[D66] Het medisch bedrijf, een bedreiging voor de gezondheid?

[R.O.]

https://www.nytimes.com/1976/05/02/archives/medical-nemesis-the-20thcenturys-leading-luddite-turns-to-medicine.html


  Medical Nemesis

By H. Jack Geiger

  * May 2, 1976

This is a digitized version of an article from The Times’s print 
archive, before the start of online publication in 1996. To preserve 
these articles as they originally appeared, The Times does not alter, 
edit or update them.
Occasionally the digitization process introduces transcription errors or 
other problems; we are continuing to work to improve these archived 
versions.

The great steel‐and‐glass structures of our hospitals, medical centers 
and research institutes—the new cathedrals of industrialized 
society—rear up on our urban skylines from Stockholm to Wichita, and in 
the developing world as well. Inside, brigades of physicians and armies 
of technologists command computers, rebuild our bodies with scalpel and 
graft, make molecules dance to order, preside over incredibly complex 
machines that breathe for us, or pump blood or wash our innermost cells. 
They are defying death, and conquering disease and disability.

Outside, by the hundreds of millions, we visit our doctors, certify our 
diseases, are processed through the multiphasic screening units, take 
our powerful (and dangerous) pills and confidently await our aging and 
our cardiac resuscitations. Collectively, we are creating “health.”

This is a mad dream of progress, says Ivan Illich in “Medical Nemesis,” 
a part of the overreaching nightmare of industrialization. Far from 
helping us, modern medicine has made us sicker. Worse, it has created in 
us a worldwide addiction, as passive medical consumers, to “therapeutic” 
relationships with monopolizing professionals and arrogant medical 
bureaucracies and institutions. Worst of all, it has robbed us of our 
autonomy and our acceptance of the human condition—including disease, 
pain and death.

With them, he adds angrily, has gone our human uniqueness, our capacity 
to struggle and adapt, our ability to care for ourselves and each other. 
There are echoes here of Rousseau's Noble Savage: the paradise we have 
lost was the one within us; it was whatever enabled us, on our own, to 
make life feel whole and coherent, even if painful. We have traded it in 
for compulsory survival in a planned and engineered hell, an 
anesthetized existence in a world turned into a hospital ward, a 
“managed maintenance of life on high levels of sub‐lethal illness.”

Illich—priest, historian, theologidn, philosopher, polemicist, 
iconoclast and, in some ways, the leading Luddite of the 20th century—is 
thus back with another major critique of the relentless 
industrialization of our so ciety. Once again, his method is the 
examination of a major social institution—what Illich sees as 
technologized, institutionalized, dehumanizing, dangerous, all‐pervasive 
and insatiably expanding medicine. His intended audience, it seems 
clear, is the American public, for the technology, institutional forms, 
values and processes he describes have, for better or for worse, reached 
their apotheosis in the United States. The ultimate target of his blame 
is not the professionals but the rest of us—all of us, at once the eager 
consumers and the passive slaves of industrialism, and, therefore, the 
willing participants in our own dehumanization. He wants us—the world's 
biggest medical‐care users and spenders—to think about our implicit 
beliefs in salvation through science and immortality through medical care.

Readers of Illich's earlier work will recognize at once that this view 
of medicine is only part of a larger picture. Institutionalized 
education stifles and crushes our ability to learn (“Deschooling 
Society”); transportation systems not only devalue human feet but 
paralyze us in frustrated, polluted immobility (“Energy and Equity”); 
urbanization destroys our competence in homemaking and our integrity as 
neighbors (“Tools for Conviviality”). The major institutions of 
industrialized society inevitably turn counterproductive and rob us 
precisely of what they set out to offer. Medicine is just another slow 
dance on the industrialized killing ground.

The process by which it makes us sick—individually and as a society —is 
iatrogenesis, the causation of disease by physicians, or by the whole of 
the medical complex. It is an old word and an old idea, but Illich has 
enlarged upon the concept, and connected it in myriad ways to larger 
issues of society and culture. His identification and discussion of 
three kinds of iatrogenesis is the core of “Medical Nemesis,” and its 
chief contribution to our thinking about the relationships between our 
medical‐care complex, our political economy and our values.

