Medical Nemesis:
The Expropriation of Health


Ivan Illich

Cultural Iatrogenesis


We have dealt so far with two ways in which the predominance of medicalized health care becomes an obstacle to a healthy life: first, clinical iatrogenesis, which results when organic coping capacity is replaced by heteronomous management; and, second, social iatrogenesis, in which the environment is deprived of those conditions that endow individuals, families, and neighborhoods with control over their own internal states and over their milieu. Cultural iatrogenesis represents a third dimension of medical health-denial. It sets in when the medical enterprise saps the will of people to suffer their reality. It is a symptom of such iatrogenesis that the term "suffering" has become almost useless for designating a realistic human response because it evokes superstition, sadomasochism, or the rich man's condescension to the lot of the poor. Professionally organized medicine has come to function as a domineering moral enterprise that advertises industrial expansion as a war against all suffering. It has thereby undermined the ability of individuals to face their reality, to express their own values, and to accept inevitable and often irremediable pain and impairment, decline and death.

To be in good health means not only to be successful in coping with reality but also to enjoy the success; it means to be able to feel alive in pleasure and in pain; it means to cherish but also to risk survival. Health and suffering as experienced sensations are phenomena that distinguish men from beasts. Only storybook lions are said to suffer and only pets to merit compassion when they are in ill health.

Human health adds openness to instinctual performance. It is something more than a concrete behavior pattern in customs, usages, traditions, or habit-clusters. It implies performance according to a set of control mechanisms: plans, recipes, rules, and instructions, all of which govern personal behavior. To a large extent culture and health coincide. Each culture gives shape to a unique Gestalt of health and to a unique conformation of attitudes towards pain, disease, impairment, and death, each of which designates a class of that human performance that has traditionally been called the art of suffering.

Each person's health is a responsible performance in a social script. How he relates to the sweetness and the bitterness of reality and how he acts towards others whom he perceives as suffering, as weakened, or as anguished determine each person's sense of his own body, and with it, his health. Body-sense is experienced as an ever-renewed gift of culture. In Java people flatly say, “To be human is to be Javanese.” Small children, boors, simpletons, the insane, and the flagrantly immoral are said to be ndurung djawa (not yet Javanese). A “normal” adult capable  of acting in terms of the highly elaborate system of etiquette, possessed of the delicate aesthetic perceptions associated with music, dance, drama, and textile design, and responsive to the subtle promptings of the divine residing in the stillness of each individual's inward-turning consciousness is ampun djawa (already Javanese). To be human is not just to breathe; it is also to control one's breathing by yogalike techniques so as to hear in inhalation and exhalation the literal voice of God pronouncing his own name, hu Allah. Cultured health is bounded by each society's style in the art of living, feasting, suffering, and dying.

All traditional cultures derive their hygienic function from this ability to equip the individual with the means for making pain tolerable, sickness or impairment understandable, and the shadow of death meaningful. In such cultures health care is always a program for eating, drinking, working, breathing, loving, politicking, exercising, singing, dreaming, warring, and suffering.

Most healing is a traditional way of consoling, caring, and comforting people while they heal, and most sick-care a form of tolerance extended to the afflicted. Only those cultures survive that provide a viable code that is adapted to a group's genetic make-up, to its history, to its environment, and to the peculiar challenges represented by competing groups of neighbors.

The ideology promoted by contemporary cosmopolitan medical enterprise runs counter to these functions. It radically undermines the continuation of old cultural programs and prevents the emergence of new ones that would provide a pattern for self-care and suffering. Wherever in the world a culture is medicalized, the traditional framework for habits that can become conscious in the personal practice of the virtue of hygiene is progressively trammeled by a mechanical system, a medical code by which individuals submit to the instructions emanating from hygienic custodians. Medicalization constitutes a prolific bureaucratic program based on the denial of each man's need to deal with pain, sickness, and death. The modern medical enterprise represents an endeavor to do for people what their genetic and cultural heritage formerly equipped them to do for themselves. Medical civilization is planned and organized to kill pain, to eliminate sickness, and to abolish the need for an art of suffering and of dying. This progressive flattening out of personal, virtuous performance constitutes a new goal which has never before been a guideline for social life. Suffering, healing, and dying, which are essentially intransitive activities that culture taught each man, are now claimed by technocracy as new areas of policy-making and are treated as malfunctions from which populations ought to be institutionally relieved. The goals of metropolitan medical civilization are thus in opposition to every single cultural health program they encounter in the process of progressive colonization.

 3 -The Killing of Pain

When cosmopolitan medical civilization colonizes any traditional culture, it transforms the experience of pain. The same nervous stimulation that I shall call “pain sensation” will result in a distinct experience, depending not only on personality but also on culture. This experience, as distinct from the painful sensation, implies a uniquely human performance called suffering. Medical civilization, however, tends to turn pain into a technical matter and thereby deprives suffering of its inherent personal meaning. People unlearn the acceptance of suffering as an inevitable part of their conscious coping with reality and learn to interpret every ache as an indicator of their need for padding or pampering. Traditional cultures confront pain, impairment, and death by interpreting them as challenges soliciting a response from the individual under stress; medical civilization turns them into demands made by individuals on the economy, into problems that can be managed or produced out of existence. Cultures are systems of meanings, cosmopolitan civilization a system of techniques. Culture makes pain tolerable by integrating it into a meaningful setting; cosmopolitan civilization detaches pain from any subjective or intersubjective context in order to annihilate it. Culture makes pain tolerable by interpreting its necessity; only pain perceived as curable is intolerable.

