0037-7856(75)90182-1] Lawrence G. Miller -- Negative Therapeutics (1)

7/27/2019 0037-7856(75)90182-1] Lawrence G. Miller -- Negative Therapeutics (1)

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REVIEW ARTICLENEGATIVE THERAPEUTICS by LAWRENCE G. MILLER

Prometheus. the spot is out there waiting, and if is also your wound. It is the vulture CJ~Zeus. Whenyou return to fhis rock. the vulture will feast contented/j, without pausing on you. and tear ,vour ,Jcshto ribbons. and dip his crooked hurter-yellow beak in pour liver. Each morniny. your lirvr and innardswill he as Hack and dead as mud. The cxdture will never consume ym-each night your slashed ,f/eshwill slow/~, and painfully heal. your liver will regain its narural colors...

ROHIXT LOWELL. Promc,thrus Bound

In Medical Nemesis Ivan Illich presents a latter-dayversion of the Promethean myth. The lone hero, Pro-metheus, has been replaced by Everyman. who com-mits collective hubris in the name of unbounded ma-terial progress-p. 154. These new Prometheansdo not usurp the privilege of the Gods; rather. theiractions constitute a denial of the human condition,of mans very nature. Thus industrial hubris callsforth a new Nemesis. the material monster bornfrom the overreaching industrial dream-p. 154. Me-dical Nemesis explores one aspect of this transgressionand retribution. the expansion of medical care andthe concomitant medicalization of society. Thebook. published in Britain earlier this year. is partof a series entitled Ideas in Progress and as such ismeant to be a working paper rather than a polishedeffort. An American edition. to be published by Pan-theon next year is intended as a more complete ver-sion, incorporating criticism of the present edition.Those familiar with Illichs earlier work. such asDrschooling Society and Tools for Conviviality. willrecognize a similar analysis, similar iconoclasm, anda commitment to a unified critique of industrialsociety: Over-medicalization and its unwarranted by-products are thus part of a deep and general crisisthat affects all our major institutions-p. 61. Illichintends this work to be articulated in clear. well-founded and simply stated categories that would beuseful in political discussion. in order to endow en-tire populations with a new courage to recover theirpower for self-care-p. 35.

In this essay. I will first present an exposition ofMedical Nemesis. then proceed to criticize the as-sumptions and methodology on which Illichs argu-ments are based. The book is an important one: theindictments are powerful. the view panoramic and thelanguage compelling. I will argue. however, that Illichfails to develop an adequate critique of medical careand in closing suggest some prerequisites for such acritique.Medical nemesis has several facets. As noted above.it is retribution for the pursuit of inhuman goals. Al-so. it is the loss of mans self-sufficiency: *the expro-priation of mans coping ability by a maintenance ser-vice which keeps him geared up at the service of theindustrial system*-p. 160. Further. it is the loss ofvital experience and the threat of anaesthetized. soli-

tary survival in a world turned into a hospitalward-p. 166.The fundamental category of Illichs analysis andthe agent of medical nemesis is iatrogenesis, the cau-sation of disease by physicians. Illich defines threelevels of iatrogenesis. corresponding to the severityof their effects on the recipients of health care. Thefirst level. clinical iatrogenesis. deals with the unde-sirable side-effects of approved, mistaken. callous. orcontra-indicated technical contacts with the medicalsystem-p. 26. This is the most conventional ofIllichs categories, and he generally defers to the de-tailed medical literature on iatrogenic disease. Thesecond level. social iatrogenesis. is approached from thepoint of view of the sociologist. Illichs major concernhere is the infiltration of the patient role into otherrelationships. a process which he calls medicaliza-tion. Most important. because it is most dangerous.is the third level, structural iatrogenesis. Here Illichadopts the stance of the anthropologist. He arguesthat the beliefs and practices fostered by professionalmedicine have destroyed the ability of the individualto care for him- or herself and others and havethwarted the power of people to cope with challengesand to adapt to change in their bodies or changein the environment-p. 65.The levels of iatrogenesis have correlates in the ex-panded social role of the physician. In clinical iatro-genesis. the physician remains in his or her medicalcapacity. albeit a somewhat blighted one. In socialiatrogenesis. he or she assumes the role of the lawyer:*the doctor exempts the patient from his normalduties and enables him to cash in on the insurance fundhe was forced to build-p. 59. Structural iatrogenesisfinds the doctor as priest aiding in the managementof an alienating society:

More and more peopk slrbconsciousl\~ kllow that the?are sick qf their jobs and qf their I&m passivities.hlrt they want to he lied to and told that physical illnessrelieves thm qf social and political responsibilitiesp. 59.Physician and patient are thus accomplices in medicalnemesis.Modern hubris. for Illich. takes the form of themad dream of unlimited progress-p. 154. In themedical sector. this is translated into increased special-


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674 L. G. MILL~.Kization and expansion. The main thrust of Illichsbook is a critique of the contemporary liberal ideo-logy that more is better.

