Pantheon Books, New York, 1976, Random House Inc.
1. The Epidemics of Modern Medicine
During the past three generations the diseases afflicting
Western societies have undergone dramatic changes. Those are equated with a
decrease in suffering and attributed to better medical care.
There is in fact no evidence of any direct relationship
between this mutation of sickness and the so-called progress of medicine.
An expanding proportion of the new burden of disease of the
last 15 years is the result of medical intervention in favor of people who are
or might become sick (iatrogenic diseases).
medical Utopia
Doctor’s 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.
Some very important statistics about diseases – page 6
Analysis of disease trends has shown that the environment is
the primary determinant of the state of
general health of any population.
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.
Useless Medical Treatment
The procedures 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.
The pain, dysfunction, disability, and anguish resulting
from technical medical intervention now rival the morbidity due to traffic and
industrial accidents and even-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.
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. 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.
Unnecessary surgery is a standard
procedure.
Doctor-inflicted pain and infirmity have
always been a part of medical practice.
The frequency of reported accidents in
hospitals is higher than in all industries but mines and high-rise
construction.
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. (clinical iatrogenesis)
On a second level, medical practice
sponsors sickness by reinforcing a morbid society that encourages people to become
consumers of curative, preventive, industrial, and environmental medicine.
(social iatrogenesis)
social overmedicalization -> the
expropriation of health
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. (cultural
iatrogenesis)
health management designed on the
engineering model
Each of its three levels iatrogenesis has
become medically irreversible: a feature built right into the medical endeavor.
Nemesis represented nature’s response to
hubris: to the individual’s presumption in seeking to acquire the attributes of
a god.
the counterintuitive behavior of large
systems
industrially determined logic and ethos
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.
2. The Medicalization of Life
Political Transmission of Iatrogenic
Disease
Until recently, medicine attempted to
enhance what occurs in nature. Now medicine tries to engineer the dreams of
reason (ex: oral contraceptives).
Social Iatrogenesis
When medical damage to individual health
is produced by a sociopolitical mode of transmission, I will speak of
"social iatrogenesis," a term designating all impairments to health
that are due precisely to those socio-economic transformations which have been
made attractive, possible, or necessary by the institutional shape health care
has taken.
Social iatrogenesis:
- increasing stress
- multiplying disabling dependence
- generating new painful needs
- lowering the levels of tolerance for
discomfort and pain
- reducing the leeway that people are wont
to concede to an individual when he suffers
- abolishing the right to self-care.
Medical Monopoly
When the intensity of biomedical
intervention crosses a critical threshold, clinical iatrogenesis turns from
error, accident, or fault into an incurable perversion of medical practice.
Value-free Cure?
Some
physicians insist that medicine cannot be practiced without the iatrogenic
creation of disease.
In every society, medicine, like law and
religion, defines what is normal, proper, or desirable.
Medicine has the
authority to label one man's complaint a legitimate illness, to declare a
second man sick though he himself does not complain, and to refuse a third
social recognition of his pain, his disability, and even his death.
Medicine is a moral enterprise. Anyway, in
the modern world, the divorce between medicine and morality has been defended
on the ground that medical categories, unlike those of law and religion, rest
on scientific foundations exempt from moral evaluation.
narcissistic scientism
The Medicalization of the Budget
The most handy measure of the
medicalization of life is the share taken out of a typical yearly income to be
spent under doctor's orders.
The proverb "Few lawyers die well,
few physicians live well" had its equivalent in most European languages.
Now physicians have come to the top, and in capitalist societies this top is
high indeed.
Indirectly, conspicuous therapies serve as
powerful devices to convince people that they should pay more taxes to get them
to all those whom doctors have declared in need.
More health damage is caused by people's
belief that they cannot cope with their illness unless they call on the doctor than
doctors could ever cause by foisting their ministrations on people.
A long debated point: that almost all
demonstrably effective technical health devices can be taken over within months
and used competently by millions of ordinary people.
barefoot medecine
a "nightmare forged from good
intentions"
The more time, toil, and sacrifice spent
by a population in producing medicine as a commodity, the larger will be the
by-product, namely, the fallacy that society has a supply of health locked away which can be mined and
marketed.
The negative function of money is that of
an indicator of the devaluation of goods and services that cannot be bought. The higher the price tag at which well-being is commandeered, the greater will
be the political prestige of an expropriation of personal health.