A myriad virtues express the different aspects of fortitude that traditionally enabled people to recognize painful sensations as a challenge and to shape their own experience accordingly. Patience, forbearance, courage, resignation, self-control, perseverance, and meekness each express a different coloring of the responses with which pain sensations were accepted, transformed into the experience of suffering, and endured. Duty, love, fascination, routines, prayer, and compassion were some of the means that enabled pain to be borne with dignity. Traditional cultures made everyone responsible for his own performance under the impact of bodily harm or grief. Pain was recognized as an inevitable part of the subjective reality of one's own body in which everyone constantly finds himself, and which is constantly being shaped by his conscious reactions to it. People knew that they had to heal on their own, to deal on their own with their migraine, their lameness, or their grief.

The pain inflicted on individuals had a limiting effect on the abuses of man by man. Exploiting minorities sold liquor or preached religion to dull their victims, and slaves took to the blues or to coca-chewing. But beyond a critical point of exploitation, traditional economies which were built on the resources of the human body had to break down. Any society in which the intensity of discomforts and pains inflicted rendered them culturally "insufferable" could not but come to an end.

 Now an increasing portion of all pain is man-made, a side-effect of strategies for industrial expansion. Pain has ceased to be conceived as a “natural” or “metaphysical” evil. It is a social curse, and to stop the “masses” from cursing society when they are pain-stricken, the industrial system delivers them medical pain-killers. Pain thus turns into a demand for more drugs, hospitals, medical services, and other outputs of corporate, impersonal care and into political support for further corporate growth no matter what its human, social, or economic cost. Pain has become a political issue which gives rise to a snowballing demand on the part of anesthesia consumers for artificially induced insensibility, unawareness, and even unconsciousness.

Traditional cultures and technological civilization start from opposite assumptions. In every traditional culture the psychotherapy, belief systems, and drugs needed to withstand most pain are built into everyday behavior and reflect the conviction that reality is harsh and death inevitable. In the twentieth century dystopia, the necessity to bear painful reality, within or without, is interpreted as a failure of the socio-economic system, and pain is treated as an emergent contingency which must be dealt with by extraordinary interventions.

The experience of pain that results from pain messages received by the brain depends in its quality and in its quantity on genetic endowment and on at least four functional factors other than the nature and intensity of the stimulus: namely, culture, anxiety, attention, and interpretation. All these are shaped by social determinants, ideology, economic structure, and social character. Culture decrees whether the mother or the father or both must groan when the child is born. Circumstances and habits determine the anxiety level of the sufferer and the attention he gives to his bodily sensations. Training and conviction determine the meaning given to bodily sensations and influence the degree to which pain is experienced. Effective magic relief is often better provided by popular superstition than by high-class religion. The prospect which is opened by the painful event determines how well it will be suffered: injuries received near the climax of sex or that of heroic performance are frequently not even felt. Soldiers wounded on the Anzio Beachhead who hoped their wounds would get them out of the army and back home as heroes rejected morphine injections that they would have considered absolutely necessary if similar injuries had been inflicted by the dentist or in the operating theater.

As culture is medicalized, the social determinants of pain are distorted. Whereas culture recognizes pain as an intrinsic, intimate, and incommunicable “disvalue,” medical civilization focuses primarily on pain as a systemic reaction that can be verified, measured, and regulated. Only pain perceived by a third person from a distance constitutes a diagnosis that calls for specific treatment. This objectivization and quantification of pain goes so far that medical treatises speak of painful diseases, operations, or conditions even in cases where patients claim to be unaware of pain. Pain calls for methods of control by the physician rather than an approach that might help the person in pain take on responsibility for his experience. The medical profession judges which pains are authentic, which have a physical and which a psychic base, which are imagined, and which are simulated. Society recognizes and endorses this professional judgment. Compassion becomes an obsolete virtue. The person in pain is left with less and less social context to give meaning to the experience that often overwhelms him.

The history of medical perception of pain has not yet been written. A few learned monographs deal with the moments during the last 250 years in which the attitude of physicians towards pain changed, and some historical references can be found in papers dealing with contemporary attitudes towards pain. The existential school of anthropological medicine has gathered valuable insights into the development of modern pain while tracing the changes in bodily perception in a technological age. The relationship between the medical institutions and the anxiety suffered by their patients has been explored by psychiatrists and occasionally by general physicians. But the relationship of corporate medicine to bodily pain in its real sense is still virgin territory for research.

