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Corrigenda: Medical Nemesis Revisted
- Martin LeatherBarrow (13 April 2002)
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And another thing ...
- Beth Bennett, Melbourne, Australia (15 April 2002)
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Too much sociology of medicine?
- Simon J Harrison (18 April 2002)
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The Limits To Medicine
- John W Allen (19 April 2002)
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full agreement!
- omar ali (29 October 2002)
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Re: The Limits To Medicine
- Paul A clerkin (11 May 2003)
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Martin LeatherBarrow, Research Associate Department of Primary Care & General Practice, The Medical School, University of Birmingham, England
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Editor- Well done on your review of Illich's Medical Nemesis, which is well worth the effort even after so many years have elapsed. I myself also first encountered this work many years ago, whilst undertaken sociology a-level and subsequent degrees. It was while taking a master's degree several years ago in medical sociology, that I embarked upon the subject matter of 'Social, Culture and Clinical Iatrogenesis' for my dissertation. In Illich's landmark work, he addresses the expressions of caution regarding the harmful effects of medical progress. For it is worth bearing in mind that it was only a decade earlier, that Seckler and Spritzer (1966) observed that 'very few people would care to challenge the fact that our present day knowledge and capabilities in medicine have been productive of more good for patient's than harm.' In the Medical Nemesis, Illich challenged the fundamental premise of medical 'progress', arguing that institutional medicine was overwhelmingly pathogenic and actively 'sickening.' For not only did a large percentage of patients experience unneccessary harms at the hands of health care providers, but, with the over-medicalisation of society, they also increasingly relinquished control of their health to institutions. According to Illich, medicine is the cause of much ill health, not only through direct aggression against individuals, but via the impact of its social organisation upon the total milieu. An essential concept employed by Illich is that of 'iatrogenesis' which implies that illness is actually caused by medicine itself. He argues that the 'medical establishment' by which he means the medical profession, pharmaceutical companies and suppliers of medical equipment, have a vested interest in 'sponsoring' sickness by creating unrealistic health demands, which can then only be meet by medical treatments of one sort or another. He continues that awe-inspiring medical technology has combined with egalitarian rhetoric to create the impression that contemporary medicine is highly effective. In its most pernicious form, medical iatrogenesis paralysed autonomous action by destroying the potential of people to deal with their own human weakness, vulnerability, and uniqueness in a personal and self-directed way. Like Prometheus and Sisyphus, who were condemned by Nemesis to a self-defeating and captive existence, the medical industry and those of us who naively subject ourselves to its machinations, have created a self-reinforing 'iatrogenic loop' where remedies themselves become pathogenic. Sharpe and Faden (1998) in a first-rate book of their own, entitled 'Medical Harm' specify that what is particularly striking about Illich's radical critique of iatrogenic illness, is that it is grounded in a version of autonomy as a substantive good, as the essence of humanity and human well-being. Because Illich emphasised self-care outside of the physician-patient dyad, he does not link his critique with the legal and ethical principle of patient self-determination. It is transparent then that Illich views autonomy as integral to individual human health. Thus, by extension, to deprive patients of their autonomy is to harm them directly and indirectly of the capacity to manage their own health. Not surprisingly, during the course of the years since publication, Illich has not been without his critics. Hirst and Woolley (1982) for instance in their book entitled 'Social Relations and Human Attributes' argued that it had become fashionable to draw conclusions from the marginal role of medicine in the revolution in population patterns that specialised medicine is an expensive and unnecessary conspiracy foisted upon society, carrying with it the unwanted side-effects of itrogenically induced illness. Interestingly, here they attack Illich and his views on medical monopoly and his comments that medical care be devolved back into society. This, they argued is an analogue of the 'anti-psychiatry' argument in the field of physical medicine. They continue that it hovers on the "verge of absurdity" but then by the same token, admit that it does indeed make many telling criticisms of modern medical practice. Whilst I concur with the editorial's comments to a certain extent that it is more polemic than analysis, it is indeed rhetorical intoxicating, but still far from mainstream acceptable to many. From my field research experience, I would suggest another twenty-five years perhaps. In pasting it is also worth noting that Illich wrote an editorial post script to this work which can be viewed in the