The Pharmaceutical Invasion
a culture can become the prey of a
pharmaceutical invasion
Powerful medical drugs easily destroy the
historically rooted pattern that fits each culture to its poisons; they usually
cause more damage than profit to health, and ultimately establish a new
attitude in which the body is perceived as a machine run by mechanical and
manipulating switches.
The fiction which is meant to exorcise the
drug by medicalizing it in fact only confounds the buyer. The warning to
consult a doctor makes the buyer believe he is incompetent to beware. In most
countries of the world, doctors are simply not well enough spread out to
prescribe double-edged medicine each time it is indicated, and most of the time
they themselves are not prepared, or are too ignorant, to prescribe with due
prudence. As a consequence the physician's function, especially in poor
countries, has become trivial: he has been turned into a routine prescription machine
that is constantly ridiculed, and most people now take the same drugs, just as
haphazardly, but without his approval.
Reliance on prescription can be useless
for the protection of patients and can even promote abuse.
In all countries, doctors work
increasingly with two groups of addicts: those for whom they prescribe drugs,
and those who suffer from their consequences. The richer the community, the
larger the percentage of patients who belong to both.
The sickness resulting from each successive
course of miracle foods is dealt with by serving still another course of drugs.
Thus overconsumption reflects a socially sanctioned, sentimental hankering for
yesterday's progress.
Opinions vary about the actual number of useful
drugs: some experienced clinicians believe that less than two dozen basic drugs
are all that will ever be desirable for 99 percent of the total population; others,
that up to four dozen items are optimal for 98 percent.
The drug age began to decline in 1956.
Considerable research has so far produced
no reason to suspect that drugs marketed under their generic names in the
United States are less effective than their brand-named counterparts, which
cost from 3 to 15 times more.
the pharmaceutical invasion
The fallacy that society is caught forever
in the drug age is one of the dogmas with which medical policy-making has been
encumbered: it fits industrialized man. He has learned to try to purchase whatever he fancies. He gets nowhere
without transportation or education; his environment has made it impossible for
him to walk, to learn, and to feel in control of his body. To take a drug, no
matter which and for what reason—is a last chance to assert control over
himself, to interfere on his own with his body rather than let others
interfere. The pharmaceutical invasion leads him to medication, by himself or
by others, that reduces his ability to cope with a body for which he can still
care.
Diagnostic Imperialism
In a medicalized society the influence of
physicians extends not only to the purse and the medicine chest but also to the
categories to which people are assigned. Medical bureaucrats subdivide 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 United States, those who are dead, those who are competent to commit a
crime, and those who are liable to commit one.
The ritualization of stages of life is
nothing new; what is new is their intense medicalization.
Once a society is so organized that
medicine can transform people into patients because they are unborn, newborn,
menopausal, or at some other "age of risk," the population inevitably
loses some of its autonomy to its healers.
the hospital – “the modern cathedral”
“For the sick, the least is best.”
(Hippocrates)
The fact that modern medicine has become
very effective in the treatment of specific symptoms does not mean that it has
become more beneficial for the health of the patient.
Old age has been medicalized at precisely
the historical moment when it has become a more common occurrence for
demographic reasons.
Only the very rich and the very
independent can choose to avoid that medicalization of the end to which the
poor must submit and which becomes increasingly intense and universal as the
society they live in becomes richer.
As the bottle became a status symbol, new
illnesses appeared among children who had been denied the breast, and since
mothers lack traditional know-how to deal with babies who do not behave like
sucklings, babies became new consumers of medical attention and of its risks.
ill-health
Preventive Stigma
Medicine has begun to market prevention.
People are turned into patients without being sick.
Medicalized prevention turns the physician
into an officially licensed magician.
In the detection of sickness medicine does
two things: it "discovers" new disorders, and it ascribes these
disorders to concrete individuals. To discover a new category of disease is the
pride of the medical scientist.
Diagnostic bias in favor of sickness
combines with frequent diagnostic error. Medicine not only imputes questionable
categories with inquisitorial enthusiasm; it does so at a rate of miscarriage
that no court system could tolerate.
In addition to diagnostic bias and error,
there is wanton aggression.