Liberal ideology relies on the assumption that healthand health care are causally related. The alternativeIllich presents rests upon a conception of healthwhich reverses this premise; for Illich. less profes-sional care is better.

The paradigm of health presented in MrdicaI Yr-fftesis is a broad one. encompassing physical. psycho-logical and social well-being. Health is a process ofadaptation in which each individual is engaged,comprising the ability to adapt to changing environ-ments. to growing up and aging, to healing whendamaged. to suffering and to the peaceful expectationof death-p. 167. As such, health is innate. thenative endowment each man is presumed to possessuntil proven ill-p. 58. so efforts to wrench it outof its individual context are inherently flawed. Insofaras humans aggregate in groups and establish a cul-ture. they define their own standards of health:

Ctr1tlrr.c.. is rhe purticulur firnl that sLrrciuul. [email protected]~i riuhilitv cukr iff u gicrn humun group; which rru/[~fffeunt thut ;t is idrnricul with the Grstalt @t/w groupshrulrll-p. 89.To Illich. therefore. in relinquishing this notion ofhealth we have lost our true culture and instead be-come colonized by a medical civilization.

This impostor lacks two crucial attributes of a trueculture. First. values and meanings are transformedinto technical problems:

C~drfrrc cof~~~onts pin. deciuncr. and death by intc~-prrting the/n; fnrdicul citilizution turns them into proh-lrfns which can be solcrd by their rrmocul. C&urc~surc .sy.sfc~fnsof mruniffgs. cosmopolitan cirilixtion u.s~steffl of rcYhrliylrrs--p. 93.Second. a framework no longer exists to provide acheck on industrial progress and other irrational fan-tasies: Inherited myths have ceased to providelimits for action-p. 154. To place the contemporarysituation in the terms of the Promethean myth. thecommon man perishes from infirmity or from vio-lencc. Only the rebel against the human conditionfalls prey to Nemesis. the envy of the gods--p. 154.By choosing health rather than disease as his start-ing point. Illich strengthens his analysis considerably.The normative concept of health Illich posits enableshim to question not merely .the goals of modern medi-cme but also the very existence of a professional divi-sion of labor. This approach can be contrasted torecent radical sociology, such as Waitzkins andWatermans The Exploitation oj Illness in CupitulisrSociery in which the emphasis on disease limits theanalysis to social iatrogenesis. the role of medicinein social control. Unfortunately. Illichs definition ofhealth implicity assumes human passivity and

atomism. Health is based on a prr-existing set of c.K-ternal constraints to which the individual must copeor adapt. and although health is shaped and condi-tioned by culture. it is primarily a personal task- p.16X. ts essence IS the ollto11o/~1o1/.sdaptation to self.to others and to the environment (p. 169. my empha-sis). Illichs brand of constrained individualism. inwhich people are obliged to cope in ;I solitar! wa!with a situation not of their own making. leads him tobase his critique on an impoverished notion of cultureand a hypostatized human nature.

Since health and culture are synonymous for Ilhch.the definition of health implies an equally normativedefinition of culture. In fact. culture is actually rf.udi-rioftrrl culture. which is presumed to exist in the so-called underdeveloped countries-p. 90. The con-tinued opposition of traditional culture to medicalcivilization leads to a broad misinterpretation ofmodern industrial society. For example.

In contrast.Mrtiicu/ ciuilirution IS plurm~d uffd orgunixl fo killpain. to c4ifninute sickness, uffd to srrtryg[r uguifat

