History, Eventually Gaining a Phd

Medical Nemesis 40 years on: the enduring legacy of Ivan Illich

S O’Mahony Consultant Physician, Cork University Hospital, Cork, Ireland

ABSTRACT Correspondence to S O’Mahony Ivan Illich’s attack on modern medicine, Medical Nemesis, appeared in 1974. The Cork University Hospital book famously opened with the statement: ‘The medical establishment has Wilton become a major threat to health.’ Forty years after its publication, this paper Cork examines the major themes of the book, and asks whether events since its Ireland publication have added weight to Illich’s thesis. e-mail [email protected] Keywords Ivan Illich, Medical Nemesis, medicalisation Declaration of Interests No conflict of interest declared

Biography of Illich

Ivan Illich was born in Vienna in 1926 to a Roman Catholic Croatian aristocrat father and a German mother of Sephardi Jewish origin.1 His parents included among their friends the poet Rainer Maria Rilke, the theologian Jacques Maritain, and the philosopher Rudolf Steiner. Illich was classified ‘half-Aryan’ as long as his father was alive but, after his death in 1943, the family fled to Italy. lllich initially studied histology and crystallography at the University of Florence, mainly to obtain an identity card under a false name. After the Second World War, Illich returned to Austria, and enrolled at the University of Salzburg to study history, eventually gaining a PhD. While working on his doctoral research he returned to Italy and began his studies for the priesthood at the Gregorian University in Rome. He was ordained in 1951.

Illich’s intellectual gifts were quickly recognised by the church. He was approached by Cardinal Giovanni Montini (later Pope Paul VI) who encouraged him to train as a church diplomat at the Accademia dei Nobili Ecclesiastici. Illich declined and decided instead on an academic career. In 1951 he moved to the USA with the intention of doing post-doctoral study at Figure 1 Medical Nemesis. Image of the copy held in the Princeton. In New York he came into contact with the Sibbald Library, RCPE large new Puerto Rican community and decided to work as a pastor with this group instead. In 1956 he was appointed Vice-Rector at the Catholic University the entire missionary enterprise in South America, in Ponce, Puerto Rico, but was recalled to New York and eventually effectively sabotaged the programme in 1960 after a series of clashes with the local by openly discouraging would-be missionaries and Catholic hierarchy. He subsequently travelled alone writing incendiary articles which attacked the throughout South America, and in 1961 set up the American Catholic mission in South America. Centre for Intercultural Formation in Cuernavaca, Mexico. This Centre was established with the support In 1968 Illich was called to the Vatican to answer charges of the US Catholic hierarchy to prepare North of heresy. Although no formal conviction was made, history American missionaries for work in South America, Catholic priests were banned from enrolling for courses and provided intensive courses in Spanish and Latin at the Centre for Intercultural Formation. Later the American culture and history. Illich came to question same year, Illich resigned from the public duties of the

134 history 135 and this and 6 40 years on years 40 th of A further version, Limits to A further version, 5 Medical Nemesis Medical 4 the heal was first published in published first was Nemesis Medical tions And yet Illich was deeply conservative, or at least he or at conservative, Illich was deeply And yet Middle in the born been he had been have would reactionary fitted him quite well, The word Ages. of existence forms pre-modern insofar as he regarded He was to our own. superior ways as being in many in the he believed while figure: anti-Enlightenment an empirical evidence of and argument rational value of earth on heaven in a …he certainlybelieve not did rational action on the partby about of brought He was bureaucracies. and governments benevolent of evidence supposed by unimpressed completely declining infant mortality such as rates, progress of levels or increased expectancies, rising life man was modern he thought Indeed, consumption. of the revolution creation: hell of his own living in a institutionalization the really was expectations rising of therefore and disappointment permanent of existential bitterness. popula edicine and Medicine on little effect that scientific medicine had Illich argued been had this argument populations; of health the overall Themes of Medical Nemesis Illich’s title of the around confusion of degree is a There polemic. medical Boyars. and Calder 1974 by is the version which I will refer to throughout this paper. to throughout which I will refer is the version of Illich’s natural development a Medical Nemesis was that He argued ideas on institutions and professions. to mission a on taken hubristically had medicine modern he were, These death. even sickness, pain, eradicate learn to must which we eternal human realities, argued, it is what verities with these coping in fact, with: cope the coin not Illich did Although ‘healthy’. be to means doctors by done harm the meaning – ‘iatrogenesis’ word types three described He certainlyhe – it. popularised by harm done or the direct clinical, of iatrogenesis: or the medicalisation social, various medical treatments; meaning the loss of and cultural, of ordinary life; with suffering. dealing of ways traditional Medicine: Medical Nemesis – The Expropriation of Health, Medical Nemesis – Medicine: ‘a published in Januarywas Progress, in 1975 in Ideas to dealing with alternatives papers of working series of Limits to Medicine A further version industrial society.’ which response the world-wide of result a (‘written as original the publication of upon received the author Boyars, Marion by in 1976 published was draft’) dismissive to those less gifted, and to those who did did who and to those gifted, less to those dismissive his views. not share and writer the psychiatrist 2002, After his death in Theodore as writes also (who Daniels Anthony Dalrymple) wrote:

3 He 3 Deschoolingin Society . He had immense immense had He him. 134–9 He died of a facial tumour, for for He died of a facial tumour, 2 2016; 46: 2016; in 1974. Medical Nemesis in 1974. namely, that industrialisation and that industrialisation and namely, Energy and Equity (1973) and Energy Conviviality for Tools © 2016 RCPE J R Coll Physicians Edinb Coll Physicians J R which, characteristically, he did not seek medical medical not seek he did characteristically, which, It is something not an illness. it’s ‘I am not ill, treatment: – a very complicated relationship.’ different completely and study in his work while at suddenly Illich collapsed immediately. died absurd and slightly paradoxical a singular, Illich was of critic quasi-Marxist a as regarded Initially figure. to be distrusted he grew modern consumer capitalism, The Right ‘inhumane’. Marxism the Left and called by The church crank. dismissed him as a communist that it Illich remarked although typically, him, disowned left had which church the was languages he was fluent in so many intellectual gifts; His tongue. mother no have to he claimed that theology, from drawing vast, was scholastic hinterland simple of boasted He history sociology. and philosophy, after his a friend wrote yet drink, and tastes in food and fine wines. foods expensive death that he enjoyed preached that educational institutions were a barrier barrier a were institutions that educational preached visiting professorships held many yet to true learning, A charismatic man with a huge at various universities. he could be cutting and of friends and disciples, circle He railed against modern mass transportation and the the crossed yet damage it caused to the environment, to He refused jet on countless occasions. Atlantic by yet ‘gauge’, a as to referred he which watch, a wear what time it was. ‘gauge bearers’ asked constantly priesthood, but, for the rest of his life, continued to to continued of his life, the rest for but, priesthood, a commitment to retained and himself as a priest, regard evolved Formation Intercultural for Centre The celibacy. Documentación), de Intercultural into CIDOC (Centro CIDOC school. language and university informal an and its focus world, the all over students from attracted issues. philosophical and social to language from shifted Western of corruption the on ideas his Illich evolved at discussions informal and lectures institutions during a to Illichknown During the 1970s became CIDOC. of the publication of a series wider audience following with beginning books, polemical 1971, which argued that educational institutions stifled educational that argued which 1971, common a had books His subsequent true learning. theme: freedom their people of robbed institutionalisation had to life human of aspects fundamental over handed and ideas his expanded He institutions. their and professions in entertainment, mass against in which he argued (1974), the same brought He respectively. transport, mass and thinking to in the mid-1970s. intellectual influence peaked Illich’s held he subsequently 1976 and in down CIDOC closed American and European at various visiting professorships and Marburg Oldenburg, Kassel, including universities, between his life of decade the last He divided Bremen. austere, aloof, ‘aristocratically Bremen, and Mexico happy.’ but absorbed S O’Mahony

