, now transformed into a system.

However, I now see a serious flaw in my approach that would vitiate my current intent. I then conceived of health as ‘the intensity of autonomous coping ability’. When I wrote that, I was unaware of the corrupting effect that system-analytic thinking would soon have on perceptions and conceptions. I was unaware that by construing health in this self-referentially cybernetic fashion, I unwittingly prepared the ground for a worldview in which the suffering person would get even further out of touch with the flesh. I neglected the transformation of the experience of body and soul when well-being comes to be expressed by a term that implies functions, feedbacks and their regulation. Ten years of research with Barbara Duden on the history of the experienced body, and several seminars on the history of the gendered self at the Wissenschaftskolleg (Berlin), in Marburg and in Penn State still lay before me.

That is the reason why I am worried by the fact that most of the current sales of LimitstoMedicine — in several languages — are bulk orders from medical schools. The book is being read as a demonstration of how you can eat your cake and have it too. You can obliterate the experienced sensual body of the past by conceiving of yourself as a self-regulatory, self-constructing system in need of responsible management and, in spite of this disembodiment, claim that you stand within the tradition of the art of suffering and the art of dying. I wrote Nemesis to illustrate what the health care system says, but I did not sufficiently stress its subtle structures which pattern our response, turning us into subsystems.

Qualitative Research

You are the perfect audience to hear my story and understand it as a cautionary tale. Most of you are graduate nurses. Those with whom I had breakfast, and those with whom I lunched, impressed me greatly. Shocked by what they were asked to do as nurses, they went on to graduate schools with the intent to do something about the system. They finished studies in ethnology, sociology, anthropology and psychology. In the late 80s, you formed your organization. You did so for mutual support in the research on the experience of encounters with the health care system. In medical circles, your initiative was less than welcome. Nevertheless, you had a few fruitful years with some definite institutional impact.

This cannot but change. I can smell that you are on the point of being co-opted. The American Medical Association now spends more than most U.S. industries on public relations. Just consider the glossy ten-page colour spread in Time and Newsweek. Competing for these public relations, you win hands down. Grants for each of the 330 papers presented at this meeting can be justified because such studies establish that professionals who provide care do indeed care for their clients — whether this is true or not.

From my contacts here, I have learned that not all of you left actual nursing to spend your lives oiling care delivery with good will, or doing engineering research on simpler means that would produce higher rates of client-perceived utility. I have met those of you who want to decipher the melody that the care system drums into us. They are the ones who intend to train cynical philosophers to bark fearlessly at a contemporary paradox: the organized pursuit of health has become the principal impediment to suffering experienced as a dignified, meaningful, patient, loving, beautiful, resigned and even joyful embodiment.

As long as you were protected by initial liminality, it was possible to envisage our care system as the institutional structure of a pathogenic pursuit of health. My host’s seminars in Penn State on the history of health-related words and concepts is a good example. But once you enjoy professional status within the system, you lose much of this freedom. Those who will then want to do research on the art of suffering in our culture rather than on postmodern health will have an increasingly difficult time. They are the ones to whom I especially direct my story. They are the ones with whom I want to plead for research on the symbolic function of the health care conglomerates. What does it tell about who we are, rather than howwell we pursue health.

Medical Nemesis

The opening sentence of LimitstoMedicine was an indictment: ‘The medical establishment has become a major threat to health.’ It seems strange now that this sentence could shock and anger in 1975. Today, it’s trite. I argued ‘that the layman and not the physician has the potential perspective and effective power to stop the current iatrogenic epidemic.’ Now the Clintons search for what I called ‘a conceptual framework within which to assess the seamy side of progress against its more publicized benefits.’ The same Congress that has effectively fired 2300 physicists who were working on research for the supercollider now does what I argued for. It ‘reclaims its own control over medical perception, classification and decision-making.’ What is it, then, that I now regret?

I am chagrined that I formulated an important and coherent statement about the art of suffering and dying in categories that lend themselves to reductionist disembodiment. In LimitstoMedicine — MedicalNemesis, I argued that the fundamental pathogen today is the pursuit of health as this has come to be culturally defined in late-industrial society. I did not understand that in the age of systems management, this pathogenic pursuit of health would become universally imposed. I felt free to speak of health in terms of personal autonomy, and as the ‘intensity of coping ability’. I conceived of health as ‘a responsible performance in a social script’ which is governed by a ‘cultural code adapted to a group’s genetic make-up, to its history, to its environment…’ I wanted to make it plausible to a generation committed to the pursuit of health that throughout history the human condition had been ‘suffered.’ But I was still under Gregory Bateson’s influence, believing that concepts like feedback, pogrom, autopsies or information — when shrewdly used — could clarify issues. I thought I could equate suffering with the management of my own balance. I was wrong. As soon as you understand suffering as coping, you make the decisive step: from bearing with your flesh, you move towards managing emotions, perceptions and states of the self conceived as a system.

