Journal of Medical Ethics, I975, I, 73-77

The medicalizationof lifeIvan Illich Centro Intercultural de Docwnentacion, Cuernavaca, Mexico

Two contributions from Dr Ivan Illich follow. Thefirst, in which he sets out his primary thesis of themedicalization of life, is a section from Dr Illich'sbook 'Medical Nemesis'. (It is reprinted with thepermission of the author and his publishers,Messrs Calder and Boyars.) The second is atranscript of the paper which Dr Illich read at theconference organized by the London Medical Groupon iatrogenic disease. Both are ultimately addressedto the recipients of medical care, the general public,although the second paper is specifically addressedto young doctors and medical students. For Dr Illichthe world is suffering from too much medicalinterference, and a medical edifice has been btiltwhich is one of the threats to the real life of hunanbeings - a threat which so far has been disguised ascare.

In 1960 it would have been impossible to get ahearing for the claim that the ongoing medicalendeavour itself was a bad thing. The NationalHealth Service in Britain had just reached a highpoint in its development. It had been planned byBeveridge on the concepts of health prevailing inthe 1930S. These assumed that there was a strictly'limited quantity of morbidity, which if treatedwould result in a reduction in subsequent sicknessrates. Thus Beveridge had expected that the annualcost of the health service would fall as effectivetherapy reduced morbidity.4' It had not beenexpected that the definition of ill health would widenthe scope of medical care and that the threshold oftolerance to disease would decline as fast as thecompetence for self-care or that new diseases wouldappear due to the same process that made medicineat least partially effective.

International cooperation had achieved itsPyrrhic victories over some tropical diseases. Therole which economic and technological develop-ment would play in spreading and aggravatingsleeping sickness, bilharzia and even malaria wasnot yet suspected.47 The spectre of new types of460ffice ofHealth Economics. Prospects in Health. OHE,162 Regent Street, LondonWiR 6DD, 1973,24 pp.47For a survey of the literature on disease-consequencesof developmental activities see Hughes, Charles C,Hunter, John M. Disease and 'develpment' in Africa,in: Social Science and Medicine, vol 3, no 4, 1970,PP 443-488.

rural and urban epidemic hunger in 'developing'nations was still hidden. The risks of environmentaldegradation were still invisible to the public atlarge. In the US people were getting ready to facethe skyrocketing costs of care, the exorbitantprivileges of doctors, and the inequitable access totheir services.'8 Nationalization, or the replacementof privileged enterprise by regulated monopoly,still seemed the answer. 4" Everywhere the belief inunlimited progress was still unshaken, and progressin medicine meant the persistent effort to improvehuman health, abolish pain, eradicate sickness andextend the life span by using ever-new engineeringinterventions. Organ grafts, dialysis, cryogenics,and genetic control still fired expectations ratherthan dread. The doctor was at the height of his roleas a culture hero. The deprofessionalized use ofmodem medicine still had the status of a crankproposal.By I975 much has changed. People have learnt

that health depends on the environment, on foodand on working conditions, and that these, witheconomic development, easily turn into dangers tohealth, especially for the poor. '0 But people also stillbelieve that health levels will improve with theamount spent on medical services, that more medicalinterventions would be better, and that doctors

48Neither had Edward Kennedy proposed that thefederal government act as the insurance agent for theentire nation, covering all medical, dental and psychiatriccosts without deductibles or upper limits, see Kennedy,Edward M. In critical condition: the crisis in America'shealth care. NY, Simon and Shuster, 1972, nor had hisopponents stated their case for an all-comprehensiveHealth Maintenance Organization. For a summary seeRoy, William R. The proposed health maintenanceorganization of z972. Washington, Science and HealthCommunications Group, Sourcebook Series, vol 2,1972.49Ehrenreich, Barbara and John. The American healthempire: power, profits and politics. A report fromthe Health Policy Advisory Center. NY, Random House,I970.

