REVIEW ARTICLE

NEGATIVE THERAPEUTICS
by LAWRENCE G. MILLER

Prometheus. the spot is out there waiting, and if is also your wound. It is the vulture CJ~Zeus. When you return to fhis rock. the vulture will feast contented/j, without pausing on you. and tear ,vour ,Jcsh to ribbons. and dip his crooked hurter-yellow beak in pour liver. Each morniny. your lirvr and innards will he as Hack and dead as mud. The cxdture will never consume ym-each night your slashed ,f/esh will slow/~, and painfully heal. your liver will regain its narural colors... ROHIXT LOWELL. Promc,thrus Bound

In Medical Nemesis Ivan Illich presents a latter-day version of the Promethean myth. The lone hero, Prometheus, has been replaced by Everyman. who commits collective hubris in the name of unbounded material progress-p. 154. These new Prometheans do not usurp the privilege of the Gods; rather. their actions constitute a denial of the human condition, of mans very nature. Thus industrial hubris calls forth a new Nemesis. the material monster born from the overreaching industrial dream-p. 154. Medical Nemesis explores one aspect of this transgression and retribution. the expansion of medical care and the concomitant medicalization of society. The book. published in Britain earlier this year. is part of a series entitled Ideas in Progress and as such is meant to be a working paper rather than a polished effort. An American edition. to be published by Pantheon next year is intended as a more complete version, incorporating criticism of the present edition. Those familiar with Illichs earlier work. such as Drschooling Society and Tools for Conviviality. will recognize a similar analysis, similar iconoclasm, and a commitment to a unified critique of industrial society: Over-medicalization and its unwarranted byproducts are thus part of a deep and general crisis that affects all our major institutions-p. 61. Illich intends this work to be articulated in clear. wellfounded and simply stated categories that would be useful in political discussion. in order to endow entire populations with a new courage to recover their power for self-care-p. 35. In this essay. I will first present an exposition of Medical Nemesis. then proceed to criticize the assumptions and methodology on which Illichs arguments are based. The book is an important one: the indictments are powerful. the view panoramic and the language compelling. I will argue. however, that Illich fails to develop an adequate critique of medical care and in closing suggest some prerequisites for such a critique. Medical nemesis has several facets. As noted above. it is retribution for the pursuit of inhuman goals. Also. it is the loss of mans self-sufficiency: *the expropriation of mans coping ability by a maintenance service which keeps him geared up at the service of the industrial system*-p. 160. Further. it is the loss of vital experience and the threat of anaesthetized. soli-

tary survival in a world turned into a hospital ward-p. 166. The fundamental category of Illichs analysis and the agent of medical nemesis is iatrogenesis, the causation of disease by physicians. Illich defines three levels of iatrogenesis. corresponding to the severity of their effects on the recipients of health care. The first level. clinical iatrogenesis. deals with the undesirable side-effects of approved, mistaken. callous. or contra-indicated technical contacts with the medical system-p. 26. This is the most conventional of Illichs categories, and he generally defers to the detailed medical literature on iatrogenic disease. The second level. social iatrogenesis. is approached from the point of view of the sociologist. Illichs major concern here is the infiltration of the patient role into other relationships. a process which he calls medicalization. Most important. because it is most dangerous. is the third level, structural iatrogenesis. Here Illich adopts the stance of the anthropologist. He argues that the beliefs and practices fostered by professional medicine have destroyed the ability of the individual to care for him- or herself and others and have thwarted the power of people to cope with challenges and to adapt to change in their bodies or change in the environment-p. 65. The levels of iatrogenesis have correlates in the expanded social role of the physician. In clinical iatrogenesis. the physician remains in his or her medical capacity. albeit a somewhat blighted one. In social iatrogenesis. he or she assumes the role of the lawyer: *the doctor exempts the patient from his normal duties and enables him to cash in on the insurance fund he was forced to build-p. 59. Structural iatrogenesis finds the doctor as priest aiding in the management of an alienating society:
More are sick hlrt they relieves and more peopk slrbconsciousl\~ kllow that the? qf their jobs and qf their I&m passivities. want to he lied to and told that physical illness thm qf social and political responsibilities

p. 59. Physician and patient are thus accomplices in medical nemesis. Modern hubris. for Illich. takes the form of the mad dream of unlimited progress-p. 154. In the medical sector. this is translated into increased special-

