6 – Specific Counterproductivity
Iatrogenesis will be controlled only if it is understood as but one aspect of the destructive dominance of industry over society, as but one instance of that paradoxical counterproductivity which is now surfacing in all major industrial sectors. Like time-consuming acceleration, stupefying education, self-destructive military defense, disorienting information, or unsettling housing projects, pathogenic medicine is the result of industrial overproduction that paralyzes autonomous action. In order to focus on this specific counterproductivity of contemporary industry, frustrating overproduction must be clearly distinguished from two other categories of economic burdens with which it is generally confused, namely, declining marginal utility and negative externality. Without this distinction of the specific frustration that constitutes counterproductivity from rising prices and oppressive social costs, the social assessment of any technical enterprise, be it medicine, transportation, the media, or education, will remain limited to an accounting of cost-efficiency and not even approach a radical critique of the instrumental effectiveness of these various sectors.
Direct costs reflect rental charges, payments made for labor, materials, and other considerations. The production cost of a passenger-mile includes the payments made to build and operate the vehicle and the road, as well as the profit that accrues to those who have obtained control over transportation: the interest charged by the capitalists who own the tools of production, and the perquisites claimed by the bureaucrats who monopolize the stock of knowledge that is applied in the process. The price is the sum of these various rentals, no matter whether it is paid by the consumer out of his own pocket or by a tax-supported social agency that purchases on his behalf.
Negative externality is the name of the social costs that are not included in the monetary price; it is the common designation for the burdens, privations, nuisances, and injuries that I impose on others by each passenger-mile I travel. The dirt, the noise, and the ugliness my car adds to the city; the harm caused by collisions and pollution; the degradation of the total environment by the oxygen I burn and the poisons I scatter; the increasing costliness of the police department; and also the traffic-related discrimination against the poor: all are negative externalities associated with each passenger-mile. Some can easily be internalized in the purchase price, as for instance the damages done by collisions, which are paid for by insurance. Other externalities that do not now show up in the market price could be internalized in the same way: the cost of therapy for cancer caused by exhaust fumes could be added to each gallon of fuel, to be spent for cancer detection and surgery or for cancer prevention through antipollution devices and gas masks. But most externalities cannot be quantified and internalized: if gasoline prices are raised to reduce depletion of oil stocks and of atmospheric oxygen, each passenger- mile becomes more costly and more of a privilege; environmental damage is lessened but social injustice is increased. Beyond a certain level of intensity of industrial production, externalities cannot be reduced but only shifted around.
Counterproductivity is something other than either an individual or a social cost; it is distinct from the declining utility obtained for a unit of currency and from all forms of external disservice. It exists whenever the use of an institution paradoxically takes away from society those things the institution was designed to provide. It is a form of built-in social frustration. The price of a commodity or a service measures what the purchaser is willing to spend for whatever he gets; externalities indicate what society will tolerate to allow for this consumption; counterproductivity gauges the degree of prevalent cognitive dissonance resulting from the transaction: it is a social indicator for the built-in counterpurposive functioning of an economic sector. The iatrogenic intensity of our medical enterprise is only a particularly painful example of how frustrating overproduction appears in equal measure as time-consuming acceleration of traffic, static in communications, training for well-rounded incompetence in education, uprooting as a result of housing development, and destructive overfeeding. This specific counterproductivity constitutes an unwanted side-effect of industrial production which cannot be externalized from the particular economic sector that produces it. Fundamentally it is due neither to technical mistakes nor to class exploitation but to industrially generated destruction of those environmental, social, and psychological conditions needed for the development of nonindustrial or nonprofessional use- values. Counterproductivity is the result of an industrially induced paralysis of practical self-governing activity.
The industrial distortion of our shared perception of reality has rendered us blind to the counterpurposive level of our enterprise. We live in an epoch in which learning is planned, residence standardized, traffic motorized, and communication programmed, and in which, for the first time, a large part of all foodstuffs consumed by humanity passes through interregional markets. In such an intensely industrialized society, people are conditioned to get things rather than to do them; they are trained to value what can be purchased rather than what they themselves can create. They want to be taught, moved, treated, or guided rather than to learn, to heal, and to find their own way. Impersonal institutions are assigned personal functions. Healing ceases to be considered a task for the sick. It first becomes the duty of the individual body repairmen, and then soon changes from a personal service into the output of an anonymous agency. In the process, society is rearranged for the sake of the health-care system, and it becomes increasingly difficult to care for one's own health. Goods and services litter the domains of freedom.
Schools produce education, motor vehicles produce locomotion, and medicine produces health care. These outputs are staples that have all the characteristics of commodities. Their production costs can be added to or subtracted from the GNP, their scarcity can be measured in terms of marginal value, and their costs can be established in currency equivalents. By their very nature these staples create a market. Like school education and motor transportation, clinical care is the result of a capital-intensive commodity production; the services produced are designed for others, not with others nor for the producer.
Owing to the industrialization of our world-view, it is often overlooked that each of these commodities still competes with a nonmarketable use-value that people freely produce, each on his own. People learn by seeing and doing, they move on their feet, they heal, they take care of their health, and they contribute to the health of others. These activities have use-values that resist marketing. Most valuable learning, body movement, and healing do not show up on the GNP. People learn their mother tongue, move around, produce their children and bring them up, recover the use of broken bones, and prepare the local diet, and do these things with more or less competence and enjoyment. These are all valuable activities which most of the time will not and cannot be undertaken for money, but which can be devalued if too much money is around.
The achievement of a concrete social goal cannot be measured in terms of industrial outputs, neither in their amount nor in the curve that represents their distribution and their social costs. The effectiveness of each industrial sector is determined by the correlation between the production of commodities by society and the autonomous production of corresponding use-values. How effective a society is in producing high levels of mobility, housing, or nutrition depends on the meshing of marketed staples with inalienable, spontaneous action.
When most needs of most people are satisfied in a domestic or community mode of production, the gap between expectation and gratification tends to be narrow and stable. Learning, locomotion, or sick-care are the results of highly decentralized initiatives, of autonomous inputs and self-limiting total outputs. Under the conditions of a subsistence economy, the tools used in production determine the needs that the application of these same tools can fulfill. For instance, people know what they can expect when they get sick. Somebody in the village or the nearby town will know all the remedies that have worked in the past, and beyond this lies the unpredictable realm of the miracle. Until late in the nineteenth century, most families, even in Western countries, provided most of the therapy that was known. Most learning, locomotion, or healing was performed by each man on his own, and the tools needed were produced in his family or village setting.
Autonomous production can, of course, be supplemented by industrial outputs that will have to be designed and often manufactured beyond direct community control. Autonomous activity can be rendered both more effective and more decentralized by using such industrially made tools as bicycles, printing presses, recorders, or X-ray equipment. But it can also be hampered, devalued, and blocked by an arrangement of society that is totally in favor of industry. The synergy between the autonomous and the heteronomous modes of production then takes on a negative cast. The arrangement of society in favor of managed commodity production has two ultimately destructive aspects: people are trained for consumption rather than for action, and at the same time their range of action is narrowed. The tool separates the workman from his labor. Habitual bicycle commuters are pushed off the road by intolerable levels of traffic, and patients accustomed to taking care of their own ailments find yesterday's remedies available only on prescription and hence largely unobtainable. Wage labor and client relationships expand while autonomous production and gift relationships wither.
Effectively achieving social objectives depends on the degree to which the two fundamental modes of production supplement or hamper each other. Effectively coming to know and to control a given physical and social environment depends on people's formal education and on their opportunity and motivation to learn in a nonprogrammed way. Effective traffic depends on the ability of people to get where they must go quickly and conveniently. Effective sick-care depends on the degree to which pain and dysfunction are made tolerable and recovery is enhanced. The effective satisfaction of these needs must be clearly distinguished from the efficiency with which industrial products are made and marketed, from the number of certificates, passenger-miles, housing units, or medical interventions performed. Beyond a certain threshold, these outputs will all be needed only as remedies; they will substitute for personal activities that previous industrial outputs have paralyzed. The social criteria by which effective need-satisfaction can be evaluated do not match the measurements used to evaluate the production and marketing of industrial goods.
Since measurements disregard the contributions made by the autonomous mode towards the total effectiveness with which any major social goal may be achieved, they cannot indicate if this total effectiveness is increasing or decreasing. The number of graduates, for instance, might be inversely related to general competence. Much less can technical measurements indicate who are the beneficiaries and who are the losers from industrial growth, who are the few that get more and can do more, and who fall into the majority whose marginal access to industrial products is compounded by their loss of autonomous effectiveness. Only political judgment can assess the balance.