The historian of pain has to face three special problems. The first is the profound transformation undergone by the relationship of pain to the other ills man can suffer. Pain has changed its position in relation to grief, guilt, sin, anguish, fear, hunger, impairment, and discomfort. What we call pain in a surgical ward is something for which former generations had no special name. It now seems as if pain were only that part of human suffering over which the medical profession can claim competence or control. There is no historical precedent for the contemporary situation in which the experience of personal bodily pain is shaped by the therapeutic program designed to destroy it. The second problem is language. The technical matter which contemporary medicine designates by the term “pain” even today has no simple equivalent in ordinary speech. In most languages the term taken over by the doctors covers grief, sorrow, anguish, shame, and guilt. The English “pain” and the German “Schmerz” are still relatively easy to use in such a way that a mostly, though not exclusively, physical meaning is conveyed. Most Indo-Germanic synonyms cover a wider range of meaning: bodily pain may be designated as “hard work,” “toil,” or “trial,” as “torture,” “endurance,” “punishment,” or more generally, “affliction,” as “illness,” “tiredness,” “hunger,” “mourning,” “injury,” “distress,” “sadness,” “trouble,” “confusion,” or “oppression.” This litany is far from complete: it shows that language can distinguish many kinds of “evils,” all of which have a bodily reflection. In some languages bodily pain is outright “evil.” If a French doctor asks a typical Frenchman where he has pain, the patient will point to the spot and say, “J'ai mal la.” On the other hand, a Frenchman can say, “Je souffre dans toute ma chair,” and at the same time tell his doctor, “Je n'ai mal nulle part.” If the concept of bodily pain has undergone an evolution in medical usage, it cannot be grasped simply in the changing significance of any one term.
A third obstacle to any history of pain is its exceptional axiological and epistemological status. Nobody will ever understand "my pain" in the way I mean it, unless he suffers the same headache, which is impossible, because he is another person. In this sense “pain” means a breakdown of the clear-cut distinction between organism and environment, between stimulus and response. It does not mean a certain class of experience that allows you and me to compare our headaches; much less does it mean a certain physiological or medical entity, a clinical case with certain pathological signs. It is not “pain in the sternocleidomastoid” which is perceived as a systematic disvalue for the medical scientist.

The exceptional kind of disvalue that is pain promotes an exceptional kind of certainty. Just as “my pain” belongs in a unique way only to me, so I am utterly alone with it. I cannot share it. I have no doubt about the reality of the pain experience, but I cannot really tell anybody what I experience. I surmise that others have “their” pains, even though I cannot perceive what they mean when they tell me about them. I am certain about the existence of their pain only in the sense that I am certain of my compassion for them. And yet, the deeper my compassion, the deeper is my certitude about the other person's utter loneliness in relation to his experience. Indeed, I recognize the signs made by someone who is in pain, even when this experience is beyond my aid or comprehension. This awareness of extreme loneliness is a peculiarity of the compassion we feel for bodily pain; it also sets this experience apart from any other experience, from compassion for the anguished, sorrowful, aggrieved, alien, or crippled. In an extreme way, the sensation of bodily pain lacks the distance between cause and experience found in other forms of suffering.

Notwithstanding the inability to communicate bodily pain, perception of it in another is so fundamentally human that it cannot be put into parentheses. The patient cannot conceive that his doctor is unaware of his pain, any more than the man on the rack can conceive this about his torturer. The certainty that we share the experience of pain is of a very special kind, greater than the certainty that we share humanity with others. There have been people who have treated their slaves as chattels, yet recognized that this chattel was able to suffer pain. Slaves are more than dogs, who can be hurt but cannot suffer. Wittgenstein has shown that our special, radical certainty about the existence of pain in other people can coexist with an inextricable difficulty in explaining how this sharing of the unique can come about.

It is my thesis that bodily pain, experienced as an intrinsic, intimate, and incommunicable disvalue, includes in our awareness the social situation in which those who suffer find themselves. The character of the society shapes to some degree the personality of those who suffer and thus determines the way they experience their own physical aches and hurts as concrete pain. In this sense, it should be possible to investigate the progressive transformation of the pain experience that has accompanied the medicalization of society. The act of suffering pain always has a historical dimension.

When I suffer pain, I am aware that a question is being raised. The history of pain can best be studied by focusing on that question. No matter if the pain is my own experience or if I see the gestures of another telling me that he is in pain, a question mark is written into this perception. Such a query is as integral to physical pain as the loneliness. Pain is the sign for something not answered; it refers to something open, something that goes on the next moment to demand, What is wrong? How much longer? Why must I/ought I/should I/can I/ suffer? Why does this kind of evil exist, and why does it strike me? Observers who are blind to this referential aspect of pain are left with nothing but conditioned reflexes. They are studying a guinea pig, not a human being. A physician, were he able to erase this value-loaded question shining through a patient's complaints, might recognize pain as the symptom of a specific bodily disorder, but he would not come close to the suffering that drove the patient to seek help. The development of this capacity to objectify pain is one of the results of overintensive education for physicians. By his training the physician is often enabled to focus on those aspects of a person's bodily pain that are accessible to management by outsiders: the peripheral-nerve stimulation, the transmission, the reaction to the stimulus, or even the anxiety level of the patient. Concern is limited to the management of the systemic entity, which is the only matter open to operational verification.