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L. G. MILL~.K atomism. Health is based on a prr-existing set of c.Kternal constraints to which the individual must cope or adapt. and although health is shaped and conditioned by culture. it is primarily a personal task- p. 16X.Its essence IS the ollto11o/~1o1/.s adaptation to self. to others and to the environment (p. 169. my emphasis). Illichs brand of constrained individualism. in which people are obliged to cope in ;I solitar! wa! with a situation not of their own making. leads him to base his critique on an impoverished notion of culture and a hypostatized human nature. Since health and culture are synonymous for Ilhch. the definition of health implies an equally normative definition of culture. In fact. culture is actually rf.udirioftrrl culture. which is presumed to exist in the socalled underdeveloped countries-p. 90. The continued opposition of traditional culture to medical civilization leads to a broad misinterpretation of modern industrial society. For example.

ization and expansion. The main thrust of Illichs book is a critique of the contemporary liberal ideology that more is better.

Liberal ideology relies on the assumption that health and health care are causally related. The alternative Illich presents rests upon a conception of health which reverses this premise; for Illich. less professional care is better. The paradigm of health presented in MrdicaI Yrfftesis is a broad one. encompassing physical. psychological and social well-being. Health is a process of adaptation in which each individual is engaged, comprising the ability to adapt to changing environments. to growing up and aging, to healing when damaged. to suffering and to the peaceful expectation of death-p. 167. As such, health is innate. the native endowment each man is presumed to possess until proven ill-p. 58. so efforts to wrench it out of its individual context are inherently flawed. Insofar as humans aggregate in groups and establish a culture. they define their own standards of health: Ctr1tlrr.c.. is rhe purticulur firnl that sLrrciuul. cop@. u~i riuhilitv cukr iff u gicrn humun group; which rru/[~
fffeunt thut ;t is idrnricul with the Grstalt

In contrast. Mrtiicu/ ciuilirution IS plurm~d uffd orgunixl fo kill pain. to c4ifninute sickness, uffd to srrtryg[r uguifat deuth ._fi-orn briffg cmwtiul rsprrienccs with which euch yf us hus to co/m to tc~fns. pain. sickness. uf~d
death ure rrnffsjtirfned b>* fnrdicul cicilixrioff iffto uccidents ,@r which people fnust seek rnrdicul trruttneffr-

@t/w groups

hrulrll-p.

89.

To Illich. therefore. in relinquishing this notion of health we have lost our true culture and instead become colonized by a medical civilization. This impostor lacks two crucial attributes of a true culture. First. values and meanings are transformed into technical problems:
C~drfrrc cof~~~onts pin. deciuncr. and death by intc~prrting the/n; fnrdicul citilizution turns them into prohlrfns which can be solcrd by their rrmocul. C&urc~s urc .sy.sfc~fnsof mruniffgs. cosmopolitan cirilixtion u .s~steffl of rcYhrliylrrs--p. 93.

p. 90. So meaning has been lost. and disease. pain and death have been stripped of their symbolic and personal value. In an important sense. Illich is correct: rrudirionul meanings and values have been lost. but the accidents which replace them conceal other values. This process corresponds to the separation of disease (or pain) from magic and artifice and its location within Nature. The importance of the transposition from artificial to natural stems from the modem conception of Nature. Unlike many traditional cultures (and presumably Illichs normative one) where humans understand their place in Nature. modern Nature is alienated from and opposed to humanity. Our vocabulary of domination, for example has been well documented.* The effects of defining disease as natural are thus threefold. First. human bodies, and to some extent minds, are placed within the realm of objects. the domain of technical control and manipulation. As Illich points out. the often stilted exchanges between doctor and patient testify to this objectification-p. 55. Second. responsibility for pain or disease is located not in the actions of people. but in supposedly random Nature. Consequently. solutions are sought in the natural realm. Third and most importantly. this process of medicalization is an historical phenomenon, not a mere syllogism. The development of attitudes toward disease. scientific or otherwise, is integrated with other human activities including those mvolved in the distribution of power. It should not be surprising, therefore. that medicalization constitutes part of an ideology which mystifies social problems by ascribing to them a totally natural origin.