made by others, most notably, the epidemiologist ability to die, the terminal shape that health can take, and Thomas McKeown.7 Like McKeown, Illich believed that has made the right to be professionally killed into a sanitation, nutrition and housing were more important major issue.’ determinants of health: The study of the evolution of disease patterns Illich believed that there is a profound difference provides evidence that during the last century between pain and suffering. Pain, he argued, is a sensation, doctors have affected epidemics no more profoundly but suffering is a practice. Pain, in the absence of a than did priests in earlier times…the combined cultural and spiritual context, is unendurable. He argued death rate from scarlet fever, diphtheria, whooping that this cultural iatrogenesis had robbed people in cough, and measles among children up to fifteen modern industrialised societies of the ability to suffer, shows that nearly 90 per cent of the total decline in thus rendering pain meaningless: mortality between 1860 and 1965 had occurred Culture makes pain tolerable by integrating it into a before the introduction of antibiotics and widespread meaningful setting; cosmopolitan civilization detaches immunization. pain from any subjective or inter-subjective context in order to annihilate it. Culture makes pain tolerable Illich went on to argue that not only did doctors by interpreting its necessity; only pain perceived as contribute little to the health of populations, they curable is intolerable…Duty, love, fascination, probably did more harm than good: ‘…only modern routines, prayer, and compassion were some of the malnutrition injures more people than iatrogenic disease means that enabled pain to be borne with dignity. in its various manifestations.’ The greatest human pain is death. Through the He had a low opinion of doctors (‘the medical guild’), medicalisation of death, he wrote, ‘healthcare has who he regarded as more concerned with their income become a monolithic world religion…The medicalization and status than the health of their patients: ‘…doctors of society has brought the epoch of natural death to an deploy themselves as they like, more so than other end. Western man has lost the right to preside at his act professionals, and they tend to gather where the climate of dying.’ is healthy, where the water is clean, and where people are employed and can pay for their services.’ Illich’s Remedies Social Iatrogenesis Illich’s diagnosis of medicine’s woes was astute, but his prescriptions were risible. He argued, for example, for Illich observed how the founders of the NHS naïvely ‘more public support for alpha waves, encounter groups believed that a free healthcare system would result in a and chiropractic.’ He advanced rather vague proposals healthier society, and thus less demand for its services. of handing back to lay people responsibility for their He coined the term ‘Sisyphus syndrome’, meaning the health, and limiting the power of doctors, insurance more healthcare given to a population, the greater its companies and pharmaceutical firms. demand for care. He used the phrase ‘social iatrogenesis’ Medical Nemesis is resistant to medical remedies. It to describe what he saw as the medicalisation of can be reversed only through a recovery of the will Western society: ‘…medical practice sponsors sickness to self-care among the laity, and through the legal, by reinforcing a morbid society that encourages people political and institutional recognition of the right to to become consumers of curative, preventive, industrial, care, which imposes limits upon the professional and environmental medicine.’ monopoly of physicians.

He described how the pharmaceutical industry, Perhaps it is unreasonable to expect Illich to provide enthusiastically supported by the medical profession, practical solutions to what he viewed as a spiritual, benefited from this medicalisation: ‘To promote Valium, rather than an organisational, or societal, malaise. Hoff-LaRoche spent $200 million in ten years and commissioned some two hundred doctors a year to Prose Style produce scientific articles about its properties.’ Medical Nemesis is not an easy read. The prose is dense, Cultural Iatrogenesis and at times, impenetrable. Illich drew not only from the medical literature, but also history, philosophy, sociology Illich went on to argue that ‘cultural’ iatrogenesis was and anthropology. His use of footnotes is even greater the most insidious form of iatrogenesis, as it sought to than the late David Foster Wallace: one 39-word corrupt the essence of what it is to be human. He sentence has eight footnotes. He defended this use of history attacked especially the medicalisation of death: ‘The footnotes: ‘The footnotes reflect the nature of this text. patient’s unwillingness to die on his own makes him I assert the right to break the monopoly that academia pathetically dependent. He has now lost his faith in his has exercised over all small print at the bottom of the

