I met yesterday with a young doctor friend who is thinking deeply about the health system and how it can be made sustainable. There is one book that I recommend to every person in health care to read, and it’s a book published 40 years ago–Limits to Medicine: the Expropriation of Health by Ivan Illich. Below is a review of the book I published some 15 years ago. It’s time for me to read it again.
The good news is that although Illich is largely unknown to those under 45 his ideas are becoming daily more relevant and, most important/ are being put into practice–handing back health to the people with doctors acting as advisers not priests.
The closest I ever came to a religious experience was listening to Ivan Illich. A charismatic and passionate man surrounded by the fossils of the academic hierarchy in Edinburgh, he argued that “the major threat to health in the world is modern medicine.” This was 1974. He convinced me, not least because I felt that what I saw on the wards of the Royal Infirmary of Edinburgh was more for the benefit of doctors than patients. I dropped out of medical school that day. Three days later I dropped back in again, unsure what else to do. Now I’m the editor of the BMJ, which is ironic. Having deserted medicine, I’ve become a pillar of the British medical establishment (yes I am, like it or not).
I devoured both Medical Nemesis and Limits to Medicine, and now I’ve reread the latter—for the first time in 25 years. The power of the book is undiminished, and its prescience seems remarkable. What was a radical polemic in 1974 is in some sense mainstream in 2002. Medicine does seem to have over-reached itself and some reigning in will benefit not only patients but also doctors.
Health, argues Illich, is the capacity to cope with the human reality of death, pain, and sickness. Technology can help, but modern medicine has gone too far—launching into a godlike battle to eradicate death, pain, and sickness. In doing so, it turns people into consumers or objects, destroying their capacity for health.
Illich sees three levels of iatrogenesis. Clinical iatrogenesis is the injury done to patients by ineffective, toxic, and unsafe treatments. The book has extensive footnotes that draw from a far wider range of sources than most medical books. Illich is equally at home with the New England Journal of Medicine and medieval German texts, making him a formidable opponent for the contemporary doctor who might dispute his conclusions. Evidence based medicine is described in these pages, 20 years before the term was coined. Illich also points out that 7% of patients suffer injuries while hospitalised. Yet only in the past few years and in a few countries have doctors begun to take patient safety seriously.
Social iatrogenesis results from the medicalisation of life. More and more of life’s problems are seen as amenable to medical intervention. Pharmaceutical companies develop expensive treatments for non-diseases. Healthcare consumes an ever growing proportion of the budget. In 1975 the United States spent $95 billion on health care, 8.4% of its gross national product—up, Illich noted, from 4.5% in 1962. In 2001 it was $1424 billion, 14% of GNP. Predictions published this month suggest will be 2815 billion, 17% of GNP by 2011. Can this be sensible?
Worse than all of this for Illich is cultural iatrogenesis, the destruction of traditional ways of dealing with and making sense of death, pain, and sickness. “A society’s image of death,” argues Illich, “reveals the level of independence of its people, their personal relatedness, self reliance, and aliveness.” For Illich ours is a morbid society, where “through the medicalisation of death, health care has become a monolithic world religion…Society, acting through the medical system, decides when and after what indignities and mutilations he [the patient] shall die…Health, or the autonomous power to cope, has been expropriated down to the last breath.” Dying has become the ultimate form of consumer resistance.
Illich’s book is more polemic than analysis and should be read as such. The rhetoric is intoxicating, and I can see why Illich captured my soul all those years ago. Illich was a Catholic priest before he became a critic of industrial society, and the story he tells reeks of “the fall of man.” Romantically, Illich seems to hanker after “the noble savage,” and most readers of his book will never have known such a person and may be sceptical that he has ever existed. Much of life before modern medicine looked nasty, brutish, and short, and have not most people offered the choice opted for the comforts of modern medicine?
It’s the ultimate book reviewer’s cliché to say that every doctor and medical student should read this book, but those who haven’t have missed something important. When sick I want to be cared for by doctors who every day doubt the value and wisdom of what they do—and this book will help make such doctors.
An abbreviate version of this review has been published in the BMJ (2002; 324: 923).