Medical Nemesis

Ivan Illich, who died in 2002 (after being diagnosed with cancer in 1983 and refusing all treatment) issued a powerful challenge to the medical institution in 1974 with his famous polemic Medical Nemesis: The Appropriation of Health.

Illich argued, first of all, that medicine is harmful to the individual. He observed that the principal determinants of health and longevity are not medical treatment, but the physical and social environment; that much medical intervention is actually harmful; and that something like 7% of all hospitalized people are injured.

Direct harm to the patient caused by medical intervention is called iatrogenic disease or injury. Since 1974, iatrogenesis has increasingly been recognized by the medical profession. The Institute of Medicine estimated in 1999 that as many as 98,000 Americans die every year as a result of errors committed in hospitals. However, the scope of iatrogenesis goes far beyond overt error. As we have discussed here, pharmaceutical interventions almost inevitably have a risk of unintended, adverse consequences. About 2% of patients die from surgery. Hospitals are very dangerous places, not only because of the possibility of error, but because they are filled with highly virulent, antibiotic resistant pathogens, and the people have all sorts of extra holes in them, many with tubes going through them, through which those nasty bugs can enter. Infections acquired in hospitals are called nosocomial infections, and they are very common.

In fact, at the time Illich wrote, most medical interventions lacked any real evidentiary basis -- they were just accepted practice. There has recently been a move toward so-called Evidence Based Medicine, but it is instructive that this has required a major advocacy effort and a huge intellectual investment even to make a beginning toward influencing medical practice.

But Illich did not stop with clinical iatrogenesis. He went on to define what he called social iatrogenesis, and cultural iatrogenesis. Social iatrogenesis is the medicalization of life. Medicine extends its domain over more and more of our existence. This is manifested in economic terms -- in 1962, the U.S. spent 6.2% of its GNP on so-called health care. Illich observed with alarm that this figure had risen to 8.4% in 1974. But today it is over 15%, and still rising. Somewhere, this must stop, but there is no sign of its even slowing down. Illich attributed this trend not only to medicalization, but also to what he called the Sisyphus Syndrome: modern health care may keep people alive, but with chronic diseases requiring yet more health care. When is this worth it, and when is it just buying us more suffering? Another cause is that the availability of medical interventions generates demand for them. Drug companies and doctors define new diseases and advertise their putative cures -- which may, in fact, make us sick in other ways, requiring yet more intervention. We take Celebrex for arthritis, and end up needing hospitalization and rehabilitation for our stroke. There are more kinds of specialists with more interventions to offer, and boat payments to make.

Finally, Illich defined cultural iatrogenesis, which is the erosion of traditional ways of dealing with pain and disability. Must we take a pill for every ache, every sad mood, every stomach upset, have surgery for our stiff joints or myopia? Or can we not learn how to live with the frailties of the flesh? Must we expend all our treasure in an ineluctably futile fight against death, or do we not benefit by facing our mortality with equanimity?

These are powerful challenges indeed. But I must close with a reminder -- imagine that you are contemplating these questions while you have acute appendicitis, or a staph infection, or chest pains, or your aching knees make it impossible for you to care for your elderly mother, or your child is diagnosed with leukemia. The perspectives of philosophy, society and culture are quite different from the perspectives of the actually sick and suffering individual. And therein lies our problem.