Medical Nemesis

I spied, recently, a notice for a new journal being inaugurated this fall: The International Journal of Illich Studies. Especially with the health care debate swirling around us, it might be worthwhile to revisit the ex-Monsignor and radical social critic, Ivan Illich. I had occasion this summer to re-read Illich’s four major books of the 1970’s: De-Schooling Society; Tools for Conviviality; Energy and Equity and Medical Nemesis.

Despite his vast erudition, Illich’s major thesis (perhaps, most illuminated in his best known work, De-Schooling Society) is really fairly simple. Illich thought that, in the process of institutionalization, various sectors of society moved from "a first watershed" (e.g., fostering learning by founding schools; improving health through better medicine) to "a second watershed" by which professional monopolies actually undermined the main initial purpose of the institution. If schools, as Illich argued, are aimed at " learning," not "education," professional educators have turned schools into a monopoly for learning. Thereby, we became blind to the educational possibilities in other institutional sectors. We actually use schools as a sorting mechanism to determine life-chances of varying classes and economic groups. We have made "certification" displace genuine learning.

In a sense, Illich’s main thesis is quite similar to Max Weber’s famous argument about the rise of rational bureaucracy by which, over time, it created an "iron cage," run by "specialists without spirit." Weber argued that a logic of means-ends rationality totally displaced a logic of the rationality of goods or ends, in themselves. Specialization and rational bureaucracy, in the end, robbed society of spontaneity. So, too, Illich thought schools tended to monopolize all the money and resources, making it harder for people, outside schools, to engage genuine learning and acquire useful skills.

Good Catholic thinker that he was, Illich, unlike Weber, did not despair of the possibility of a rational discussion of the goods or ends to be pursued. While he agreed with Weber that, in point of fact, most of the logic of modernity favored a crass utilitarian means-ends rationale, Illich argued, in Tools for Conviviality, that we could come to some consensus on the goods of human agency and living life, joyously, amid the necessary limits. Energy and Equity was an early embrace of an ecological ethic and a fierce complaint against energy misuse. Illich famously championed the bicycle as an optimum means of transportation.

I suppose Medical Nemesis might be the most useful of Illich’s works to read at the present moment. Just as Illich was not against schools, as such, but the way they monopolized resources and imagination for learning through alternative institutions (and by creating a professional monopoly which, actually, systematically blocked creative non-school-based alternatives to learning), so Illich did not reject doctors or modern medicine or hospitals, as such. He did remind us that the major breakthroughs on health came more likely from changes in our environment ( e.g. clean water; a sewage system; removal of rodents) than from medicine as such: "The principal determinants of health and longevity are not medical treatment but the physical and social environment.” He also coined an important word, iatrogenesis, to signal the many diseases actually caused by doctors or a stay in the hospital  

Like schools, Illich argued that a recuperation of health depended on a recovery of personal responsibility for health care. Modern medicine robbed us of personal agency on health. Our grandmothers knew remedies for flu, sore throats or other common diseases that we no longer remember. Illich lamented the erosion of many traditional ways of dealing with pain and disability. He also called for a limitation of the professional monopolies’ power almost totally to define what constitutes health and how to achieve it. Illich knew, as we do, that health care is costly and grossly unevenly distributed. He decried what he saw as useless medical treatment and what he termed “ the medicalization of life” (a pill for every complaint or ailment). While he never sought  “death panels,” he did think we needed to accept limits. He did not approve of long lingering life on life-support machines which promised little recovery or true respite.

Illich’s radical proposals for an overhaul and restructuring of modern institutions were never likely to be adopted. He was better at diagnosing the ills of modernity than prescribing a cure. I first read Medical Nemesis in 1976, when I was visiting Zambia for three months. It struck me that Lusaka had modern hospitals with state of the art machines but lacked the technicians to repair or care for them when they broke down. Outlying areas did not have simple clinics for ordinary health care. Nemesis, in Greek mythology, was the goddess of retribution and vengeance because of hubris, a pride which did not acknowledge limits. Perhaps, our current debate on health care would be deeper and more meaningful if we spent more time talking about the limits of what medicine can do and learning, as humans, to accept better some of our own limits to recovered health. In a sense, Illich’s goal for medicine was of a piece with his notion of the good in Tools for Conviviality: self-reliance; autonomy; dignity for all, particularly the weaker.

Illich famously refused ordinary medical treatment for a cancerous growth on his face. The treatment would have disabled him in ways trying to cope with the cancer through holistic health measures did not (and he used judicious smoking of opium to soothe the pain but not dissolve normal consciousness). Arguably, he lived, as long and as productively, as if he had let modern medicine take its course. Illich died at age 76 in 2002.

John Coleman, S.J.