20 mai 2017

Ivan Illich, Medical Nemesis, The Expropriation of Health (note de lectura)

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.


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


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

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.

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 set out to improve and equalize the opportunity for each man to cope in autonomy and ended by destroying it.

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