Terminal Ceremonies
Therapy reaches its apogee in the
death-dance around the terminal patient.
the ritualization of crisis, a general
trait of a morbid society
Hospital death is now endemic.
Death without medical presence becomes
synonymous with romantic pigheadedness, privilege, or disaster.
Hospital "worship" is unrelated
to the hospital's performance.
Black Magic
Even in those circumstances in which the
physician is technically equipped to play the technical role to which he
aspires, he inevitably also fulfills religious, magical, ethical, and political
functions. In each of these functions the contemporary physician is more
pathogen than healer or just anodyne.
It took scientific medicine considerable
time to recognize its own practitioners as part-time magicians.
Whenever a sugar pill works because it is
given by the doctor, the sugar pill acts as a placebo.
The doctors are part-time magicians.
The separate cults of education,
transportation, and mass communication promote, under different names, the same
social myth which Voegelin describes as contemporary gnosis. Common to a
gnostic world-view and its cult are six characteristics: (1) it is practiced by
members of a movement who are dissatisfied with the world as it is because they
see it as intrinsically poorly organized. Its adherents are (2) convinced that
salvation from this world is possible (3) at least for the elect and (4) can be
brought about within the present generation. Gnostics further believe that this
salvation depends (5) on technical actions which are reserved (6) to initiates
who monopolize the special formula for it. All these religious beliefs underlie
the social organization of technological medicine, which in turn ritualizes and
celebrates the nineteenth-century ideal of progress.
The first occupation to monopolize health
care is that of the physician of the late twentieth century.
Entire branches of medicine continue to be
financed because they have been invested with nontechnical, usually symbolic
power.
It can be argued that in precisely those
narrow areas in which high-cost medicine has become more specifically
effective, its symbolic side-effects have become overwhelmingly health-denying:
the traditional white medical magic that supported the patient's own efforts to
heal has turned black.
Social iatrogenesis is a nocebo.
Medical procedures turn into black magic when, instead of mobilizing his self healing
powers, they transform the sick man into a limp and mystified voyeur of his own
treatment. Medical procedures turn into sick religion when they are performed as rituals that focus the entire expectation
of the sick on science and its functionaries instead of encouraging them to
seek a poetic interpretation of their predicament or find an admirable example
in some person—long dead or next door—who learned to suffer.
Medical procedures multiply disease by moral degradation when they isolate the sick in a
professional environment rather than providing society with the motives and
disciplines that increase social tolerance for the troubled. Magical havoc, religious
injury, and moral degradation generated under the pretext of a biomedical pursuit
are all crucial mechanisms contributing to social iatrogenesis. They are amalgamated
by the medicalization of death.
the medicalization of the miracle
Patient Majorities
Whenever medicine's diagnostic power
multiplies the sick in excessive numbers, medical professionals turn over the
surplus to the management of nonmedical trades and occupations. By dumping, the
medical lords divest themselves of the nuisance of low-prestige care and invest
policemen, teachers, or personnel officers with a derivative medical fiefdom. Each
civilization defines its own diseases. What is sickness in one might be chromosomal
abnormality, crime, holiness, or sin in another. Each culture creates its
response to disease.
Previously modern medicine controlled only
a limited market; now this market has lost all boundaries. Unsick people have
come to depend on professional care for the sake of their future health. The
result is a morbid society that demands universal medicalization and a medical
establishment that certifies universal morbidity.
everybody tends to be a patient in some
respect
Part III. Cultural Iatrogenesis
Introduction
clinical iatrogenesis, which results when
organic coping capacity is replaced by heteronomous management
social iatrogenesis, in which the
environment is deprived of those conditions that endow individuals, families,
and neighborhoods with control over their own internal states and over their
milieu
cultural iatrogenesis sets in when the
medical enterprise saps the will of people to suffer their reality
Professionally organized medicine has come
to function as a domineering moral enterprise that advertises industrial
expansion as a war against all suffering. It has thereby undermined the ability
of individuals to face their reality, to express their own values, and to
accept inevitable and often irremediable pain and impairment, decline and
death.
To a large extent culture and health
coincide.
Medicalization constitutes a prolific
bureaucratic program based on the denial of each man's need to deal with pain,
sickness, and death.
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. This progressive flattening out of personal,
virtuous performance constitutes a new goal which has never before been a
guideline for social life. Suffering, healing, and dying, which are essentially
intransitive activities that culture taught each man, are now claimed by
technocracy as new areas of policy-making and are treated as malfunctions from
which populations ought to be institutionally relieved.
