Medical Nemesis, by Ivan Illich, New York: Random House, Pantheon Books, 1976, 294 pp., $8.95
Medical Nemesis is an all-out attack on the medical establishment—on its methods and its practitioners, on its results and side-effects, and on the basic cultural assumptions on which it rests. Illich's claim is that the social benefits of modern medicine are less than its social costs, that it does more harm than good. His aim is to demystify the medical profession, to remove its power and autonomy, and to place health care back in the hands of "the people."
Can Illich be correct? Is health care a rip-off? Would people like you be better off without people like me?
WHY PICK ON MEDICINE?
It is tempting to shrug off Illich's arguments as the fulminations of a cleric who is jealous of a more successful profession. (After getting degrees in history, philosophy, and theology, he worked for five years as a parish priest in New York.) Consider that the physician has taken over much of the "business" of religion. He or she presides over the previously sacred acts of birth and death, even over sex and madness. People believe more in his power to heal than in God's. His temples—the hospitals—invoke more respect and mystery than the churches. The fraction of the total income spent on health care approaches a tenth, the portion traditionally tithed to religion. The "magic" of medical technology rivals the miracles of old and seems to be more reproducible.
Sour grapes? No, there is more here than meets the icon. This critique is even more powerful than Illich's previous analyses of education (Deschooling Society, 1971) and transportation (Energy and Equity, 1974). The theme is the same—that industrialization is counterproductive, that technical progress is an illusion. Illich must be taken seriously because he is a member of the braintrust of the counterculture, which is making a sustained and partially successful attack on the industrial aspects of our society, and because many people of good will and sound thinking already recognize areas of medical technology where there are often excesses in zeal and in cost. But how much is too much? And who should decide?
Let us examine some of Illich's arguments. His book is organized in four Parts: Clinical Iatrogenesis, Social Iatrogenesis, Cultural Iatrogenesis, and The Politics of Health. Iatrogenic illness means illness caused by the physician, for example, the bad effects of having been given too much of a drug, damage done to a patient during surgery, or a contagious disease acquired while in hospital.
By clinical iatrogenesis, Illich means the direct harm done to patients' health by physicians, nurses, pharmacists, etc., in the clinical situation and the indirect harm due to a failure to decrease illness. He starts with a bold claim—that the effectiveness attributed to physicians is an illusion, as evident from disease statistics showing that most of the decline of mortality from contagious diseases (such as tuberculosis, cholera, dysentery, typhoid, scarlet fever, diphtheria, whooping cough, and measles) occurred before the introduction of antibiotics and before widespread immunization. He attributes this to improved housing, decreased virulence of microbes, and higher host-resistance due to better nutrition. Actually, sanitary engineers have probably prevented more illness and saved more lives than all the doctors in history by improving water supplies, drainage, and waste removal. Illich is derelict here in not recognizing the contribution of technology to the decline of contagious diseases.
He claims, with partial evidence, that "in contrast to environmental improvements and modern nonprofessional health measures, specifically medical treatment of people is never significantly related to a decline in the compound disease burden or to a rise in life expectancy." True, education, socioeconomic status, water quality, and even sex are more highly correlated with life expectancy than are medical treatment variables. Even a cure for all cancers or all heart disease would only add a few years to average life expectancy; of course, it could add many years for each of the individuals afflicted. But Illich is wrong about the "never"; for example, prenatal and postnatal care has decreased infant mortality, which in turn increases life expectancy.
Illich jumps from the justified assertion that survival rates for the most common types of cancer (lung, breast, colon, and rectum) have not improved much in the last 25 years, to the unjustified conclusion that there is little evidence of effective treatment in most cancers other than cervix and skin. He is just wrong about this. This is a common failing (or is it just a rhetorical trick?) of Illich's—to jump from a single finding in a technical article to sweeping generalization, banishing further discussion and leaving the bewildered reader with a footnote to an obscure journal in German, French, or Spanish. One must respect Illich's apparently universal scholarship but, at the same time, suspect his eagerness to oversimplify.
To imply that there are no benefits and no effectiveness insults the common sense of the very same "people" whose judgment he would trust if medicine were to be taken away from the professional. We do know people who went to the hospital with appendicitis, a broken leg, or a breech delivery and came out of the experience with lives and limbs unimpaired.
Nevertheless, Illich has thrown down a potentially useful challenge. There is needed in modern medicine more attention to analysis of outcomes instead of processes and more effort at minimizing costs while maintaining important factors of quality in health care.
By social iatrogenesis, Illich means the damage to health caused by social and economic transformations resulting from the way health care is organized. This includes increased stress stemming from medical bureaucracy, disabling dependence due to lowering individuals' tolerance of discomfort, reduction of social tolerance for suffering individuals, interference with the right to self-care, and rendering into gobbledygook the language with which people describe their bodily experiences. The section is subtitled "Medicalization of Life."