5OO0n the link between poverty and ill health in the US,see Kosa, John et al. eds. Poverty and health: a socio-logical analysis. A Commonwealth Fund Book, Camb-ridge, Mass, Harvard Univ. Press, 1969.

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74 Ivan Illich

know best what these services should be.',' Peoplestill trust the doctor with the key to the medicinecabinet and still value its contents, but increasinglythey disagree on the manner in which doctorsshould be organized or controlled. Shall doctorsbe paid out of the individual's pocket, by insurance,or from taxes? Shall they practise as individuals orin groups? Shall they be accountable for healthmaintenance or for repairs? Shall the policy forhealth centres be set by specialists or by thecommunity? In each case opposing parties stillpursue the same goal of increasing the medicaliza-tion of health, albeit by different means. Too few,and the wrong kind of public controls over doctors,medicines, research, hospitals or insurance areblamed for current frustrations.52

In the meantime, total expectations increase fasterthan resources for care. Total suffering increaseswith more therapy. Total damages increase expo-nentially with the cost of care. More and morepatients are told by their doctors that they havebeen damaged by previous medication and that thetreatment now being given is conditioned by theconsequences of their previous treatment, whichsometimes had been given in a life-saving endeavour,and much more often for weight control, hyper-tension, flu or mosquito bite. A top official ofthe USDepartment of Health could say that 8o per centof all funds channelled through his office provideno demonstrable benefits to health, and much of therest is spent to offset iatrogenic damage. Economistsmight say that declining marginal utilities aredwarfed in comparison to the marginally risingdisutilities produced by the medical endeavour.Soon the typical patient will come to understandthat he is forced to pay more, not simply for less

5'Strickland, Stephen P. US health care: what's wrongand what's right. NY, Universe Books, I972, I27 pp.A public opinion survey comes to the conclusion that6i% of the population and 68% ofUS doctors are awarethat basic changes are needed in the organization of USmedicine. Physicians rank the problems as: high costof treatment, shortage of doctors, malpractice suitswhich hamper medical action, unnecessary hospitaliza-tion, limited insurance, rising expectation and lack ofpublic education. The public blames shortage of doctors,costly and complicated insurance, unnecessary treat-ment, and doctors refusing house calls. The option ofdecreasing overall medicalization does not even enterthe questions or the answers.52To verify this summary on the overall trend ofdiscussion, at least in the USA, consult Marien, Michael,World institute guide to alternative futures for health, Abibliocritique of trends, forecasts, problems, proposals,draft, World Institute Council, NY, July, 1973, which isan annotated bibliography evaluating 612 books, articlesand reports concerned with health policy in its broadestdimensions. The guide deals mainly with US writingson US subjects published or republished during thelast ten years. For France, consult Mathe, C and G. Lasante est-elle au-dessus de nos moyens P Paris, Plon, I97o.

care, but for worse torts, for evil that he is thevictim of, for daging 'health production' -however well intentioned. For the time being, whenpeople are hurt by the medical system, they arestill believed to be exceptions. Rich people feel thatthey have had bad luck and poor people that theyhave been treated unjustly. But it is now only amatter of time before the majority of patients findout what epidemiological research discovers:53most of the time they would have been better offsuffering without recourse to medicine. When thisinsight spreads, a sudden loss of confidence mightshake the present medical enterprise beyond repair.During the last half dozen years the attitudes of

students towards their teachers have changed. Ithappened quite suddenly when students aroundI968 admitted openly to each other what they hadalways known: that they learned from books,companions, cramming for examinations and a rarepersonal moment with a teacher, but not from thecurricular system. Since then, many students havebecome consciously refractory to the teacher as anadministrator of teaching procedures. The teacherbecame aware that he had lost respect, except onthe rare occasions when he fell out of his role as abureaucrat. It is not surprising, therefore, that atleast in the US and France, the drop-out rateamong teachers has risen enormously.When the crisis of confidence takes place in the

medical system it will have deeper effects than thecrisis in the school system. Students know that theywill one day get out of school, the later the brightertheir prospects. Patients, however, may come tofeel that they might never get out of the hands ofthe doctors once having started on a patient career.Students who cynically accumulate certificatesraise their chances on the job market, no matterhow little they have learned. Patients will reasonablyfeel that they add to their original complaint notonly new illnesses but also new certificates testifyingto their job incompetence.Today it is possible to foresee such a sudden crisis

in health consciousness. The vague intuition ofmiions of victims of medical care requires clearconcepts to gel into a powerful force. Without anintellectual framework, public recognition of iatro-genic medicine could easily lead to impotent anger

