Friday 18 January 2013

Book review: Limits to Medicine

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.

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.

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.

Unintended consequences
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.

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.


  1. 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.

    Keep 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.

    1. 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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