The persons most hurt by counterproductive institutionalization are usually not the poorest in monetary terms. The typical victims of the depersonalization of values are the powerless in a milieu made for the industrially enriched. Among the powerless may be people who are relatively affluent within their society or those who are inmates of benevolent total institutions. Disabling dependence reduces them to modernized poverty. Policies meant to remedy the new sense of privation will not only be futile but will aggravate the damage. By promising more staples rather than protecting autonomy, they will intensify disabling dependence.
The poor in Bengal or Peru still survive with occasional employment and an occasional dip into the market economy: they live by the timeless art of making do. They still can stretch out provisions, alternate between fat and lean periods, knit gift relationships whereby they barter or otherwise exchange goods and services neither made for nor accounted for by the market. In the country, in the absence of television, they enjoy living in homes built on traditional models. Drawn or pushed into town, they squat on the margins of the steel-and-petroleum sector, where they build a provisional economy with scraps of waste that can serve as building blocks for self-made shacks. Their exposure to extreme famine grows with their dependence on marketed food.
Given sufficient generations, during its entire evolution Homo sapiens has shown high competence in developing a great variety of cultural forms, each meant to keep the total population of a region within the limits of resources that could be shared or formally exchanged in its limited milieu. The worldwide and homogeneous disabling of the communal coping ability of local populations has developed with imperialism and its contemporary variants of industrial development and compassionate chic.
The invasion of the underdeveloped countries by new instruments of production organized for financial efficiency rather than local effectiveness and for professional rather than lay control inevitably disqualifies tradition and autonomous learning and creates the need for therapy from teachers, doctors, and social workers. While road and radio mold the lives of those whom they reach to industrial standards, they degrade their handicrafts, housing, or health care much faster than they crush the skills they replace. Aztec massage gives relief to many who would no longer admit it because they believe it outdated. The common family bed becomes disreputable much faster than its occupants become aware of discomfort. Where development plans have worked, they have often succeeded because of the unforeseen resilience of the adobe-cum-oildrum sector. The continued ability to produce foods on marginal land and in city backyards has saved productivity campaigns from the Ukraine to Venezuela. The ability to care for the sick, the old, and the insane without nurses or wardens has buffered the majority against the rising specific disutilities which symbolic enrichment has brought. Poverty in the subsistence sector, even when this subsistence is retrenched by considerable market dependence, does not crush autonomy. People remain motivated to squat on thoroughfares, to nibble at professional monopolies, or to circumvent the bureaucrats.
When perception of personal needs is the result of professional diagnosis, dependence turns into painful disability. The aged in the United States can again serve as the paradigm. They have been trained to experience urgent needs that no level of relative privilege can possibly satisfy. The more tax money that is spent to bolster their frailty, the keener is their awareness of decay. At the same time, their ability to take care of themselves has withered, as social arrangements allowing them to exercise autonomy have practically disappeared. The aged are an example of the specialization of poverty which the over-specialization of services can bring forth. The elderly in the United States are only one extreme example of suffering promoted by high-cost deprivation. Having learned to consider old age akin to disease, they have developed unlimited economic needs in order to pay for interminable therapies, which are usually ineffective, are frequently demeaning and painful, and call more often than not for reclusion in a special milieu.
Five faces of industrially modernized poverty appear caricatured in the pampered ghettos of rich men's retirement: the incidence of chronic disease increases as fewer people die in their youth; more people suffer clinical damage from health measures; medical services grow more slowly than the spread and urgency of demand; people find fewer resources in their environment and culture to help them come to terms with their suffering, and thus are forced to depend on medical services for a wider range of trivia; people lose the ability to live with impairment or pain and become dependent on the management of every discomfort by specialized service personnel. The cumulative result of overexpansion in the health-care industry has thwarted the power of people to respond to challenges and to cope with changes in their bodies or in their environment.
The destructive power of medical overexpansion does not, of course, mean that sanitation, inoculation, and vector control, well-distributed health education, healthy architecture, and safe machinery, general competence in first aid, equally distributed access to dental and primary medical care, as well as judiciously selected complex services, could not all fit into a truly modern culture that fostered self-care and autonomy. As long as engineered intervention in the relationship between individuals and environment remains below a certain intensity, relative to the range of the individual's freedom of action, such intervention could enhance the organism's competence in coping and creating its own future. But beyond a certain level, the heteronomous management of life will inevitably first restrict, then cripple, and finally paralyze the organism's nontrivial responses, and what was meant to constitute health care will turn into a specific form of health denial.
7 – Political Countermeasures
Fifteen years ago it would have been impossible to get a hearing for the claim that medicine itself might be a danger to health. In the early 1960s, the British National Health Service still enjoyed a worldwide reputation, particularly among American reformers. The service, created by Albert Beveridge, was based on the assumption that there exists in every population a strictly limited amount of morbidity which, if treated under conditions of equity, will eventually decline. Thus Beveridge had calculated that the annual cost of the Health Service would fall as therapy reduced the rate of illness. Health planners and welfare economists never expected that the service's redefinition of health would broaden the scope of medical care and that only budgetary restrictions would keep it from expanding indefinitely. It was not predicted that soon, in a regional screening, only sixty-seven out of one thousand people would be found completely fit and that 50 percent would be referred to a doctor, while according to another study, one in six people screened would be defined as suffering from one to nine serious illnesses. Nor had the health planners forecast that the threshold of tolerance for everyday reality would decline as fast as the competence for self-care was undermined, and that one-quarter of all visits to the doctor for free service would be for the untreatable common cold. Between 1943 and 1951, 75 percent of the persons questioned claimed to have suffered from illness during the preceding month. By 1972, 95 percent of those surveyed in one study considered themselves unwell during the fourteen days prior to questioning, and in another study in which 5 percent considered themselves free of symptoms, 9 percent claimed to have suffered from more than six different symptoms in the two weeks just past. Least of all did the health planners make provision for the new diseases that would become endemic through the same process that made medicine at least partially effective. They did not forecast the need for special hospitals dedicated to the soothing of terminal pain, usually suffered by the victims of unsound or ineffective surgery for cancer, or the need for other hospital beds for those affected by medicine-induced disease.
The sixties also witnessed the rise and fall of a multinational consortium for the export of optimism to the third world which took shape in the Peace Corps, the Alliance for Progress, Israeli aid to Central Africa, and in the last brush-fires of medical-missionary zeal. The Western belief that its medicines could cure the ills of the nonindustrialized tropics was then at its height. International cooperation had just won major battles against mosquitoes, microbes, and parasites, ultimately Pyrrhic victories which were advertised as the beginning of a final solution to tropical disease. The role that economic and technological development would play in spreading and aggravating sleeping sickness, bilharziasis, and even malaria was not yet suspected. Those who saw world hunger and new pestilence on the horizon were treated like prophets of doom or romantics; the Green Revolution was still considered the opening phase of a healthier and more equitable world. It would have seemed unbelievable that within ten years malnutrition in two forms would become by far the most important threat to modern man. The new high- caloric undernourishment of poor populations was not foreseen, nor was the fact that overfeeding would be identified as the main cause for the epidemic diseases of the rich. In the United States the new frontiers had not yet been obstructed by competing bureaucratic schemes. Hopes for better health still focused on equality of access to the agencies that would do away with specific diseases, Iatrogenesis was still an issue for the paranoid.
But by 1975 much of this had changed. A generation ago, children in kindergarten had painted the doctor as a white-coated father-figure. Today, however, they will just as readily paint him as a man from Mars or a Frankenstein. Muckracking feeds on medical charts and doctors' tax returns, and a new mood of wariness among patients has caused medical and pharmaceutical companies to triple their expenses for public relations. Ralph Nader has made the consumers of health staples money-and quality-conscious. The ecological movement has created an awareness that health depends on the environment—on food and working conditions and housing — and Americans have come to accept the idea that they are threatened by pesticides, additives, and mycotoxins and other health risks due to environmental degradation. Women's liberation has highlighted the key role that the control over one's body plays in health care. A few slum communities have assumed responsibility for basic health care and have tried to unhook their members from dependence on outsiders. The class-specific nature of body perception, language, concepts, access to health services, infant mortality, and actual, specifically chronic, morbidity has been widely documented, and the class-specific origins and prejudices of physicians are beginning to be understood. The World Health Organization, meanwhile, is moving to a conclusion that would have shocked most of its founders: in a recent publication WHO advocates the deprofessionalization of primary care as the most important single step in raising national health levels.