BMJ(1995;311:1652- 53)entitled 'From Medicine to Medicalisation to Systematisation' in which he write's in an labyrinth style all his own of how differently he would now pen the book. What he fails to realise is that one cannot re-write a classic (sic). It may not be everyone's cup of tea, however when the first issue of the BMJ for 2002 includes a news article that contains a synopsis of a report by the Audit Commission on the current problem pertaining to clinical iatrogenesis and pharmaceuticals, it would be of considerable benefit to all those concerned and engaged in the area of health, illness and medicine. The synopsis incidentally, reads 'the number of patient's who die in England and Wales after errors in drug prescribing or from adverse drug reactions, is showing a marked upward trend' the Audit Commission warned (Eaton,2002;324:8/5th January). Yours Faithfully, Martin LeatherBarrow |
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Beth Bennett, Lecturer Victoria University, Melbourne, Australia
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I have felt a little concerned that my current masters thesis examining the non-disclosure of iatrogenic harm to affected people, in part simply re-iterates Illich’s 1977 critique of professions as cartels (1). Richard Smith’s review of Illich's Limits to Medicine, and Medical Nemesis; and Martin LeatherBarrow's subsequent letter, provide some re- assurance that Illich's analyses remain relevant! To add to the adulation: Illich's critique of professions can be applied (for example) to 1. elements of the Bristol Royal Infirmary story (in particular, responses
by peers and professional organisations to Stephen Bolsin's disclosures);
Beth Bennett (1) Illich, I. Disabling professions. In I. Illich, I. K. Zola, J. McKnight, J. Caplan, & H. Shaiken, Disabling Professions (pp. 11-39). London: Marion Boyars, 1977. |
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Simon J Harrison, medical student University of Bristol
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Smith's inspiring review of Illich pinpoints a problem in medical practice and education - its 'sociologicalisation'. Smith almost says 'that every doctor and medical student should read this book.' However he concedes that 'Illich's book is more polemic than analysis'. This appears to be a pervasive tendency in the sociology of medicine - as taught to students: the attempt to 'cure' medicine, to wage war against it (polemicise), rather than to examine it (analyse), to prescribe, rather than describe. Just because medicine is not the cure for life, does that mean that sociology is the cure for medicine? Indeed we might echo Shah's editorial in the same issue (p.862): 'Sociologicalisation can be dangerous. .. But many of these problems ... represent poor standards of practice.' If this is the case, then, as a medical student, I must ask, not just 'too much medicine?' but 'too much sociology of medicine?' After all,where would we be, had Smith dropped out of medicine altogether in 1974? A clear example of a 'sociologistico-genic' threat to medicine, if ever there was one. |
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John W Allen, Staff grade Community Paediatrician Heysham Health Centre LA3 2LL
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Editor I write to support your review of Illich's work. I first learnt about Ivan Illich when training in Public Health Medicine. It was regarded as doctor bashing and derided. As time goes on it is clear that the truth behind his work is confirmed and his work remains unchallenged. I believe that not only doctors but the public are unaware of the significance Illich's work. Your support as editor of the BMJ is one step forward. How would you take it further? |
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omar ali, pediatrician, saudi aramco oil company aramco, abqaiq 31311, saudi arabia
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Dear Sir, I must say that it was a very pleasant surprise to see you and so many of the respondents agreeing with Illich in a leading medical journal. The US, unfortunately, continues to be the world leader in insane medicalization and relentless growth of the medical cartel, but it seems there is some reason for hope in England and Canada. Congratulations on an excellent review. Omar Ali MD FAAP |
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Paul A clerkin, Registered Nurse Agency Nurse Q 4017
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I must confess some surprise at Richard Smith's enlightened understanding of Ivan Illich's classic work ' Medical Nemesis '. I have just spent two years working as an RN in the UK, unfortunately all the doctors I came across did not display Smith's insightfulness, in fact the word parochial is the word that most springs to mind regarding my association with the british medical profession. If there's one thing the experience of nursing teaches, its how totally useless modern medicine really is, I think Illich is absolutely correct in his analysis of medical practice and the resultant euphoria that arose, which wrongly credits medical science with the control of disease, when in fact the general decrease in morbidity and mortality are in fact the result of better standards of living. But of course it wasn't Illich who first twigged medicine is largely quackery but Florence Nightingale ! Competing interests: None declared |
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