Ivan Illich’s book Medical Nemesis: The Expropriation of Health (1975) investigates the evolution of healthcare as an industry, and the way in which it has altered the relationships between society and health care providers. Illich identifies misconceptions in the medical industry, and notes that there have been a number of issues that have surfaced due to the “medicalization” of our society.
A few of the problems identified by Illich include the “political and technological transformations” of practicing medicine, and the impact of how physicians act and engage with patients, and the perceptions held by society regarding the medical industry. Illich notes that the most important factors in improved health are not the diagnosis or attempts at curing disease, but in “higher host-resistance due to better nutrition,” (pg. 16) and the profound impact of a population’s environment on its state of general health. Illich contends that there is a lack of appreciation of the role of environmental factors on health, and that when doctors and providers speak of medical procedures and devices, they are not incorporated into a “layman’s culture,” rather health is presented as a specialized science that is above the “normal” citizen’s realm of comprehension (pg. 21). This ideology of health has created a change in that “the depersonalization of diagnosis and therapy has changed malpractice from an ethical into a technological problem” (pg. 30). In this case, Illich is assigning medical “progress” and evolution the label of technology, and linking malpractice to a more general definition that includes “professional callousness, negligence, and sheer incompetence” (pg. 29-30).
Illich explains that the health professionals have a “culturally health-denying effect insofar as they destroy the potential of people to deal with their human weakness, vulnerability, and uniqueness in a personal and autonomous way. The patient is the group of contemporary medicine is but one instance of mankind in the grip of its pernicious techniques” (pg. 33). Illich takes issue with the ways in which individuals are classified in the realm of medicine, and they are segmented based on the desires of providers who are arguably arbitrary specialists who are more effective an unnecessarily diagnosing and segmenting populations than they are at curing disease or improving health outcomes. Illich notes that modern medial progress has been much more effective in identifying epidemics and prolonging life in those with chronic illness, as opposed to actually curing conditions and improving quality of health. There seems to be a vast misconception as to the definition of health, and Illich proposes that the solution to the problems of this perception can “only come from within man and not from yet another managed (heteronomous” sources depending once again on presumptuous expertise and subsequent mystification” (pg. 35). In essence, Illich argues that the improvement of health must come from an individual’s own desire to improve their health, and not simply partaking a passive role to the highly regarded medical specialist. Illich notes the flaw in the general belief held by society that only medical professionals “know what constitutes sickness, who is sick, and what shall be done to the sick and to those whom they consider I at special risk” (pg. 47).
This mindset and the overall medicalization of society places substantial control in the hands of doctors in that they shape the whole of society by removing the power of the individual and assigning labels that will shape the way they perceive themselves and the ways in which they are seen by society. Illich supports this belief by saying “the physician acts primarily as an actuary, and his diagnosis can defame the patient, and sometimes his children, for life” (pg. 90). Medical diagnosis can create a stigmatization of individuals that not only become barriers that are sometimes impossible to overcome, but also strip any healing power from the individual. They become reliant on the physician. Healing becomes something that is given by the medical professional, not something that is done by the individual. Healing transforms a person into “a limp and mystified voyeur of his own treatment,” instead of “mobilizing his self-healing powers” (pg. 114). Medicalization strips society of it power over its own health, and makes it reliant on a field that has far less medical impact than it would have a person believe.
This dynamic allows for a patient to be removed from his own personal suffering, and thrown into a dynamic that interprets his condition based on medical rules and assumptions that are only explained to him to the extent of which a physician deems appropriate. Illich notes that this puts the individual in the “place as a subject who does not speak the language of his master” (pg. 171). People are trained for health consumption rather than for health action, and due to this divide between the medical scientist and the uneducated layman, their range of action is significantly reduced.
Illich concludes his observations of the flaws in the medicalized society by claiming 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” (pg. 216). This would suggest that the needed shift in medicine would rely on the empowerment of the individual, and a removal of the reliance on a medical system. As Illich notes, personal responsibility for health care should be made the central issue, and limitations of professional monopolies should be the end goal.
Illich, I. (1975). Medical nemesis: The expropriation of health. New York: Pantheon Books.