Doctors themselves are beginning to look askance at what doctors do. When physicians in New England were asked to evaluate the treatment their patients had received from other doctors, most were dissatisfied. Depending on the method of peer evaluation used, between 1.4 percent and 63 percent of patients were believed to have received adequate care. Patients are told ever more frequently by their doctors that they have been damaged by previous medication and that the treatment now prescribed is made necessary by the effects of such prior medication, which in some cases was given in a life-saving endeavor, but much more often for weight control, mild hypertension, flu, or mosquito bite or just to put a mutually satisfactory conclusion to an interview with the doctor. In 1973 a retiring senior official of the U.S. Department of Health, Education, and Welfare could say that 80 percent of all funds channeled through his office provided no demonstrable benefits to health and that much of the rest was spent to offset iatrogenic damage. His successor will have to deal with these data if he wants to maintain public trust.
Patients are starting to listen, and a growing number of movements and organizations are beginning to demand reform. The attacks are founded on five major categories of criticism and are directed to five categories of reform: (1) Production of remedies and services has become self-serving. Consumer lobbies and consumer control of hospital boards should therefore force doctors to improve their wares. (2) The delivery of remedies and access to services is unequal and arbitrary; it depends either on the patient's money and rank, or on social and medical prejudices which favor, for example, attention to heart disease over attention to malnutrition. The nationalization of health production ought to control the hidden biases of the clinic. (3) The organization of the medical guild perpetuates inefficiency and privilege, while professional licensing of specialists fosters an increasingly narrow and specialized view of disease. A combination of capitation payment with institutional licensing ought to combine control over doctors with the interest of patients. (4) The sway of one kind of medicine deprives society of the benefits competing sects might offer. More public support for alpha waves, encounter groups, and chiropractic ought to countervail and complement the scalpel and the poison. (5) The main thrust of present medicine is the individual, in sickness or in health. More resources for the engineering of populations and environments ought to stretch the health dollar.
These proposed remedial policies could control to some degree the social costs created by overmedicalization. By joining together, consumers do have power to get more for their money; welfare bureaucracies do have the power to reduce inequalities; changes in licensing and in modes of financing can protect the population not only against nonprofessional quacks but also, in some cases, against professional abuse; money transferred from the production of human spare parts to the reduction of industrial risks does buy more "health" per dollar. But all these policies, unless carefully qualified, will tend to reduce the externalities created by medicine at the cost of a further increase of medicine's paradoxical counterproduct, its negative effect on health. All tend to stimulate further medicalization. All consistently place the improvement of medical services above those factors which would improve and equalize opportunities, competence, and confidence for self- care; they deny the civil liberty to live and to heal, and substitute promises of more conspicuous social entitlements to care by a professional.
In the following five sections I will deal with some of these possible countermeasures and examine their relative merits.
Consumer Protection for Addicts
When people become aware of their dependence on the medical industry, they tend to be trapped in the belief that they are already hopelessly hooked. They fear a life of disease without a doctor much as they would feel immobilized without a car or a bus. In this state of mind they are ready to be organized for consumer protection and to seek solace from politicians who will check the high-handedness of medical producers.40 The need for such self-protection is obvious, the implicit dangers obscure. The sad truth for consumer advocates is that neither control of cost nor assurance of quality guarantees that health will be served by medicine that measures up to present medical standards.
Consumers who band together to force General Motors to produce an acceptable car have begun to feel competent to look under the hood and to develop criteria for estimating the cost of a cleaner exhaust system. When they band together for better health care, they still believe — mistakenly — that they are unqualified to decide what ought to be done for their bowels and kidneys and blindly entrust themselves to the doctor for almost any repair. Cross-cultural comparison of practices provides no guide. Prescriptions for vitamins are seven times more common in Britain than in Sweden, gamma globulin medication eight times more common in Sweden than in Britain. American doctors operate, on the average, twice as often as Britons; French surgeons amputate almost up to the neck. Median hospital stays vary not with the affliction but with the physician: for peptic ulcers, from six to twenty-six days; for myocardial infarction, from ten to thirty days. The average length of stay in a French hospital is twice that in the United States. Appendectomies are performed and deaths from appendicitis are diagnosed three times more frequently in Germany than anywhere else.
Titmuss has summed up the difficulty of cost-benefit accounting in medicine, especially at a time when medical care is losing the characteristics it used to possess when it consisted almost wholly in the personal doctor-patient relationship. Medical care is uncertain and unpredictable; many consumers do not desire it, do not know they need it, and cannot know in advance what it will cost them. They cannot learn from experience. They must rely on the supplier to tell them if they have been well served, and they cannot return the service to the seller or have it repaired. Medical services are not advertised as are other goods, and the producer discourages comparison. Once he has purchased, a consumer cannot change his mind in mid-treatment. By defining what constitutes illness the medical producer has the power to select his consumers and to market some products that will be forced on the consumer, if need be, by the intervention of the police: the producers can even sell forcible internment for the disabled and asylums for the mentally retarded. Malpractice suits have mitigated the layman's sense of impotence on several of these points, but basically, they have reinforced the patient's determination to insist on treatment that is considered adequate by informed medical opinion. What further complicates matters is that there is no “normal” consumer of medical services. Nobody knows how much health care will be worth to him in terms of money or pain. In addition, nobody knows if the most advantageous form of health care is obtained from medical producers, from a travel agent, or by renouncing work on the night shift. The family that forgoes a car to move into a Manhattan apartment can foresee how the substitution of rent for gas will affect their available time; but the person who, upon the diagnosis of cancer, chooses an operation over a binge in the Bahamas does not know what effect his choice will have on his remaining time of grace. The economics of health is a curious discipline, somewhat reminiscent of the theology of indulgences which flourished before Luther. You can count what the friars collect, you can look at the temples they build, you can take part in the liturgies they indulge in, but you can only guess what the traffic in remission from purgatory does to the soul after death. Models developed to account for the willingness of taxpayers to foot rising medical bills constitute similar scholastic guesswork about the new world-spanning church of medicine. To give an example: it is possible to view health as durable capital stock used to produce an output called “healthy time.” Individuals inherit an initial stock, which can be increased by investment in health capitalization through the acquisition of medical care, or through good diet and housing. “Healthy time”is an article in demand for two reasons. As a consumer commodity, it directly enters into the individual's utility function; people usually would rather be healthy than sick. It also enters the market as an investment commodity. In this function, “healthy time” determines the amount of time an individual can spend on work and on play, on earning and on recreation. The individual's “healthy time” can thus be viewed as a decisive indicator of his value to the community as a producer.
Orientation on policy and theories on the dollar value of “health” production divide the adherents of squabbling academic factions much as realism and nominalism divided medieval divines. But to the point that concerns the consumer, they just state in a roundabout way what every Mexican bricklayer knows: only on those days when he is healthy enough to work can he bring beans and tortillas to his children and have a tequila with his friends. The belief in a causal relationship between doctor's bills and health — which would otherwise be called modernized superstition — is a basic technical assumption for the medical economist.
Different systems have been used to legitimize the economic value of the specific activities in which physicians engage. Socialist nations assume the financing of all care and leave it to the medical profession to define what is needed, how it must be done, who may do it, what it should cost, and who shall get it. More brazenly than elsewhere, input/output calculations of such investments in human capital seem to determine Russian allocations. Most welfare states intervene with laws and incentives in the organization of their health-care markets, although only the United States has launched a national legislative program under which committees of producers determine what outputs offered on the “free market” the state shall approve as “good care.” In late 1973 President Nixon signed Public Law 92-603 establishing mandatory cost and quality controls (by Professional Standard Review Organizations) for Medicaid and Medicare, the tax-supported sector of the health- care industry, which since 1970 has been second in size only to the military- industrial complex. Harsh financial sanctions threaten physicians who refuse to open their files to government inspectors searching for evidence of over-utilization of hospitals, fraud, or deficient treatment. The law requires the medical profession to establish guidelines for the diagnosis and treatment of a long list of injuries, illnesses, and health conditions, mandating the world's most costly program for the medicalization of health, production through legislated consumer protection. The new law guarantees the standard set by industry for the commodity. It does not ask if its delivery is positively or negatively related to the health of people.
Attempts to exercise rational political control over the production of medical health care have consistently failed. The reason lies in the nature of the product now called “medicine,” a package made up of chemicals, apparatus, buildings, and specialists, and delivered to the client. The purveyor rather than his clients or political boss determines the size of the package. The patient is reduced to an object — his body — being repaired; he is no longer a subject being helped to heal. If he is allowed to participate in the repair process, he acts as the lowest apprentice in a hierarchy of repairmen. Often he is not even trusted to take a pill without the supervision of a nurse.