Coping

The use of the English term, coping, is of very recent coinage. This is a point made at the first international meeting of Historians of Health Care last fall. It is either an abuse or an arbitrary predating to speak about ‘coping with sickness’ in pre-modern times. Sickness, like pain, disability, tiredness and fear were suffered, borne, shared, alleviated, dreaded or cured. Each language has its own rich and precise vocabulary for dealing with woe, discomfort, torture and all sorts of paroxysms. Great traditions differ from each other fundamentally through their set of notions and practices for dealing with this dark side of the human condition. Within each tradition, the interpretation of discomfort and anguish changes over time and is usually specific to social class. Any attempt to catch this wealth of cultural constellations of suffering in one net by calling it coping is a colonization of the past by imposing a profoundly modern notion.

Since the fifteenth century, the verb ‘to cope’ has been attested, and means ‘to come to blows with someone’. By the end of the seventeenth, it had been gentled. The QED takes an example from Lord Byron: ‘Brisk confidence is still best with women to cope.’ After World War II, it entered slang and kids began to cope with their love life. People learned to cope with husbands, jobs, treatments, unemployment, flu. But in 1967, the American Heritage usage panel still considered it, if not slang, then a kind of newspeak that is permissible in casual writing. Bateson took up the word to introduce systems theory into anthropology. He had a good ear for popular idioms. At about just that time, at least in California, ‘to cope’ was first used as an intransitive verb. It bespeaks a way of existence so new that traditional languages have no word for it. The word was ‘welcome because it filled a void in the description of general disarray’ — the judgment of one member on the usage panel, the one who was a musicologist.

Coping flourishes within this epistemic void. The recognition of widespread disorder allows me to chronicle my own growing clarity. It is within this void that words and diagrams have conjured up an emblem that now stands for the self, a new kind of black box.

Ethical or Epistemic Ritual?

When, barely fifty, I defined health as ‘the intensity of autonomous coping ability’, I did so in search of a contemporary way of referring to a moral ‘ego’ in a time ‘after virtue’. Unwittingly, however, I suggested responsibility, autopoiesis, and self-perception in terms of the ego’s tolerances and immunities. There is no better ordinary verb to say how a person behaves, once conceived as a black box.

Now, near seventy, I re-read my tract in a milieu infected by deconstruction. I became acutely aware that within the system-analytic framework implied by the new, intransitive activity of coping with my life, the traditional art of living cannot be pursued. Self-perception in systems terms dissolves the kind of flesh that could practise either the art of enjoyment — the sunny phase, or the art of suffering — the shady side. MedicalNemesis was an attempt to vindicate the art of living, the art of enjoyment and suffering, even within a culture shaped by progress, comfort, care and insurance providing entitlement to pain killing, normalization and, ultimately, euthanasia. Hazardous medicalization, socially disabling professionalism and debilitating ritualism engendering the myths of amnesia, anaesthesia and a-mortality were the themes of the book’s three sections. It was written before prevention and neo-witchcraft had really taken off; neither the acceptance of current anti-smoking rules, nor the public financing of acupuncture for jailed drug addicts was then on the agenda. From a historical perspective, I indicted a cultural corruption; I raised ultimate questions of ethics.

The issue now facing us is a question of truth. I want to indict health care not as a demoralizing but as a nihilist agency. The decisive result of every brush with the health care system today is epistemic — a recasting of the ego. From T-cell watch to safe sex, from urine test to Zen-do, what is done in the pursuit of health boomerangs as an interpretation of the self. In 1994, each of these routines bolsters the coping ability of the self as an immune system.

My evidence is anecdotal: Dr Zimmermann, after a day in her clinic, found that three of her eleven visitors had come for referral to a T-cell count: one because she was losing her hair; the second because of pimples; and I forget the symptom adduced by the third. Dr Zimmermann reflected on the formation of physicians: the first thing you have to learn is a hierarchy of suspected aetiologies. In Protestant Germany in 1850, masturbation was in first place for men and hysteria for women; a few decades later it was tuberculosis; then, syphilis. Now, she sees that it’s the subscription to a Self-Care journal that transmits system ideology.

Timetables, college catalogues and computer games do the same, but health care does it with a vengeance. Ego as an immune system is of such complexity that only tests can tell how it should feel. When the oncologist gave up further chemotherapy on Jim, I asked him how he felt. He told me to call next day, but only after 11 a.m., when the lab test would be back. The Orphic ‘know thyself’ now reads: ‘check how your system is coping’.

The term ‘immune system’ does not appear in the index of a single biological textbook before 1972. Ten years later it is hard to find a learned paper that deals with immunity and does not use the term. During the early 80s, the concept appears in textbooks dealing with a market, a cultural unit, the psychic constitution of a family — as entities endowed with an immune system, if these entities are not themselves simply described as such. Donna Haraway calls this thing ‘a potent polymorphous object of belief, knowledge and practice … a guide to the recognition and mis-recognition of self in Western bio-politics.’

