A few quotations from Ivan Illich's "Medical Nemesis" for our day

"Medical tyranny" has actually been building for a long time

(Audio recording of this post.)

I’ve been making my way through Limits to Medicine / Medical Nemesis by Ivan Illich. (“The medical establishment has become a major threat to health”, the book somewhat famously begins.¹) I’ve mentioned Illich before, lived 1926 - 2002, a Roman Catholic priest and cultural critic. His name is often thrown in there with a medley of other names (like Jacques Ellul), people who sniffed out the harms of the technocracy while it was still relatively undeveloped compared to what we are living with today.

One thing I appreciate about Medical Nemesis (written in 1975), in our medical tyranny times, is that (were Illich alive today) I suspect he’d say that what we’re witnessing now is actually a natural outgrowth of trends that have been building for decades. The world didn’t qualitatively change overnight (the rate of change increased). I was pondering last night, what would Illich think about the president of the United States ordering everyone to be officially certified by the medical profession as “clean enough to be around”, either by vaccination or regular testing. And I think he’d say, OK, I couldn’t have predicted this particular disease, but that sort of edict is fully in line with trends I already see in the 1970s. Those trends would have included the idea that it is the medical profession, a sort of priesthood, that gets to define illness and health, not you, and also the idea that illness is not determined by how you feel but by what our tests say.

(This is an aside but interestingly, on the subject of medical certification, he says that one of the first known state orders requiring someone to be certified as medically fit was a 1766 edict by Holy Roman Empress Maria Theresa, ordering the court physician to certify that prisoners were sufficiently physically fit that they could be tortured and still give accurate testimony!)

Below are a few quotations I found helpful from the earlier sections of the book. This is not a summary of the book, I am not quite up for that project right now and do recommend you read it yourself! But here are a few quotations I found helpful.

Remove everyone’s tonsils! / Incentives for the “inspecting” professions

One human problem with the “inspecting” professions is that job effectiveness can be measured by how many problems are discovered (or it may be worried that the bosses will measure job effectiveness by how many problems are discovered). If you keep reporting “all is well”, then why do I need to even employ you, Mr. Inspector? Well, inasmuch as medicine is also an “inspecting” profession of sorts it suffers from the same problem. The following quotation² isn’t especially profound perhaps but I did find it interesting.

Trained to “do something” and express his concern, [a doctor] feels active, useful, and effective when he can diagnose disease… The classic demonstration of this bias came in an experiment conducted in 1934. In a survey of 1,000 eleven-year-old children from the public schools of New York, 61 percent were found to have had their tonsils removed. “The remaining 39 percent were subjected to examination by a group of physicians, who selected 45 percent of those for tonsilectomy and rejected the rest. The rejected children were re-examined by another group of physicians, who recommended tonsilectomy for 46 percent of those remaining after the first examination. When the [still] rejected children were examined a third time, a similar percentage was selected for tonsilectomy so that after three examinations only sixty-five children remained who had not been recommend for tonsillectomy...”

The point is quite clear, I trust. (Illich doing his best to make me feel good about rarely seeing a doctor there.)

Illich is not anti-medicine, he is well read and would happily acknowledge a small number of genuinely helpful advancements… but much of medicine is “over-sold”. And many preventative diagnoses do more harm than good, as they tell people who feel perfectly fine (and may, as in the example above, actually be perfectly fine) that they are actually not fine, which makes them anxious and sends them off searching for a cure which may be unnecessary, or not exist, or which has side effects just as bad or worse than whatever they’ve been diagnosed with.

The pandemic response, prophesied

In a section that is especially about the problems of preventative medicine / mass diagnosis, Illich wrote a few sentences that felt so much like the world around me right now. He writes,

Once a society organizes for a preventative disease-hunt, it gives epidemic proportions to diagnosis. This ultimate triumph of therapeutic culture turns the independence of the average person into an intolerable form of deviance.

In the long run the main activity of such an inner-directed systems society leads to the phantom production of life expectancy as a commodity. By equating statistical man with biologically unique men, an insatiable demand for finite resources is created. The individual is subordinated to the greater “needs” of the whole, preventative procedures become compulsory, and the right of the patient to withhold consent for his own treatment vanishes as the doctor argues that he must submit to diagnosis, since society cannot afford the burden of curative procedures that would be even more expensive.

Let me just remind you that this was written in 1975! Now Illich didn’t have COVID in mind, obviously, he was probably thinking more about things like cancers and heart conditions for which doctors want to examine you regularly so they can tell you if you “have” them even if you feel fine. But my bigger point here is that the dysfunctions associated with the recent pandemic response didn’t appear in March 2020 - they were already around and just saw a large expansion. If I was to apply the above quotation to our present situation:

Once a society organizes for a preventative disease-hunt, it gives epidemic proportions to diagnosis.