The argument that institutional health care (remedial or preventive) ceases after a certain point to correlate with any further “gains” in health can be misused for transforming clients hooked on doctors into clients of some other service hegemony: nursing homes, social workers vocational counselors, schools. What started out as a defense of consumers against inadequate medical service, will, first, provide the medical profession with assurance of continued demand and then with the power to delegate some of these services to other industrial branches: to the producers of foods, mattresses, vacations, or training. Consumer protection thus turns quickly into a crusade to transform independent people into clients at all cost.
Unless it disabuses the client of his urge to demand and take more services, consumer protection only reinforces the collusion between giver and taker, and can play only a tactical and a transitory role in any political movement aimed at the health-oriented limitation of medicine. Consumer-protection movements can translate information about medical ineffectiveness now buried in medical journals into the language of politics, but they can make substantive contributions only if they develop into defense leagues for civil liberties and move beyond the control of quality and cost into the defense of untutored freedom to take or leave the goods. Any kind of dependence soon turns into an obstacle to autonomous mutual care, coping, adapting, and healing, and what is worse, into a device by which people are stopped from transforming the conditions at work and at home that make them sick. Control over the production side of the medical complex can work towards better health only if it leads to at least a very sizable reduction of its total output, rather than simply to technical improvements in the wares that are offered.
Equal Access to Torts
The most common and obvious political issue related to health is based on the charge that access to medical care is inequitable, that it favors the rich over the poor, the influential over the powerless. While the level of medical services rendered to the members of technical elites does not vary significantly from one country to another, say from Sweden and Czechoslovakia to Indonesia and Senegal, the value of the services rendered to the typical citizen in different countries varies by factors exceeding the proportion of one to one thousand. In many poor countries, the few are socially predetermined to get much more than the majority, not so much because they are rich as because they are children of soldiers or bureaucrats or because they live close to the one large hospital. In rich countries members of different minorities are underprivileged, not because, in terms of money per capita, they necessarily get less than their share, but because they get substantially less than they have been trained to need. The slum dweller cannot reach the doctor when he needs him, and what is worse, the old, if they are poor and locked in a “home,” cannot get away from him. For these and similar reasons, political parties convert the desire for health into demands for equal access to medical facilities. They usually do not question the goods the medical system produces but insist that their constituents have a right to all that is produced for the privileged.
In the poor countries, the poor majorities clearly have less access to medical services than the rich: the services available to the few consume most of the health budget and deprive the majority of services of any kind. In all of Latin America, except Cuba, only one child in forty from the poorest fifth of the population finishes the five years of compulsory schooling; a similar proportion of the poor can expect hospital treatment if they become seriously ill. In Venezuela, one day in a hospital costs ten times the average daily income; in Bolivia, about forty times the average daily income. Everywhere in Latin America, the rich constitute the 3 percent of the population who are college graduates, labor leaders, political party officials, and members of families who have access to services either through money or simply through connections. These few receive costly treatment, often from the doctors of their choice. Most of the physicians, who come from the same social class as their patients, were trained to international standards on government grants.
Notwithstanding unequal access to hospital care, the availability of medical service does not inevitably correlate with personal income. In Mexico about 3 percent of the population has access to the Institute de Seguridad y Servicios Sociales de las Trabajadores del Estado (ISSSTE), that special part of the social security system which still holds a record for combining personal nursing care with advanced technological sophistication. This fortunate group is made up of government employees who receive truly equal treatment, whether they are ministers or office boys, and can count on high-quality care because they are part of a demonstration model. The newspapers, accordingly, inform the schoolmaster in a remote village that Mexican surgery is as well endowed as its counterpart in Chicago and that the surgeons who operate on him measure up to the standards of their colleagues in Houston. When high-level officials are hospitalized, they may be annoyed because for the first time in their lives they have to share a hospital room with a workman, but they are also proud of the high level of socialist commitment their nation shows in providing the same for boss and custodian. Both kinds of patient tend to overlook the fact that they are equally privileged exploiters. Providing the 3 percent with beds, equipment, administration, and technical care takes one-third of the public-health-care budget of the entire country. To be able to afford to give all of the poor equal access to medicine of uniform quality in poor countries, most of the present training and activity of the health professions would have to be discontinued. However, delivery of effective basic health services for the entire population is cheap enough to be bought for everyone, provided no one could get more, regardless of the social, economic, medical, or personal reasons advanced for special treatment. If priority were given to equity in poor countries and service limited to the basics of effective medicine, entire populations would be encouraged to share in the demedicalization of modern health care and to develop the skills and confidence for self-care, thus protecting their countries from social iatrogenic disease.
In the rich countries, the economics of health are somewhat different. At first sight, concern for the poor appears to demand further increases in the total health budget. Yet the more people come to depend on care by service institutions, the more difficult it is to identify equity with equal access and equal benefits. Is equity realized when equal numbers of dollars are available for the education of rich and poor? Or does it require that the poor get the same “education” although more will have to be spent on their account to achieve equal results? Or must the educational system, in order to be equitable, assure that the poor are not humiliated and hurt more than the rich with whom they compete on the academic ladder? Or is equity in learning opportunities provided only when all citizens share the same kind of learning environment? This battle of equity versus equality in the access to institutional care, already being waged in education, is now shaping up in the medical field. In contrast to education, however, the issue in health can easily be resolved on available evidence. The per capita expenditure on health care, even for the poorest sector within the United States population, indicates that the base line at which such care turns iatrogenic has long since been passed. In rich countries, the total budget of services for the poor, if used for that which reinforces self-care, is more than ample. More access, even though restricted to those who now receive less, would only equalize the delivery of professional illusions and torts.
There are two aspects to health: freedom and rights. Above all, health designates the range of autonomy within which a person exercises control over his own biological states and over the conditions of his immediate environment. In this sense, health is identical with the degree of lived freedom. Primarily the law ought to guarantee the equitable distribution of health as freedom, which, in turn, depends on environmental conditions that only organized political efforts can achieve. Beyond a certain level of intensity, health care, however equitably distributed, will smother health-as-freedom. In this fundamental sense, health care is a matter of well-ordered liberty. Implicit in this concept is a preferred position of inalienable freedoms to do certain things, and here civil liberty must be distinguished from civil rights. The liberty to act without restraint from government has a wider scope than the civil rights the state may enact to guarantee that people will have equal powers to obtain certain goods or services.
Civil liberties ordinarily do not force others to carry out my wishes; a person may publish his or her opinion freely as far as the government is concerned, but this does not imply a duty for any one newspaper to print that opinion. A person may need to drink wine in his kind of worship, but no mosque has to welcome him to do so within its walls. At the same time, the state as a guarantor of liberties can enact laws that protect equal rights without which its members would not enjoy their freedoms. Such rights give meaning to equality, while liberties give shape to freedom. One sure way to extinguish freedom to speak, to learn, or to heal is to delimit them by transmogrifying civil rights into civic duties. The freedoms of the self-taught will be abridged in an overeducated society just as the freedom to health care can be smothered by overmedicalization. Any sector of the economy can be so expanded that for the sake of more costly levels of equality, freedoms are extinguished.
We are concerned here with movements that try to remedy the effects of socially iatrogenic medicine through political and legal control of the management, allocation, and organization of medical activities. Insofar as medicine is a public utility, however, no reform can be effective unless it gives priority to two sets of limits. The first relates to the volume of institutional treatment any individual can claim: no person is to receive services so extensive that his treatment deprives others of an opportunity for considerably less costly care per capita if, in their judgment (and not just in the opinion of an expert), they make a request of comparable urgency for the same public resources. Conversely, no services are to be forcibly imposed on an individual against his will: no man, without his consent, shall be seized, imprisoned, hospitalized, treated, or otherwise molested in the name of health. The second set of limits relates to the medical enterprise as a whole. Here the idea of health-as-freedom has to restrict the total output of health services within subiatrogenic limits that maximize the synergy of autonomous and heteronomous modes of health production. In democratic societies, such limitations are probably unachievable without guarantees of equity — without equal access. In that sense, the politics of equity is probably an essential element of an effective program for health. Conversely, if concern with equity is not linked to constraints on total production, and if it is not used as a countervailing force to the expansion of institutional medical care, it will be futile.
Public Controls over the Professional Mafia
A third category of political remedies for unhealthy medicine focuses directly on how doctors do their work. Like consumer advocacy and legislation of access, this attempt to impose lay control on the medical organization has inevitable health- denying effects when it is changed from an ad hoc tactic into a general strategy.