3. The Killing of Pain
When cosmopolitan medical civilization
colonizes any traditional culture, it transforms the experience of pain.
People unlearn the acceptance of suffering
as an inevitable part of their conscious coping with reality and learn to interpret
every ache as an indicator of their need for padding or pampering.
Any society in which the intensity of
discomforts and pains inflicted rendered them culturally "insufferable"
could not but come to an end. Now an increasing portion of all pain is
man-made, a side-effect of strategies for industrial expansion.
Traditional cultures and technological
civilization start from opposite assumptions. In every traditional culture the
psychotherapy, belief systems, and drugs needed to withstand most pain are
built into everyday behavior and reflect the conviction that reality is harsh
and death inevitable. In the twentieth century dystopia, the necessity to bear
painful reality, within or without, is interpreted as a failure of the
socio-economic system, and pain is treated as an emergent contingency which
must be dealt with by extraordinary interventions.
As culture is medicalized, the social
determinants of pain are distorted.
Three special problems for the historian
of pain:
a) the profound transformation undergone
by the relationship of pain to the other ills man can
suffer
b) the language: the term taken over by
the doctors covers grief, sorrow, anguish, shame, and guilt
c) its exceptional axiological and epistemological
status.
Pain is the sign for something not
answered; it refers to something open, something that goes on the next moment
to demand, What is wrong? How much longer? Why must I/ought I/should I/can I/
suffer? Why does this kind of evil exist, and why does it strike me?
Living in a society that values
anesthesia, both doctors and their potential clients are retrained to smother
pain's intrinsic question mark.
To enable individuals to transform bodily
pain into a personal experience, any culture provides at least four
interrelated subprograms: words, drugs, myths, and models.
As long as the doctor conceived of himself
primarily as a healer, pain assumed the role of a step towards the restoration
of health. Where the doctor could not heal, he felt no qualms about telling his
patient to use analgesics and thus moderate inevitable suffering.
It would be a grave mistake to believe
that resignation to pain is due exclusively to Jewish or Christian influence.
Thirteen distinct Hebrew words were translated by a single Greek term for
"pain" when two hundred Jews of the second century B.C. translated
the Old Testament into Greek.
The category of modern medical pain is
totally alien to the Hebrew text.
In the New Testament, pain is considered
to be intimately entwined with sin.
For the Neo-Platonist, pain was
interpreted as the result of some deficiency in the celestial hierarchy.
Progress in civilization became synonymous
with the reduction of the sum total of suffering.
With rising levels of induced
insensitivity to pain, the capacity to experience the simple joys and pleasures
of life has equally declined. Increasingly stronger stimuli are needed to
provide people in an anesthetic society with any sense of being alive.
Drugs, violence, and horror turn into
increasingly powerful stimuli that can still elicit an experience of self.
Widespread anesthesia increases the demand for excitation by noise, speed,
violence—no matter how destructive.
suffering is a responsible activity
Increasingly, pain-killing turns people
into unfeeling spectators of their own decaying selves.
4. The Invention and Elimination of
Disease
The French Revolution gave birth to two
great myths: one, that physicians could replace the clergy; the other, that
with political change society would return to a state of original health.
Sickness became a public affair. In the name of progress, it has now ceased to
be the concern of those who are ill.
the mirage of health
The object of medical treatment was
defined by a new, though submerged, political ideology and acquired the status of
an entity that existed quite separately from both doctor and patient.
We tend to forget how recently disease
entities were born.
All disease is a socially created reality.
Advanced industrial societies have a high
stake in maintaining the epistemological legitimacy of disease entities.
In fact, the overwhelming majority of diagnostic
and therapeutic interventions that demonstrably do more good than harm have two
characteristics: the material resources for them are extremely cheap, and they
can be packaged and designed for self-use or application by family members.
5. Death against Death
Death as Commodity
In every society the dominant image of
death determines the prevalent concept of health. Such an image, the culturally
conditioned anticipation of a certain event at an uncertain date, is shaped by
institutional structures, deep-seated myths, and the social character that
predominates. A society's image of death reveals the level of independence of
its people, their personal relatedness, self-reliance, and aliveness.