9 137 Medical 40 years on years 40 true? 11 Medical Nemesis Medical letters page was equally busy. busy. equally was page letters 10 Rhodes accused Illich of a lack of a of Illich accused Rhodes 8 He mocked Illich as a ‘classic Old-Testament ‘classic Old-Testament Illich as a He mocked 12 BritishJournal Medical The gist of your leading article on Ivan Illich’s article leading Illich’s on Ivan your The gist of with is wrong much while clearly Nemesis is that, and other is nothing that doctors there medicine, that Illich is a somewhat citizens cannot set to rights, the put cannot one that and if interesting, wild man, industrial of prophet a not think Illich is back…I clock a now is he us, of rest the like medical) nemesis: (or its occurrence. witness of Alex Paton, a physician at Dudley Road Hospital in Road at Dudley a physician Alex Paton, who three the of reviewer only the was Birmingham, reasoned, closely is argument ‘…his supportedIllich: dull, but never often exasperating, sometimes obscure, documented.’ fully and spellbinder’ and ‘extremely dangerous for people of for dangerous ‘extremely spellbinder’ and wrote situation’, ‘In almost every intelligence’. moderate he in some and his case ‘Illich overstates Horrobin, be must which to the uninformed a view presents that Illich was however, He conceded, misleading.’ frankly convincing’. ‘seductively eloquent’ and ‘brilliantly David Horrobin, the controversial doctor, pharmaceutical doctor, controversial the Horrobin, David book, an entire wrote publisher, and entrepreneur Illich’s refuting A Reply to Ivan Illich, Medical Hubris: thesis. s come Illich’s prophecie Have out Illich went the 1970s, of After the high-water mark a him as dismissed establishment medical the fashion: of the by His argument was weakened on. crank and moved and his dismissal of technology, obscurity of his prose, the impracticality and vagueness of his suggested him as just another It is tempting to regard solutions. 1960s the of counter-culture the to footnote historical of what he warned much on, 40 years yet, and 1970s, than a was more there Indeed, come to pass. has against public in Illich’s prophet Testament touch of the Old The Illich’s, of disciple and polemicist doctor, Bradshaw, John wrote: originality: ‘nothing said by Illich has not already been not already has Illich by said ‘nothing originality: to be new really is nothing doctor…there some by said Chemical of Professor Discombe, George here.’ found Nigeria, Zaria, Bello University, Abmadu Pathologythe at for fondness a ‘Dr Illich betrays unimpressed: also was – phrases emotive and abstract nouns, exotic words, mystogogue… a know which to by signs proper and good line as a dealer in Utopias – in the of Illich is revealed Chesterton…’ G.K. and Marx Karl Rousseau, Bacon, the book, along with an editorial comment. Philip an editorial comment. with along the book, of the Faculty Dean of Medicine at the Rhodes, Illich’s found readers, many like Adelaide, of University is the however, ‘Such, less than engaging: style prose to recourse the the imagery, obscurity of the language, history and selective that one’s iconography, mythology, author means could very of what the interpretation be wrong.’ easily Medical o Illich’s ‘Apophasis’ 134–9 The original Greek word means word The original Greek 1 2016; 46: 2016; prompted the British Medical Nemesis prompted to take the unprecedented decision to the unprecedented to take was a Catholic priest. priest. Catholic a was Nemesis Medical Illich, like the Biblical prophets, often spoke in in spoke often prophets, Biblical the like Illich, 1 To Illich, the history of the West was thus the tragedy the thus was West the historythe of Illich, To the as of the institutionalization of Christianity, the false adopted Christ, of the Body truly Church, the Church institution…If an of guise dangerous and those to institutionalization, not succumbed had come into have not even other institutions would levels. two had therefore, apophasis, Illich’s existence. He denied that mandatory schooling was true true medicine was modern that teaching, learning or was true and that economic development healing, the that he denied level the deeper at compassion; was body human the that bureaucracy, a was Church be could suffering and death that and machine, a avoided. © 2016 RCPE J R Coll Physicians Edinb Coll Physicians J R ‘denial’ or ‘negation’. There is a long tradition of Christian is a long tradition of Christian There ‘negation’. ‘denial’ or Eckhartincluding Meister St and theology, apophatic Illich told his friends that In later life, of the Cross. John biographer, His ‘apophatic’. theologypersonal his was including Medical books, Illich’s that argues Hartch, Todd Christianity: of corruption the about really were Nemesis, , after the publication of Medical Nemesis years Many that Duden, Barbara historian the friend, his told Illich been the have ‘could as easily the subject of the book postal service the of corruption because the underlying was the true object of his itself, not medicine West, study.’ The publication of Medical Journal of reviews individual three 1974, in December publish, emporary Contemporary reaction t Medical Nemesis and that the not guess unfamiliar with Illich would A reader of author as a kind of theological or be defined may Apophasis not its true subject by philosophical thinking that reveals mentioning this subject. page.’ Illich employed this particular style deliberately: he he particularthis deliberately: style Illich employed page.’ take should argued, he all, after (who, people lay wanted an to access have health) to their own for responsibility medical impress to wanted he and bibliography extensive that I suspect possible. as evidence much with as readers his not wear he did off: wished to show Illich simply also of been stripped If Medical Nemesis had learning lightly. it might have irrelevancies, and footnotes repetition, is not however, Unreadability, essay. long been a readable Medical a book; for to success an insuperable obstacle established Illich a star as Nemesis was a bestseller and the Christopher Hitchens mould. public intellectual in public speaker; accomplished and charismatic a Illich was the book after hearing him bought I suspect that many pages. the first few up after gave and speak, riddles and parables. and parables. riddles Nemesis S O’Mahony