Four and a half million men and women in two hundred occupations are employed in the production and delivery of medically approved health services in the United States. (Only 8 percent are physicians, whose net income after deductions for rent, personnel, and supplies represents 15 percent of total health expenditures and whose average income in 1973 was $50,000.) The total does not include osteopaths, chiropractors, and others who might have specialized university training and require a license to practice, but who, unlike pharmacists, optometrists, laboratory technicians, and similar physicians' underlings, do not produce health care of the same prestige. Even further removed from the establishment, and therefore excluded from these statistics, are thousands of purveyors of nonconventional health care, ranging from mail-order herbalists and masseurs to teachers of yoga.
Of the many claimants to competence who are more or less integrated into the official establishment, about thirty categories are licensed in the United States. In no state of the union is a license required for fewer than fourteen kinds of practitioners. These licenses are issued on completion of formal educational programs and sometimes on the evidence of a successful examination; in rare instances, proficiency or experience is a prerequisite for admission to independent practice. Competent or successful work is nowhere a condition for continuing in practice. Renewal is automatic, usually upon payment of a fee; only fifteen out of fifty states permit a physician's license to be challenged on grounds of incompetence. While claims to specialist standing come and go on the fringes, the specialties recognized by the American Medical Association have steadily increased, doubling in the last fifteen years: half the practicing American physicians are specialists in one of sixty categories, and the proportion is expected to increase to 55 percent before 1980. Within each of these fields a fiefdom has developed with specialized nurses, technicians, journals, congresses, and sometimes organized groups of patients pressing for more public funds. The cost of coordinating the treatment of the same patient by several specialists grows exponentially with each added competence, as does the risk of mistakes and the probability of damage due to the unexpected combination of different therapies. As the number of patient relationships outgrows the elements in the total population, the occupations dealing with medical information, insurance, and patient defense multiply unchecked. Of course, physicians lord it over these fiefs and determine what work these pseudo- professions shall do. But with the recognition of some autonomy many of these specialized groups of medical pages, ushers, footmen, and squires have also gained some power to evaluate how well they do their own work. By gaining the right to self-evaluation according to special criteria that fit its own view of reality, each new specialty generates for society at large a new impediment to evaluating what its work actually contributes to the health of patients. Organized medicine has practically ceased to be the art of healing the curable, and consoling the hopeless has turned into a grotesque priesthood concerned with salvation and has become a law unto itself. The policies that promise the public some control over the medical endeavor tend to overlook the fact that to achieve their purpose they must control a church, not an industry.
Dozens of concrete strategies are now being discussed and proposed to make the health industry more health-serving and less self-serving: decentralization of delivery; universal public insurance; group practice by specialists; health- maintenance programs rather than sick-care; payment of a fixed amount per patient per year (capitation) rather than fee-for-service; elimination of present restrictions on the use of health manpower; more rational organization and utilization of the hospital system; replacement of the licensing of individuals by the licensing of institutions held to performance standards; and the organization of patient cooperatives to balance or support a professional medical power.
Each of these proposals would indeed improve medical efficiency, but at the cost of a further decline in society's effective health care. To increase efficiency by upward mobility of personnel and downward assignment of responsibility could not but tighten the integration of the medical-care industry and with it social polarization.
As the training of middle-level professionals becomes more expensive, nursing personnel in the lower ranks is becoming scarce. Poor salaries, growing disdain for servant and housekeeping roles, an increase in chronic patients (and consequent growing tedium in their care), disappearance of the religious motivation for nuns and deacons, and new opportunities for women in other fields all contribute to a manpower crisis. In England nearly two-thirds of all low-level hospital personnel come from overseas, usually from former colonies; in Germany, from Turkey and Yugoslavia; in France, from North Africa; in the United States, from racial minorities. The creation of new ranks, titles, curricula, roles, and specialties at the bottom level is a doubtfully effective remedy. The hospital only reflects the labor economy of a high-technology society: transnational specialization on the top, bureaucracies in the middle, and at the bottom, a new subproletariat made up of migrants and the professionalized client.76
The multiplication of paraprofessional specialists further decreases what the diagnostician does for the person who seeks his help, while the multiplication of generalist auxiliaries tends to reduce what uncertified people may do for each other or for themselves. Institutional licensing would indeed permit a more efficient deployment of personnel, a more rational health-manpower mix, and greater opportunity for advancement: it would no doubt greatly improve the delivery of medical staples such as dental work, bonesetting, and the delivery of babies. But if it became the model for over-all health care, it would be equivalent to the creation of a medical Ma Bell. Lay control over an expanding medical technocracy is not unlike the professionalization of the patient: both enhance medical power and increase its nocebo effect. As long as the public bows to the professional monopoly in assigning the sick-role, it cannot control hidden health hierarchies that multiply patients. The medical clergy can be controlled only if the law is used to restrict and disestablish its monopoly on deciding what constitutes disease, who is sick, and what ought to be done to him or her.
Misdirection of blame for iatrogenesis is the most serious political obstacle to public control over health care. To turn doctor-baiting into radical chic would be the surest way to defuse any political crisis fueled by the new health consciousness. If physicians were to become conspicuous scapegoats, the gullible patient would be relieved from blame for his therapeutic greed. School-baiting did save the institutional enterprise when crisis last hit in education. The same strategy could now save the medical system and keep it essentially as it is.
Quite suddenly in the 1970s the schools lost their status as sacred cows. Driven by Sputnik, racial conflict, and new frontiers, the school bubble had outgrown all nonmilitary budgets and had burst. For a short while, the hidden curriculum of the school system lay exposed. It became conventional wisdom that after a certain point in its expansion, the school system inevitably reproduces a meritocratic class society and neatly arranges people according to levels of highly specialized torpor for which they are trained in graded, age-specific, competitive, and compulsory rituals. Frustration of an expensive dream had led many people to grasp that no amount of compulsory learning could equitably prepare the young for industrial hierarchies, and that all effective preparation of children for an inhuman socio-economic system
constituted systematic aggression against their persons. At this point a new vision of reality could have grown into a radical revolt against a capital-intensive system of production and the beliefs that bolster it. But instead of blaming the hubris of pedagogues, the public conceded to pedagogues more power to do precisely as they pleased. Disgruntled teachers focused criticism on their peers, the methods, the organization of schooling, and the financing of institutions, all of which were defined as obstacles to effective education.
School-baiting enabled liberal schoolmasters to mutate into a new breed of adult educators. School-baiting not only saved but — momentarily — upgraded the salary and prestige of the teacher. Whereas before the crisis point the schoolmaster had been restricted in his pedagogical aggression to an age-specific group below sixteen years of age, which was exposed to him during class hours in the school building to be initiated into a limited number of subjects, the new knowledge-merchant now considers the world his classroom. While the curricular teacher could disqualify only those nonstudents who dared to learn a curricular matter on their own, the new manager of lifelong and recurrent “education,” “conscientization,” “sensitivity training,” or “politicization” presumes to degrade in the eyes of the public any behavioral patterns that he has not approved. The school-baiting of the sixties could easily set the pattern for the coming medical war. Following the lead of the teachers who declare that the world is their classroom, some chic crusading physicians now jump onto the bandwagon of medicine-baiting and channel public frustration and anger at curative medicine into a call for a new elite of scientific guardians who would control the world as their ward.
The Scientific Organization—of Life
Belief in medicine as an applied science generates a fourth kind of countermeasure to iatrogenesis which inevitably increases the irresponsible power of the health profession — and thereby the damage medicine does. The proponents of higher scientific standards in medical research and social organization argue that pathogenic medicine is due to the overwhelming number of bad doctors let loose on society. Fewer decision-makers, more carefully screened, better trained, more tightly supervised by their peers, and more effectively in command over what is done for whom and how, would ensure that the powerful resources now available to medical scientists would be applied for the benefit of the people. Such idolatry of science overlooks the fact that research conducted as if medicine were an ordinary science, diagnosis conducted as if patients were specific cases and not autonomous persons, and therapy conducted by hygienic engineers are the three approaches which coalesce into the present endemic health-denial.
As a science, medicine lies on a borderline. Scientific method provides for experiments conducted on models. Medicine, however, experiments not on models but on the subjects themselves. But medicine tells us as much about the meaningful performance of healing, suffering, and dying as chemical analysis tells us about the aesthetic value of pottery.