Wherever the metropolitan medical
civilization has penetrated, a novel image of death has been imported. Insofar
as this image depends on the new techniques and their corresponding ethos, it
is supranational in character.
The image of a "natural death,"
a death which comes under medical care and finds us in good health and old age,
is a quite recent ideal. In five hundred years it has evolved through five
distinct stages, and is now ready for a sixth. Each stage has found its
iconographic expression: (1) the fifteenth-century "dance of the
dead"; (2) the Renaissance dance at the bidding of the skeleton man, the
so-called "Dance of Death"; (3) the bedroom scene of the aging lecher
under the Ancien Régime; (4) the nineteenth-century doctor in his struggle
against the roaming phantoms of consumption and pestilence; (5) the
mid-twentieth-century doctor who steps between the patient and his death; and
(6) death under intensive hospital care.
The Devotional Dance of the Dead
For a thousand years Christian churches
and cemeteries remained dance floors. Death was an occasion for the renewal of
life.
Dancing with the dead on their tombs was
an occasion for affirming the joy of being alive and a source of many erotic
songs and poems.
Primitive societies conceived of death as
the result of an intervention by an alien actor. They did not attribute
personality to death. Death is the outcome of someone's evil intention. This
somebody who causes death might be a neighbor who, in envy, looks at you with
an evil eye, or it might be a witch, an ancestor who comes to pick you up, or
the black cat that crosses your path. Throughout the Christian and Islamic
Middle Ages, death continued to be regarded as the result of a deliberate
personal intervention of God.
The Danse Macabre
By the end of the fifteenth century, no
longer just a mirror image, he assumes the leading role among the "last
four things," preceding judgment, heaven, and hell.
The representation of each man as entwined
with his own mortality has now changed to show his frenzied exhaustion in the
grip of death painted as a force of nature. The intimate mirror-image of the
"self" which had been colored by the "new devotion" of the
German mystics has been replaced by a death painted as the egalitarian
executioner of a law that whirls everyone along and then mows them down. From a
lifelong encounter, death has turned into the event of a moment.
With the predominance of serial time,
concern for its exact measurement, and the recognition of the simultaneity of events,
a new framework for the recognition of personal identity is manufactured.
The identity of the person is sought in
reference to a sequence of events rather than in the completeness of one's life
span. Death ceases to be the end of a whole and becomes an interruption in the
sequence.
Thus during the sixteenth century, death
ceases to be conceived of primarily as a transition into the next world, and
the accent is placed on the end of this life.
In popular devotion a new kind of
curiosity about the afterlife developed.
Fantastic horror stories about dead bodies
and artistic representations of purgatory both multiplied.
The question whether medicine ever could "prolong"
life was considered blasphemous.
The new image of death helped to reduce
the human body to an object. Up to this time, the corpse had been considered
something quite unlike other things: it was treated almost like a person.
During the Middle Ages, the human body had
been sacred; now the physician's scalpel had access to the corpse itself.
Bourgeois Death
Francis Bacon was the first to speak about
the prolongation of life as a new task for physicians.
The medical profession did not even consider
facing this task, until, some one hundred and fifty years later, there appeared
a host of clients who were anxious to pay for the attempt. This was a new type
of rich man who refused to die in retirement and insisted on being carried away
by death from natural exhaustion while still on the job. He refused to accept death
unless he was in good health in an active old age.
Clinical Death
We have seen death turn from God's call
into a "natural" event and later into a "force of nature";
in a further mutation it had turned into an "untimely" event when it
came to those who were not both healthy and old. Now it had become the outcome
of specific diseases certified by the doctor.
While "timely" death had
originated in the emerging class consciousness of the bourgeois,
"clinical" death originated in the emerging professional
consciousness of the new, scientifically trained doctor. Henceforth, a timely
death with clinical symptoms became the ideal of middle-class doctors, and it
was soon to become incorporated into the aspirations of trade unions.
Trade Unions Claims to a Natural Death
In our century a valetudinarian's death
while undergoing treatment by clinically trained doctors came to be perceived,
for the first time, as a civil right.
A reputable dictionary of philosophical
concepts states that "natural death comes without previous sickness,
without definable specific cause." It was this macabre hallucinatory
death-concept that became intertwined with the concept of social progress.
the right to a natural death
First of all, this new image of death
endorses new levels of social control. Society has become responsible for
preventing each man's death: treatment, effective or not, can be made into a
duty. Any fatality occurring without medical treatment is liable to become a
coroner's case. The encounter with a doctor becomes almost as inexorable as the
encounter with death.