Second. a framework no longer exists to provide a check on industrial progress and other irrational fanmyths have ceased to provide tasies: Inherited limits for action-p. 154. To place the contemporary situation in the terms of the Promethean myth. the common man perishes from infirmity or from violencc. Only the rebel against the human condition falls prey to Nemesis. the envy of the gods--p. 154. By choosing health rather than disease as his starting point. Illich strengthens his analysis considerably. The normative concept of health Illich posits enables him to question not merely .the goals of modern medicme but also the very existence of a professional division of labor. This approach can be contrasted to recent radical sociology, such as Waitzkins and Watermans The Exploitation oj Illness in Cupitulisr Sociery in which the emphasis on disease limits the analysis to social iatrogenesis. the role of medicine in social control. Unfortunately. Illichs definition of health implicity assumes human passivity and

Responsibility then becomes diffuse. and problems come to require natural solutions, meaning further medicalization. An instructive contemporary example is the search for genetic origins of criminahty: when criminality has been designated a disease. its etiology and therapy must fit the medical pattern*. As lllich affirms, values and meanings acquire a technical context, but techniques in turn carry an implicit ideology: values are submerged. not lost. In a similar vein. lllich argues that the loss of traditional values. as expressed;n myths. has led to the loss of cultural limits to action. Illich himself relies on myths and ancestral Gods to make certain that his analysis is foreign to an industrially dctcrmined logic or ethos-p. 28. The universe to which these myths belong is an active one. populated by Gods wielding immanent natural forces. Since the range of human action was narrowly circumscribed---p. 162. man could seek to extend his capacities only at the risk of hubris and the ineluctable nemesis. The unified cosmos reigns no longer; modern Nature is passive. the Gods having been replaced for Illich by limits in the external world and in ourselves. The role of man. with respect to Nature. is equally passive. We are to act so that the natural boundaries of endeavour are estimated. recognized and translated into politically determined limits-p. 166. But myths have not disappeared and absolute natural boundaries do not exist. Our myths are scientized and feign objectivity. such as the myths of biologically-determined race differences or sex roles. They no more correspond to natural boundaries than the Promethean myth: both are formulated by men in particular social and institutional contexts with particular goa!s. Our boundaries, the categories of Nature and human nature. are largely artificial and thus ideological: we both define and create our limitations. How does this process come about! To Illich. the loss of limits to action has occurred through the machinations of the medical and para-medical monopoly. unchecked by even the usual market constraints. The preeminence of this guild enables it to define the terms in which health is conceived. provided, and extended: health yields to health care. health care to management. and management to addiction to further health care. The first stage of the process is aided and abetted by political parties. which coin the desire for health into the design of medical facilities-p. 70. Then. as the management model is applied to health care. wage-labour and client-relationships expand while autonomous production and gift-relationships wither-p. 63. The individual. deprived of a true notion of health and the means to attain it becomes dependent on the management of his intimacy: he renounces his autonomy

* Beckwith J. and King J. The XYY syndrome: a dangerous myth. .VCW Scimisr 64. 474. 1974: Borgaonkar D. S. and Shah S. 4. The Xll chromosome male-- or syndrome. Prq. .Ifctl. Gcrwr. 10. I?S. 1974. f Gintrs H. Power and alienarion. In Rrtrdirqz in Polfric.01 Eu~r~oru~~ (Edited b! Weaver J.). 1972. ZGintis H. Deschooling Sociq: toward a political ecnnom> of education. Hwwtl Etl~r. RCV. 42. 70. 1972. 9;Gramsci A. S&crim froru r/w Pmm .Voruhooks (Edited h! Hoare Q. and Smith G. IK. ) Nen l-or]\. 1971.

