Wednesday, March 9, 2016

Ivan Illich illustrated: Medical Nemesis - Limits to Medicine - The Expropriation of Health

Quotes from Medical Nemesis by Ivan Illich
Art by Emma Holister

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p 53 The Medicalization of Life

"...some critics recommend enlightened cost consciousness on the part of consumers; (55) . . .

. . others, not trusting the self-control of laymen, recommend mechanisms to heighten the cost consciousness of producers.(56)

Physicians, they argue, would prescribe more responsibly and less wantonly if they were paid (as are general practitioners in Britain) on a 'capitation' basis that provided a fixed amount for the maintenance of their clients rather than a fee for service...."

 ('the village of the damned' - 1960 sci-fi trailer)

... "But like all other such remedies, capitation enlarges the iatrogenic fascination with the health supply. ...

People forgo their own lives to get as much treatment as they can.

In England the National Health Service has tried, albeit unsuccessfully, to ensure that cost inflation will be less plagued by conspicuous flimflam.(57)

The national Health Service Act of 1946 established access to healthcare resources for all those in need as a human right.

The need was assumed to be finite and quantifiable, the ballot box the best place to decide the total budget for health, and doctors the only ones able to determine the resources that would satisfy the need of each patient. 

But need as assessed by medical practitioners has proved to be just as extensive in England as anywhere else. 

The fundamental hope for the success of the English health-care system lay in the belief in the ability of the English to ration supply."

"notes: 55) John and Sylvia Jewkes, Value for Money in Medicine (Oxford: Blackwell, 1963, pp. 30-7, argue: 'It may be that, as electorates become more sophisticated, they will recognize they have in fact to pay for free services'; also that relatively cheap prevention through more healthy everyday habits is more effective than purchase of repairs.

56) Fuchs, in Who Shall Live?, chap. 3, argues for institutional licensing as a substitute for the licensing of individuals.  Under such a system, medical-care institutions would be licenses by the state and would then be free to hire and use personnel as each saw fit.  This system would deploy resources more efficiently and proved more upward job mobility.  But the physician's control over care produced and delivered by others would be weakened.

57) For a bibliography on socialized medicine in Britain, consult Freidson, Profession of Medicine, p. 34 n.9"

The Medicalisation of Life (continued)


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, and therefore as clients who can now either be submitted to therapy to bring them closer to the established standard of health or concentrated into some special environment built to cater to their deviance.

Basaglia points out that in the first historical stage of this process, the diseased are exempted from production.  At the next stage of industrial expansion, a majority come to be defined as deviant and in need of therapy.  When this happens, the distance between the sick and the healthy is again reduced. 

In advanced industrial societies the sick are once more recognized as possessing a certain level of productivity which would have been denied them at an earlier stage of industrialization. 

Now that everybody tends to be a patient in some respect, wage labour acquires therapeutic characteristics. 

Lifelong health education, counselling, testing, and maintenance are built right into factory and office routine.  

Therapeutic dependencies permeate and colour productive relations. 

Homo sapiens, who awoke to myth in a tribe and grew into politics as a citizen, is now trained as a lifelong inmate of an industrial world.  The medicalization of industrial society brings its imperialistic character to ultimate fruition.

Chapter 3 ‘The Killing of Pain’ 

Pages 151 to 154

By 1853, barely a century and a half after pain was recognized as a mere physiological safeguard, a medicine labelled as a ‘pain-killer’ was marketed in La Crosse, Wisconsin.  A new sensibility had developed which was dissatisfied with the world, not because it was dreary or sinful or lacking in enlightenment or threatened by barbarians, but because it was full of suffering and pain.  

Progress in civilization became synonymous with the reduction of the sum total of suffering.  

From then on, politics was taken to be an activity not so much for maximizing happiness as for minimizing pain.  The result is a tendency to see pain as essentially a passive happening inflicted on helpless victims because the toolbox of the medical corporation is not being used in their favour.

In this context it now seems rational to flee pain rather than to face it, even at the cost of giving up intense aliveness.  

It seems reasonable to eliminate pain, even at the cost of losing independence.  It seems enlightened to deny legitimacy to all nontechnical issues that pain raises, even if this means turning patients into pets.  

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 anaesthetic 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 anaesthesia increases the demand for excitation by noise, speed, violence – no matter how destructive. 

