Medical Nemesis

...when suffering, mourning, and healing outside the patient role are labeled a form of deviance. – Ivan Illich, Medical Nemesis

I want to start some Covid talk. There’s plenty of that all over the place, so I want to invite readers to engage from a slightly different perspective that’s the norm out there at the moment – the norm being a lot of narrative-building and defending, strawmen-building and fighting, name-calling, categorization and miscategorization.

It’s most unfortunate that even in Catholic online circles, the conversation about this situation can’t seem to occur without the immediate response to an assertion or suggestion is almost always, Well, you’re just…..

So I thought I’d start with Ivan Illich. Maybe it will give you some relief. Maybe it will frustrate you more. Who knows.

Not Tolstoy’s Ivan Ilych. You might confuse them. Both dead, but one fictional and one actually existed.

Who was Ivan Illich, the real thinker and activist who died in 2002? For an introduction you might go to the article in the most recent First Things on “The Genius of Ivan Illich.”

Ivan Illich’s star once burned brightly. From the late sixties through the mid-seventies—when his influence was greatest—this learned Roman Catholic became a countercultural guru, notorious for facing a 1968 Vatican inquisition that led him to cease exercising his priesthood, though he never renounced it. During this period, he published in rapid sequence incendiary books on the “counterproductivity” of modern institutions that won him admiring readers, including ­California’s young governor, Jerry Brown. His essays appeared in the New York Review of Books and other leading intellectual publications. He jetted across the globe, speaking to rapt audiences. Yet, by the time of his death at seventy-six in 2002, Illich was no longer fashionable. A New York Times obituary was typical in treating him largely as a hippie-generation relic who once preached “counterintuitive sociology to a disquieted baby-boom ­generation.”

From another good summary, more directly related to the subject of this blog post:

After his death in 2002, the psychiatrist and writer Anthony Daniels (who also writes as Theodore Dalrymple) wrote:

And yet Illich was deeply conservative, or at least he would have been had he been born in the Middle Ages. The word reactionary fitted him quite well, insofar as he regarded pre-modern forms of existence as being in many ways superior to our own. He was an anti-Enlightenment figure: while he believed in the value of rational argument and of empirical evidence …he certainly did not believe in a heaven on earth brought about by rational action on the part of benevolent governments and bureaucracies. He was completely unimpressed by supposed evidence of progress such as declining infant mortality rates, rising life expectancies, or increased levels of consumption. Indeed, he thought modern man was living in a hell of his own creation: the revolution of rising expectations was really the institutionalization of permanent disappointment and therefore of existential bitterness.

I first encountered Illich early, as we like to say, in my homeschool journey. Reading Deschooling Society was an exhilarating confirmation of all of my intuitions about the mess that is modern education.

I later encountered more via the technology-contemplating newsletter of L.M. Sacasas, The Convivial Society – also deeply inspired by Illich.

Last week, I read Medical Nemesis – available in pdf form here. It had a similar effect.

If I could summarize both works, I’d say Illich’s theme is: Institutional forces take over these needs – education and health care – in the name of justice, efficiency and the common good of society. What ends up happening, not surprisingly, is that the institutional definitions and processes become determinative and definitive with an ultimate net loss to human freedom and, paradoxically, the needs they claimed to address.

Conviviality is his great theme, and what does that mean? From the Latin – to live – with. To live together, as human beings, developing tools to enrich our living, but always wary of the point at which the tools take over.

So with education and schools, at the core is the insight that these institutional forces develop in a way that makes their definitions and processes dogmatic, makes human beings dependent on them for meeting these needs, and diminishes the individual ability and communal space for meeting those needs outside of the institution.

Pithy, dramatic illustration: In Germany, educating your child outside of the government school system is illegal.

And on a less pithy and dramatic level, but more fundamental: Our American definition of an “educated person” is overwhelmingly a person who has successfully navigated formal school systems.

You can read more about Deschooling Society here.

But let’s turn to Medical Nemesis.

You can pick up the theme from the book’s full title: Medical Nemesis – the Expropriation of Health.

In the next post, I’m going to pull more from the work of contemporary Illich interpreter David Cayley (whose book was the subject of the First Things essay I cited at the beginning.) and others. In an essay from April 2020, Cayley explains the themes of Medical Nemesis before he goes on to use them to examine the response to the pandemic.

(I have broken up the text into more easily-read paragraphs.)

…the main point of his book was to identify and describe the counterproductive effects that he felt were becoming evident as medicine crossed its second watershed.  He spoke of these fall-outs from too much medicine as iatrogenesis, and addressed them under three headings: clinical, social and cultural.  The first everyone, by now, understands – you get the wrong diagnosis, the wrong drug, the wrong operation, you get sick in hospital etc.  This collateral damage is not trivial. …

…

….but this accidental harm was not, by any means, Illich’s focus.  What really concerned him was the way in which excessive medical treatment weakens basic social and cultural aptitudes. 

An instance of what he called social iatrogenesis is the way in which the art of medicine, in which the physician acts as healer, witness, and counsellor, tends to give way to the science of medicine, in which the doctor, as a scientist, must, by definition, treat his or her patient as an experimental subject and not as a unique case. 

And, finally, there was the ultimate injury that medicine inflicts: cultural iatrogenesis. 

This occurs, Illich said, when cultural abilities, built up and passed on over many generations, are first undermined and then, gradually, replaced altogether. 

These abilities include, above all, the willingness to suffer and bear one’s own reality, and the capacity to die one’s own death.  The art of suffering was being overshadowed, he argued, by the expectation that all suffering can and should be immediately relieved – an attitude which doesn’t, in fact, end suffering but rather renders it meaningless, making it merely an anomaly or technical miscarriage.  

And death, finally, was being transformed from an intimate, personal act – something each one can do – into a meaningless defeat – a mere cessation of treatment or “pulling the plug,” as is sometimes heartlessly said. 

Behind Illich’s arguments lay a traditional Christian attitude.  He affirmed that suffering and  death are inherent in the human condition – they are part of what defines this condition.  And he argued that the loss of this condition would involve a catastrophic rupture both with our past and with our own creatureliness.  To mitigate and ameliorate the human condition was good, he said.  To lose it altogether was a catastrophe because we can only know God as creatures – i.e. created or given beings – not as gods who have taken charge of our own destiny.  

Medical Nemesis is a book about professional power – a point on which it’s worth dwelling for a moment in view of the extraordinary powers that are currently being asserted in the name of public health.  According to Illich, contemporary medicine, at all times, exercises political power, though this character may be hidden by the claim that all that is being asserted is care.

I would add to this quick summary that essential in Illich’s critique is not just the disappearing of suffering and death as Cayley highlights here, but, as I said at the beginning, the impact of institutionalization and professionalization that insists that the individual not only need not but probably cannot and maybe even should not see herself as ultimately responsible for her own development and care – and the elimination of the means for individuals to meet these needs on their own and the branding of those who refuse to relinquish their autonomy as heretics.

As every reader of Illich will tell you, like any thinker, Illich’s analysis and prescriptions are not infallible. But in any circumstance, especially those in which we find ourselves, they are certainly worth contemplating.