and his health nn/st decline--p. 169. Health care fails changing adaptive ability hccause it is manipulative. into passive medical consumer discipline--p. 39. It expands. however. because it is addictive: People in modern societies believe that they depend on the medical industry but they do not know for what purpose-p. 69. We are left with an unhealthy society which depends on unhealthy people whose survival, discipline and functioning are assured through dclivery of the necessary therapeutic services--p. 16X. The manipulation-addiction model is appealing at. a time when the impetus for reform takes the shape of consumerism. But in treating people as passive. manipulated consumers. Illich neglects the role of people in pr-otl~?ry their values and social relations by their day-to-day activities. The values of depcndency and passivity which Illich criticizes should not hc viewed as aberrations caused by manipulation. but rather as implicit in the structure of social relations. The ultimate source of these relations lies in the activities in which people spend the bulk of their time. primarily the workplace. The shaping of the workplace in turn is the prerequisite of thosr who determine the mode of industrial production. the dominant economic class.* Institutions of socialization. whether medical or educational. ma) contribute to efficiency and stability. but they rcprod~~, I.U~/MY tl?an SU/$V the models for our social relations.: To revise Iliichs conclusion. health care fails and expands not out of manipulation-addiction but rather because it does not deal with the fundamental social problems that normal operation of capitalist institutions generates. Likewise. technologically-directed explanations and ideas of human limits arise not mysteriously but rather from a concrete basis in actual social relations and through subtle limitations placed on discourse and argument. Such ideologies serve to legitimate and justify the social order; their fabrication and propagation cannot be ignored.5 While my analysis has been schematic at best. the implications are clear: to fully understand health beliefs. activities and ideologies in contemporary society we must look beyond medical attitudes. and bevond even Illichs industrial ethos. to the econoflffc and social bases of human activity. Illichs perspective remains consistent throughout; medical nemesis has developed due to lack of belief in boundaries to action. and it can be overcome by restitution of such faith. Despite repeated mention of the industrial mode of production, in his solution . Illich emerges as an unregenerate idealist. The first step towards cultural health is education. which will lead to the recognition of our present delusions-p. 165. This in turn will spawn an ethical awakening-p. 164 reinforced by political action designed to deprofessionalize medicine. But is enlightenment a sufficient condition for fundamental reform? Onl! if we assume. with Illich. the primac! of consumer relations and the manipulative sources of social deca!. If instead we allow the importance of the relations of production. and the material conditions of work which shape those relations. then enlightenment alone must fail. Deprofessionalization would lead to little change. or at best chaos: since the forces which structure our relations would remain untouched.

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L. G.

MILLIK

The inadequacy of Illichs analysis and solution can now be summarized. Illich assumes the existence of a set of traditional values which have been lost and can be reclaimed. He assumes that beliefs. delimiting the true human condition. once constrained human action but now must be replaced by a new set of consensual myths. He assumes that our plight is due to our passivity and exposure to manipulation. Xbove all. Illich assumes a conception of human nature surprisingly similar to that of a nineteenth century liberal: men and women are isolated individuals who act in their own enlightened self-interest-p. 163 or with reasonable self-restraint-p. 159. which in turn are dictated by received ideas and beliefs. Societies are aggregations of such individuals and function to prevent overt conflict of self-interests. To complete the picture. Illich adds his own invisible hand. an innate respect for the ideal human .condition. The solution to which these creatures are adapted also bears striking utilitarian characteristics. Rather than aiming at the reformulation of collective goals. Illichs program is decidedly individualistic. resulting in legal and political procedures that permit individuals and groups to resolve conflicts arising from their pursuit of different goals-p. 165. The Icgislation he envisions has five major objectives: (1) to prohibit the licensing of any group of medical professionals: (2) to allow people to drop out and organise for a less destructive way of life-p. 166: (3) to shift responsibility for the use of drugs to the sick man and his next .of kin-p. 167: (4) to allow each person to define his own health to the extent that others are not harmed: (5) to make possible the election of healers on the basis of their performance in the community. So medicine. for Illich. would become a system of smallscale entrepreneurs operating in an ideal free market maintained by the state. Since this framework is suited to human nature. a world of health and harmony. marked by minimal and only occasional professional medical mtervention-p. 169 would result. If the people to populate this world ever oxisted. they do not exist now. Illichs most serious error is one he rccognizcs himself:

methodology. Throughout abound. for example:

.~ILY/~cu/ .!~wrc.v.s

negatmls

Illich proceeds. however. to separate the individual from society and pretend that we can shed our socialization and thus rediscover our true natures. which after a11 are only manipulatively suppressed. But new values and new myths have replaced the old. and material conditions have changed the percieved limits to human action. To use Illichs metaphor, we can no more return to the old ways than we can divest ourselves of our skins. The reliance on an intrinsic human essence is not surprising considered in the light of Illichs negative