"3Dingle, John H. The Ills of man, in: ScientificAmerican, 229, no 3, Sept 23, 1973, pp 77-82. Opinionsconverge as to the ineffectiveness ofmedicne. The ills ofman are differently perceived and defined in theperspective of the people still at large, the physician, thepatient guided by the physician and by the keepers ofvital statistics. From all four points of view, the chiefburdens of man's ailments, numerically at least, consistof acute, benign, self-limiting illness. However, aslongevity increases the chronic, degenerative diseasesrapidly come to be the dominant cause not only of deathbut also of disability. Onthis too,the four distinct publicsagree.

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The medicalization of life 75

which might be channelled by the profession tostrengthen medical controls even further.55 But ifthe experience of harm already done could bearticulated in such clear, well founded, and simplystated categories that would be useful in politicaldiscussion, it might endow entire populations witha new courage to recover their power for self-care.The evidence needed for the indictment of our

current medical system is not secret; it can begleaned from prestigious medical journals andresearch reports.56 It has not yet been put intopolitical use, however, because it has not beenproperly gathered, clearly classified and presentedin non-medical terms. The first task will be tosuggest several categories of damage to health thatare due to specific forms of medicalization. In eachof these areas of over-medicalization, professionalpresumption and public credulity have reachedhealth-denying levels.

Dependence on care

One simple and obvious measure for the medicaliza-tion of life is the rising share of national budgetsspent at the behest of doctors. The US now spendsgo billion dollars a year for health care. Thisamount is equivalent to I7.4% of the GNP.'7 Toassign a growing amount of national earnings tomedicine, a country does not have to be rich. NewGuinea, Nigeria and Jamaica are countries in which

55Hoffman, Allan, Inglis, David Rittenhouse. Radia-tion and infants. A review of Sternglass, Ernest J.Low level radiation, in: Bulletin ofthe Atomic Scientists,December, 1972, pp 45-52. The reviewers foresee thepossibility of an immineanti-scientific backlash fromthe general public when the kind of evidence providedby Sternglass becomes generally known. The public willcome to feel that it has been lulled into a sense of securityby unfounded optimism on the part of the spokesmanfor scientific institutions with regard to the threatconstituted by low level radiation. The reviewers arguefor policy research to prevent such a backlash or toprotect the scientific community from its consequences. Iargue that a backlash against medicalization is equallyimminent and that it will have characteristics thatdistinguish it clearly from a reaction against high-energytechnology. The effects of a synergy of various iatrogenicpandemics will be directly observable by the generalpublic. They will appear on a much shorter time-scalethan the consequences of mutagenic radiation levels,and they will affect directly the quality of life of theobserver rather than that of his offspring.56Brook, Robert, Quality of care assessment: choosinga method for peer review in: New England Journal ofMedicine, vol 288, 1973, p 1323ff. Depending on themethod, from 1.4 to 63.2% of patients were judged tohave received adequate care.57Maxwell, R. Health care: the proving dilemma;needs versus resources in Western Europe, the US and theUSSR, Dekinsey & Co, NY, I974.

