Title: Limits to Medicine. Medical Nemesis: The Expropriation of Health (1975)
Author: Ivan Illich
Publisher: Marion Boyars
Ivan Illich was a philosopher and historian who published
several books in the 1970s targeting areas like medicine, transport, education
and energy use. His thesis was that modern, western, industrialisation and in
particular the institutionalization of specialised knowledge by the professions
has far-reaching negative consequences. His 1975 book Limits to Medicine. Medical Nemesis: The Expropriation of Health made his case against modern, institutionalised medicine. He felt that more
expensive and specialised medicine was more likely to be harmful and less effective, and that
important aspects of the life experience such as birth, mating, suffering,
aging and dying were being medicalized. His points were interesting and
controversial in their time, and the following 40-odd years of growth in specialised
industrial medicine has made many of them prescient.
Illich compares medicine to religion. To carry that further,
I would say that giving this book to a doctor is like giving a copy of The God Delusion to a minister of
religion. However Illich is not a scientist, and therefore he doesn’t give you
the stats. Then again, much of what he is saying is not measurable, like the
loss of autonomy of the individual to cope with what life has dealt them. Illich
may be right, but he does not provide us with a confidence interval. If he isn't right, at least he makes us think.
I tried to be lenient regarding his lack of science (his
anti-science?) but it often let him down. Treating patients based on
probabilities of success is considered by Illich to be experimentation. While
it may lack compassion and seem formulaic, all treatments (and in fact all
decisions, in the absence of certainty) are based on balancing probabilities.
The other big negative about the book is its sheer density.
I was often reading sentences twice (and I have read the book before!) and
sometimes I just gave up trying to decipher the meaning. Here are some of the
issues that I think I understood.
Iatrogenesis
Much of the book is taken up with an explanation of the
three main forms of iatrogenesis
(harm from medicine).
1. Clinical iatrogenesis. This includes the usual kind of
iatrogenesis: direct harm from medical practice, but also includes the harm of
removing an individual’s ability to cope autonomously (much more on this later).
2. Social iatrogenesis involves the conversion of
health care to the default: a staple. It occurs when normal experiences (such
as suffering, mourning and healing) are labelled and accepted as deviances, and
therefore fall under the purview of medicine. It also covers the “disease-hunts” (screening) that are often ineffective, but turn healthy people into
patients anxious for a verdict, and expose many of them to unnecessary and
harmful procedures.
3. Cultural iatrogenesis occurs when the traditional
cultural means of managing sickness, suffering and dying and the cultural
meaning of these experiences are lost; replaced by values imposed by medical
enterprise and treated as malfunctions.
The player as umpire
Illich was not a doctor, so how can he comment on the state
of medicine, right? His argument was that doctors are the last people who
should be asked to comment on and control the state of medicine. Doctors have a
vested interest in promoting disease and healthcare consumption. And
professional control means that if you pass a few tests you are in, and
renewal of your privilege after that is virtually automatic. Outsiders are banned from providing simple but effective remedies.
Nemesis
The concept of Nemesis comes from the Greek Nemesis: the
punishment for attempts to be a hero rather than a human being; for being a
god; for hubris. The harm caused by iatrogenesis on all levels is resistant to
medical treatment, as this is what caused them in the first place. This is like being
caught up in the medico-legal vicious cycle of impairment evaluation and
compensation claims: the deeper the patient goes, the worse their health and
greater their impairment.
Heavy stuff? That’s only the half of it, but the bits I did
understand still made me think. For example, in our desire to diagnose as many
people with as many diseases as we can, we do not pay heed to the negative
effects of simply diagnosing someone, with anything. The stress, fear,
apprehension, dependence, incapacity, social role changes, and separation from
the healthy that any diagnosis involves is often lost in our enthusiasm to make
the diagnosis. There are many other examples of the unintended, and intended, negative consequences of modern medicine.
Quotes
You can agree or disagree with the guy, but he made some
great quotes.
- The medical establishment has become a major threat to health.
- The organized pursuit of health has become the principal impediment to suffering experienced as a dignified, meaningful, patient, loving, beautiful, resigned and even joyful embodiment.
- More health damage is caused by people’s belief that they cannot cope with their illness unless they call a doctor than doctors could ever cause.
- Along with sick-care, health-care has become a commodity, something one pays for rather than something one does.
- The medical decision rule pushes [the doctor] to seek safety by diagnosing illness rather than health.
- Magic works if and when the intent of patient and magician coincide.
- With the development of the therapeutic service sector of the economy, an increasing proportion of all people come to be perceived as deviating from some desirable norm.
- Referencing the discovery of the specific gravity of urine: With this first measurement doctors began to read diagnostic and curative meaning into any new measurement they learned to perform.
- What was meant to constitute health care will turn into a specific form of health denial.
The gist
The gist of this book cannot be summed up in one sentence. I
like that he agrees with me that the benefits from modern medicine have been
exaggerated and the harms underestimated, but he goes much further. Some of his
major points are as follows:
- The disaffected are treated as being in need of technical repair.
- Simple and cheap measures (public health measures such as sanitation and housing) have done more good than modern, complex and costly measures that are often ineffective and harmful, yet these are what we focus our time and money on to further refine them, usually by adding complexity and cost.
- Medical practice sponsors sickness and encourages people to become medical consumers.
- Modern medicine reduces the ability of the individual and society to cope with weakness. Just as modern transport has reduced the efficiency and benefits of walking, and as modern education has reduced the need and desire for self-directed exploration of knowledge, medicine has reduced our ability to cope (and in many cases barred us from coping) with illness, suffering, pain, grieving, impairment, ageing and dying.
- Pain, impairment and death are no longer challenges to be confronted, but problems that should be managed out of existence.
- There is no longer such a thing as a natural or timely death. All deaths are now due to a treatable disease and should be resisted at any cost.
The bottom line
This book is heavy going and hard to swallow at times,
particularly when getting political (like regaining “control over the tools of
production”). Many of the messages take you outside your comfort zone and force
you to consider whether or not we are better off because of modern medicine. Any
book that discusses the medicalization of life is interesting; this book also discusses
the medicalization of health, and that’s even more interesting.
The book may be heavy going and hard to swallow at times but so is reading a years subscription to NEJM, Science or Nature. There is a whole lot of bullshit one must sort through to find a nugget of truth in these writings.
ReplyDeleteKeep up the good work. It's good that you apply your skepticism to books that favor your own bias. You sir are a true skeptic.
Thanks, I was mainly skeptical because I figure that if a person cannot make their point easily understood, they might not have a clear grasp of it themself.
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