First, and most conventional, is clinical iatrogenesis, the damage done 
to us by individual clinical intervention. Here Illich has seized on a 
powerful truth. He knows that most of the improvements in health over 
the past few centuries are not due to medical advances but simply to 
improvements in the standard of living: more food, clean water, 
sanitation, better housing, more income and edcation. The great plagues 
of pre‐and early industrial society, the epidemics of infectious 
disease, were on the decline long before physicians knew clearly what 
they were, let alone what to do about them.

Against the new epidemics of chronic disease, medicine is not 
“miraculous,” it is not even very effective. For all the early 
intervention, the powerful drugs, the incredibly skilled surgery, the 
complex machines, life expectancy beyond infancy has not improved 
significantly in the past 100 years. Cancer survival rates resist 
change, many heart attack victims survive as well at home as in coronary 
care units, and today's drug “breakthrough” has a way of becoming 
tomorrow's tragic mistake. Further, Illich knows all about the 
unnecessary surgery, the drug reactions, the malpractice and the 
“accidents” of technical malfunction.

There are two troubles with all this. First, none of it is news; a 
growing number of scientists, physicians and medical journalists, from 
René Dubos in “The Mirage of Health” through Rick Carlson in “The Limits 
of Medicine,” have been saying the same things to the general public, 
with increasing urgency, throughout the past decade. Second, Illich 
concentrates on the curing functions of medicine, where the record is 
not very good and overlooks the caring functions—the ability to relieve, 
to support, to rehabilitate, to make life not only tolerable but rich 
and useful even in the presence of continuing disease.

Much more important is social iatrogenesis, the over‐medicalization of 
society, the manipulated addiction of populations so they depend on 
medical care and medical institutions, the mystification of medical 
knowledge, the expenditure of enormous sums for medical care and 
research, the infiltration of patient and therapist roles into all areas 
of social life, the medical preemption of normal stages of life, so that 
pregnancy becomes “a state of risk,” old age becomes “geriatrics,” and 
dying becomes indecent outside the intensive care unit.

Let Ilitch describe it, for he is nowhere more eloquent than here. 
Social iatrogenesis obtains, he says, when: “… health care is turned 
into a standardized item, a staple; when all suffering is ‘hospitalized’ 
and homes become inhospitable to birth, sickness and death; when the 
language in which people could experience their bodies is turned into 
bureaucratic gobbledegook; or when suffering, mourning and healing 
outside the patient role are labeled a form of deviance.” It induces 
people to “forgo their own lives to get as much treatment as they can” 
and furthers “the fallacy that society has a supply of health locked 
away that can be mined and marketed.”

It continues to the point at which, “until proved healthy, the citizen 
is now presumed to be sick … the result is a morbid society that demands 
universal medicalization and a medical establishment that certifies 
universal morbidity.”

Finally, there is cultural iatrogenesis, which “sets in when the medical 
enterprise saps the will of people to suffer their reality.” 
Professionally organized medicine, Illich contends, “has oome 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 accept inevitable and often irremediable 
pain, impairment, decline and death.” In effect 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 treated as malfunctions from which populations ought to be 
institutionally relieved. When pain is killed and death denied, when 
culture—a system of values and beliefs—is replaced simply by a system of 
techniques, autonomy withers and an essential aspect of our humanity fades.

What does Illich want us to do? Just as we must stop—even retrogress 
—general industrialization, he says, so must we eliminate much of the 
output of the medical industry, reappropriate our own health care and 
return it to the individual. Illicit suggests specifically that we 
deprofessionalize and demystify healing by prohib iting the licensing 
and regulation of doctors or any other group of healers, leaving anyone 
free to practice anything and leaving all of us free to choose anyone 
(or no one) to give us treatment. He wants an end to “the myth that 
increasing dependence of people on the right of access to impersonal 
institution is better than trust in one another.” Indeed, he attacks 
even modest liberal strategies for change, such as national health 
insurance, for it would increase the access of the poor to medical care 
and hospitals, reinforcing their passive‐addictive dependency, when what 
we need is fewer organized health services, not more! He wants an 
emphasis on self‐care, with responsibility for treatment shifted to the 
sick man and his next of kin. He wants us to be free to drop out, 
reverse the growth of industrialization and organize for a less 
destructive way of life. Nowhere does he explicitly argue for a major 
redistribution of resources, or public control of the process of 
industralization.