The personal performance of suffering escapes such experimental control and is therefore neglected in most experiments that are conducted on pain. Animals are usually used to test the “pain-killing” effects of pharmacological or surgical interventions. Once the results of animal tests have been tabulated, their validity is verified in people. Painkillers usually give more or less comparable results in guinea pigs and humans, provided those humans are used as experimental subjects and under experimental conditions similar to those under which the animals were tested. As soon as the same interventions are applied to people who are actually sick or have been wounded, the effects of the drugs are completely out of line with those found in the experimental situation. In the laboratory people feel exactly like mice. When their own life becomes painful, they usually cannot help suffering, well or badly, even when they want to respond like mice.

Living in a society that values anesthesia, both doctors and their potential clients are retrained to smother pain's intrinsic question mark. The question raised by intimately experienced pain is transformed into a vague anxiety that can be submitted to treatment. Lobotomized patients provide the extreme example of this expropriation of pain: they “adjust at the level of domestic invalids or household pets.” The lobotomized person still perceives pain but he has lost the capacity to suffer from it; the experience of pain is reduced to a discomfort with a clinical name.

For an experience of pain to constitute suffering in the full sense, it must fit into a cultural framework. To enable individuals to transform bodily pain into a personal experience, any culture provides at least four interrelated subprograms: words, drugs, myths, and models. Pain is shaped by culture into a question that can be expressed in words, cries, and gestures, which are often recognized as desperate attempts to share the utter confused loneliness in which pain is experienced: Italians groan and Prussians grind their teeth.

Each culture also provides its own psychoactive pharmacopeia, with customs that designate the circumstances in which drugs may be taken and the accompanying ritual. Muslim Rayputs prefer alcohol and Brahmins marijuana, though they intermingle in the same villages of western India. Peyote is safe for Navajos and mushrooms for the Huicholes, while Peruvian highlanders have learned to survive with coca. Man has not only evolved with the ability to suffer his pain, but also with the skills to manage it: poppy growing during the middle Stone Age probably preceded the planting of grains. Massage, acupuncture, and analgesic incense were known from the dawn of history. Religious and mythic rationales for pain have appeared in all cultures: for the Muslims it is Kismet, god-willed destiny; for the Hindus, karma, a burden from past incarnation; for the Christians, a sanctifying backlash of sin. Finally, cultures always have provided an example on which behavior in pain could be modeled: the Buddha, the saint, the warrior, or the victim. The duty to suffer in their guise distracts attention from otherwise all-absorbing sensation and challenges the sufferer to bear torture with dignity. The cultural setting not only provides the grammar and technique, the myths and examples used in its characteristic “craft of suffering well,” but also the instructions on how to integrate this repertoire. The medicalization of pain, on the other hand, has fostered a hypertrophy of just one of these modes — management by technique — and reinforced the decay of the others. Above all, it has rendered either incomprehensible or shocking the idea that skill in the art of suffering might be the most effective and universally acceptable way of dealing with pain. Medicalization deprives any culture of the integration of its program for dealing with pain.

Society not only determines how doctor and patient meet, but also what each of them shall think, feel, and do about pain. As long as the doctor conceived of himself primarily as a healer, pain assumed the role of a step towards the restoration of health. Where the doctor could not heal, he felt no qualms about telling his patient to use analgesics and thus moderate inevitable suffering. Like Oliver Wendell Holmes, the good doctor who knew that nature provided better remedies for pain than medicine could say “[with the exception of] opium, which the Creator himself seems to prescribe, for we often see the scarlet poppy growing in the cornfields as if it were foreseen that wherever there is hunger to be fed there must also be pain to be soothed; [with the exception of] a few specifics which our doctor's art did not discover; [with the exception of] wine, which is a food, and the vapours which produce the miracle of anaesthesia . . . I firmly believe that if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind—and all the worse for the fishes.”

The ethos of the healer gave the physician the capacity for the same dignified failure for which religion, folklore, and free access to analgesics had trained the common man. The functionary of contemporary medicine is in a different position: his first orientation is treatment, not healing. He is geared, not to recognize the question marks that pain raises in him who suffers, but to degrade these pains into a list of complaints that can be collected in a dossier. He prides himself on the knowledge of pain mechanics and thus escapes the patient's invitation to compassion.

One source of European attitudes towards pain certainly lies in ancient Greece. The pupils of Hippocrates distinguished many kinds of disharmony, each of which caused its own kind of pain. Pain thus became a useful tool for diagnosis. It revealed to the physician which harmony the patient had to recover. Pain might disappear in the process of healing, but this was certainly not the primary object of the doctor's  treatment. Whereas the Chinese tried very early to treat sickness through the removal of pain, nothing of this sort was prominent in the classical West. The Greeks did not even think about enjoying happiness without taking pain in their stride. Pain was the soul's experience of evolution. The human body was part of an irreparably impaired universe, and the sentient soul of man postulated by Aristotle was fully coextensive with his body. In this scheme there was no need to distinguish between the sense and the experience of pain. The body had not yet been divorced from the soul, nor had sickness been divorced from pain. All words that indicated bodily pain were equally applicable to the suffering of the soul.