the medicalization of the budget has recently passedthe IO% mark.During the past 20 years, while the US price

index has risen by about 74%, the cost of medicalcare has escalated by 330%. 58 Most of the increasewas paid out of an increased tax burden; whileout-of-pocket payments for health services rosethreefold, public expenditures for health roseexponentially. A good deal of this enriched not onlydoctors but also bankers; the so-called adminis-trative costs in the insurance business have risen to70% of insurance payments to commercial carriers.The rate of increase can be explained by rising

costs of hospital care. The cost of keeping a patientfor one day in a community hospital in the US hasrisen 5S0% since i95o. The bill for patient carein major hospitals rose even faster: it tripled ineight years. Again, administrative expenses grewfastest, multiplying since I964 by a factor of 7,laboratory costs by a factor of 5.59 Building ahospital bed now costs in excess of $85,ooo, ofwhich two-thirds buys mechanical equipmentwritten off or made redundant within ten years.There is no precedent for a similar expansion of amajor sector of the civilian economy. It is ironic,therefore, that during this unique boom the USwitnessed another parallel event, also unprece-dented in any industrial society: the life expectancy

58Feldstein, Martin S, The medical economy, in: Scien-tific American, 229, no 3, Sept 1973, pp 157-I59,believes that the phenomenal rise in the cost of healthservices in the US is due to the growing incidence ofprepayment for health services there. As a result ofprepayment, hospitals are moved towards increasinglyexpensive and new ways of doing things, rather thanproviding old products more efficiently and cheaply.Changing products rather than rising labour costs, badadministration or lack of technological progress havecaused this rise. One of the main reasons for this changein products is increased insurance coverage whichencourages hospitals to provide more expensive productsthan the consumer actually wishes to purchase. Hisout-of-pocket costs appear increasingly modest, eventhough the service offered by the hospital is increasinglymore costly. High-oost hospital care is thus self-reinforc-ing. Cohen, Victor, More hospitals to fill: abuses grow, in:Technology Review, Oct-Nov 1973, pp I4-I6, dealswith recent US hospital building sprees and theireffects. Since empty hospital beds in modern hospitalscost up to 66% of full beds, the filling of these bedsbecomes a major concern on a growing administration.This adds to the duplication of facilities and waste ofcomplex equipment on people who cannot use it.Specialized personnel are spread thin. Medical standardsare relaxed to keep the beds full, and unnecessaryhospitalization leads to unnecessary surgery. See alsoLee, M L. A conspicuous production theory of hospitalbehaviour, in: Southern Economic Journal, July, 1971,pp 48-58.59Knowles, John J. The hospital, in: Scientific American,229, no 3, Sept I973, pp I28-I37.

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for adult American males declined, and is expectedto decline even further. 0

In England the National Health Service ensuredthat the same kind of cost-inflation would be lessplagued by conspicuous flim-flam. A stern commit-ment to equality prevented those astoundingmisallocations to prestigious gadgetry that haveprovided an easy starting point for public criticismin the US. Tight-fisted misallocations have madepublic criticism in the UK less colourful. Whilethe life expectancy of adults in England has not yetdeclined, chronic diseases of middle-aged menhave already shown an increase similar to thatobserved a decade earlier across the Atlantic. In theSoviet Union physicians and hospital days percapita have also more than tripled and costs haverisen by 300% over the last 20 years.61 All politicalsystems generate the same dependence on physicians,even though capitalism imposes a much highercost.Only in China, at least at first sight, the trend

seems to run in the opposite direction: primary careis given by non-professional health techniciansassisted by health apprentices who leave theirregular jobs in the factory when called to assist amember of their brigade.2 In fact, however, theChinese commitment to the ideology of techno-logical progress is reflected already in the pro-fessional reaches of medical care. China possessesnot only a paramedical system, but also medicalpersonnel whose standards are known to be of thehighest order by their counterparts around theworld. Most investnents during recent years havegone towards the further development of thisextremely well qualified and very orthodox medicalprofession; 'barefoot medicine' is increasinglylosing its makeshift, semi-independent character

