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Big Ideas
Ivan Illich on medical nemesis
Illich began his polemic, first published in 1975, with a powerful
opening statement ‘The medical establishment has become a major
threat to health’ (1990, p.11), and over the next 254 pages he delivered a
blistering critique about the limits of Westernised medicine. Described
in his obituaryasan ‘archaeologist of ideas’ (Todd and LaCecla, 2002) his
stance against the hubris of industrialism, capitalism and bureaucracy
spanned not only medicine, but also education (Deschooling Society,
Illich, 1970) and the environment (Tools for Conviviality, Illich, 1973).
How Illich was ableto take a metaphoricalscalpelto these secular sacred
cows may only be understood with reference to some biographical
details. Born in 1926 in Vienna to a Jewish mother and Christian father,
and expelled from his birthplace by the National Socialist Party in 1941
because of his Jewish ancestry, he moved to Florence where he
eventually read Histology and Crystallography at Florence University.
He then entered the priesthood, studied theology and philosophy at the
Vatican's Gregorian University, and in the post war period worked as a
priest with the Puerto Rican community in New York before moving to
Puerto Rica as vice rector of the Catholic University, where he founded
the Centro Intercultural De Documentacion (CIDOC) at Cuernavaa,
Mexico. This institution offered briefings and courses for missionaries
arriving from North America and its radicalism attracted many, but it
came into conflict with a conservative Vatican which resulted in its
eventual disbandment and Illich resigning from active duty as a priest
(Todd and La Cecla, 2002). Illich's publications throughout his lifetime
were prodigious, the output of a highly educated polymath, who not
only spoke and worked in ten languages but was also a seasoned
traveller and connected with people at many levels, both as a priest and
as global celebrity in the heady counterculture of the 1970s (Wall,
2005). In setting out some of the key concepts from Medical Nemesis I
hope to show how this work deserves not only to be in the pantheon of
great works and big ideas from the 20th century, but also part of today's
curriculum for those studying nursing and medicine in the 21st century.
A key concept in Illich's work was his notion that the threat posed
by medicine to health had reached epidemic proportions; a state of
affairs he referred to as medical iatrogenesis, derived from ‘iatro’ (Gk
iatros healer or physician) and ‘genesis’ (Gk: gignesthai to be born or
origin of anything). He described the effect of medicine on disease as
an illusion and, drawing on past and recent evidence (Chadwick, 1842;
McKeown and Record, 1962), rightly identified that the environment
was the primary determinant of the general health of any population.
Whilst he acknowledged the value of chemotherapy in controlling
previously life-threatening infections, and other life-saving procedures
such as blood transfusions and surgical techniques, his overriding
argument was that the harms caused by medical interventions
outweighed the benefits. His defined clinical iatrogenesis as the damage
doctors inflicted on patients through malpractice, the side effects of
prescribed drugs and hospital acquired injuries and accidents, which he
was able to substantiate with due reference to the medical literature.
Illich's concept of clinical iatrogenesis is just as relevant today as it was
over thirty years ago for, as evidence-based findings show, hospitals
continue to cause real harm. For example, in one study of two British
hospitals, it was shown that 10% of patients admitted (Vincent et al.,
2000) experienced adverse effects leading, in a third of cases, to
moderate or greater disability or even death. Indeed, a post Illich version
of iatrogenesis, known as ‘E-iatrogenesis’, has now entered the medical
lexicon and is used to describe the harms caused to patients by the use
(or rather misuse) of electronic patient records and other forms of
health information technology (Weiner et al., 2007).
From Illich's perspective, medicine had seeped into every facet of
people's lives, leading to social iatrogenesis, that is, the medicalisation
of all aspects of life. Through a powerful medical bureaucracy and
‘diagnostic imperialism’ doctors now decide who may be excused
from work through sickness, become soldiers, practise prostitution,
run for vice-presidency of the United States and, of course, those who
are dead. As Illich argued, medicine has created another illusion
whereby only medicine can control health, disease or postpone our
own mortality and, in the process, has medicalised many of the
activities and skills that were traditionally part of families and
communities. Health care has become a standardised item and the
patient has become a consumer, in thrall to an industrialised health
care system, controlled by professionals and backed by a pharmaceu-
tical industry. Increasing and indeed unstoppable demands for more
medicine and health care within the developed and underdeveloped
world has not, as Illich was able to show, resulted in better health but
has instead disempowered people by creating a medical dependency.
Illich's argument remains compelling, given that in 2011 the USA
spent 17.4% of their GNP (Gross National Product) on health (private
and public), far more than the OECD average of 9.5% and the UK,
which spent 9.8% (OECD Health Data, 2011). The USA also spends far
more on investigations than any other OECD country, with 34.3 CTs
(computed tomography) per million, which is far more than OECD
average of 22.1. Likewise, there were 25.9 MRIs (medical resonance
imaging) per million in the USA in 2007, which is more than twice the
OECD average of 12.0. Nevertheless, despite these vast sums and what
may be described as the overuse of technology, infant mortality, a
good indicator of the health of any country, was 6.5 per 1000 live
births in 2008 which was well above the OECD average of 4.4 (OECD
Health Data, 2011).