The good death has irrevocably become that
of the standard consumer of medical care. Just as at the turn of the century
all men were defined as pupils, born into original stupidity and standing in
need of eight years of schooling before they could enter productive life, today
they are stamped from birth as patients who need all kinds of treatment if they
want to lead life the right way.
During the late Middle Ages, the discovery
of "natural" death became one of the mainsprings of European lyric
and drama. But the same imminence of death, once perceived as an extrinsic
threat coming from nature, became a major challenge for the emerging engineer. If
the civil engineer had learned to manage earth, and the pedagogue-become-educator
to manage knowledge, why should the biologist physician not manage death? When
the doctor contrived to step between humanity and death, the latter lost the
immediacy and intimacy gained four hundred years earlier. Death that had lost
face and shape had lost its
dignity.
For every premature or clinically
unnecessary death, somebody or some body can be found who irresponsibly delayed
or prevented a medical intervention.
Death Under Intensive Care
We cannot fully understand the deeply
rooted structure of our social organization unless we see in it a multifaceted
exorcism of all forms of evil death. Our major institutions constitute a
gigantic defense program waging war on behalf of "humanity" against
death-dealing agencies and classes.
Curiously, death became the enemy to be
defeated at precisely the moment at which megadeath came upon the scene.
The impersonal rituals of industrialized
medicine create an ersatz unity of mankind. They tie all its members into a
pattern of "desirable" death by proposing hospital death as the goal
of economic development.
The expectation of medicalized death hooks
the rich on unlimited insurance payments and lures the poor into a gilded deathtrap.
The contradictions of bourgeois individualism are corroborated by the inability
of people to die with any possibility of a realistic attitude towards death.
Like all other major rituals of industrial
society, medicine in practice takes the form of a game.
Through the medicalization of death,
health care has become a monolithic world religion whose tenets are taught in
compulsory schools and whose ethical rules are applied to a bureaucratic
restructuring of the environment: sex has become a subject in the syllabus and
sharing one's spoon is discouraged for the sake of hygiene.
Mechanical death has conquered and
destroyed all other deaths.
6. Specific Counterproductivity
Like time-consuming acceleration,
stupefying education, self-destructive military defense, disorienting
information, or unsettling housing projects, pathogenic medicine is the result
of industrial verproduction that
paralyzes autonomous action.
pathogenic medicine
Frustrating overproduction must be clearly
distinguished from two other categories of economic burdens with which it is
generally confused, namely, declining marginal utility and negative
externality.
a radical critique of the instrumental
effectiveness
Direct costs reflect rental charges,
payments made for labor, materials, and other considerations.
Negative externality is the name of the social costs that are
not included in the monetary price; it is the common designation for the
burdens, privations, nuisances, and injuries that I impose on others.
Counterproductivity is something other than either an individual or a
social cost; it is distinct from the declining utility obtained for a unit of
currency and from all forms of external disservice. It exists whenever the use
of an institution paradoxically takes away from society those things the
institution was designed to provide. It is a form of built-in social
frustration.
Counterproductivity is the result of an
industrially induced paralysis of practical self-governing activity.
Schools produce education, motor vehicles
produce locomotion, and medicine produces health care.
the industrialization of our world-view
The arrangement of society in favor of
managed commodity production has two ultimately destructive aspects: people are
trained for consumption rather than for action, and at the same time their
range of action is narrowed.
When perception of personal needs is the
result of professional diagnosis, dependence turns into painful disability.
The ecological movement has created an
awareness that health depends on the environment—on food and working conditions
and housing—and Americans have come to accept the idea that they are threatened
by pesticides, additives, and mycotoxins and other health risks due to
environmental degradation.
Consumer Protection for Addicts
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 a bus. In this
state of mind they are ready to be organized for consumer protection and to
seek solace from politicians who will check the high-handedness of medical
producers.
The sad truth for consumer advocates is
that neither control of cost nor assurance of quality guarantees that health
will be served by medicine that measures up to present medical standards.