60The trend is not limited to North America: Longone,P., Mortalite et morbidit4, see note I. Four factorscharacterinze European mortality and morbidity today:mortality of adult males is stationary or increases;the relative life span of men as compared with womendecreases, accidents increase as a cause of death, fetal andperinatal death claim 30% of conceptions. There is alsolamentable lack of research on the subject. Accidents perioo,ooo have not changed since I9oo, but since othercauses of death have declined, they have become moreimportant.61Field, Mark. Soviet socialized medicine. NY, FreePress, I967.62Horn, Joshua. Away with all pests. An English sur-geon in People's China, z954-I969. Monthly ReviewPress, I969. Sidel, Victor. The barefoot doctors of thePeople's Republic ofChina, in: TheNew England Journalof Medicine, June If, I972. Sidel, Victor, Sidel, Ruth.The delivery of medical care in China. The main featureof the Chinese system is an integrated network ofneighbourhood stations that serve the functions ofpreventive medicine, primary medical care and referralto larger centres. in Scientific American, vol 230, no 4,April I974, pp I9-27. Seldon, Mark. China: revolution

and is being integrated into a unitary health caresystem. After a short honeymoon with a radicaldeprofessionalization of health care, the system ofreferral from the neighbourhood through severallevels of increasingly more complex hospitals hasgrown at a remarkable speed. I believe that thisdevelopment of a technical-professional side ofmedical care in China would have to be consciouslylimited in the very near future if it were to remain abalancing complement rather than an obstacle tohigh-level self care.The proportion of national wealth which is

channelled to doctors and expended under theircontrol varies from one nation to another, and fallsbetween one-tenth and one-twentieth of all availablefunds. This means that the average expenditure percapita varies by a factor of up to I,000: from about$320 in the US through $9.60 in Jamaica to $0.40in Nigeria. Most of this money is spent everywhereon the same kinds of things. But the poorer thecountry, the higher the unit price tends to be.Modern hospital beds, incubators, laboratoryequipment, or respirators cost even more in Africathan in Germany or France where they are made;they break down more easily in the tropics, aredifficult to service, and are more often out of use.The same is true for the investment in the trainingof doctors who use such highly capitalized equip-ment. The education of a cardiologist represents acomparable capital investment whether he comesfrom a socialist school system or is the cousin of anindustrialist in Brazil sent on a government scholar-ship to study in Germany. The poorer the country,the greater the concentration of rising medicalexpenditures. Beyond a certain point, which mayvary from country to country, intensive treatmentof the patient requires the concentration of largesums of public funds to provide a very few withthe doubtful privileges doctors confer. Thisconcentration ofpublic resources is obviously unjustwhen the ability to pay for a small fraction of thetotal cost of treatment is a condition for getting theremainder underwritten by tax funds. It is dearlya form of exploitation when about 8o per cent of the

and health. Health/PAC Bullei, No 47, Dec. 197220 pp. (Published by Health Policy Advisory Center, I7Murray Street, New York, NY Iooo7.) Djerassi, Carl.The Chinese achievement infertility control. One-third ofthe women of child-bearing age may be practisingbirth control, in: Bulletin of the Atomic Scientsts,June, 1974, pp 17-24. ortY Inteton Center. Abibliography of Chinese sources on medicine and publichealth in the People's Republic of China: z6o0-z970.DHEW Publication no (NIH) 73-439. Lin, Paul T K.Medicine in China, in: The Center Magazne, May/June,1974. Liang et al. Chinese health care. Determinants ofthe system, in: American Joumal of Public Health, vol63, no 2, p I02ff. February 1973.63Bryant, John H. Health and the developing world.Ithaca, London, Cornell Univ. Press, 1971.

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real costs of private clinics in poor Latin Americancountries are paid for by taxes collected for theeducation of doctors, the operation of ambuilances,and the price support of medical equipment. Insocialist countries, the public assigns to doctors alonethe power to decide who 'needs' this kind of treat-ment, and to reserve lavish public support to thoseon whom they experiment or practice. The recogni-tion of the doctor's ability to identify needs onlybroadens the base from which doctors can sell theirservices. 6'This professionally consecrated favouritism, how-

