Other People's Lives: Reflections on Medicine, Ethics, and Euthanasia.

• Position: Book review

Part One: In Defense of Medicine

Chapter III. The Attack on Medicine

The doctor, looking grave and solemn, began his examination. He took the patient's pulse rate and body temperature, and proceeded to the percussion and auscultation. With a certainty that left no room for doubt, Ivan Ilyich knew that all this was rubbish and fraud. (26) Ivan Illich. (27) The hero of this story is the near namesake of Tolstoy's Ivan Ilyich, professor Ivan Illich of Cuernavaca, Mexico. Illich, the Vienna-born quadruple graduate of European universities, and one time parish priest ministering to Manhattan's poor, has become the theorist and ardent advocate of rebellion against Western industrialized civilization. The grave moral failures of our civilization certainly have fed this movement, but some of its ideas can be traced to earlier sources, to the anarchism of Proudhon and Kropotkin, early 19th century's romanticism, the views of J. J. Rousseau, and to the even earlier myth of the Happy Savage. Illich's anti-industrialism writings often surprise by their vehemence, uncompromising thoroughness, and unexpected targets of assault. In Illich's view, the expanding technology very soon reaches the point beyond which it inevitably turns against people.

In the 1970s, Illich was widely acclaimed in the intellectual and professional circles of Western Europe and North America as the prophet who told us the truth about ourselves. Illich's teachings on the sinister activities of the medical Mafia not only supplied arguments for the Western European and, in particular, Holland's anti-medical campaign of the 1970s and 1980s, but, surprisingly, met with an enthusiastic response from many doctors. At the assembly of the British Medical Association in Edinburgh, Illich was given a standing ovation. Prominent physicians declared that when they read Illich's works, scales fell from their eyes. Apparently, the disappointment of "modern" physicians with their role, and with medicine in general, made them receptive to Illich's ideas. His name may now be almost forgotten, but this man has substantially contributed to the present crisis of medicine.

Several features of Illich's writings made for the powerful impact these publications had at the time. Their subject matter was of vital importance: it was the heavy price mankind was paying for industrialization, man's entanglement in the complexities of societal structure, the abysmal contrast between the First and the Third World. Illich's onslaught on institutions people had considered friendly (e.g., formal educational institutions), attested to the originality of the author's thought and his intellectual courage. The solution he proposed--no less than a total destruction of our civilization--showed Illich as a thorough thinker who wouldn't content himself with half-measures.

Yet Illich's success among intellectuals of the 1970s is an astonishing story. His allegations were, to put it mildly, biased and unreasonable, and his propositions radical and absurd. In his view, the school, for instance, was not a teaching institution with some faults and negative aspects; it was a criminal conspiracy to create social inequalities, and nothing else. This is patently untrue. It is also worth pointing out that without formal education nobody would be able to raise or debate the issues of Illich's writings. Neither could prof. Illich's favorite bike be designed or produced by uneducated workers. The village blacksmith wouldn't be able to make the lightweight metal frame, the precision bearing or the rubber tires, all of which require formal education in the sciences and engineering principles.

In Illich's view, the only aim of professional groups is power, and enslavement of other people.... Medicine is the area of Illich's particular interest. The doctors, he asserts, do not provide any useful services, but only seek to enhance their own wealth and power over the people. This is not true. Any man who once experienced the excruciating pain and pressure of urinary retention, and the wonderful relief provided by inserting a catheter, will refute Illich's absurd statement. A multitude of similar examples could be cited.

But a few points in Illich's "medical" writings deserve our attention. First of all, the myth of the medical Mafia. To prove its existence Illich cites "the conspiracy set up 2500 years ago on the island of Kos," that is, the Hippocratic school and the Oath of Hippocrates. But the Hippocratic Oath ranks among the most beautiful documents in human history. In order to present it as evidence of criminal conspiracy, Illich had to "adjust" the Oath's contents. Taking the Oath the physician vows not to divulge secrets he may learn upon entering the sick person's house. He also vows to revere the master who taught him the Art, and, if the master's children wish to learn, to teach them without a fee. In Illich's interpretation, however, the physician swore not to disclose the secrets of their trade to anyone but fellow physicians and their children, thereby setting up a "criminal family" bound by a code of silence, i.e., a Mafia.

