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.
Joanna Moncrieff 
Illich’s book was also a big influence during my medical training and helped me decide to go into psychiatry. His message was the answers to human suffering lie in social connection and cultural meanings, but this is often a message that people do not want to hear.
Thank-you, Joanna. As usual, your writing is excellent. And both Illich’s thoughts, and yours, are manifest in the plight of Mr. Garth Daniels, in Australia. >madinamerica.com< has a current piece. Medical hubris and arrogance has led to deliberate torture being considered "good medical practice". And Weds. was Kent State Day…. I'm so busy fighting back and defending in the Psych Wars, that I didn't notice….. Keep up the good work, Joanna.
(c)2016, Tom Clancy, Jr.,
Why on earth does allowing myself to have medical tests at my discretion mean that I have lost my dignity, that may be your opinion and belief but is certainly not mine or many other people’s. You are equally as guilty of clear bias in not accepting medical models for mental illness and twisting research to meet your views. If there are illnesses with biological causes for the rest of the body why would there not be for the brain? Admittedly we are behind in the evidence and research stakes due to psychiatry not being a “sexy” subject. I am sure that many psychiatric illnesses have a stronger psychological basis and may not require psychiatric medication but equally many of them do.
It is very condescending to assume that the majority of psychiatrists are unaware of the long term effects of antipsychotics and do not discuss this with patients, they are! However I and many of my patients who have an ‘SMI’ take the balanced decision that the long term risk is outweighed by the benefit. Whilst you appear to be very anti-medication you seem not to have a lot of advice on how to manage these over medicalised normal mental states, how for instance do my family manage my 4 week periods of sleeping 2 hrs per night, relentless decorating and rearranging the house, constant talking, overspending and climbing the banisters over a large drop to paint the ceiling as it never occurs to me that I would injure myself. Then there’s the months of depression with significant suicidal risk, psychomotor retardation and often detention in hospital. To be fair I probably get a couple of months of good function when I’m able to work. The alternative is a low dose antipsychotic and antidepressant with which I can be well for 2-3 yrs at a time (usually until I forget what it’s like to be ill and decide the fight against weight gain and sedation isn’t worth the benefit so I stop it with rapid relapse). Should I not be allowed to make that choice? What do you think it does to the self esteem and dignity of people like me to have you suggesting that these are merely normal mental states and that we should stop medicalising ourselves and get on with it?
Dear Fiona,
Thank you for your comments. I fully recognise that there are situations in which drug treatment is helpful, and in which people can make informed and rational decisions about the risks and benefits. I think antipsychotics and other sedative drugs can be helpful in reducing the symptoms of mania and acute psychosis. The main point of my work on psychiatric drugs is that we misunderstand how they work and that we do not have evidence that they work by targeting an underlying disease or abnormality (as is usually suggested or implied).
I am also concerned that we do not have a good evidence base for the risks and benefits of long-term antipsychotic treatment (or other long-term drug treatment). That is why I am doing the Radar study, to try and produce evidence on this.
To say that psychiatric drugs do not work by targeting an underlying brain abnormality is not to say that there is no such abnormality present in mental disorders. However, I do not think we currently have evidence of any specific abnormalities in most mental disorders. Suggesting that mental health problems are not best viewed as a disease is not to say that they are not sometimes deeply problematic- for those who suffer them and for others. I am not suggesting that people with severe mental disorders can ‘just get on with it’, but I don’t think there are any easy solutions either. I believe drugs can be helpful in some situations, but not in others. I do not think it is useful to encourage the view that drugs are more helpful than the evidence suggests they are.
I am glad you think that psychiatrists are fully aware of the risks and benefits of antipsychotics, and discuss these with their patients. Historically, the profession has often been reluctant to admit the harms associated with its treatments, however. Hopefully, as you suggest, that is changing with the new climate of greater openness and the emphasis on mutual decision making.
Best wishes,
Joanna
Was having Magnesium IV’s for my migraine and guess what, it calmed me down one heck of a lot as well as helping with the migraine. So I looked at the molecular biology that magnesium is involved in.(this is 10 or so years ago) I discovered that the N-methyl D-Aspartate receptor (a glutamate receptor which is the major excitatory neurotransmitter in the CNS and along with GABA accounts for 90% of neurotransmitters) is gated (think of a gate keeper) in a voltage dependent way by MAGNESIUM ions… so if the mag is not there, what do you think will happen. To function correctly that mag needs to be there and is only pushed out of the way by the AMPA receptor sitting next to the NMDA. The psychiatric drugs will make you worse without exception and should only be used in the short term. The body responds by changing itself, it doesn’t want them, they are not part of evolutionary correct nutrients. Then when you stop the drugs you rebound back into mania so you have to go back onto lithium, benzo’s….what ever, it’s vicious cycle. The only way to deal with these problems is by working with the requirements of the body and they do not include ANY psychiatric drugs, especially in the long term. I found that I have to attenuate my life…no strong inputs.. calm, level, considered… no drama going on plus the magnesium and I’m fine.
The only things ‘holding’ psychiatry together are the drug companies and the state which uses coercion to force people onto these drugs. These companies will fail because of pharmacogentics and in particular the emerging Cytochrome P450 test. When the hedge funds fully understand the implications of this test, they will massively ‘short’ (bet against) Pharma. Those against psychiatry needs to focus on this financial area if they are to be really effective.
I wonder if mental health problems stem from a lack of a perceived meaningful life. If the American Dream is the yardstick then we are in large part doomed to not achieving the ends. Some of us may scrape by with the powerful illusion associated with aspiration. Therefore, a big lot of us are destined for lack of meaning and mental health collapses. I think Illich suggested meaning could be found in the struggle for survival, but that struggle needs to be honest, personal, and freely chosen. Here, I contemplate on the choices of the Sumaritan described by Illich, and not the violence of sectarian associations
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