deuth ._fi-orn riffg cmwtiul rsprrienccs with whicheuch yf us hus to co/m to tc~fns. pain. sickness. uf~ddeath ure rrnffsjtirfned b>* fnrdicul cicilixrioff iffto ucci-dents ,@r which people fnust seek rnrdicul trruttneffr-p. 90.So meaning has been lost. and disease. pain and deathhave been stripped of their symbolic and personalvalue. In an important sense. Illich is correct: rrudi-rionul meanings and values have been lost. but theaccidents which replace them conceal other values.This process corresponds to the separation of disease(or pain) from magic and artifice and its locationwithin Nature.The importance of the transposition from artificialto natural stems from the modem conception ofNature. Unlike many traditional cultures (and presum-ably Illichs normative one) where humans under-stand their place in Nature. modern Nature isalienated from and opposed to humanity. Our voca-bulary of domination, for example has been well docu-mented.* The effects of defining disease as naturalare thus threefold. First. human bodies, and to someextent minds, are placed within the realm of objects.the domain of technical control and manipulation.As Illich points out. the often stilted exchangesbetween doctor and patient testify to this objectifica-tion-p. 55. Second. responsibility for pain or diseaseis located not in the actions of people. but in suppo-sedly random Nature. Consequently. solutions aresought in the natural realm. Third and most impor-tantly. this process of medicalization is an historicalphenomenon, not a mere syllogism. The developmentof attitudes toward disease. scientific or otherwise, isintegrated with other human activities including thosemvolved in the distribution of power. It should notbe surprising, therefore. that medicalization consti-tutes part of an ideology which mystifies social prob-lems by ascribing to them a totally natural origin.


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Responsibility then becomes diffuse. and problemscome to require natural solutions, meaning furthermedicalization. An instructive contemporary exampleis the search for genetic origins of criminahty: whencriminality has been designated a disease. its etiologyand therapy must fit the medical pattern*. As lllichaffirms, values and meanings acquire a technical con-text, but techniques in turn carry an implicit ideology:values are submerged. not lost.

In a similar vein. lllich argues that the loss of tradi-tional values. as expressed;n myths. has led to theloss of cultural limits to action. Illich himself relieson myths and ancestral Gods to make certain thathis analysis is foreign to an industrially dctcrminedlogic or ethos-p. 28. The universe to which thesemyths belong is an active one. populated by Godswielding immanent natural forces. Since the rangeof human action was narrowly circumscribed---p.162. man could seek to extend his capacities only atthe risk of hubris and the ineluctable nemesis. Theunified cosmos reigns no longer; modern Nature ispassive. the Gods having been replaced for Illich bylimits in the external world and in ourselves. The roleof man. with respect to Nature. is equally passive.We are to act so that the natural boundaries of en-deavour are estimated. recognized and translated intopolitically determined limits-p. 166.

But myths have not disappeared and absolutenatural boundaries do not exist. Our myths are scien-tized and feign objectivity. such as the myths of biolo-gically-determined race differences or sex roles. Theyno more correspond to natural boundaries than thePromethean myth: both are formulated by men inparticular social and institutional contexts with par-ticular goa!s. Our boundaries, the categories ofNature and human nature. are largely artificial and thusideological: we both define and create our limitations.

How does this process come about! To Illich. theloss of limits to action has occurred through themachinations of the medical and para-medicalmonopoly. unchecked by even the usual market con-straints. The preeminence of this guild enables it todefine the terms in which health is conceived. pro-vided, and extended: health yields to health care.health care to management. and management to ad-diction to further health care. The first stage of theprocess is aided and abetted by political parties.which coin the desire for health into the design ofmedical facilities-p. 70. Then. as the managementmodel is applied to health care. wage-labour andclient-relationships expand while autonomous pro-duction and gift-relationships wither-p. 63. The in-dividual. deprived of a true notion of health and themeans to attain it becomes dependent on the man-agement of his intimacy: he renounces his autonomy

* Beckwith J. and King J. The XYY syndrome: a danger-ous myth. .VCW Scimisr 64. 474. 1974: Borgaonkar D. S.and Shah S. 4. The Xll chromosome male-- or syn-drome. Prq. .Ifctl. Gcrwr. 10. I?S. 1974.

f Gintrs H. Power and alienarion. In Rrtrdirqz in Polfri-c.01 Eu~r~oru~~ (Edited b! Weaver J.). 1972.

ZGintis H. Deschooling Sociq: toward a politicalecnnom> of education. Hwwtl Etl~r. RCV. 42. 70. 1972.

9;Gramsci A. S&crim froru r/w Pmm .Voruhooks(Edited h! Hoare Q. and Smith G. IK. ) Nen l-or]\. 1971.

and his health nn/st decline--p. 169. Health care failshccause it is manipulative. changing adaptive abilityinto passive medical consumer discipline--p. 39. Itexpands. however. because it is addictive: People inmodern societies believe that they depend on themedical industry but they do not know for what pur-pose-p. 69. We are left with an unhealthy societywhich depends on unhealthy people whose survival,discipline and functioning are assured through dcli-very of the necessary therapeutic services--p. 16X.