In the pursuit of applied science the medical profession has largely ceased to strive towards the goals of an association of artisans who use tradition, experience, learning, and intuition, and has come to play a role reserved to ministers of religion, using scientific principles as its theology and technologists as acolytes. As an enterprise, medicine is now concerned less with the empirical art of healing the curable and much more with the rational approach to the salvation of mankind from attack by illness, from the shackles of impairment, and even from the necessity of death. By turning from art to science, the body of physicians has lost the traits of a guild of craftsmen applying rules established to guide the masters of a practical art for the benefit of actual sick persons. It has become an orthodox apparatus of bureaucratic administrators who apply scientific principles and methods to whole categories of medical cases. In other words, the clinic has turned into a laboratory. By claiming predictable outcomes without considering the human performance of the healing person and his integration in his own social group, the modern physician has assumed the traditional posture of the quack.
As a member of the medical profession the individual physician is an inextricable part of a scientific team. Experiment is the method of science, and the records he keeps — if he likes it or not — are part of the data for a scientific enterprise. Each treatment is one more repetition of an experiment with a statistically known probability of success. As in any operation that constitutes a genuine application of science, failure is said to be due to some sort of ignorance: insufficient knowledge of the laws that apply in the particular experimental situation, a lack of personal competence in the application of method and principles on the part of the experimenter, or else his inability to control that elusive variable which is the patient himself. Obviously, the better the patient can be controlled, the more predictable will be the outcome in this kind of medical endeavor. And the more predictable the outcome on a population basis, the more effective will the organization appear to be. The technocrats of medicine tend to promote the interests of science rather than the needs of society. The practitioners corporately constitute a research bureaucracy. Their primary responsibility is to science in the abstract or, in a nebulous way, to their profession. Their personal responsibility for the particular client has been resorbed into a vague sense of power extending over all tasks and clients of all colleagues. Medical science applied by medical scientists provides the correct treatment, regardless of whether it results in a cure, or death sets in, or there is no reaction on the part of the patient. It is legitimized by statistical tables, which predict all three outcomes with a certain frequency. The individual physician in a concrete case may still remember that he owes nature and the patient as much gratitude as the patient owes him if he has been successful in the use of his art. But only a high level of tolerance for cognitive dissonance will allow him to carry on in the divergent roles of healer and scientist.
The proposals that seek to counter iatrogenesis by eliminating the last vestiges of empiricism from the encounter between the patient and the medical system are latter-day crusaders of an inquisitorial kind. They use the religion of scientism to devalue political judgment. While operational verification in the laboratory is the measure of science, the contest of adversaries appealing to a jury that applies past experience to a present issue, as this issue is experienced by actual persons, constitutes the measure of politics. By denying public recognition to entities that cannot be measured by science, the call for pure, orthodox, confirmed medical practice shields this practice from all political evaluation.
The religious preference given to scientific language over the language of the layman is one of the major bulwarks of professional privilege. The imposition of this specialized language upon political discourse about medicine easily voids it of effectiveness.
The deprofessionalization of medicine does not imply the proscription of technical language any more than it calls for the exclusion of genuine competence, nor does it oppose public scrutiny and exposure of malpractice. But it does imply a bias against the mystification of the public, against the mutual accreditation of self-appointed healers, against the public support of a medical guild and of its institutions, and against the legal discrimination by, and on behalf of, people whom individuals or communities choose and appoint as their healers. The deprofessionalization of medicine does not mean denial of public funds for curative purposes, but it does mean a bias against the disbursement of any such funds under the prescription or control of guild members. It does not mean the abolition of modern medicine. It means that no professional shall have the power to lavish on any one of his patients a package of curative resources larger than that which any other could claim for his own. Finally, it does not mean disregard for the special needs that people manifest at special moments in their lives: when they are born, break a leg, become crippled, or face death. The proposal that doctors not be licensed by an in-group does not mean that their services shall not be evaluated, but rather that this evaluation can be done more effectively by informed clients than by their own peers. Refusal of direct funding to the more costly technical devices of medical magic does not mean that the state shall not protect individual people against exploitation by ministers of medical cults; it means only that tax funds shall not be used to establish any such rituals. Deprofessionalization of medicine means the unmasking of the myth according to which technical progress demands the solution of human problems by the application of scientific principles, the myth of benefit through an increase in the specialization of labor, through multiplication of arcane manipulations, and the myth that increasing dependence of people on the right of access to impersonal institutions is better than trust in one another.
Engineering for a Plastic Womb
So far I have dealt with four categories of criticism directed at the institutional structure of the medical-industrial complex. Each gives rise to a specific kind of political demand, and all of them become reinforcements for the dependence of people on medical bureaucracies because they deal with health care as a form of therapeutic planning and engineering. They indicate strategies for surgical, chemical, and behavioral intervention in the lives of sick people or people threatened with sickness. A fifth category of criticism rejects these objectives. Without relinquishing the view of medicine as an engineering endeavor, these critics assert that medical strategies fail because they concentrate too much effort on sickness and too little on changing the environment that makes people sick.
Most research on alternatives to clinical intervention is directed towards program engineering for the professional systems of man's social, psychological, and physical environment. “Non-health-service health determinants” are largely concerned with planned intervention in the milieu. Therapeutic engineers shift the thrust of their interventions from the potential or actual patient towards the larger system of which he is imagined to be a part. Instead of manipulating the sick, they redesign the environment to ensure a healthier population.
Health care as environmental hygienic engineering works within categories different from those of the clinical scientist. Its focus is survival rather than health in its opposition to disease; the impact of stress on populations and individuals rather than the performance of specific persons; the relationship of a niche in the cosmos to the human species with which it has evolved rather than the relationship between the aims of actual people and their ability to achieve them.
In general, people are more the product of their environment than of their genetic endowment. This environment is being rapidly distorted by industrialization. Although man has so far shown an extraordinary capacity for adaptation, he has survived with very high levels of sublethal breakdown. Dubos fears that mankind will be able to adapt to the stresses of the second industrial revolution and overpopulation just as it survived famines, plagues, and wars in the past. He speaks of this kind of survival with fear because adaptability, which is an asset for survival, is also a heavy handicap: the most common causes of disease are exacting adaptive demands. The health-care system, without any concern for the feelings of people and for their health, simply concentrates on the engineering of systems that minimize breakdowns.
Two foreseeable and sinister consequences of a shift from patient-oriented to milieu-oriented medicine are the loss of the sense of boundaries between distinct categories of deviance, and a new legitimacy for total treatment. Medical care, industrial safety, health education, and psychic reconditioning are all different names for the human engineering needed to fit populations into engineering systems. As the health-delivery system continually fails to meet the demands made upon it, conditions now classified as illness may soon develop into aspects of criminal deviance and asocial behavior. The behavioral therapy used on convicts in the United States and the Soviet Union's incarceration of political adversaries in mental hospitals indicate the direction in which the integration of therapeutic professions might lead: an increased blurring of boundaries between therapies administered with a medical, educational, or ideological rationale.
The time has come not only for public assessment of medicine but also for public disenchantment with those monsters generated by the dream of environmental engineering. If contemporary medicine aims at making it unnecessary for people to feel or to heal, eco-medicine promises to meet their alienated desire for a plastic womb.
8 – The Recovery of Health
Much suffering has been man-made. The history of man is one long catalogue of enslavement and exploitation, usually told in the epics of conquerors or sung in the elegies of their victims. War is at the heart of this tale, war and the pillage, famine, and pestilence that came in its wake. But it was not until modern times that the unwanted physical, social, and psychological side-effects of so-called peaceful enterprises began to compete with war in destructive power.
Man is the only animal whose evolution has been conditioned by adaptation on more than one front. If he did not succumb to predators and forces of nature, he had to cope with use and abuse by others of his own kind. In his struggle with the elements and with his neighbor, his character and culture were formed, his instincts withered, and his territory was turned into a home.
Animals adapt through evolution in response to changes in their natural environment. Only in man does challenge become conscious and the response to difficult and threatening situations take the form of rational action and of conscious habit. Man can design his relations to nature and neighbor, and he is able to survive even when his enterprise has partly failed. He is the animal that can endure trials with patience and learn by understanding them. He is the sole being who can and must resign himself to limits when he becomes aware of them. A conscious response to painful sensations, to impairment, and to eventual death is part of man's coping ability. The capacity for revolt and for perseverance, for stubborn resistance and for resignation, are integral parts of human life and health.
But nature and neighbor are only two of the three frontiers on which man must cope. A third front where doom can threaten has always been recognized. To remain viable, man must also survive the dreams which so far myth has both shaped and controlled. Now society must develop programs to cope with the irrational desires of its most gifted members. To date, myth has fulfilled the function of setting limits to the materialization of greedy, envious, murderous dreams. Myth assured the common man of his safety on this third frontier if he kept within its bounds. Myth guaranteed disaster to those few who tried to outwit the gods. The common man perished from infirmity or from violence; only the rebel against the human condition fell prey to Nemesis, the envy of the gods.