You mean like testing everybody and their kitten, who all feel fine, three times a day anyway to make sure they don’t actually have COVID? Yes, and their kitten!

This ultimate triumph of therapeutic culture turns the independence of the average person into an intolerable form of deviance.

If you won’t submit to the orders of the health professionals because you feel fine, that isn’t you exercising your right to define what sickness is for you, that’s deviance. Doctors get to define sickness.

The individual is subordinated to the greater “needs” of the whole

Stop being so selfish.

preventative procedures become compulsory, and the right of the patient to withhold consent for his own treatment vanishes

No you don’t have any right to decline vaccination or testing.

since society cannot afford the burden of curative procedures that would be even more expensive.

We can’t have you using up hospital space and resources that other people might need.

Written in 1975. Pretty good prophecy, Mr. Illich.

Everyone is sick

And finally, for this post, Illich spends time talking about how the desire for better health / more medicine is basically infinite. It finally manifests itself in the desire to live longer, after all, and inasmuch as everyone is still dying eventually, apparently (in the paradigm of health and medicine which he rejects but which most of the people around us have adopted), that means there are needs that doctors are still not meeting.

Like any other growth industry, the health system directs its products where demand seems unlimited: into defense against death.

Ergo the realm of life covered by the medical profession has grown larger and larger - Part II of the book is in fact called “the medicalization of life”. The fraction of our money that we spend on healthcare has itself ballooned - what other areas of human life can really be said to have infinite demand like that? I can’t eat infinite amounts of food but you nearly could see infinite doctors for infinite real or potential ailments.

Previously modern medicine controlled only a limited market; now this market has lost all boundaries. Unsick people have come to depend on professional care for the sake of their future health.

They are “unsick” because they feel fine. But in the context, they now depend upon professional care because a doctor has diagnosed them with this or that condition by a blood test or a screening or some such, and they can imagine what it might lead to in 20 years, and so now instead of just living a normal life as they would have two centuries ago, they look to and lean upon the priests of medicine to save them. Screening for asymptomatic disorders, Illich says,

…transforms people who feel healthy into patients anxious for their verdict.

It is worth asking (and this is part of Illich’s point) whether that makes human life, holistically considered, better or worse. A bigger theme for Illich is that social institutions have a sort of “sweet spot”. If they are below the sweet spot and they did more, that would be better for society. But you can also easily be already above the sweet spot, where you are already doing too much and it would be better for society if you did less, and the medical profession (he would almost certainly say) is doing too much. It’s not all bad, certainly, but it is doing too much.

A couple centuries ago everyone also was presumed healthy unless they had some specific ailment that might send them to a doctor (or a doctor to them). Today, especially if you exceed a certain age (but really anyone), get the right test and any doctor would be happy to give you a list of all the things that are wrong with you.

Health has ceased to be a native endowment each human being is presumed to possess until proven ill, and has become an ever-receding goal to which one is entitled by virtue of social justice.

He also says, and again although he’s not talking about airborne viruses I cannot help but think of our pandemic response here, that

Until proved healthy, the citizen is now presumed sick.

And then, in a footnote on the same,

Since the sixties a citizen without a medically recognized status has come to constitute an exception. A fundamental condition of contemporary political control is the conditioning of people to believe they need such a status for the sake not only of their own but of other people’s health.

And later he writes,

Claiming access to treatment becomes a political duty, and medical certification a powerful device for social control.

I’m just saying, that all sounds very familiar today!

You can see implicit in the above (especially in the comment about “a citizen without a medically recognized status” now being a rarity) that part of the power of the medical profession today is to decide what counts as illness… and the number of ailments you could be diagnosed with has expanded tremendously over the last century.

Each civilization defines its own diseases. What is sickness in one might be chromosomal abnormality, crime, holiness, or sin in another.

That is an interesting thought. Illich also considers part of his mission to bring philosophy back into medicine, and you can see that in that quotation. And testing creates new sick people, he says.

People are turned into patients without being sick. The medicalization of prevention thus becomes another major symptom of social iatrogenesis. It tends to transform personal responsibility for my future into my management by some agency.

Again that all sounds quite familiar.

Whew. This post could be very long but I’ll stop now. But if you’re intrigued, I do recommend the book. Maybe we’ll get one more post of quotations in a few days.

1. As that quotation may imply to you, Illich spends a good amount of time talking about how the shifting of, you might say, “responsibility for health” away from “everyone” and toward a small class of paid professionals has probably done more harm than good, especially for the poor… but this post doesn’t go into that part of his argument very much.

2. Illich identifies the source of his further quotation as “Harry Bakwin, ‘Pseudodoxia Pediatrica’, New England Journal of Medicine 232 (1945); 691-97