In view of that heritage, it would be a grave mistake to believe that resignation to pain is due exclusively to Jewish or Christian influence. Thirteen distinct Hebrew words were translated by a single Greek term for “pain” when two hundred Jews of the second century B.C. translated the Old Testament into Greek. Whether or not pain for the Jew was considered an instrument of divine punishment, it was always a curse. No suggestion of pain as a desirable experience can be found in the Scriptures or the Talmud. It is true that specific organs were affected by pain, but those organs were conceived of also as seats of very specific emotions; the category of modern medical pain is totally alien to the Hebrew text. In the New Testament, pain is considered to be intimately entwined with sin. While for the classical Greek pain had to accompany pleasure, for the Christian pain was a consequence of his commitment to joy. No culture or tradition holds a monopoly on realistic resignation.

The history of pain in European culture would have to trace more than these classical and Semitic roots to find the ideologies that supported personal acceptance of pain. For the Neo-Platonist, pain was interpreted as the result of some deficiency in the celestial hierarchy. For the Manichaean, it was the result of positive malpractice on the part of an evil demiurge or creator. For the Christian, it was the loss of original integrity produced by Adam's sin. But no matter how much these religions opposed each other on dogma and morals, all of them saw pain as the bitter taste of cosmic evil, the manifestation of nature's weakness, of a diabolical will, or of a well-deserved divine curse. This attitude towards pain is a unifying and distinctive characteristic of Mediterranean postclassical cultures which lasted until the seventeenth century. As an alchemic doctor put it in the sixteenth century, pain is the “bitter tincture added to the sparkling brew of the world's seed.” Each person was born with the call to learn to live in a vale of pain. The Neo-Platonist interpreted bitterness as a lack of perfection, the Cathar as disfigurement, the Christian as a wound for which he was held responsible. In dealing with the fullness of life, which found one of its major expressions in pain, people were able to stand up in heroic defiance or stoically deny the need for alleviation; they could welcome the opportunity for purification, penance, or sacrifice, and reluctantly tolerate the inevitable while seeking to relieve it. Opium, acupuncture, or hypnosis, always in combination with language, ritual, and myth, was applied to the unique human performance of suffering pain. One approach to pain was, however, unthinkable, at least in the European tradition: the belief that pain ought not to be suffered, alleviated, and interpreted by the person affected, but that it should be — ideally always — destroyed through the intervention of a priest, politician, or physician.

There were three reasons why the idea of professional, technical pain-killing was alien to all European civilizations. First: pain was man's experience of a marred universe, not a mechanical dysfunction in one of its subsystems. The meaning of pain was cosmic and mythic, not individual and technical. Second: pain was a sign of corruption in nature, and man himself was a part of that whole. One could not be rejected without the other; pain could not be thought of as distinct from the ailment. The doctor could soften the pangs, but to eliminate the need to suffer would have meant to do away with the patient. Third: pain was an experience of the soul, and this soul was present all over the body. Pain was a nonmediated experience of evil. There could be no source of pain distinct from pain that was suffered.

The campaign against pain as a personal matter to be understood and suffered got under way only when body and soul were divorced by Descartes. He constructed an image of the body in terms of geometry, mechanics, or watchmaking, a machine that could be repaired by an engineer. The body became an apparatus owned and managed by the soul, but from an almost infinite distance. The living body experience which the French refer to as “la chair” and the Germans as “der Leib” was reduced to a mechanism that the soul could inspect.

For Descartes pain became a signal with which the body reacts in self-defense to protect its mechanical integrity. These reactions to danger are transmitted to the soul, which recognizes them as painful. Pain was reduced to a useful learning device: it now taught the soul how to avoid further damage to the body. Leibnitz sums up this new perspective when he quotes with approval a sentence by Regis, who was in turn a pupil of Descartes: “The great engineer of the universe has made man as perfectly as he could make him, and he could not have invented a better device for his maintenance than to provide him with a sense of pain.” Leibnitz's comment on this sentence is instructive. He says first that in principle it would have been even better if God had used positive rather than negative reinforcement, inspiring pleasure each time a man turned away from the fire that could destroy him. However, he concludes that God could have succeeded with this strategy only by working miracles, and since, as a matter of principle, God avoids miracles, “pain is a necessary and brilliant device to ensure man's functioning.” Within two generations of Descartes's attempt at a scientific anthropology, pain has become useful. From being the experience of the precariousness of existence, it had turned into an indicator of specific breakdown.

By the end of the last century, pain had become a regulator of body functions, subject to the laws of nature; it needed no more metaphysical explanation. It had ceased to deserve any mystical respect and could be subjected to empirical study in order to do away with it. By 1853, barely a century and a half after pain was recognized as a mere physiological safeguard, a medicine labeled as a “pain-killer” was marketed in La Crosse, Wisconsin. A new sensibility had developed which was dissatisfied with the world, not because it was dreary or sinful or lacking in enlightenment or threatened by barbarians, but because it was full of suffering and pain. Progress in civilization became synonymous with the reduction of the sum total of suffering. From then on, politics was taken to be an activity not so much for maximizing happiness as for minimizing pain. The result is a tendency to see pain as essentially a passive happening inflicted on helpless victims because the toolbox of the medical corporation is not being used in their favor.