It is this method \vh~ch forms the hasps of Ill~ch~ critique. The socialization process in industrial society is repressive and dehumanizing: Illich rejects sncialization. Professional health care induces dependency : Illich rejects professional medicine. Medical institutions are manipulative: Illich rejects an organized health deliverv system. Political institutions cncourage the expansion of medicine: Illich rcjccts a political solution for an essentially individual one. But in rejecting socialization. Illich athrms the existence of an idealized utilitarian human nature uprooted from any social context. In re,iecting professional health care. he embraces an entrepreneurtal free market and thus the commoditv nature of health. In rejecting organized medical institutions he adopts a /uis.w-_~fitire attitude which reinforces capitalist ideology. In rejecting a political solution. Illich athrms the utilitarian. individualist ethos of personal action. As Gintis and Marcuse remind 115. the negative method used alone leads to implicit affirmation of the basic principles of the existing social order.* Such a critique is hardly radical. I have dwelt at length on Illichs errors and misconceptions. The negative method has also provided the basis for an exemplary description of the dilemma of modern medicine. Other reviewers have concentrated on the lapses in this description and these ccrtainly exist.t What is more important however. is the enormous power of the negative method in Illichs hands; hence his ability to slice through the mystitications of liberal ideology such as welfare medtcme and technological progress. In the areas where Illich proceeds beyond negation. his analysis is truly illuminating. The chapters on the changing nature of pain and disease are provocative and the chapter on death is brilliant. Illich explores the relation between health and its negation to point to a syntheses which emphasizes their intimate connection at the substrata of human consciousness. Amidst the burgeoning literature on death and the developing specialty of thanatology. it should give us pause. I have thus far argued that Illichs analysis of Teditine is inadequate and that the ncgativc method is inherently limited. What shape would a proper critique of medicine take.! As in the cast of Illichs chapter on death. it would be dialectical in methodology. attempting to understand the relation bctwcen health and death. thesis and antithesis and to comprehend both in consciousness or s!.nthesis. The critique
would seek to identify the posItIon of medicine among capitalist institutions. and to understand the role of medicine in the formation of personal attitude? and

Negative thcrapeutlcs social relations. It would attempt to identify the contradictions inherent in health care. among them the use -01 Inherently alienating technology to provide humane care. and also the efforts made by doctor and patient to deal with the body while the self is in the room. By placing these contradictions in the context of a broader critique. suggestions for action which go beyond reform may result. An additional important aspect of an analysis of medicine would be historical to help us construct the relation between present and past and to provide a well of conclusions on which to draw. For example. the last vears of the nineteenth and early years of the tweniieth centuries saw the consolidation of four trends crucial to the comprehension of modern American medicine. First, the need to provide a healthy and continually productive labor force amidst potentiall? dangerous conditions led to the involvement of medicine with the forces of production b> waq of Workmens Compensation and industrial Insurance schemes. Second. the drive to rationalize the delivery of health care on the industrial model contributed * Anderson 0. IV. T/W L r~c~.srQ~~ilihri~rr~ New Haven. 1967. Landefeld S. The Hospital Idea. S,~r/~esis. 2. 1974. Rosenkrantz B. G. Puhlk HcuIrh trrd t/w Srclrc. Cambridge Univcrsit) Press. MA. 1972. Markowitz G. and Rosncr D. Elitism in Medicine. -1)~. Q. 34. 1973.

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to the rise of the modern hospital and its foundation on hierarchical principles. Third. the advent of the bacteriological model of disease and the concomitant triumphs in public health led to the description of health as a commodity. The motto of the NCM York Public Health Department at the turn of the century was public health is purchasable-within natural limitation a community can determine its own death rate. Finally. the developing professional consciousness of physicians led to changes in mcdicdl education which fundamentallv altered the size and class composition of the medjcal profession.* In closing. Ict me reemphasize that Illichs book is an important one. of benefit to anyone concerned not only with medicine but also with social well-being. Its excellent bibliography provides a myriad of sources for further study. Most of all. Mcdicul ~Ver~c,sis is a challenge to those disturbed $4 the state of medicine and society to build an accurate and useful critique. We can journey with Illich. but we must eventually transcend him.
Aclir7o~lrd~mle,~r-~I

thank Ms. L. J. Daston for her in-

valuable assistance. Hartwrd Mdicul Shol. Boston. Mz4. L.S.A.