Ivan Illich’s book Limits to Medicine: Medical Nemesis- the Expropriation of Health blew me away when I first read it as a medical student many years ago. Re-reading it recently, I was struck by its originality and audacity, as well as the continuing relevance of Illich’s thought. Illich was a visionary in a proper sense, a man who dared to question some of our deepest-held beliefs, and to imagine a radically different way of living.
When I signed up to do medicine at University, being a doctor seemed an entirely progressive and benevolent enterprise. What could anyone object to about making sick people better? I wanted to go abroad and spread the wonders of western medicine to the underdeveloped world. But I soon started to hear concerns about the direction of medicine. Wendy Savage came to speak about the over-medicalisation of childbirth. An older student suggested that western doctors working in Africa and Asia could undermine local health systems. Some people objected to the free alcohol and other perks that the pharmaceutical companies lavished on medical students from the moment they arrived.
There was also something disconcerting for me about the relentless study of the facts of the human body. In dissection classes we traced the anatomy of the arm, leg and torso in minute detail, and in other lectures we acquired a meticulous understanding of the cellular structure, physiology and biochemistry of the body. The whole biology of the human being was laid before us, including the cadaver of some poor soul who had donated their body to medical science. I never doubted that this sort of knowledge is necessary if we want to understand the body’s various systems, in order to intervene and improve them when they go wrong, but I found it uncomfortable for reasons I could not put my finger on.
Limits to Medicine put my unease into words. Written as part of a broader critique of industrialised society and its institutions, Illich’s basic thesis is that technological hubris has led us to forget the limits of the human condition. We have come to believe that technology can eradicate all human suffering and provide unblemished and everlasting happiness. We have paid for this irrational expectation with our autonomy, our dignity and our ability to endure.
Difficult as this is to write as a doctor, there is something inherently degrading about medicine. After all, it involves allowing someone else to interfere with your body, your own personal, physical self. When it was just the local doctor backed up with a few basic medicines, it was a relatively private and contained degradation, but now there is a whole system geared up to examining, testing and adjusting different parts of you. Submitting yourself to medicine now requires the wholesale signing away of your bodily integrity.
Illich recognised that modern medicine has developed some incredibly effective interventions. Many of the most useful, such as vaccination, are relatively simple and can be administered without too much interference. Others, the treatment of heart attacks or cancer for example, require a great deal of bodily intrusion, including surgery to remove diseased parts, insertion of devices, and the ingestion of powerful and debilitating drugs like chemotherapy. There is no doubt that these interventions can give people more years of good or reasonable quality life. There is a trade-off, however, which is rarely acknowledged since medicine has become such an apparently indispensable part of our lives. Medical miracles come at a cost- and that cost is dignity.
Medicine is no longer confined to the alleviation of suffering, but now involves a life-time of scrutiny, with checks and screening from cradle to grave. Then, when you really get sick, it unleashes relentless efforts to identify, remove or neutralise that part of your body that is malfunctioning. These efforts are concentrated in the last few months of life in a heroic battle to defy the inevitable (http://www.forbes.com/sites/michaelbell/2013/01/10/why-5-of-patients-create-50-of-health-care-costs/#75e96a834781).
The problem with medicine is not just its relation with the individual body, however. It is also the premise that we can, and should, do all we can to fight and delay death. Medicine has created a myth that we can heal everything, given enough time and money. Consequently many people have come to believe that medicine has effectively conquered disease; that there is a treatment for every symptom or that the cure is just around the corner. Despite the late 20th century’s growing scepticism, faith in scientific progress to solve every problem remains strong.
But we are mortal, and death will come sooner or later. The diseases of aging like most cancers and dementia will most likely never be cured. In any case, there will always be illnesses we cannot treat, that cause early death, pain, suffering and grief. The wishful thinking that medicine has come to embody obscures the limitations of the human condition, leaving people less aware of their own nature. This denial of our frailty and mortality reduces our ability to withstand the inevitable tragedy of life.
Illich’s more specific criticisms of medicine were prescient. He described disease-mongering and the ‘pharmaceutical invasion,’ and pointed to the importance of evidence-based medicine and patient and public involvement long before they started to be accepted by mainstream medicine. His criticism of diagnosis for denying the autonomy of ‘self-definition’ is more profound than any of the current debates about the DSM-5 (see for example the BPS critique of DSM-5). Despite its impassioned arguments, Limits to Medicine is an incredibly scholarly book, drawing extensively on anthropology and cross-cultural literature, as well as scholarship on the epistemology of sickness and the linguistics of suffering among many other areas.
Illich was a remarkable man, an academic and onetime priest, who lived according to his principles, and refused treatment for the cancer that eventually killed him. Although Illich’s vision of an alternative society is described in more detail elsewhere (such as in his famous critique of modern education, Deschooling Society), Limits to Medicine sets out some of the principles on which such a society would be based. It would be organised around the needs of people to live meaningful lives, and not around production and consumption for its own sake. It would foster the autonomy of individuals and communities and their ability for self-reliance, but also recognise the necessity of inter-dependence and mutual support. It would integrate the most useful aspects of modern technology, including medical interventions, but submit these to democratic scrutiny.
Limits to Medicine has much to say about psychiatry, and the current Pharma-driven mental health industry epitomises Illich’s ever-expanding, technocratic monster. The idea that our discontents are a manifestation of faulty brains that can be abolished with sophisticated medical treatment is just the sort of illusion that Illich is responding to. Medicine’s promise of a quick fix diminishes the capacity of individuals and communities to deal with the difficulties and differences that are labelled as mental health problems. While not denying medicine’s many achievements, Illich’s message is one I believe still needs to be heard.