This raised threshold of physiologically mediated experience, which is characteristic of a medicalized society, makes it extremely difficult today to recognize in the capacity for suffering a possible symptom of health.  The reminder that suffering is a responsible activity is almost unbearable to consumers, for whom pleasure and dependence on industrial outputs coincide.  By equating all personal participation in facing unavoidable pain with ‘masochism’, they justify their passive life-style.  

Yet, while rejecting the acceptance of suffering as a form of masochism, anaesthesia consumers tend to seek a sense of reality in ever stronger sensations.  They tend to seek meaning for their lives and power over others by enduring undiagnosable pains and unrelievable anxieties: the hectic life of business executives, the self-punishment of the rat-race, and the intense exposure to violence and sadism in films and on television.  

In such a society the advocacy of a renewed style in the art of suffering that incorporates the competent use of new techniques will inevitably be misinterpreted as a sick desire for pain: as obscurantism, romanticism, dolorism, or sadism.

Ultimately, the management of pain might substitute a new kind of horror for suffering:  the experience of artificial painlessness.  

Lifton describes the impact of mass death on survivors by studying people who had been close to ground zero in Hiroshima.  He found that people moving amongst the injured and dying simply ceased to feel; they were in a state of numbness, without emotional response.  He believed that after a while this emotional closure merged with a depression which, twenty years after the bomb, still manifested itself in the guilt or shame of having survived without experiencing any pain at the time of the explosion.  

These people live in an interminable encounter with death which has spared them, and they suffer from a vast breakdown of trust in the larger human matrix that supports each indvidual human life.  

They experienced their anaesthetized passage through this event as something just as monstrous as the death of those around them, as a pain too dark and too overwhelming to be confronted, or suffered.

What the bomb did in Hiroshima might guide us to an understanding of the cumulative effect on a society in which pain has been medically ‘expropriated’.  

Pain loses its referential character if it is dulled, and generates a meaningless, questionless residual horror.  

The sufferings for which traditional cultures have evolved endurance sometimes generated unbearable anguish, tortured imprecations, and maddening blasphemies; they were also self-limiting.  The new experience that has replaced dignified suffering is artificially prolonged, opaque, depersonalized maintenance.  Increasingly, pain-killing turns people into unfeeling spectators of their own decaying selves.

Chapter 7 Political Countermeasures

p.259 Engineering for a Plastic Womb

In general, people are more the product of their environment than of their genetic endowment.

This environment is being rapidly distorted by industrialization.  Although man has so far shown an extraordinary capacity for adaptation, he has survived with very high levels of sublethal breakdown.

Dubos fears that mankind will be able to adapt to the stresses of the second industrial revolution and overpopulation just as it survivied famines, plagues, and wars in the past.

He speaks of this kind of survival with fear because adaptability, which is an asset for survival, is also a heavy handicap: the most common causes of disease are exacting adaptive demands. The healthcare system, without any concern for the feelings of people and for their health, simply concentrates on the engineering of systems that minimize breakdowns.

Two foreseeable and sinister consequences of a shift from patient-oriented to milieu-oriented medicine are the loss of the sense of boundaries between distinct categories of deviance, and a new legitimacy for total treatment.

Medical care, industrial safety, health education, and psychic reconditioning are all different names for the human engineering needed to fit populations into engineering systems.

As the health-delivery system continually fails to meet the demands made upon it, conditions now classified as illness may soon develop into aspects of criminal deviance and asocial behavior.

The behavioral therapy used on convicts in the United States and the Soviet Union's incarceration of political adversaries in mental hospitals indicate the direction in which the integration of therapeutic professions might lead: an increased blurring of boundaries between therapies administered with a medical educational, or ideological rationale.

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.

(note for below sketches: giftig in german = poisonous, gift=poison)

p 252 The Scientific Organization - of Life

"As a science, medicine lies on a borderline, Scientific method provides for experiments conducted on models, Medicine, however, experiments not on models but on the subjects themselves.  But medicine tells us as much about the meaningful performance of healing, suffering, and dying as chemical analysis tells us about the aesthetic value of pottery."

"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.  By turning from art to science, the body of physicians has lost the traits of a guild of craftsmen applying rules established to guide the masters of a practical art for the benefit of actual sick persons.  It has become an orthodox apparatus for bureaucratic administrators who apply scientific principles and methods to whole categories of medical cases.  In other words, the clinic has turned into a laboratory.  By claiming predictable outcomes without considering the human performance of the healing person and his integration in his own social group, the modern physician has assumed the traditional posture of the quack."

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