persona: he was frequently dismissed by critics in ad into a benefit of 4-6 weeks at best. Perspective is hominem attacks as a ‘Jeremiah’. When Medical Nemesis almost exclusively absent as we focus solely on what was published in 1974, US spending on healthcare was is perceived as benefit. 8% of the GDP; it is now 18%. Healthcare makes up 10% of the entire global economy. Medicine has indeed The medical profession and their patients may not be become, in Illich’s phrase, ‘a vast monolithic world exercised about social and cultural iatrogenesis, but religion’. Even meliorists such as Atul Gawande admit clinical iatrogenesis is now recognised as a major societal that the growth of health care as a percentage of the issue, one in urgent need of fixing. Atul Gawande, in his global economy is threatening other aspects of human book Complications, summarised the problem: life, such as transport, housing and education.13 In 1991, the New England Journal of Medicine published Medicalisation has continued unchecked, and Illich would a series of landmark papers from a project known as have been wryly amused by the invention of new the Harvard Medical Practice Study – a review of diseases, such as social anxiety disorder (shyness), male- more than thirty thousand hospital admissions in pattern alopecia (baldness), testosterone-deficiency New York State. The study found that nearly 4 syndrome (old age), and erectile dysfunction (impotence). percent of hospital patients suffered complications from treatment which either prolonged their hospital Illich, along with the French historian Philippe Áries,14 stay or resulted in disability or death, and that two- railed against the medicalisation of death. In the 40 years thirds of such complications were due to errors in since 1975, death has moved from the home to the care. One in four, or 1 percent of admissions, hospital. And hospitals have become a dustbin for all involved actual negligence. It was estimated that, sorts of societal problems, not just dying. Illich assumed nationwide, upward of forty-four thousand patients that this medicalisation was something doctors actively die each year at least partly as a result of errors in sought, to enhance their power, but doctors and care.17 hospitals did not ask for these problems – society was quite happy to hand them over, as long as the problems Many within medicine view with alarm the direction could be given a medical gloss. In 2002, Leibovici and modern healthcare has taken. Denis McCullough, an Lièvre corrected the Illichian view in the British Medical American gerontologist, wrote: ‘Economic interests, as Journal: well as cultural and social pressures, encourages both an These aspects of medicalization make doctors excessive use of health services and an expansion of miserable. The bad things of life: old age, death, pain people’s expectations beyond what is realistic, what the and handicap are thrust on doctors to keep families health service is able to deliver.’18 The economist Alan and society from facing them. Some of them are an Enthoven has argued that increasing spending on integral part of medicine, and accepted as such. But medicine will reach a tipping point, beyond which more there is a boundary beyond which medicine has only spending causes more harm than good.19 We have seen a small role. When doctors are forced to go beyond the rise in the concept of disease ‘awareness’, promoted, that role they do not gain power or control: they not infrequently, by pharmaceutical companies. Genetics suffer.15 has the potential to turn us all into ‘patients’ by identifying our predisposition to various diseases. Illich’s prediction of ever-increasing medicalisation has Guidelines from the European Society of Cardiology on come true, but doctors are as much victims as their treatment of hypertension and hypercholesterolaemia patients. identified 76% of the adult population of Norway as being at ‘increased risk’.20 This ‘disease mongering’ Modern medicine has been called ‘a culture of excess’. In (driven mainly by the pharmaceutical industry) has, 2011, the Lancet Oncology Commission produced a wrote Iona Heath, ‘meant a shift of attention from the lengthy report called Delivering Affordable Cancer Care in sick to the well and from the poor to the rich.’21 Illich High-Income Countries.16 The authors, a gathering of the wrote: ‘…a culture can become prey of a pharmaceutical great and the good of modern oncology, concluded (in a invasion. Each culture has its poisons, its remedies, its passage that could have been written by Illich) that placebos, and its ritual settings for their administration. cancer care is in crisis, driven by overuse and futility: Most of these are destined for the healthy rather than In developed countries, cancer treatment is becoming the sick.’ a culture of excess. We over-diagnose, overtreat and overpromise. This extends from use of complex Influence of Illich technology, surgery and drugs to events related to the acceptance of treatment side-effects. Second, we Anthony Daniels spoke for many when he wrote: ‘My are a society that focuses almost exclusively on attitude to Illich was composed half of admiration, half of history benefit, and such benefit is often small. For example, irritation.’ Illich was a hugely influential intellectual figure a 20% improvement in survival for a patient with a in the 1970s and had many disciples, including John non-resectable metastatic solid tumour translates Bradshaw, who wrote Doctors on Trial in 1978, which