In fact, the zygote is on the way toward acquiring legal status as a human subject, partly because the Pope and constitutional jurists imply that its genome and cytoplasm have the potential to develop into a self by recognizing the ‘other’ — in this case, the mother. Conceiving living beings as immune systems provides the pseudo-legitimation of reducing a human being to ‘a life’ upon which ethics committees can pass judgments. In a world made up of systems, the immune system replaces what was formerly called an individual or person. While the early twentieth century practised animism by accepting homoeconomicusas a natural fact, which legitimated seeing bacteria ‘competing’ for scarce oxygen, so the late twentieth century practises its necromancy by giving substance to system concepts, and by reducing persons born for suffering and delight to provisionally self-sustaining information loops.

When I wrote LimitstoMedicine —MedicalNemesis, the book that you have read in preparation for this meeting, all this I did not know.

Ivan Illich

LIMITS TO MEDICINE

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 TheHospitalizationofSpace, and John McKnight, Director of Urban Studies at Northwestern University, is working on TheServicedSociety. 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 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

Author’s Note

I wrote MedicalNemesis as a draft for the IdeasInProgress series and rewrote this draft both in French for the parallel series Techno-Critique and in German for Rowohlt Verlag. Other translations appeared in Italian, Spanish, Dutch, Swedish, Norwegian and Serbo-Croat.

The criticism, advice and documentation that I have received as a result of the circulation of my draft have enabled me to complete this book. I dedicate it in gratitude to my critics.

IVAN ILLICH

27 February 1976

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 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. 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 Homosapiens, “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-consumingacceleration 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 specificcounterproductivity. 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.

1ToolsforConviviality (London: Calder & Boyars, 1973).

2DeschoolingSociety, Ruth N. Anshen, ed. (London: Calder & Boyars, 1971).

3EnergyandEquity (London: Calder & Boyars, 1974).

PART I

Clinical Iatrogenesis

1

The Epidemics of Modern Medicine

During the past three generations the diseases afflicting Western societies have undergone dramatic changes.1 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 dependent variables of political and technological transformations, 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 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 antibioticsbecame routine, it had slipped into eleventh place with a rate of 48. Cholera,11 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 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,17the 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 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—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, redefine 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 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 is 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 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

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-cancercases 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 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 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 clinicaliatrogenesis. 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-sixhours, 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.57Unnecessary surgery is a standard procedure.58Disablingnondiseasesresult 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 nondisease 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, negligence,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 breakdown,” 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

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 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 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 socialiatrogenesis, 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 iatrogenesis, 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 designed 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 medicalnemesis. The Greeks saw gods in the forces of nature. For them, nemesis represented divine vengeance 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 reversalofnemesis 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 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.

1 Erwin H. Ackerknecht, HistoryandGeographyoftheMostImportantDiseases (New York: Hafner, 1965).

2 Odin W. Anderson and Monroe Lerner, MeasuringHealthLevelsintheUnitedStates,1900–1958, Health Information Foundation Research Series no. 11 (New York: Foundation, 1960). Marc Lalonde, ANewPerspectiveontheHealthofCanadians:AWorkingDocument (Ottawa: Government of Canada, April 1974). This courageous French-English report by the Canadian Federal Secretary for Health contains a multicolored centerfold documenting the change in mortality for Canada in a series of graphs.

3 René Dubos, TheMirageofHealth:UtopianProgressandBiologicalChange (New York: Anchor Books, 1959), was the first to effectively expose the delusion of producing “better health” as a dangerous and infectious medically sponsored disease. Thomas McKeown and Gordon McLachlan, eds., MedicalHistoryandMedicalCare:ASymposiumofPerspectives (New York: Oxford Univ. Press, 1971), introduce the sociology of medical pseudo-progress. John Powles, “On the Limitations of Modern Medicine,” in Science,MedicineandMan (London: Pergamon, 1973), 1:1–30, gives a critical selection of recent English-language literature on this subject. For the U.S. situation consult Rick Carlson, TheEndofMedicine (New York: Wiley Interscience, 1975). His essay is “an empirically based brief, theoretical in nature.” For his indictment of American medicine he has chosen those dimensions for which he had complete evidence of a nature he could handle. Jean-Claude Polack, LaMédecineducapital (Paris: Maspero, 1970). A critique of the political trends that seek to endow medical technology with an effective impact on health levels by a “democratization of medical consumer products.” The author discovers that these products themselves are shaped by a repressive and alienating bourgeois class structure. To use medicine for political liberation it will be necessary to “find in sickness, even when it is distorted by medical intervention, a protest against the existing social order.”