Appendix 7. Extracts from ‘Medical Nemesis –
The
Expropriation of Health’ by Ivan Illich
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’.
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
expropriate the power of the individual to heal himself and shape his
or her environment.
More and more people subconsciously know
that they are sick and tired of their jobs and of their leisure
passivities, but they want to hear the lie that physical illness
relieves them of social and political responsibilities. They want
their doctor to act as lawyer and priest. As a lawyer, the doctor
exempts the patient from his normal duties and enables him to cash in
on the insurance fund he was forced to build. As a priest, he becomes
the patient’s accomplice in creating the myth that he is an
innocent victim of biological mechanisms rather than a lazy, greedy
or envious deserter of a social struggle for control over the tools
of production. Social life becomes a giving and receiving of therapy:
medical, psychiatric, pedagogic or geriatric.
People who are angered, sickened and
impaired by their industrial labour and leisure can escape only into
a life under medical supervision and are thereby seduced or
disqualified from political struggle for a healthier world.
Medicine has the authority to label one
man’s complaint a legitimate illness, to declare a second man sick
though he does not himself complain, and to refuse a third social
recognition of his pain, his disability and even his death. It is
medicine which stamps some pain as ‘merely subjective’, some
impairment as malingering, and some deaths – though not others –
as suicide. The judge determines what is legal and who is guilty. The
priest declares what is holy and who has broken a taboo. The
physician decides what is a symptom and who is sick.
For rich and poor…life is reduced to a
‘span’, to a statistical phenomenon which, for better or worse,
must be institutionally planned and shaped. This life-span is brought
into existence with the pre-natal check-up…and it will end with a
mark on a chart…
To be in good health means not only to be
successful in coping with reality but also to enjoy the success; it
means to be able to feel alive in pleasure and in pain; it means to
cherish but also to risk survival. Health and suffering, as
experienced sensations are phenomena that distinguish men from
beasts. Only storybook lions are said to suffer
and only pets to merit compassion when they are in ill-health.
Medicalisation constitutes a prolific
bureaucratic programme based on the denial of each man’s need to
deal with pain, sickness and death. The modern medical enterprise
represents an endeavour to do for people what their genetic and
cultural heritage formerly equipped them to do for themselves.
Medical civilization is planned and organized to kill pain, to
eliminate sickness, and to abolish the need for an art of suffering
and of dying.
Culture makes pain tolerable by
interpreting its necessity; only pain perceived as curable is
intolerable.
A myriad virtues express the different
aspects of fortitude that traditionally enabled people to recognize
painful sensations as a challenge and to shape their own experience
accordingly. Patience, forbearance, courage, resignation,
self-control, perseverance, and meekness each express a different
colouring of the responses with which pain sensations were accepted,
transformed into the experience of suffering and endured. Duty, love,
fascination, routines, prayer, and compassion were some of the means
that enabled pain to be borne with dignity.
The pupils of Hippocrates distinguished
many kinds of disharmony, each of which caused its own type of
pain…Pain might disappear in the process of healing, but this was
certainly not the primary object of the…treatment. The Greeks did
not even think about enjoying happiness without taking pain in their
stride. Pain was the soul’s experience of evolution…
The body had not yet been divorced from
the soul, nor had sickness been divorced from pain. All words that
indicated bodily pain were equally applicable to the suffering of the
soul.
[The] raised threshold of physiologically
mediated experience, which is characteristic of a medicalised
society, makes it extremely difficult today to recognize in the
capacity for suffering a possible symptom of health. The reminder
that suffering is a responsible activity is almost unbearable to
consumers, for whom pleasure and dependence on industrial outputs
coincide.
During the 17th
and 18th
centuries, doctors who applied measurements to sick people were
liable to be considered quacks by their colleagues. During the French
Revolution, English doctors still looked askance at clinical
thermometry, Together with the routine taking of the pulse, it became
accepted clinical practice only around 1845, nearly thirty years
after the stethoscope was first used by Laenne.
An advanced industrial society is
sick-making because it disables people from coping with their
environment and, when they break down, it substitutes a ‘clinical’
prosthesis for the broken relationships.
People would rebel against such an
environment if medicine did not explain their biological
disorientation as a defect in their health, rather than as a defect
in the way of life which is imposed on them or which they impose on
themselves.
The medical diagnosis of substantive
disease entities that supposedly take shape in the individual’s
body is a surreptitious and amoral way of blaming the victim. The
physician, himself a member of the dominating class, judges that the
individual does not fit into an environment that has been engineered
and is administered by other professionals, instead of accusing his
colleagues of creating environments into which the human organism
cannot fit.
Before sickness came to be perceived
primarily as an organic or behavioural abnormality, he who got sick
could still find in the eyes of the doctor a reflection of his own
anguish and some recognition of the uniqueness of his suffering. Now,
what he meets is the gaze of a biological accountant engaged in
input/output calculations. His sickness is taken from him and turned
into the raw material for an institutional enterprise. His condition
is interpreted according to a set of abstract rules in a language he
cannot understand. He is taught only about alien entities that the
doctor combats, but only just as much as the doctor considers
necessary to gain the patient’s cooperation. Language is taken over
by the doctors: the sick person is deprived of meaningful words for
his anguish, which is thus further increased by linguistic
mystification.
…while the industrial worker refers to
his ache as a drab ‘it’ that hurts, his predecessors had many
colourful and expressive names for the demons that bit or stung them.
Through the medicalisation of death,
health care has become a monolithic world religion…
Like time-consuming acceleration,
stupefying education, self-destructive military defence, disorienting
information, or unsettling housing projects, pathogenic medicine is
the result of industrial overproduction that paralyses autonomous
action.
The patient is reduced to an object
– his body – being repaired; he is no longer a subject being
helped to heal. If he is allowed to participate in the repair
process, he acts as the lowest apprentice in a hierarchy of
repairmen. Often he is not even trusted to take a pill without the
supervision of a nurse.
When people become aware of their
dependence on the medical industry, they tend to be trapped in the
belief that they are already hopelessly hooked. They fear a life of
disease without a doctor much as they would feel immobilized without
a car or bus.
Increasing and irreparable damage
accompanies present industrial expansion in all sectors. In medicine
this damage appears as iatrogenesis. Iatrogenesis is clinical when
pain, sickness and death result from medical care; it is social when
health policies reinforce an industrial organization that generates
ill-health; it is cultural and symbolic when medically sponsored
behaviour and delusions restrict the vital autonomy of people by
undermining their competence in growing up, caring for each other,
and aging, or when medical intervention cripples personal responses
to pain, disability, impairment, anguish and death.
Man’s consciously lived fragility,
individuality, and relatedness make the experience of pain, of
sickness, and of death an integral part of his life. The ability to
cope with this trio autonomously is fundamental to his health. As he
becomes dependent on the management of his intimacy, he renounces his
autonomy and his health must
decline.
The true miracle of modern
medicine is diabolical. It consists in making not only individuals
but whole populations survive on inhumanly low levels of personal
health. Medical nemesis is the negative feedback of a social
organization that sets out to improve and equalize the opportunity
for each man to cope in autonomy and ended by destroying it.
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