Unless it disabuses the client of his urge
to demand and take more services, consumer protection only reinforces the
collusion between giver and taker, and can play only a tactical and a
transitory role in any political movement aimed at the health-oriented
limitation of medicine. Consumer-protection movements can translate information
about medical ineffectiveness now buried in medical journals into the language
of politics, but they can make substantive contributions only if they develop
into defense leagues for civil liberties and move beyond the control of quality
and cost into the defense of untutored freedom to take or leave the goods.
Equal Access to Torts
The most common and obvious political
issue related to health is based on the charge that access to medical care is
inequitable, that it favors the rich over the poor, the influential over the
powerless.
One sure way to extinguish freedom to
speak, to learn, or to heal is to delimit them by transmogrifying civil rights
into civic duties. The freedoms of the self-taught will be abridged in an
overeducated society just as the freedom to health care can be smothered by
overmedicalization. Any sector of the economy can be so expanded that for the
sake of more costly levels of equality, freedoms are extinguished.
Public Control over the Professional Mafia
A third category of political remedies for
unhealthy medicine focuses directly on how doctors
do their work. Like consumer advocacy and legislation of access, this attempt
to impose lay control on the medical organization has inevitable health denying
effects when it is changed from an ad hoc tactic into a general strategy.
The cost of coordinating the treatment of
the same patient by several specialists grows exponentially with each added
competence, as does the risk of mistakes and the probability of damage due to
the unexpected combination of different therapies.
Organized medicine has practically ceased
to be the art of healing the curable, and consoling the hopeless has turned
into a grotesque priesthood concerned with salvation and has become a law unto
itself. The policies that promise the public some control over the medical endeavor
tend to overlook the fact that to achieve their purpose they must control a church,
not an industry.
The Scientific Organization of Life
Such idolatry of science overlooks the
fact that research conducted as if medicine were an ordinary science, diagnosis
conducted as if patients were specific cases and not autonomous persons, and
therapy conducted by hygienic engineers are the three approaches which coalesce
into the present endemic health-denial.
In the pursuit of applied science the medical profession has largely
ceased to strive towards the goals of an association of artisans who use
tradition, experience, learning, and intuition, and has come to play a role
reserved to ministers of religion, using scientific principles as its theology
and technologists as acolytes. As an enterprise, medicine is now concerned less
with the empirical art of healing the curable and much more with the rational
approach to the salvation of mankind from attack by illness, from the shackles
of impairment, and even from the necessity of death.
The technocrats of medicine tend to
promote the interests of science rather than the needs of society.
The
practitioners corporately constitute a research bureaucracy. Their primary
responsibility is to science in the abstract or, in a nebulous way, to their
profession. Their personal responsibility for the particular client has been
resorbed into a vague sense of power extending over all tasks and clients of
all colleagues. Medical science applied by medical scientists provides the
correct treatment, regardless of whether it results in a cure, or death sets
in, or there is no reaction on the part of the patient. It is legitimized by statistical
tables, which predict all three outcomes with a certain frequency. The individual
physician in a concrete case may still remember that he owes nature and the
patient as much gratitude as the patient owes him if he has been successful in the
use of his art. But only a high level of tolerance for cognitive dissonance
will allow him to carry on in the divergent roles of healer and scientist. the religion
of scientism
Deprofessionalization of medicine means
the unmasking of the myth according to which technical progress demands the
solution of human problems by the application of scientific principles, the
myth of benefit through an increase in the specialization of labor, through
multiplication of arcane manipulations, and the myth that increasing dependence
of people on the right of access to impersonal institutions is better than
trust in one another.
Engineering for a Plastic Womb
Medical strategies fail because they
concentrate too much effort on sickness and too little on changing the
environment that makes people sick.
alternatives to clinical intervention
The time has come not only for public
assessment of medicine but also for public disenchantment with those monsters
generated by the dream of environmental engineering. If contemporary medicine
aims at making it unnecessary for people to feel or to heal, eco-medicine
promises to meet their alienated desire for a plastic womb.
8. The Recovery of Health
Much suffering has been man-made. The
history of man is one long catalogue of enslavement and exploitation, usually
told in the epics of conquerors or sung in the elegies of their victims. War is
at the heart of this tale, war and the pillage, famine, and pestilence that
came in its wake. But it was not until modern times that the unwanted physical,
social, and psychological side-effects of so-called peaceful enterprises began to
compete with war in destructive power.