138 J R Coll Physicians Edinb 2016; 46: 134–9 © 2016 RCPE history The 24 139 40 years on years 40 . http://blogs.bmj. . blogs BMJ Medical Nemesis Medical which shares some of the aims of which shares 25 2006; 3: e146. http://dx.doi.org/10.1371/ e146. 3: PLoS Medicine 2006; 2003; 57: 928. 57: Health 2003; J Epidemiol Community Academic medicine, so powerful in shaping opinion, opinion, in shaping so powerful medicine, Academic Smith R. The case for slow medicine. medicine. slow for case The Smith R. 1 June 2009. The 2009. 1 June Conundrum. The Cost Yorker New A. Gawande http://www.newyorker.com/magazine/2009/06/01/the-cost- 4/4/16). (accessed conundrum The Medicine’. ‘Slow York New of a Dose Old, Very the For A. Zuger http://www.nytimes.com/2008/02/26/ Times 26 February 2008. 4/4/16). (accessed health/views/26books.html?_r=0 BMJ Almost certainly. medicine? much Too Smith R. R, Moynihan http://dx.doi.org/10.1136/bmj.324.7342.859 859. 324: 2002; arising Ethical dilemmas I et al. Hetlevik AL, Kirkengen Getz L, on cardiovascular guidelines implementation of the European from Scand J Prim Care Health in clinical practice. prevention disease 202–8. 22: 2004; but nonetheless daunting mongering: disease Combating I. Heath essential. journal.pmed.0030146 1978. House, Wildwood London: Doctors . JS. Bradshaw on Trial of expropriation the Medical nemesis: medicine. Limits to Smith R. health. com/bmj/2012/12/17/richard-smith-the-case-for-slow-medicine 4/4/16). (accessed http://dx.doi. h1217. 350: 2015; BMJ medicine. much Too Godlee F. org/10.1136/bmj.h1217 the Slow Medicine Movement. Movement. Medicine the Slow barely it is bombastic, Medical Nemesis is a paradox: is a powerful but at its core, over-stated, and readable, thesis Illich’s after its publication, Forty years argument. in strength. grown only has British Medical Association has backed a ‘Too Much ‘Too a has backed Association British Medical Medicine’ campaign thing. thing. partners’ ‘industrial with relationship a developed has new a But uncritical. and close unhealthily is that A ideas. Illich’s by influenced been has generation this within medicine: is developing resistance growing Slow the as such strands, various has movement by inspired 1989, in in Italy founded Medicine Movement, Slow the of meeting a At Movement. Food Slow the Gianfranco in 2013, in Bologna Medicine Movement of health systems the characteristics Domenighetti listed poor opacity, uncertainty, ‘complexity, follows: as asymmetry in decision-making, variability measurement, corruption.’ and interest, conflict of information, of 24 17 18 19 20 21 22 23 25 , Illich, Illich, 22 23 BritishJournal Medical 2008; 371: 644–5. 