Summary:
In
this book, Ivan Illich offers a harsh critique of health care as provided in
western industrialized societies during the 1970s. However, he did not write
this book as a health care expert. He was trained as a medieval historian and
philosopher, and taught the history of friendship and the history of the art of
suffering. Indeed, he admitted: “I
do not care about health.” (p. i) And yet, he could have written the same
critique 40 years later.
What
brought Illich’s attention to health care was his broader interest in how
modern responses to societal level challenges become counterproductive and even
harmful:
The threat which current medicine represents to
the health of populations is analogous to the threat which the volume and
intensity of traffic represent to mobility, the threat which education and the
media represent to learning, and the threat which urbanization represents to
competence in homemaking. (p. 7)
Illich’s
general thesis is that health care can work against the healing people seek
from it, that health care can be as pathogenic as disease, and that health care
can expropriate health. Health care is a
nemesis to its subjects, he
asserted, because it is “a social organization that set out to improve and
equalize the opportunity for each man to cope in autonomy and ended by
destroying it.” (p. 275)
Illich
builds his argument around the concept of
iatrogenesis, which he differentiates into three
categories: 1) clinical iatrogenesis, 2) social iatrogenesis, and 3) cultural
iatrogenesis, each of which is given a separate section in the book.
Clinical
iatrogenesis is the harm done to people as the result of actions taken to restore
health or prevent illness, such as an adverse drug event, a hospital-acquired
infection, or perforated bowel from a screening colonoscopy. Illich
characterizes clinical iatrogenesis as it is understood and used in biomedical
circles, but he brings a particular poignancy to it when he refers to
“remedies, physicians, or hospitals [as] the pathogens, or ‘sickening’ agents”
at work. (p. 27)
With
social iatrogenesis, Illich is referring to the harm societal arrangements for
health care can inflict on people it’s meant to help. These arrangements
comprise hospitals, physicians, health care product industries, insurers, and
government agencies. The net effect of their actions is to standardize health
care, and in Illich’s view, standardizing health care amounts to the
“medicalization of life.” The more life is medicalized, the more people are
forced to operate under the influence of organized health care, “when all
suffering is ‘hospitalized’ and homes become inhospitable to birth, sickness,
and death; when the language in which people could experience their bodies is
turned into bureaucratic gobbledegook; or when suffering, mourning, and healing
outside the patient role are labeled a form of deviance.”
(p. 41) Harm results
to people whose ideas of what constitutes illness and whose preferences in the
management of their illnesses do not match up with standardized health care.
They could be harmed by treatments they don’t think they need, such as drugs to
blunt grief, or in the ways they do not prefer, such as in a hospital. Thus, in
social iatrogenesis, the social arrangements of health care are the pathogens.
Before
the social movements and transformations produced standardized health care,
people of various cultures coped and adjusted in their own ways to the
suffering they experienced. Illich’s cultural iatrogenesis occurs when
societies capitulate to “professionally organized medicine [that] has come to
function as a domineering moral enterprise that advertise industrial expansion
as a war against all suffering.” (p. 127) Illich is not saying that suffering
is good and should be preserved, but rather that societies coming under the
control of industrialized health care suffer more and suffer in ways they no
longer have the authority or will to manage. Cultural iatrogenesis also
manifests when professionally organized medicine supplants community responses
to health problems people in that community experience: “The siren of one
ambulance can destroy Samaritan attitudes in a whole Chilean town.” (p. 8) He
elaborates on how cultural iatrogenesis works against people with examples
involving treatment of pain, creating and eliminating diseases, and death and
dying.
Illich’s thoughts on
countering the counter productivity of industrial health care take up the last
section of the book. He does not propose tearing down organized health care,
but rather getting it to where “health is identical with the degree of lived
freedom,” because “beyond a certain level of intensity, health care, however
equitably distributed, will smother health-as-freedom.” (p. 242) Illich is
beseeching organized health care to leave life less medicalized so as to leave
more room for people to decide themselves if their challenges are a matter of
health or not, and how they would prefer to manage them when health care may
have a role. To this end, he concentrated this section of the book mostly on
the political responses required to restore “freedom and rights” people ought
to have to manage their health.
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