The manipulation-addiction model is appealing at.a time when the impetus for reform takes the shapeof consumerism. But in treating people as passive.manipulated consumers. Illich neglects the role ofpeople in pr-otl~?ry their values and social relationsby their day-to-day activities. The values of depcn-dency and passivity which Illich criticizes should nothc viewed as aberrations caused by manipulation. butrather as implicit in the structure of social relations.The ultimate source of these relations lies in the ac-tivities in which people spend the bulk of their time.primarily the workplace. The shaping of the work-place in turn is the prerequisite of thosr who deter-mine the mode of industrial production. the dominanteconomic class.*

Institutions of socialization. whether medical oreducational. ma) contribute to efficiency and stability.but they rcprod~~, I.U~/MYl?an SU/$V the models forour social relations.: To revise Iliichs conclusion.health care fails and expands not out of manipula-tion-addiction but rather because it does not dealwith the fundamental social problems that normal op-eration of capitalist institutions generates. Likewise.technologically-directed explanations and ideas ofhuman limits arise not mysteriously but rather from aconcrete basis in actual social relations and throughsubtle limitations placed on discourse and argument.Such ideologies serve to legitimate and justify thesocial order; their fabrication and propagation cannotbe ignored.5 While my analysis has been schematicat best. the implications are clear: to fully understandhealth beliefs. activities and ideologies in contempor-ary society we must look beyond medical attitudes.and bevond even Illichs industrial ethos. to theeconoflffc and social bases of human activity.Illichs perspective remains consistent throughout;medical nemesis has developed due to lack of beliefin boundaries to action. and it can be overcome byrestitution of such faith. Despite repeated mention ofthe industrial mode of production, in his solution .Illich emerges as an unregenerate idealist. The first steptowards cultural health is education. which will leadto the recognition of our present delusions-p. 165.This in turn will spawn an ethical awakening-p.164 reinforced by political action designed to depro-fessionalize medicine.But is enlightenment a sufficient condition for funda-mental reform? Onl! if we assume. with Illich. theprimac! of consumer relations and the manipulativesources of social deca!. If instead we allow the impor-tance of the relations of production. and the materialconditions of work which shape those relations. thenenlightenment alone must fail. Deprofessionalizationwould lead to little change. or at best chaos: sincethe forces which structure our relations would remainuntouched.


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676 L. G. MILLIKThe inadequacy of Illichs analysis and solution cannow be summarized. Illich assumes the existence ofa set of traditional values which have been lost and

can be reclaimed. He assumes that beliefs. delimitingthe true human condition. once constrained humanaction but now must be replaced by a new set ofconsensual myths. He assumes that our plight is dueto our passivity and exposure to manipulation. Xboveall. Illich assumes a conception of human nature sur-prisingly similar to that of a nineteenth century liberal:men and women are isolated individuals who actin their own enlightened self-interest-p. 163 or withreasonable self-restraint-p. 159. which in turn aredictated by received ideas and beliefs. Societies areaggregations of such individuals and function to pre-vent overt conflict of self-interests. To complete thepicture. Illich adds his own invisible hand. an innaterespect for the ideal human .condition.

The solution to which these creatures are adaptedalso bears striking utilitarian characteristics. Ratherthan aiming at the reformulation of collective goals.Illichs program is decidedly individualistic. resultingin legal and political procedures that permit indivi-duals and groups to resolve conflicts arising fromtheir pursuit of different goals-p. 165. The Icgisla-tion he envisions has five major objectives: (1) to pro-hibit the licensing of any group of medical profes-sionals: (2) to allow people to drop out and organisefor a less destructive way of life-p. 166: (3) to shiftresponsibility for the use of drugs to the sick manand his next .of kin-p. 167: (4) to allow each personto define his own health to the extent that othersare not harmed: (5) to make possible the election ofhealers on the basis of their performance in the com-munity.

So medicine. for Illich. would become a system ofsmallscale entrepreneurs operating in an ideal freemarket maintained by the state. Since this frameworkis suited to human nature. a world of health and har-mony. marked by minimal and only occasional pro-fessional medical mtervention-p. 169 would result.If the people to populate this world ever oxisted. theydo not exist now. Illichs most serious error is onehe rccognizcs himself:

Illich proceeds. however. to separate the individualfrom society and pretend that we can shed our sociali-zation and thus rediscover our true natures. whichafter a11 are only manipulatively suppressed. But newvalues and new myths have replaced the old. andmaterial conditions have changed the percieved limitsto human action. To use Illichs metaphor, we canno more return to the old ways than we can divestourselves of our skins.The reliance on an intrinsic human essence is notsurprising considered in the light of Illichs negative

methodology. Throughout .~ILY/~cu/! ~wrc.v.s negatmlsabound. for example:

It is this method \vh~ch forms the hasps of Ill~ch~critique. The socialization process in industrial societyis repressive and dehumanizing: Illich rejects snciali-zation. Professional health care induces dependency :Illich rejects professional medicine. Medical institu-tions are manipulative: Illich rejects an organizedhealth deliverv system. Political institutions cncour-age the expansion of medicine: Illich rcjccts a politicalsolution for an essentially individual one.But in rejecting socialization. Illich athrms theexistence of an idealized utilitarian human natureuprooted from any social context. In re,iecting profes-sional health care. he embraces an entrepreneurtalfree market and thus the commoditv nature of health.In rejecting organized medical institutions he adoptsa /uis.w-_~fitire attitude which reinforces capitalist ideo-logy. In rejecting a political solution. Illich athrmsthe utilitarian. individualist ethos of personal action.As Gintis and Marcuse remind 115. the negative methodused alone leads to implicit affirmation of the basicprinciples of the existing social order.* Such a critiqueis hardly radical.

I have dwelt at length on Illichs errors and miscon-ceptions. The negative method has also provided thebasis for an exemplary description of the dilemmaof modern medicine. Other reviewers have concen-trated on the lapses in this description and these ccr-tainly exist.t What is more important however. is theenormous power of the negative method in Illichshands; hence his ability to slice through the mystitica-tions of liberal ideology such as welfare medtcme andtechnological progress. In the areas where Illich pro-ceeds beyond negation. his analysis is truly illuminat-ing. The chapters on the changing nature of pain anddisease are provocative and the chapter on death isbrilliant. Illich explores the relation between healthand its negation to point to a syntheses which empha-sizes their intimate connection at the substrata ofhuman consciousness. Amidst the burgeoning litera-ture on death and the developing specialty of thana-tology. it should give us pause.

I have thus far argued that Illichs analysis of Tedi-tine is inadequate and that the ncgativc method isinherently limited. What shape would a proper criti-que of medicine take.! As in the cast of Illichs chapteron death. it would be dialectical in methodology. at-tempting to understand the relation bctwcen healthand death. thesis and antithesis and to comprehendboth in consciousness or s!.nthesis. The critiquewould seek to identify the posItIon of medicine amongcapitalist institutions. and to understand the role ofmedicine in the formation of personal attitude? and


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Negative thcrapeutlcs 677social relations. It would attempt to identify the con-tradictions inherent in health care. among them theuse -01 Inherently alienating technology to providehumane care. and also the efforts made by doctorand patient to deal with the body while the self isin the room. By placing these contradictions in thecontext of a broader critique. suggestions for actionwhich go beyond reform may result.An additional important aspect of an analysis ofmedicine would be historical to help us construct therelation between present and past and to provide awell of conclusions on which to draw. For example.the last vears of the nineteenth and early years ofthe tweniieth centuries saw the consolidation of fourtrends crucial to the comprehension of modern Amer-ican medicine. First, the need to provide a healthyand continually productive labor force amidst poten-tiall? dangerous conditions led to the involvement ofmedicine with the forces of production b> waq ofWorkmens Compensation and industrial Insuranceschemes. Second. the drive to rationalize the deliveryof health care on the industrial model contributed

to the rise of the modern hospital and its foundationon hierarchical principles. Third. the advent of thebacteriological model of disease and the concomitanttriumphs in public health led to the description ofhealth as a commodity. The motto of the NCM YorkPublic Health Department at the turn of the centurywas public health is purchasable-within naturallimitation a community can determine its own deathrate. Finally. the developing professional conscious-ness of physicians led to changes in mcdicdl educationwhich fundamentallv altered the size and class com-position of the medjcal profession.*

In closing. Ict me reemphasize that Illichs bookis an important one. of benefit to anyone concernednot only with medicine but also with social well-be-ing. Its excellent bibliography provides a myriad ofsources for further study. Most of all. Mcdicul ~Ver~c,-sis is a challenge to those disturbed $4 the state ofmedicine and society to build an accurate and usefulcritique. We can journey with Illich. but we musteventually transcend him.

* Anderson 0. IV. T/W L r~c~.srQ~~ilihri~rr~ New Haven.1967. Landefeld S. The Hospital Idea. S,~r/~esis. 2. 1974.Rosenkrantz B. G. Puhlk HcuIrh trrd t/w Srclrc.CambridgeUnivcrsit) Press. MA. 1972. Markowitz G. and RosncrD. Elitism in Medicine. -1)~. Q. 34. 1973.

Aclir7o~lrd~mle,~r-~I thank Ms. L. J. Daston for her in-valuable assistance.Hartwrd Mdicul Shol.Boston. Mz4. L.S.A.

0037-7856(75)90182-1] Lawrence G. Miller -- Negative Therapeutics (1)

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