371: 2008; 1974; 4: 573–4. 4: BMJ 1974; 134–9 . London: Profile Books, 2002. Books, Profile London: . 2016; 46: 2016; . Montreal: Eden Montreal: Ivan Illichto Reply A . Medical Hubris. Complications The Prophet of Cuernavaca: Ivan Illich and the Crisis of the of Cuernavaca: The Prophet The closest I ever came to a religious experience came to a religious I ever The closest charismaticand A Illich. Ivan to listening was the of the fossils by surrounded man, passionate ‘the that He argued in Edinburgh. hierarchy academic is modern world to health in the threat major not least me, He convinced was 1974. This medicine.’ of the wards on the that what I saw because I felt the Infirmary for Royal more was Edinburgh of patients. than benefit of doctors . New New The Hour of our Death. Weaver) Helen by (Translated Ariès P. 1981. Knopf, A. Alfred York: inside medicine. peering from Medicalisation: M. Lièvre L, Leibovici 866. 324: BMJ 2002; affordable Delivering K et al. Sikora J, Peppercorn Sullivan R, 933– 12: Lancet Oncol 2011; in high-income countries. cancer care http://dx.doi.org/10.1016/S1470-2045(11)70141-3 80. Hartch T. Hartch T. 2015. Press, University Oxford Oxford: . West 923–4. 57: Health 2003; J Epidemiol Community Ivan Illich. Obituary. 925. 57: Health 2003; J Epidemiol Community Illich. Ivan L. Levin CriterionThe New January 2003; 1926–2002. Illich, Ivan A. Daniels 78–81. 21: 1974. & Boyars, Calder Medical Nemesis. London: Illich I. The Expropriation of Medical Nemesis: Limits to Medicine. Illich I. 1976. Boyars, Marion London: Health. Lancet thesis. The McKeown B. Bynum 576–7. 4: BMJ 1974; Care. Medical of Indictment P. Rhodes 574–6. 4: BMJ 1974; Enthusiast. A Romantic G. Discombe ‘Medicalization’ of A. Paton Health. 1975; 1: 94. 1: BMJ 1975; Nemesis. Medical JS. Bradshaw D. Horrobin 1977. Press, A. Gawande © 2016 RCPE J R Coll Physicians Edinb Coll Physicians J R wrote this in 2002: wrote naturally, wrote the foreword for Bradshaw’s polemic. polemic. Bradshaw’s for the foreword wrote naturally, the of editor then Smith, Richard Illich’s marginalisation may have been a defensive defensive a been have may marginalisation Illich’s the Since the 1970s, parton the of doctors. response anti- been has profession in the medical ethos dominant the and politicians patients, Doctors, Illichian. that consensus pharmaceutical industry a broad formed be a good only could healthcare, more medicine, more reached the Illichian conclusion that ‘western doctors ‘western that Illichianconclusion the reached indirectly, or directly productive, certainly more are today health.’ than of sense, in every of ill-health, 14 15 16 References 1 2 3 4 5 6 7 8 9 10 11 12 13