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Nemesis or Sisyphus?
The death last year of Ivan Illich is an opportunity for us to reflect on his controversial “Nemesis” challenge in 1974 that too much dependence on modern medicine is harmful to the health of the individual and society.1 It followed the challenge by Archie Cochrane2 for evidence of the effectiveness of treatment offered by doctors. Both these challenges were largely unheeded at the time. Medical science progressed much as analysed in the book Little Science, Big Science and Beyond.3 Now we are well into the uncertainties of De Solla Price’s “beyond” in what Beck calls the “risk society”,4 with all that means for fear of unknown risks and incurable diseases. Medical science is indeed making health care more powerful and successful than ever, but the potential for harm, as iatrogenic disease and medical accidents (what Illich identified as direct medical harms) is also greater.5
In admiration of the success of the Cochrane Collaboration in catalysing the current “Evidence Based Healthcare” movement, I ventured to suggest an “Illich Collaboration”6 to assemble comparably reliable evidence to prevent direct medical harms. However, Illich also pointed to the indirect harms that render people less able to cope with the usual challenges of living and dying. The tendency that the more health care given to a population the greater its demand for care (the “Sisyphus syndrome”—after the Greek myth of Sisyphus, who was condemned to roll stones up hill for ever…). This is because modern health care leads to increased longevity7 with more opportunity to accumulate chronic diseases—needing health care. An econometric analysis8 suggests that this Sisyphus syndrome may not be as great a problem as previously thought but that needs to be confirmed.
Is health care a “service industry”?
Voluntary choice of the “no treatment now” option?
Hypothesis generation from the medical humanities for research into the positive attributes of health.
Beyond this chronic disease related Sisyphus syndrome is another that depends on whether or not a healthcare system should be regarded as a service industry. If so there are clear implications that encourage demand. As originally envisaged by the founding fathers of the National Health Service in the UK, a free healthcare system should result in a healthier society, and there would be less demand. This is clearly not the case and demand for medical care continues unabated. Demand for complementary and alternative therapies is also great.9 Edward Shorter10 attributes demand to a “pas de deux” between doctors and patients, which today we see as consumer demand for personal service and choice fuelled by the ever widening taxonomy of disease and professional differentiation (that is, more diseases and more experts). The distinguished medical historian Roy Porter, who also died last year, warned11 that medical consumerism, like all other forms of consumerism, is designed to be unsatisfying. Central to such medical consumerism is autonomy—which from the ethical viewpoint, is defined as the “right to decide whether or not to undergo any medical intervention even when a refusal may result in harm to themselves or in their own death”.12 While the “no treatment now” option always needs to be considered, the world’s economic and political topography now may dictate that fewer choices in self determination are possible than when Illich wrote his warning, and dependence on a healthcare system may for many have to be the price of “staying the course”. This is difficult but it is perhaps time to change the emphasis from the economics of health care to exploring the economics of health.13 Evidently social reform cannot replace health care but it deserves further evaluation as separate determinant of health and wellbeing.7
If health care shares features with service industries, what are implications for demand generation?
Can emphasis on patient autonomy and avoiding harm lead to voluntary demand reduction?
Can more research into generic healthcare solutions help patient/user collaboration and autonomy?
Whether or not we can learn to live with less dependence on drugs, therapies, and professional advisors, though desirable in the interest of independent “health”, is however doubtful. To attempt to do so would need to take us “beyond” contemporary healthcare strategies to explore the varied heritage of human experience of life and death. Here the recently established discipline of medical humanities may help. Leo Tolstoy (in The Death of Ivan Iliych14 describes graphically Ivan’s final illness in 19th century Russia as he achieves a vision of equanimity or redemption in a peaceful death, portrayed as a triumphal fulfilment of his life.
Can we avoid Illich’s “Nemesis”? I hope so—research may throw more light on some positive characteristics of “health” (for example, resilience, courage, altruism, good humour, etc). Specifically, research might focus on how to develop the mental “toolkit” for coping with disability, such as remarkably reporteded recently,15 the “dis-eases” of life and how to face death with autonomy and something approaching equanimity.
Nemesis or Sisyphus?