Illich goes a step beyond Milton Friedman, who has argued that medical doctors have successfully cornered most of the health-care market through state enforcement of licensing. Illich calls medicine a radical monopoly, because not only has professional competition been eliminated, but substitution, by way of lay people caring for themselves and one another, has been prevented. For example, most medicinal drugs are available only by prescription; note that this too depends on state enforcement.
Illich believes, bitterly, that many people who are just "sick and tired" of industrial labor are labeled by physicians as ill and thereby removed from "political struggle for a healthier world." Like Dr. Thomas Szasz has done for psychiatry, Illich claims that medicine is not a value-free science but in fact is a normative endeavor, a moral enterprise. It defines what is normal, proper, and desirable. It stamps some pain as subjective, some impairment as malingering, and some deaths as suicide. It creates sickness by defining some body states, even without symptoms, as illness. This is powerful stuff, for in the modern era we allow illness, mental or physical, as an excuse, relieving people of responsibility for their actions. Like Szasz, Illich finds this irksome.
HEALTH AND WEALTH
In "The Medicalization of the Budget," Illich protests rising expenditures on health care and astutely recognizes government medical programs as devices for the transfer of economic power from the tax-paying majority to a minority receiving health care—and to their doctors. In this vein he attacks the national health insurance proposals, predicting that, instead of making us healthier, they will make the health establishment wealthier and the government bureaucracy more powerful.
Although Illich is concerned about the multiplicity of drugs fostered by "the pharmaceutical invasion," he shows that per capita use of medically prescribed drugs is not correlated with commercial promotion—as critics of advertising would have it—but with the number of doctors, even in socialist countries. But he blunders in professing admiration for Salvador Allende's action in Chile of "reducing the pharmacopoeia to a few dozen items, more or less the same as those carried by the Chinese barefoot doctor." For it may be true that perhaps four dozen items are optimal for 98 percent of the population, but what do we do for the other 2 percent?
Illich describes as "diagnostic imperialism" the power of medical bureaucrats to certificate people for various purposes. They "subdivide the people into those who may drive a car, those who may stay away from work, those who must be locked up, those who may become soldiers, those who may cross borders, cook, or practice prostitution, those who may not run for the vice-presidency of the U.S., those who are dead, those who are competent to commit a crime," and those who are likely to commit one. This medicalized status can have two effects—exemption from work, prison, military service, etc.; or sanctioning others' encroachment on one's freedom, for example, by putting one into an institution.
The effects on the elderly are the most profound, since the 10 percent of the population who are over 65 receive about 30 percent of all medical attention. Old age has been "medicalized." And the aged form a ready-made political interest group. They can be counted on to support any proposal for increased government health-care spending but "will feel painfully deprived at any relative level of tax-supported privilege" because their underlying "disease," aging, is incurable.
Illich rightfully criticizes the practice of bringing terminal patients into the hospital to die and of going too far in behalf of patients whose prognosis is hopeless. But attempts are being made to improve both situations: the first, by preparing the family members to handle a death at home; the second, by use of the "living will," in which a person states his wishes not to have "extreme measures" of mechanical life support, resuscitation, etc. used in a hopeless situation.
In his third section Illich claims that "the medical enterprise saps the will of people to suffer their reality." He states that all traditional cultures equip individuals "with the means for making pain tolerable, sickness or impairment understandable, and the shadow of death meaningful." He seems to resent the fact that "medical civilization is planned and organized to kill pain, to eliminate sickness, and to abolish the need for suffering." What is wrong with this as an ideal?
While there is utility in pain sensation, which apprises us of dangerous external forces and internal body states, there is no virtue in bearing pain, per se, as Illich would have us believe. While there is dignity in bearing pain well, there is no nobility in refusing to eliminate the source of pain or in refusing pain-killing medication.
He blunders again when he asserts that "all disease is a socially created reality." Certainly it is true that our perceptions of bodily states are filtered through socially and culturally "tinted glasses" and that some psychologic and physiologic states have been arbitrarily classed as abnormal. But it is also true that the crushing cardiac pain of angina pectoris, the consequences of dysentery or a skull fracture, and the gnawing bone pain and wasting of metastatic carcinoma are similar across all social and cultural lines.
Disease, in the sense of dis-ease, is a reality that does exist in individual people, independent of "social creation."
In a 13-page historical digression entitled "The Devotional Dance of the Dead," Illich recalls the medieval conception of death, describing "a world in which everyone dances through life embracing his own mortality." Recognition of one's own mortality is a useful stage in personal growth and emotional maturity; and denial of mortality, as pointed out so well by Elizabeth Kubler-Ross, is a stage that must be "worked through" by a dying person. But Illich's treatment of this subject is a mixture of poetic blather and paeans to superstition. Ingmar Bergman did it much better in "The Seventh Seal."
