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The appropriation of health
In 1974 Richard Smith, the editor of the British Medical Journal, and I each attended lectures by Ivan Illich. Smith, then a medical student in Edinburgh, heard him claim that “the major threat to health in the world is modern medicine.” While a visiting professor in Boston that same year I heard him make the same claim. Smith recalls that listening to Illich was “the closest I ever came to a religious experience”.1 I had a somewhat different reaction, one tempered by the exchange between Illich and a medical student after his lecture. The student, raising his hand, said “but Dr. Illich, I just want to help sick people”, to which Illich replied with a sneer that “you’re no better than the Nazi doctors.” Smith’s reaction was to drop out of medical school (for three days). Mine was disgust.
Looking back today I realise that I misunderstood what Illich was up to. I subsequently read Deschooling Society, in which he attacked the educational system for serving to indoctrinate the young in the overproduction of goods to satisfy the consumer society. Much the same theme reappears towards the end of Medical Nemesis, in which he wrote that “like school education and motor transportation, clinical care is the result of a capital-intensive comodity production” in which the patient as an individual becomes a technological product. He argued that medicine “constitutes a prolific bureaucratic program based on the denial of each man’s need to deal with pain, sickness, and death”.
As an anaesthetist Illich’s pronouncement of the need to experience pain is of special interest to me. He wrote, in a chapter entitled The Killing of Pain, that the medicalisation of pain “has rendered either incomprehensible or shocking the idea that skill in the art of suffering might be the most effective and universally acceptable way of dealing with pain.” Illich traces his views on pain to those of the church and of most religions, for which historically “it was unthinkable that pain ought not be suffered, alleviated, and interpreted by the person afflicted, but that it should be—ideally always—destroyed through the intervention of a priest, politician, or physician.” The “opportunity for purification, penance, or sacrifice” was to be welcomed.
Illich believed that “better health care will depend not on some new therapeutic standard, but on the level of willingness and competence to engage in self-care”, and he defined self-care broadly as consisting of “personal activities [that] are shaped and conditioned by the culture in which the individual grows up: patterns of work and leisure, of celebration and sleep, of production of food and drink, of family relations and politics”. In Tools for Conviviality, written three years before the publication of Medical Nemesis, Illich described this ideal state as an “autonomous and creative intercourse among persons within their environment… individual freedom realized in interpersonal interdependence and, as such, an intrinsic ethical ideal.” He called this a state of conviviality, and his notion of its health enhancement is remarkably in tune with current views of the impact of the social environment on health.
Illich’s attack has been largely ignored by the medical profession and there is little if any evidence that it has affected the continuing growth of the medical establishment. But Medical Nemesis has not been forgotten. It was reprinted in 1990 by Penguin and in 1995 by Marion Boyars. The latter, retitled Limits to Medicine, includes a new preface, and in it he makes his purpose crystal clear. “I used medicine as a paradigm for any mega-technique that promises to transform the conditio humana. I examined it as a model for any enterprise claiming, in effect, to abolish the need for the art of suffering by a technically engineered pursuit of happiness.” In the preface Illich made the extraordinary and revealing statement that “ emphatically, I do not care about health”. Should there be any doubt as to the sincerity of this statement or of his views on the medical enterprise, how he responded to his own ill health is instructive. After Illich’s death in December, 2002, an obituary in the London Independent reported that when he was “diagnosed with cancer in 1983, he refused all treatment…As the tumour on his cheek became more prominent and painful and subject to epileptic attacks, he refused to accept the diagnosis imposed by the doctors. ‘I am not ill, it’s not an illness’, he declared. ‘It is something completely different–a very complicated relationship.’”
The appropriation of health