Despite coy suggestions, scattered everywhere in “Medical Nemesis,” of 
the need for radical political and economic change, Illich thus rejects 
political and economic solutions in favor of a sterile individualism. 
These are the politics of life style—and the economics of Milton 
Friedman. Medicine would become the province of small‐scale 
entrepreneurs in an ideal free market (an Implicit statement of its 
commodity nature). Real change in the distranition of resources and 
power would be approached, if at all, through an individualist ideal of 
personal action, and enlightenment—a kind of spiritual recognition of 
the limits of growth and material progress —substituted for economic 
reform. The polemic that began with such a sociocultural bang ends in a 
political whimper.

“Medical Nemesis” already has a history, as a result of an unusual (and 
highly intelligent) idea. An earlier and much simpler version was 
published in England more than a year ago as “an outline for a seminar 
and a draft for a book”—a trial balloon, a lightning rod intended to 
draw criticism, commentary, correction and rebuttal. The new American 
version is enlarged and reworked in response to those responses.

The professional responses—in the British Medical Journal, Lancet and 
elsewhere — took Illich seriously, agreed that unlimited demand for 
medical care is self‐defeating and that the provision or ever.increasing 
resources for medicine will solve nothing, quarreled with the 
feasibility of his proposals that we turn back and disassemble the 
industrial machine and argued that he was not radical enough! One 
physician, in the unkindest and elitist cut of all, pointed out that 
Illich has said nothing that has not already been said by doctors: 
“There are already more radical thinkers within the ranks of medicine 
than Illich, and they understand more about biology.”

It is all the more disappointing, then, that from Mich's cocoon of 
apparent radical humanism there ultimately emerges no bright butterfly 
of revolutionary change but rather, in a curious inversion, a 
caterpillar of petty conservatism.

There are good arguments for more self‐care and personal responsibility 
in health. Whatever the responses to the arguments in this book and 
despite his political shortcomings, we should be grateful to Illich. No 
polemicist writing today has his passion, his range, his glittering and 
pyrotechnic arsenal. At this point it is the questons that count, not 
the answers. Illich is not concerned with how we can “improve” our 
medical care system, or finance it, or increase the access of the poor 
to it in its present form, or better organize it. Instead, he asks why 
we have it, what we really expect from it, how it mirrors—and 
reinforces—our social order, what it reveals about us. He uses medicine 
to ask us what we want from life, and he questions our dreams of reason. 
He cares deeply about the human condition, and he has maintained the 
essential ingredient of that oaring, a capacity for outrage. If we can 
confront his outraged—and outrageous —questions, we will, inevitably, 
begin to change.

On 19-08-2020 20:48, R.O. wrote:
>
> https://www.kb.nl/sites/default/files/styles/plaatje_260px/public/illich.png?itok=ka8nPZqd
>
>
> https://www.kb.nl/zorg-voor-de-gezondheid-en-zorgen-over-de-gezondheidszorg
>
>
> [...]
>
> Achterhuis werd in zijn kritiek op de gezondheidszorg uit de jaren 90 
> geïnspireerd door de Oostenrijks-Amerikaans-Mexicaans-Duitse filosoof 
> Ivan Illich. In zijn boek /Het medisch bedrijf/ (1976) onderscheidt 
> Illich drie aspecten in de gezondheidszorg die problemen kunnen 
> opleveren: 1. klinisch, 2. sociaal 3. structureel. Een voorbeeld van 
> een probleem veroorzaakt door sociale factoren is de keuze om wel of 
> niet behandeld te worden. Volgens Illich en Achterhuis is dit niet 
> altijd gerelateerd aan de ziekte zelf. Het heeft vaak te maken met hoe 
> dicht je bij een arts woont of hoe je omgeving op je ziekte reageert. 
> Daarbij worden mensen structureel vaker medicijnen voorgeschreven waar 
> ze afhankelijk van worden. Een voorbeeld hiervan is slaappillen. Het 
> gebruik van slaappillen intensiveert het gebruik van deze medicijnen. 
> Dit resulteert vaak in verslavingen die iemand juist zieker maken.
>
>
> [...]
>
>
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> D66 mailing list
> D66 at tuxtown.net
> http://www.tuxtown.net/mailman/listinfo/d66
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