ever, does not constitute the most important aspectof the misallocation of funds. The concentration ofresources on a cancer hospital in Sao Paolo mightdeprive dozens of villages in the Mato Grosso ofanychance for a small clinic, but it does not underminethe ability of people to care for themselves. Publicsupport for a nationwide addiction to therapeuticrelationships is pathogenic on a much deeper level,but this is usually not recognized. More healthdamages are caused by the belief of people that theycannot cope with illness without modem medicinesthan by doctors who foist their ministrations onpatients.Handbooks that deal with iatrogenesis concentrate

overwhelmingly on the clinical variety. Theyrecognize the doctor as a pathogen alongsideresistant strains of bacteria, hospital corridors,poisonous pesticides, and badly engineered cars. Ithas not yet been recognized that the proliferation ofmedical institutions, no matter how safe and wellengineered, unleashes a social pathogenic process.Overmedicalization changes adaptive ability intopassive medical consumer discipline.An analogy with the transportation system might

clarify the dangers of overmedicaliztion so clearlyreflected in the budget. No doubt cars are dangerous.They kill more than one-quarter of those in the USwho die between childhood and the age of 6o. Ifdrivers were better educated, laws better enforced,vehicles better constructed and roads better plan-ned, fewer people would die in cars. The samecould be said about doctors: they are dangerous. Ifdoctors were differently organized, if patients werebetter educated by them, for them and with them, ifthe hospital system were better planned, theaccidents which now result from contact betweenpeople and the medical system could be reduced.But the reason why high speed transportation

now produces accidents lies deeper than the kindof cars people drive, and even deeper than thedecision to depend for locomotion mainly on cars,rather than on buses or trains. It is not the choiceof the vehicle but the decision to organize modem

64Fuchs, Victor. The contribution of health sernicesto the American economy, in: Milbank Memorial FundQuarterly. volXLIV, 4 part II, October I966,pp 65-103.

society around high-speed transportation whichturns locomotion from a healthy activity into ahealth-denying form of consumption. No matterhow well constructed the vehicle, or how wellprogrammed the landing, at some point of accelera-tion the rhythm of the machine will destroy therhythm of life. At a given point of acceleration,things and the people strapped to them begin tomove in an engineered time-space continuumwhich is biologically antithetical to that for whichthe human animal has evolved. The more hurried acrowded world becomes, the higher must be theincidence of trauma which results from unhealthyencounters, violent separation, and enervatingrestraint. Vehicles become unhealthy when theycompel people to speed. It is not their specificconstruction or the choice of a private car over apublic bus that makes transportation unhealthy,but their speed itself and the intensity oftheir use.

This health-denying aspect of the speedup intraffic is generally not taken into account when thehealth dangers of traffic are discussed. In a biblio-graphy of traffic medicine6 listing 6,ooo items, Idid not find one paper dealing with the impact ofacceleration on health. The same applies to biblio-graphies on iatrogenic diseases. More than onethousand items are listed each year under this titlein the standard Index Medicus. People with apenchant for the grotesque might enjoy reading thegory details, but they will not find any mention ofthe health-denying effect of a growing dependenceon medical care.The proliferation of medical agents is health-

denying not only or primarily because of the specificfunctional or organic lesions produced by doctors,but because they produce dependence. And thisdependence on professional intervention tends toimpoverish the non-medical health-supporting andhealing aspects of the social and physical environ-ments, and tends to decrease the organic andpsychological coping ability of ordinary people.Modem apartments are increasingly unfit for thesick, and family members are often frightened bythe idea that they might be asked to care for theirown sick. 66

6"Hoffman, Herman. Ausgerriihlte internationale Biblio-graphie z952-z963 zur Verkehrsmedizin. Munchen,Lehman I967.66The medicalization of care has a profound impacton the structure of contemporary man-made space. Theempire of the health professions is cemented intomodem society. The forthcoming book by RoslynLindheim (Calder and Boyars, I975) will demonstratethis. For the moment consult: Lindheim, Roslyn. Newenvironment for births. Manuscript at CIDOC, 1971.Hwnanization of medical care: an architects view. Thirddraft. I, April I974. Environmentsfor the elderly. Future-oriented designfor living? 2o, February I974. mimeo,

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