Perhaps Illich's greatest condemnation was reserved for what he
termed cultural iatrogenesis, which he believed had led to the
medicalisation of death and an inability to accept suffering and death
as meaningful aspects of life. For the majority in the developed world,
death will take place in hospital despite most of us wanting to die at
home in order to avoid what Illich referred to as the exile, loneliness and
indignities of hospital life. By the time of Illich's polemic, hospitals had
become places where even natural death was resisted at all costs and
where, as he stated, ‘mechanical death has destroyed and conquered all
other deaths’ (Illich, 1973, p.210). This situation continues today for, as
Clark (2002) found, nearly a third of patients admitted to ITU beds in the
UK die within six months, whilst in the USA it costs twice as much to die
in an intensive care unit as it does to survive (2002). This depersona-
lised, technological medicine may, as Barnet (2003) notes, explain the
rise in support for assisted suicide by people who feel that dying in a
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medically managed setting is an option they would rather reject.
Outside of the heroic efforts by the hospice and palliative care
movement to enable a ‘good death’, one which is pain free and dignified
(Ellershaw et al., 2003), the use of medical technology aimed at
preserving life, however futile, continues, as evidenced by a recent
quality of death index. This ranked 40 countries (Economist Intelligence
Unit, 2010) according to their End of Life Care (EoLC) provision and
highlighted that in most developed countries the focus is still on
preventing death rather than helping people achieve this without
suffering, pain, discomfort or stress. It should be noted that the UK was
ranked first because of its network of hospices and statutory
involvement in EoLC, whilst the USA was ranked ninth because of the
financial burden it imposes at the end of life. China, Mexico and Brazil
ranked at the bottom because, as this report noted, their commitment to
stronghospital programmes and the power of medicinemeans that they
see little value in hospices. This is a shame and perhaps only identifies
the need for today's medical establishment to acquaint themselves with
Illich's medical nemesis to understand that minimal medical interven-
tion is more likely to result in a ‘good death’ than the current and futile
overload of technological wizardry at the end of life stage. ‘Less not
more’ in terms of medical interventions is prescribed by Illich
throughout his polemic as necessary for a full and healthy life. As he
concluded:
‘Healthy people are those who live in healthy homes on a healthy
diet in an environment equally fit for birth, growth, work, healing
and dying; they are sustained by a culture than enhances the
conscious acceptance of limits to population,of ageing, of incomplete
recovery and ever-imminent death. Healthy people need minimal
bureaucratic interference to mate, give birth, share the human
condition, and die’ (Illich, 1973, 275).
I hope that this paper has highlighted some of Illich's big ideas, and
will entice a new generation of nurses to explore what I believe to be a
masterpiece and help them consider and reflect upon the limits of
medicine and its effects upon the human condition. Illich's polemic is
not an easy read, some of his arguments are convoluted, and there are
strands of philosophy, as well as factual information, which may
discombobulate the reader. Illich was a troublesome priest in the best
Thomas à Beckett tradition and this comes across in some of his
provocative statements. Having heard him speak and defend his
position at a conference during the 1990s I can attest that he was as
provocative in person as he is on paper. It is also worth noting that,
when published, Medical Nemesis earned criticisms from the political
left and right for its lack of discussion about the role of capitalism in
relation to medicine. This may seem odd given that the driving force
behind medical hegemony is capitalism (Scott-Samuel, 2003) but this
omission does not detract from its overall power and ability to make
one question the status quo. Medical Nemesis has stood the test of time
and continues to give us a real insight into the limits of medicine; it is
incisive and insightful and bound together with a real understanding
and concern for the human condition.
References
Barnet, R.J., 2003. Ivan Illich and the nemesis of medicine. Medicine, Health Care and
Philosophy 6, 273–286.
Chadwick, E., 1842. Report of the Poor Law Commissioners to the Secretary of State, on
an Inquiry into the Sanitary Condition of the Labouring Population of Great Britain,
19, p. 1.
Clark, D., 2002. Between hope and acceptance: the medicalisation of dying. British
Medical Journal 905–907.
Economist Intelligence Unit, 2010. The Quality of Death: Rating End of Life Care across
the World. Economic Intelligence Unit. http://www.eiu.com/site_info.a.
Ellershaw, J., Ward, C., Neuberger, J., 2003. Care of the dying patients: the last hour or
days of life. British Medical Journal 326, 30–34.
Illich, I., 1970. Deschooling Society. Harper and Row, New York.
Illich, I., 1973. Tools for Conviviality. Harper and Row, New York.
McKeown, T., Record, R.G., 1962. Reason for the decline in mortality in England and
Wales during the nineteenth century. Population Studies 15, 94–122.
OECD Health Data, 2011. How Does the United States Compare? http://www.oecd.org/
dataoecd/46/2/38980580.pdf.
Scott-Samuel, A., 2003. Less medicine, more health: a memoir of Ivan Illich. Journal of
Epidemiology and Community Health 57 (12), 955.
Todd, A., La Cecla, F., 2002. Ivan Illich Obituary The Guardian 9th December 2002.
Vincent, C., Neale, G., Woloshyndwych, M., 2000. Adverse events in British Hospitals:
preliminary retrospective record reviews. British Medical Journal 322, 517–519.
Wall, R., 2005. A Turbulent Priest in the Global Village: Ivan Illich 1926–2002. http://
www.lewrockwell.com/wall/wall28.html.
Weiner, J.P., Kfur, T., Chan, K., Fowles, J.B., 2007. ‘E-Iatrogenesis’: the most critical
unintended consequence of CPOE and other HIT. Journal of the American Medical
Association 14, 387–388.
Ruth Davies
College of Human and Health Science, Swansea University, United Kingdom
Tel.: +44 1792 602253.
E-mail address: R.E.Davies@swansea.ac.uk.
6 Big Ideas