Man is the only animal whose evolution has
been conditioned by adaptation on more than one front. If he did not succumb to
predators and forces of nature, he had to cope with use and abuse by others of
his own kind. In his struggle with the elements and with his neighbor, his
character and culture were formed, his instincts withered, and his territory
was turned into a home.
But nature and neighbor are only two of
the three frontiers on which man must cope. A third front where doom can
threaten has always been recognized. To remain viable, man must also survive
the dreams which so far myth has both shaped and controlled. Now society must
develop programs to cope with the irrational desires of its most gifted
members. To date, myth has fulfilled the function of setting limits to the
materialization of greedy, envious, murderous dreams. Myth assured the common
man of his safety on this third frontier if he kept within its bounds. Myth guaranteed
disaster to those few who tried to outwit the gods. The common man perished
from infirmity or from violence; only the rebel against the human condition
fell prey to Nemesis, the envy of the gods.
Industrialized Nemesis
With the industrialization of desire and
the engineering of corresponding ritual responses, hubris has spread.
Nemesis for the masses is now the
inescapable backlash of industrial progress. Modern nemesis is the material
monster born from the overarching industrial dream. It has spread as far and as
wide as universal schooling, mass transportation, industrial wage labor, and
the medicalization of health.
The main source of pain, of disability,
and of death is now engineered, albeit nonintentional, harassment. Our
prevailing ailments, helplessness, and injustice are largely the side-effects
of strategies for more and better education, better housing, a better diet, and
better health.
General law: When more than a certain
proportion of value is produced by the industrial mode, subsistence activities
are paralyzed, equity declines, and total satisfaction diminishes.
Defenders of industrial progress are
either blind or corrupt if they pretend that they can calculate the price of
progress. The torts resulting from nemesis cannot be compensated, calculated,
or liquidated. The down-payment for industrial development might seem
reasonable, but the compound-interest installments on expanding production now
accrue in suffering beyond any measure or price. When members of a society are
regularly asked to pay an even higher price for industrially defined
necessities—in spite of evidence that they are purchasing more suffering with
each unit—Homo
economicus, driven by the
pursuit of marginal benefits, turns into Homo religiosus, sacrificing himself to industrial ideology.
From Inherited Myth to Respectful Procedure
The loss of a normative "human
condition" introduces a newness not only into the human act but also into
the human attitude towards the framework in which a person acts. If this action
is to remain human after the framework has been deprived of its sacred
character, it needs a recognized ethical foundation within a new imperative.
This imperative can be summed up only as follows: "Act so that the effect
of your action is compatible with the permanence of genuine human life."
Very concretely applied, this could mean: "Do not raise radiation levels
unless you know that this action will not be visited upon your
grandchild." Such an imperative obviously cannot be formulated as long as "genuine
human life" is considered an infinitely elastic concept.
Recent history has shown that the taboos
of traditional cultures are irrelevant in combatting an overextension of
industrial production. The taboos were tied to the values of a particular
society and its mode of production, and it is precisely those that were
irrevocably lost in the process of industrialization.
Better health care will depend, not on
some new therapeutic standard, but on the level of willingness and competence
to engage in self-care.
The Right to Health
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 behavior 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.
Medical nemesis is the experience of people
who are largely deprived of any autonomous ability to cope with nature, neighbors,
and dreams, and who are technically maintained within environmental, social,
and symbolic systems. Medical nemesis cannot be measured, but its experience
can be shared. The intensity with which it is experienced will depend on the
independence, vitality, and relatedness of each individual..
Health as a Virtue
Health designates a process by which each person
is responsible, but only in part responsible to others. To be responsible may
mean two things. A man is responsible for what he has done, and responsible to
another person or group. Only when he feels subjectively responsible or
answerable to another person will the consequences of his failure be not
criticism, censure, or punishment but regret, remorse, and true repentance.
A world of optimal and widespread health
is obviously a world of minimal and only occasional medical intervention.
Healthy people are those who live in healthy homes on a healthy diet in an
environment equally fit for birth, growth, work, healing, and dying; they are
sustained by a culture that enhances the conscious acceptance of limits to
population, of aging, of incomplete recovery and ever imminent death. Healthy
people need minimal bureaucratic interference to mate, give birth, share the
human condition, and die.
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