In his final chapter, "The Politics of Health," Illich provides his summary and recommendations. He places professional health care in the larger framework of industrialized society, where the efficiency of mass production and the division of labor do have some negative side-effects. For example, "people are conditioned to get things rather than to do them; they are trained to value what can be purchased rather than what they themselves can create." "It becomes increasingly difficult to care for one's own health." As astute as his observations and insights are, he betrays his Luddite prejudices when he refuses to consider the benefits of technology. For example, he forgets his own insight that the Industrial Revolution created jobs for the old, the weak, and the infirm, who had previously been doomed to short lives of beggary or starvation.
Here are some of the "political countermeasures" that Illich seems to endorse:
1. Consumer lobbies and consumer control of hospital boards to force doctors to improve their wares
2. Nationalization of health production to control the "hidden biases of the clinic"
3. Replacing professional licensing with licensing of institutions and capitation payment
4. More public support for alpha waves, encounter groups, and chiropractic
5. More resources for the engineering of populations and environments, "to stretch the health dollar."
To be frank, it is not clear to the reader exactly how much Illich endorses these proposals. His discussion of them is a recounting of advantages and disadvantages, in a ping-pong style that is difficult to follow. I believe that he finally rejects proposal 5, and he qualifies the others with requirements such as: the total output of health services should be restricted to within "subiatrogenic" limits; and "no professional shall have the power to lavish on anyone of his patients a package of curatives larger than that which any other could claim for his own."
Even with Illich's qualifications, it is difficult to conceive of a program more likely to result in disaster for patients, for expenditures, and for the liberty which Illich claims to espouse. His keen critical sense has not been sufficiently trained on these proposals, which are more akin to madness than to folly. We see how fine is the line between genius and madness. While we must credit Illich for his analytical insight into the indirect social and cultural effects of the medical enterprise, we must be wary of the naivete of his synthetic sense and the danger of his political proposals, especially if they become the slogans of the media, the masses, or the politicians who would use them.
We sometimes speak of, and use, "heroic measures" in medicine. We employ extraordinary procedures; we keep people alive in intensive care units when multiple organ systems have shut down; we perform open-heart surgery; we sustain comatose people with intravenous feeding and artificial breathing apparatus. Perhaps we are "playing God"—deciding who shall live a few more hours or weeks or years. But we are definitely playing "hero," and Illich would remind us of the myth of Prometheus, who, driven by pride and greed, trespassed the limits of humanity and stole fire from heaven. He thus brought Nemesis on himself. Nemesis is the goddess of retribution, a symbol of righteous indignation. So Prometheus was chained to a rock, with an eagle preying all day on his liver; and instead of letting him die, the gods renewed his torture nightly by regrafting his liver. "His unending suffering turned the hero into an immortal reminder of inescapable cosmic retaliation."
Illich believes that "industrial hubris has destroyed the mythical framework of limits to irrational fantasies." "Modern nemesis is the material monster born from the overarching industrial dream. It has spread as far and wide as universal schooling, mass transportation, industrial wage labor, and the medicalization of health."
Maybe some of the things we enjoy are "irrational fantasies." Consider downhill skiing with the aid of a mechanical lift to take us back up a 10,000-foot mountain; vacation flights by thousands to tropical islands in the middle of an ocean; a $5,000 camper truck parked in the garage of any industrial worker who wants one; coronary bypass surgery to relieve the crushing pain of angina pectoris for a few years; or radiation treatment with a linear accelerator to cure cancer of the vocal cord which would otherwise slowly suffocate one to death. Not all of us would want or need many of these things, but in a free country with a free market, you pay your money and you take your choice. I suspect that Ivan Illich would dismantle the technology that makes the choice possible.
There is a vital lesson in the Nemesis myth, but Illich missed it. Industry, for all its pervasive effect on the way we live, does not attempt to dominate society. It offers us choices, alternatives that we can take or refuse. The institution that does attempt to dominate society is government itself. Not only does political authority have the hubris to claim to speak for all of society, it has fooled much of the public and the intelligentsia into believing that it is proper to do so. It has usurped the taxing authority to confiscate the surplus—nay, the very economic substance—of the rest of the institutions of society; it has contaminated our history with its wars; it has expropriated our savings by inflating the supply of money; it has destroyed our inner cities by encouraging flight to the suburbs; it has eroded our families by subsidizing the separation of the old and the young and by its subversive welfare programs; it is responsible for most of the excesses of schooling, the distortion of transportation, and the explosion of health-care costs that Illich would have us blame on industry. Ours is the tragedy of political nemesis.
Dr. Maccabee earned a Ph.D. from the University of California Berkeley in 1966 and subsequently taught and did research on medical applications of nuclear technology. Desiring more involvement with the practical side of cancer treatment, he received an M.D. from the University of Miami in 1975 and is currently a resident physician in radiation oncology at the University of California San Francisco.
This article originally appeared in print under the headline "Political Nemesis".
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