An unexpected element of post-pandemic reflections has been the revival of interest in the work of Ivan Illich, a significant public intellectual of the 1960s and 1970s, whose star has waned somewhat in recent decades.
Illich (1926-2002) was an unconventional Catholic priest, who was recognized by the church both for his intellectual brilliance and his clashes with the hierarchy. Ultimately, this led to his resignation from active priesthood, although not from engagement with the study and practice of faith. His critical writings on social and environmental issues laid the foundations for much subsequent Green thinking about education, community and respect for nature. Probably his most influential work, however, was the critique of institutionalised medicine, initially published as Medical Nemesis (1975) and subsequently revised as Limits to Medicine (2002). Its coruscating first sentence still resonates: ‘The medical establishment has become a major threat to health’.
As various critics pointed out, Medical Nemesis is not, in fact, a particularly original book. Its value is its synthesis of a range of ideas from medical sociology, epidemiology and public health together with an organic vision of society derived from Catholic traditions. The result is a polemic whose challenges remain as relevant today as when they were first presented.
Illich distinguishes three forms of damage that result from the activities of the medical establishment. He borrows the medical term ‘iatrogenesis’ – illness or disability caused by clinical interventions – and expands it to embrace the social and cultural harms that may also be caused by the institutional complex that defines and delivers modern health care.
He begins by despatching the claim that the reduction in mortality throughout the Global North since 1850 can be credited to the development of scientific medicine. This introduced a wider public to the work of scholars like Thomas McKeown. The main causes of death had been infections. These had declined as a result of improvements in sanitation, nutrition and personal hygiene rather than vaccination or antibiotics. Those interventions only arrived at the end of the decline and mopped up a few residual cases. From this, Illich went on to present contemporary data about the iatrogenic consequences of medical errors or negligence, hospital-acquired infections and poorly-regulated pharmaceuticals.
As various critics observed, Illich’s historical sources tended to recognize scientific medicine only in clinical settings rather than seeing the medical role in collaborations with engineers that produced many environmental improvements. Much of the work cited on current harms had actually been produced by doctors concerned about quality and safety. Although any mutual influence is not clear, Illich’s work is contemporary with the movement for Evidence-Based Medicine. Finally, it now seems to be accepted that scientific medicine has contributed to increases in life expectancy at birth since 1950, although these remain modest compared with the period 1850-1950.
Thus far, Illich’s critique, although vividly expressed, does not go much further than thoughtful members of the medical establishment would accept. There is a path into the future through incremental improvements in pharmaceuticals and technology that builds on the foundations laid by public health interventions in the past. Illich’s second and third forms of iatrogenesis, however, question that path.
As Aldis Petriceks notes, in a recent issue of the American Journal of Public Health, Medical Nemesis continues themes introduced by Illich in an earlier book, Tools for Conviviality (1973). What does it do to a society when the very definition of health and illness comes to be monopolized by a particular group? What does it do to individuals when they lose the ability to make their own choices and are required to defer to expert regimes? As we might now express it, what is life like in an iatrocracy, where a biomedical complex asserts its right to rule through the minute regulation of everyday life?
In developing this criticism, Illich draws on ideas developed by medical sociologists inspired by the seminal work of Talcott Parsons. In The Social System (1951), Parsons introduced the idea that institutionalised medicine should be understood as an agency of social control, paralleling the criminal law and its associated occupations. While it was a softer system, with more routes back from deviance in body or mind, these nevertheless required compliance with the directions of control agents. The benefits of modern medicine came at the price of a loss of autonomy and self-management. Subsequent authors developed this in analyses of the process of medicalization, which Illich adopts as a core theme. Medicine, and its associated professions, organizations and commercial interests, comes to penetrate every aspect of life, requiring obedience to its prescriptions, not simply to treat illness but to prevent it ever occurring and to prolong lives regardless of quality. Health was no longer something to be pursued as a personal goal but to be imposed as a condition of membership in a society.
“The medical corps retains the power to define health and to determine which methods of care deserve public financing. It rules against heretical opinions…[it is] an established church” Medical Nemesis p.78
It might be argued that contemporary medicine places more emphasis on patient engagement and patient choice: ‘No decision about me without me’ as one UK slogan has it. However, it is not clear how genuine those choices are and how far they are simply another way of engineering apparent consent. The condition for patient participation is acceptance of the ultimate goal set by a biomedical-industrial complex, even if there is some space to shape the means. The question is how to overcome vaccine hesitancy rather than whether to, for instance. Illich discusses the potential role of what Donald Light, a prominent contemporary medical sociologist, has since called “countervailing powers” – law, politics, community organisations – in holding the biomedical industrial complex to account. Are their goals proper ones for a society to pursue to the exclusion of others, like personal autonomy and self-realisation, including the right to make ‘bad’ medical choices.
The mobilization of countervailing powers is, though, inhibited by the cultural iatrogenesis inflicted by modern biomedicine. This has conjured up a vision of the elimination of pain, suffering and death. If only tech bros from California invested enough, at least some of us could live for ever. Illich draws on a variety of sources, particularly the work of Rene Dubos, an evolutionary biologist, to underline the biological implausibility of this conceit. Of course, the promise of immortality is seductive. But it is also profoundly disabling. In Petriceks’ words:
“For him [Illich], health could never simply be about “saving lives” or “eliminating disease,” but rather the art of living and dying well, which included a humility toward the unknown and an awareness of death.”
Whether motivated by faith or an agnostic philosophy like Stoicism, a reasonable person will seek to avoid suffering and death but they will not allow their lives to be driven by fear of them. A society based on fear, or where fear is promoted to protect the interests of a biomedical complex, is not one that humans should accept.
As with many polemicists, Illich often exaggerates or overstates his case. Contemporary biomedicine has contributed much to the quality of everyday life in the modern world. But his questions are serious ones. How far should our lives be governed by one, rather narrow, vision of a good society? Is iatrocracy consistent with human flourishing? They have not lost their significance with the passage of time, even if our answers may now be a little different.
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