Prometheus was hero, not Everyman. Driven by radical greed (pleonexia), he trespassed beyond the limits of man (aitia and mesotes) and in unbounded presumption (hubris) stole fire from heaven. He thus inevitably brought Nemesis on himself. He was put into irons and chained to a Caucasian rock. An eagle preyed all day on his liver, and heartlessly healing gods kept him alive by regrafting his liver each night. Nemesis inflicted on him a kind of pain meant for demigods, not for men. His hopeless and unending suffering turned the hero into an immortal reminder of inescapable cosmic retaliation.
The social nature of nemesis has now changed. With the industrialization of desire and the engineering of corresponding ritual responses, hubris has spread. Unbounded material progress has become Everyman's goal. Industrial hubris has destroyed the mythical framework of limits to irrational fantasies, has made technical answers to mad dreams seem rational, and has turned the pursuit of destructive values into a conspiracy between purveyor and client. Nemesis for the masses is now the inescapable backlash of industrial progress. Modern nemesis is the material monster born from the overarching industrial dream. It has spread as far and as wide as universal schooling, mass transportation, industrial wage labor, and the medicalization of health.
Inherited myths have ceased to provide limits for action. If the species is to survive the loss of its traditional myths, it must learn to cope rationally and politically with its envious, greedy, and lazy dreams. Myth alone can do the job no more. Politically established limits to industrial growth will have to take the place of mythological boundaries. Political exploration and recognition of the necessary material conditions for survival, equity, and effectiveness will have to set limits to the industrial mode of production.
Nemesis has become structural and endemic. Increasingly, man-made misery is the by-product of enterprises that were supposed to protect ordinary people in their struggle with the inclemency of the environment and against the wanton injustice inflicted on them by the elite.
The main source of pain, of disability, and of death is now engineered, albeit nonintentional, harassment. Our prevailing ailments, helplessness, and injustice are largely the side-effects of strategies for more and better education, better housing, a better diet, and better health.
A society that values planned teaching above autonomous learning cannot but teach man to keep his engineered place. A society that relies for locomotion on managed transport must do the same. Beyond a certain level, energy used for transportation immobilizes and enslaves the majority of nameless passengers and provides advantages only for the elite. No new fuel, technology, or public controls can keep the rising mobilization and acceleration of society from producing rising harriedness, programmed paralysis, and inequality. The same is true for agriculture. Beyond a certain level of capital investment in the growing and processing of food, malnutrition will become pervasive. The results of the Green Revolution will then rack the livers of consumers more thoroughly than Zeus's eagle. No biological engineering can prevent undernourishment and food poisoning beyond this point. What is happening in the sub-Saharan Sahel is only a dress rehearsal for encroaching world famine. This is but the application of a general law: When more than a certain proportion of value is produced by the industrial mode, subsistence activities are paralyzed, equity declines, and total satisfaction diminishes. It will not be the sporadic famine that formerly came with drought and war, or the occasional food shortage that could be remedied by good will and emergency shipments. The coming hunger is a by-product of the inevitable concentration of industrialized agriculture in rich countries and in the fertile regions of poor countries. Paradoxically, the attempt to counter famine by further increases in industrially efficient agriculture only widens the scope of the catastrophe by depressing the use of marginal lands. Famine will increase until the trend towards capital-intensive food production by the poor for the rich has been replaced by a new kind of labor-intensive, regional, rural autonomy. Beyond a certain level of industrial hubris, nemesis must set in, because progress, like the broom of the sorcerer's apprentice, can no longer be turned off.
Defenders of industrial progress are either blind or corrupt if they pretend that they can calculate the price of progress. The torts resulting from nemesis cannot be compensated, calculated, or liquidated. The down-payment for industrial development might seem reasonable, but the compound-interest installments on expanding production now accrue in suffering beyond any measure or price. When members of a society are regularly asked to pay an even higher price for industrially defined necessities — in spite of evidence that they are purchasing more suffering with each unit — Homo economicus, driven by the pursuit of marginal benefits, turns into Homo religiosus, sacrificing himself to industrial ideology. At this point, social behavior begins to resemble that of the drug addict. Expectations become irrational and nightmarish. The self-inflicted portion of suffering outweighs the damage done by nature and all the torts inflicted by neighbors. Hubris motivates self-destructive mass behavior. Classical nemesis was the punishment for the rash abuse of privilege. Industrial nemesis is the retribution for dutiful participation in the technical pursuit of dreams unchecked by traditional mythology or rational self- restraint.
War and hunger, pestilence and natural catastrophes, torture and madness remain man's companions, but they are now shaped into a new Gestalt by the nemesis that overtakes them. The greater the economic progress of any community, the greater the part played by industrial nemesis in pain, impairment, discrimination, and death.
The more intense the reliance on techniques making for dependence, the higher the rate of waste, degradation, and pathogenesis which must be countered by yet other techniques and the larger the work force active in the removal of garbage, in the management of waste, and in the treatment of people made literally redundant by progress.
Reactions to impending disaster still take the form of better educational curricula, more health-maintenance services, or more efficient and less polluting energy transformers, and solutions are still sought in better engineering of industrial systems. The syndrome corresponding to nemesis is recognized, but its etiology is still sought in bad engineering compounded by self-serving management, whether under the control of Wall Street or of The Party. Nemesis is not yet recognized as the materialization of a social answer to a profoundly mistaken ideology, nor is it yet understood as a rampant delusion fostered by the nontechnical, ritual structure of our major industrial institutions. Just as Galileo's contemporaries refused to look through the telescope at Jupiter's moons because they feared that their geocentric world-view would be shaken, so our contemporaries refuse to face nemesis because they feel incapable of putting the autonomous rather than the industrial mode of production at the center of their sociopolitical constructs.
From Inherited Myth to Respectful Procedure
Primitive people have always recognized the power of a symbolic dimension; they have seen themselves as threatened by the tremendous, the awesome, the uncanny. This dimension set boundaries not only to the power of the king and the magician, but also to that of the artisan and the technician. Malinowski claims that only industrial society has allowed the use of available tools to their utmost efficiency; in all other societies, recognizing sacred limits to the use of sword and of plow was a necessary foundation for ethics. Now, after several generations of licentious technology, the finiteness of nature intrudes again upon our consciousness. The limits of the universe are subject to operational probings. Yet at this moment of crisis it would be foolish to found the limits of human actions on some substantive ecological ideology which would modernize the mythic sacredness of nature. The engineering of an eco-religion would be a caricature of traditional hubris. Only a widespread agreement on the procedures through which the autonomy of postindustrial man can be equitably guaranteed will lead to the recognition of the necessary limits to human action.
Common to all ethics is the assumption that the human act is performed within the human condition. Since the various ethical systems assumed, tacitly or explicitly, that this human condition was more or less given, once and for all, the range of human action was narrowly circumscribed.
In our industrialized epoch, however, not only the object but also the very nature of human action is new. Instead of facing gods we confront the blind forces of nature, and instead of facing the dynamic limits of a universe we have now come to know, we act as if these limits did not translate into critical thresholds for human action. Traditionally the categorical imperative could circumscribe and validate action as being truly human. Directly enjoining limits to one's actions, it demanded respect for the equal freedom of others. The loss of a normative “human condition“ introduces a newness not only into the human act but also into the human attitude towards the framework in which a person acts. If this action is to remain human after the framework has been deprived of its sacred character, it needs a recognized ethical foundation within a new imperative. This imperative can be summed up only as follows: “Act so that the effect of your action is compatible with the permanence of genuine human life.” Very concretely applied, this could mean: “Do not raise radiation levels unless you know that this action will not be visited upon your grandchild.” Such an imperative obviously cannot be formulated as long as “genuine human life” is considered an infinitely elastic concept.
Is it possible, without restoring the category of the sacred, to attain the ethics that alone would enable mankind to accept the rigorous discipline of this new imperative? If not, rationalizations could be created for any atrocity: “Why should background radiation not be raised? Our grandchildren will get used to it!” In some instances, fear might help preserve minimal sanity, but only when consequences were fairly imminent. Breeder reactors might not be made operational for fear that they would serve the Mafia for next year's extortions or cause cancer before the operator died. But only the awe of the sacred, with its unqualified veto, has so far proved independent of the computations of mundane self-interest and the solace of uncertainty about remote consequences. This could be reinvoked as an imperative that genuine human life deserves respect both now and in the future. This recourse to the sacred, however, has been blocked in our present crisis. Recourse to faith provides an escape for those who believe, but it cannot be the foundation for an ethical imperative, because faith is either there or not there; if it is absent, the faithful cannot blame the infidel. Recent history has shown that the taboos of traditional cultures are irrelevant in combatting an overextension of industrial production. The taboos were tied to the values of a particular society and its mode of production, and it is precisely those that were irrevocably lost in the process of industrialization.