In this context it now seems rational to flee pain rather than to face it, even at the cost of giving up intense aliveness. It seems reasonable to eliminate pain, even at the cost of losing independence. It seems enlightened to deny legitimacy to all nontechnical issues that pain raises, even if this means turning patients into pets. With rising levels of induced insensitivity to pain, the capacity to experience the simple joys and pleasures of life has equally declined. Increasingly stronger stimuli are needed to provide people in an anesthetic society with any sense of being alive. Drugs, violence, and horror turn into increasingly powerful stimuli that can still elicit an experience of self. Widespread anesthesia increases the demand for excitation by noise, speed, violence — no matter how destructive.

This raised threshold of physiologically mediated experience, which is characteristic of a medicalized society, makes it extremely difficult today to recognize in the capacity for suffering a possible symptom of health. The reminder that suffering is a responsible activity is almost unbearable to consumers, for whom pleasure and dependence on industrial outputs coincide. By equating all personal participation in facing unavoidable pain with “masochism,” they justify their passive life-style. Yet, while rejecting the acceptance of suffering as a form of masochism, anesthesia consumers tend to seek a sense of reality in ever stronger sensations. They tend to seek meaning for their lives and power over others by enduring undiagnosable pains and unrelievable anxieties: the hectic life of business executives, the self-punishment of the rat-race, and the intense exposure to violence and sadism in films and on television. In such a society the advocacy of a renewed style in the art of suffering that incorporates the competent use of new techniques will inevitably be misinterpreted as a sick desire for pain: as obscurantism, romanticism, dolorism, or sadism.

Ultimately, the management of pain might substitute a new kind of horror for suffering: the experience of artificial painlessness. Lifton describes the impact of mass death on survivors by studying people who had been close to ground zero in Hiroshima. He found that people moving amongst the injured and dying simply ceased to feel; they were in a state of numbness, without emotional response. He believed that after a while this emotional closure merged with a depression which, twenty years after the bomb, still manifested itself in the guilt or shame of having survived without experiencing any pain at the time of the explosion. These people live in an interminable encounter with death which has spared them, and they suffer from a vast breakdown of trust in the larger human matrix that supports each individual human life. They experienced their anesthetized passage through this event as something just as monstrous as the death of those around them, as a pain too dark and too overwhelming to be confronted, or suffered.

What the bomb did in Hiroshima might guide us to an understanding of the cumulative effect on a society in which pain has been medically “expropriated.” Pain loses its referential character if it is dulled, and generates a meaningless, questionless residual horror. The sufferings for which traditional cultures have evolved endurance sometimes generated unbearable anguish, tortured imprecations, and maddening blasphemies; they were also self-limiting. The new experience that has replaced dignified suffering is artificially prolonged, opaque, depersonalized maintenance. Increasingly, pain-killing turns people into unfeeling spectators of their own decaying selves.

 4 – The Invention and Elimination of Disease

The French Revolution gave birth to two great myths: one, that physicians could replace the clergy; the other, that with political change society would return to a state of original health. Sickness became a public affair. In the name of progress, it has now ceased to be the concern of those who are ill.

For several months in 1792, the National Assembly in Paris tried to decide how to replace those physicians who profited from care of the sick with a therapeutic bureaucracy designed to manage an evil that was destined to disappear with the advent of equality, freedom, and fraternity. The new priesthood was to be financed by funds expropriated from the Church. It was to guide the nation in a militant conversion to healthy living which would make medical sick-care less necessary. Each family would again be able to take care of its members, and each village to provide for the sick who were without relatives. A national health service would be in charge of health care and would supervise the enactment of dietary laws and of statutes compelling citizens to use their new freedoms for frugal living and wholesome pleasures. Medical officers would supervise the compliance of the citizenry, and medical magistrates would preside over health tribunals to guard against charlatans and exploiters.

Even more radical were the proposals from a subcommittee for the elimination of beggary. In content and style they are similar to Red Guard and Black Panther manifestos demanding that control over health be returned to the people. Primary care, it was asserted, belongs only to the neighborhood. Public funds for sick-care are best used to supplement the income of the afflicted. If hospitals are needed, they should be specialized: for the aged, the incurable, the mad, or foundlings. Sickness is a symptom of political corruption and will be eliminated when the government is cleaned up.
The identification of hospitals with pestholes was current and easy to explain. They had appeared under Christian auspices in late antiquity as dormitories for travelers, vagrants, and derelicts. Physicians began to visit hospitals regularly at the time of the crusades, following the example of the Arabs. During the late Middle Ages, as charitable institutions for the custody of the destitute, they became part and parcel of urban architecture. Until the late eighteenth century the trip to the hospital was taken, typically, with no hope of return. Nobody went to a hospital to restore his health. The sick, the mad, the crippled, epileptics, incurables, foundlings, and recent amputees of all ages and both sexes were jumbled together; amputations were performed in the corridors between the beds. Inmates were given some food, chaplains and pious lay folk came to offer consolation, and doctors made charity visits. The cost of remedies made up less than 3 percent of the meager budget. More than half went for the hospital soup; the nuns could get along on a pittance. Like prisons, hospitals were considered a last resort; nobody thought of them as tools for administering therapy to improve the inmates.