In the industrial era, the medical Mafia has expanded and consolidated their power by gaining access to government and its means of enforcement. In Illich's view, the mandatory vaccinations (common in the European countries), and the legislation regulating the practice of medicine are but means to increase the Mafia's power and protect doctors' monopoly. It is twisted thinking to consider vaccinations a source of "power" (which no doctor is seeking). Why not look at what the vaccinations really are and what they do? Smallpox, the scourge that killed hundreds of thousands in Europe, and disfigured many millions, is now eradicated on our planet due to mandatory vaccinations carried out in most countries. Undoubtedly, the vaccinations against diphtheria, tetanus, and poliomyelitis prevented much suffering and saved many lives. A disease prevented, or eradicated, diminishes rather than enhances the power of doctors.

Illich suggests that government regulation of medical practice serves only to protect the doctors' monopoly on health care. Therapeutic interventions carry some risk, and quackery is by no means risk-free. There have been case reports of lungs collapsed due to acupuncture, and massive deep bleeding caused by this procedure. The fact that the "healer" had no knowledge of human anatomy and did not know what he was doing is no excuse. Society needs laws to determine the responsibility of medical practitioners for bodily injuries they may inflict, and laws that prevent the worst disasters by barring ignorant individuals from performing invasive procedures.

The American and Dutch Attack on Medicine. Bioethics (28) should be seen as the scientifically equipped, institutionalized manifestation of a much broader popular anti-medical wave. (29) The other causes seem to have been the post-World War II anti-establishment, anti-intellectual, and anti-technology rebellion (and the reverse grievance: that medicine is not as infallibly effective as engineering); patients' repugnance of medical invasions of their bodies; democratic resentment of doctors who wield so much power though no one had elected them; the popular media's education of the public on health issues; and sado-masochistic musing involving doctors and nurses. The attack on medical practice includes a narrower current of discriminatory eugenics, the abhorrence of anyone who is congenitally disabled, crippled or disfigured, and resentment of doctors who keep them alive.

In the United States, the rebellion against medical paternalism has converted the principle of patient consent into the postulate that doctors should carry out the patient's orders. Putting this postulate into full effect would mean the end of medicine. Addressing the doctors in an uncivil or brutal way is becoming a fashion in letters to editors and in other media. In the face of the tragedy of breast cancer, the wrath turns against the doctors who have advised radical mastectomies.

In Holland, the attack reached its climax in the 1970s and 1980s when the government, the body politic, the media, and a large part of the public joined the campaign. Members of parliament were elected, cabinet ministers secured their positions, television networks improved their ratings, and newspapers increased their circulation by assaulting the medical profession. The Parliament and the media extolled the "alternative medicine" while "university medicine" was derided and its total failure presented as a foregone conclusion. The "big money" earned by medical specialists was loudly decried. No one explained that of this gross income a large part was spent on salaries of secretaries and assistants, social security payments, and the lease of hospital facilities, while up to 70% of the remaining sum paid taxes. Greed was the only motivation ever mentioned and the only one accepted by the public. When the medical profession did not rush to adopt the nonsensical "alterative method of treating cancer with diet," Mrs. Ria Beckers, leader of the leftist political party, shouted in the Parliament that doctors were burying this excellent method because applying it would reduce the their income.

People who publicly attacked the medical profession were never required to substantiate their claims. Even entirely implausible allegations were accepted and immediately published. An indignant letter to the Brabants Dagblad, a large circulation Dutch daily newspaper, stated that family doctors, afraid of losing their income, did not join group practices, and as a result young people unnecessarily died! Group practices had no influence whatsoever on doctors' income or young people's mortality; but no correction appeared. No accusation was ever refuted, not only because the editors wouldn't have printed it, but, first of all, because the Dutch doctors ducked for cover and tried...