It is not necessary, probably not feasible, and certainly not desirable to base the limitation of industrial societies on a shared system of substantive beliefs aiming at the common good and enforced by the power of the police. It is possible to find the needed basis for ethical human action without depending on the shared recognition of any ecological dogmatism now in vogue. This alternative to a new ecological religion or ideology is based on an agreement about basic values and on procedural rules.
It can be demonstrated that beyond a certain point in the expansion of industrial production in any major field of value, marginal utilities cease to be equitably distributed and over-all effectiveness begins, simultaneously, to decline. If the industrial mode of production expands beyond a certain stage and continues to impinge on the autonomous mode, increased personal suffering and social dissolution set in. In the interim — between the point of optimal synergy between industrial and autonomous production and the point of maximum tolerable industrial hegemony — political and juridical procedures become necessary to reverse industrial expansion. If these procedures are conducted in a spirit of enlightened self-interest and a desire for survival, and with equitable distribution of social outputs and equitable access to social control, the outcome ought to be a recognition of the carrying capacity of the environment and of the optimal industrial complement to autonomous action needed for the effective pursuit of personal goals. Political procedures oriented to the value of survival in distributive and participatory equity are the only possible rational answer to increasing total management in the name of ecology.
The recovery of personal autonomy will thus be the result of political action reinforcing an ethical awakening. People will want to limit transportation because they want to move efficiently, freely, and with equity; they will limit schooling because they want to share equally the opportunity, time, and motivation to learn in rather than about the world; people will limit medical therapies because they want to conserve their opportunity and power to heal. They will recognize that only the disciplined limitation of power can provide equitably shared satisfaction.
The recovery of autonomous action will depend, not on new specific goals people share, but on their use of legal and political procedures that permit individuals and groups to resolve conflicts arising from their pursuit of different goals. Better mobility will depend, not on some new kind of transportation system, but on conditions that make personal mobility under personal control more valuable. Better learning opportunities will depend, not on more information about the world better distributed, but on the limitation of capital-intensive production for the sake of interesting working conditions. Better health care will depend, not on some new therapeutic standard, but on the level of willingness and competence to engage in self-care. The recovery of this power depends on the recognition of our present delusions.
The Right to Health
Increasing and irreparable damage accompanies present industrial expansion in all sectors. In medicine this damage appears as iatrogenesis. Iatrogenesis is clinical when pain, sickness, and death result from medical care; it is social when health policies reinforce an industrial organization that generates ill-health; it is cultural and symbolic when medically sponsored behavior and delusions restrict the vital autonomy of people by undermining their competence in growing up, caring for each other, and aging, or when medical intervention cripples personal responses to pain, disability, impairment, anguish, and death.
Most of the remedies now proposed by the social engineers and economists to reduce iatrogenesis include a further increase of medical controls. These so-called remedies generate second-order iatrogenic ills on each of the three critical levels: they render clinical, social, and cultural iatrogenesis self-reinforcing.
The most profound iatrogenic effects of the medical technostructure are a result of those nontechnical functions which support the increasing institutionalization of values. The technical and the nontechnical consequences of institutional medicine coalesce and generate a new kind of suffering: anesthetized, impotent, and solitary survival in a world turned into a hospital ward. Medical nemesis is the experience of people who are largely deprived of any autonomous ability to cope with nature, neighbors, and dreams, and who are technically maintained within environmental, social, and symbolic systems. Medical nemesis cannot be measured, but its experience can be shared. The intensity with which it is experienced will depend on the independence, vitality, and relatedness of each individual.
The perception of nemesis leads to a choice. Either the natural boundaries of human endeavor are estimated, recognized, and translated into politically determined limits, or compulsory survival in a planned and engineered hell is accepted as the alternative to extinction. Until recently the choice between the politics of voluntary poverty and the hell of the systems engineer did not fit into the language of scientists or politicians. Our increasing confrontation with medical nemesis now lends new significance to the alternative: either society must choose the same stringent limits on the kind of goods produced within which all its members may find a guarantee for equal freedom, or society must accept unprecedented hierarchical controls to provide for each member what welfare bureaucracies diagnose as his or her needs.
In several nations the public is now ready for a review of its health-care system. Although there is a serious danger that the forthcoming debate will reinforce the present frustrating medicalization of life, the debate could still become fruitful if attention were focused on medical nemesis, if the recovery of personal responsibility for health care were made the central issue, and if limitations on professional monopolies were made the major goal of legislation. Instead of limiting the resources of doctors and of the institutions that employ them, such legislation would tax medical technology and professional activity until those means that can be handled by laymen were truly available to anyone wanting access to them. Instead of multiplying the specialists who can grant any one of a variety of sick- roles to people made ill by their work and their life, the new legislation would guarantee the right of people to drop out and to organize for a less destructive way of life in which they have more control of their environment. Instead of restricting access to addictive, dangerous, or useless drugs and procedures, such legislation would shift the full burden of their responsible use onto the sick person and his next of kin. Instead of submitting the physical and mental integrity of citizens to more and more wardens, such legislation would recognize each man's right to define his own health — subject only to limitations imposed by respect for his neighbor's rights. Instead of strengthening the licensing power of specialized peers and government agencies, new legislation would give the public a voice in the election of healers to tax-supported health jobs. Instead of submitting their performance to professional review organizations, new legislation would have them evaluated by the community they serve.
Health as a Virtue
Health designates a process of adaptation. It is not the result of instinct, but of an autonomous yet culturally shaped reaction to socially created reality. It designates the ability to adapt to changing environments, to growing up and to aging, to healing when damaged, to suffering, and to the peaceful expectation of death. Health embraces the future as well, and therefore includes anguish and the inner resources to live with it.
Health designates a process by which each person is responsible, but only in part responsible to others. To be responsible may mean two things. A man is responsible for what he has done, and responsible to another person or group. Only when he feels subjectively responsible or answerable to another person will the consequences of his failure be not criticism, censure, or punishment but regret, remorse, and true repentance. The consequent states of grief and distress are marks of recovery and healing, and are phenomenologically something entirely different from guilt feelings. Health is a task, and as such is not comparable to the physiological balance of beasts. Success in this personal task is in large part the result of the self-awareness, self-discipline, and inner resources by which each person regulates his own daily rhythm and actions, his diet, and his sexual activity. Knowledge encompassing desirable activities, competent performance, the commitment to enhance health in others — these are all learned from the example of peers or elders. These personal activities are shaped and conditioned by the culture in which the individual grows up: patterns of work and leisure, of celebration and sleep, of production and preparation of food and drink, of family relations and politics. Long-tested health patterns that fit a geographic area and a certain technical situation depend to a large extent on long-lasting political autonomy. They depend on the spread of responsibility for healthy habits and for the sociobiological environment. That is, they depend on the dynamic stability of a culture.
The level of public health corresponds to the degree to which the means and responsibility for coping with illness are distributed among the total population. This ability to cope can be enhanced but never replaced by medical intervention or by the hygienic characteristics of the environment. That society which can reduce professional intervention to the minimum will provide the best conditions for health. The greater the potential for autonomous adaptation to self, to others, and to the environment, the less management of adaptation will be needed or tolerated.
A world of optimal and widespread health is obviously a world of minimal and only occasional medical intervention. Healthy people are those who live in healthy homes on a healthy diet in an environment equally fit for birth, growth, work, healing, and dying; they are sustained by a culture that enhances the conscious acceptance of limits to population, of aging, of incomplete recovery and ever- imminent death. Healthy people need minimal bureaucratic interference to mate, give birth, share the human condition, and die.
Man's consciously lived fragility, individuality, and relatedness make the experience of pain, of sickness, and of death an integral part of his life. The ability to cope with this trio autonomously is fundamental to his health. As he becomes dependent on the management of his intimacy, he renounces his autonomy and his health must decline. The true miracle of modern medicine is diabolical. It consists in making not only individuals but whole populations survive on inhumanly low levels of personal health. Medical nemesis is the negative feedback of a social organization that set out to improve and equalize the opportunity for each man to cope in autonomy and ended by destroying it.