Logically, some extremists went beyond the recommendations made by the committee on beggary. Some demanded the outright abolition of all hospitals, saying that they “are inevitably places for the aggregation of the sick and breed misery while they stigmatize the patient. If a society continues to need hospitals, this is a sign that its revolution has failed.”

A misunderstanding of Rousseau vibrates in this desire to restore sickness to its “natural state,” to bring society back to “wild sickness,” which is self-limiting and can be borne with virtue and style and cared for in the homes of the poor, just as previously the sicknesses of the rich had been taken care of. Sickness becomes complex, untreatable, and unbearable only when exploitation breaks up the family, and it becomes malignant and demeaning only with the advent of urbanization and civilization. For Rousseau's followers the sickness seen in hospitals was man-made, like all forms of social injustice, and it thrived among the self-indulgent and those whom they had impoverished. “In the hospital, sickness is totally corrupted; it turns into ‘prison fever’ characterized by spasms, fever, indigestion, pale urine, depressed respiration, and ultimately leads to death: if not on the eighth or eleventh day, then on the thirteenth.” It is this kind of language that made medicine first become a political issue. The plans to engineer a society into health began with the call for a social reconstruction that would eliminate the ills of civilization. What Dubos has called “the mirage of health” began as a political program.

In the public rhetoric of the 1790s, the idea of using biomedical interventions on people or on their environment was totally absent. Only with the Restoration was the task of eliminating sickness turned over to the medical profession. After the Congress of Vienna, hospitals proliferated and medical schools boomed. So did the discovery of diseases. Illness was still primarily nontechnical. In 1770, general practice knew of little besides the plague and the pox, but by 1860 even the ordinary citizen recognized the medical names of a dozen diseases. The sudden emergence of the doctor as savior and miracle worker was due not to the proven efficacy of new techniques but to the need for a magical ritual that would lend credibility to a pursuit at which a political revolution had failed. If “sickness” and “health” were to lay claim to public resources, then these concepts had to be made operational. Ailments had to be turned into objective diseases that infested mankind, could be transplanted and cultivated in the laboratory, and could be fitted into wards, records, budgets, and museums. Disease was thus accommodated to administrative management; one branch of the elite was entrusted by the dominant class with autonomy in its control and elimination. The object of medical treatment was defined by a new, though submerged, political ideology and acquired the status of an entity that existed quite separately from both doctor and patient.

We tend to forget how recently disease entities were born. In the mid-nineteenth century, a saying attributed to Hippocrates was still quoted with approval: “You can discover no weight, no form nor calculation to which to refer your judgment of health and sickness. In the medical arts there exists no certainty except in the physician's senses.” Sickness was still personal suffering in the mirror of the doctor's vision. The transformation of this medical portrait into a clinical entity represents an event in medicine that corresponds to the achievement of Copernicus in astronomy: man was catapulted and estranged from the center of his universe. Job became Prometheus.
The hope of bringing to medicine the elegance that Copernicus had given astronomy dates from the time of Galileo. Descartes traced the coordinates for the implementation of the project. His description effectively turned the human body into clockworks and placed a new distance, not only between soul and body, but also between the patient's complaint and the physician's eye. Within this mechanized framework, pain turned into a red light and sickness into mechanical trouble. A taxonomy of diseases became possible. As minerals and plants could be classified, so diseases could be isolated and categorized by the doctor-taxonomist. The logical framework for a new purpose in medicine had been laid. Instead of suffering man, sickness was placed in the center of the medical system and could be subjected to (a) operational verification by measurement, (b) clinical study and experiment, and (c) evaluation according to engineering norms.

Antiquity knew no yardstick for disease. Galileo's contemporaries were the first to try to apply measurement to the sick, but with little success. Since Galen had taught that urine was secreted directly from the vena cava and that its composition was a direct indication of the nature of the blood, doctors had tasted and smelled urine and assayed it by the light of sun and moon. After the sixteenth century, alchemists had learned to measure specific gravity with considerable precision, and they subjected the urine of the sick to their methods. Dozens of distinct and differing meanings were ascribed to changes in the specific gravity of urine. With this first measurement, doctors began to read diagnostic and curative meaning into any new measurement they learned to perform.
The use of physical measurements prepared for a belief in the real existence of diseases and their ontological autonomy from the perception of doctor and patient. The use of statistics underpinned this belief. It "showed" that diseases were present in the environment and could invade and infect people. The first clinical tests using statistics, which were performed in the United States in 1721 and published in London in 1722, provided hard data indicating that smallpox was threatening Massachusetts and that people who had been inoculated were protected against its attacks. They were conducted by Dr. Cotton Mather, who is better known for his inquisitorial fury at the time of the Salem witch trials than for his spirited defense of smallpox prevention.

During the seventeenth and eighteenth centuries, doctors who applied measurements to sick people were liable to be considered quacks by their colleagues. During the French Revolution, English doctors still looked askance at clinical thermometry. Together with the routine taking of the pulse, it became accepted clinical practice only around 1845, nearly thirty years after the stethoscope was first used by Laennec.

As the doctor's interest shifted from the sick to sickness, the hospital became a museum of disease. The wards were full of indigent people who offered their bodies as exhibits to any physician willing to treat them.20 The realization that the hospital was the logical place to study and compare “cases” developed towards the end of the eighteenth century. Doctors visited hospitals where all kinds of sick people were mingled, and trained themselves to pick out several “cases” of the same disease. They developed “bedside vision,” or a clinical eye. During the first decades of the nineteenth century, the medical attitude towards hospitals went through a further development. Until then, new doctors had been trained mostly by lectures, demonstrations, and disputations. Now the “bedside” became the clinic, the place where future doctors were trained to see and recognize diseases. The clinical approach to sickness gave birth to a new language which spoke about diseases at the bedside, and to a hospital reorganized and classified by disease for the exhibition of ailments to students.

The hospital, which at the very beginning of the nineteenth century had become a place for diagnosis, was now turned into a place for teaching. Soon it would become a laboratory for experimenting with treatments, and towards the turn of the century a place concerned with therapy. Today the pesthouse has been transformed into a compartmentalized repair shop. All this happened in stages. During the nineteenth century, the clinic became the place where disease carriers were assembled, diseases were identified, and a census of diseases was kept. Medical perception of reality became hospital-based much earlier than medical practice. The specialized hospital demanded by the French Revolutionaries for the sake of the patient became a reality because doctors needed to classify sickness. During the entire nineteenth century, pathology remained overwhelmingly the classification of anatomical anomalies. Only towards the end of the century did the pupils of Claude Bernard also begin to label and catalogue the pathology of functions. Like sickness, health acquired a clinical status, becoming the absence of clinical symptoms, and clinical standards of normality became associated with well-being.

Disease could never have been associated with abnormality if the value of universal standards had not come to be recognized in one field after another over a period of two hundred years. In 1635, at the behest of Cardinal Richelieu, the king of France formed an academy of the forty supposedly most distinguished men of French letters for the purpose of protecting and perfecting the French language. In fact, they imposed the language of the rising bourgeoisie which was also gaining control over the expanding tools of production. The language of the new class of capitalist producers became normative for all classes. State authority had expanded beyond statute law to regulate means of expression. Citizens learned to recognize the normative power of an elite in areas left untouched by the canons of the Church and the civil and penal codes of the state. Offenses against the codified laws of French grammar now carried their own sanctions; they put the speaker in his place — that is, deprived him of the privileges of class and profession. Bad French was that which fell below academic standards, as bad health would soon be that which was not up to the clinical norm.

In Latin norma means “square,” the carpenter's square. Until the 1830s the English word “normal” meant standing at a right angle to the ground. During the 1840s it came to designate conformity to a common type. In the 1880s, in America, it came to mean the usual state or condition not only of things but also of people. In France, the word was transposed from geometry to society — ecole normale designated a school at which teachers for the Empire were trained—and was first given a medical connotation around 1840 by Auguste Comte. He expressed his hope that once the laws relative to the normal state of the organism were known, it would be possible to engage in the study of comparative pathology.

During the last decade of the nineteenth century, the norms and standards of the hospital became fundamental criteria for diagnosis and therapy. For this to happen, it was not necessary that all abnormal features be considered pathological; it was sufficient that disease as deviance from a clinical standard make medical intervention legitimate by providing an orientation for therapy.

The age of hospital medicine, which from rise to fall lasted no more than a century and a half, is coming to an end. Clinical measurement has been diffused throughout society. Society has become a clinic, and all citizens have become patients whose blood pressure is constantly being watched and regulated to fall “within” normal limits. The acute problems of manpower, money, access, and control that beset hospitals everywhere can be interpreted as symptoms of a new crisis in the concept of disease. This is a true crisis because it admits.of two opposing solutions, both of which make present hospitals obsolete. The first solution is a further sickening medicalization of health care, expanding still further the clinical control of the medical profession over the ambulatory population. The second is a critical, scientifically sound demedicalization of the concept of disease.

Medical epistemology is much more important for the healthy solution of this crisis than either medical biology or medical technology. Such an epistemology will have to clarify the logical status and the social nature of diagnosis and therapy, primarily in physical—as opposed to mental—sickness. All disease is a socially created reality. Its meaning and the response it has evoked have a history. The study of this history will make us understand the degree to which we are prisoners of the medical ideology in which we were brought up.

A number of authors have recently tried to debunk the status of mental deviance as a “disease.” Paradoxically, they have rendered it more and not less difficult to raise the same kind of question about disease in general. Leifer, Goffman, Szasz, Laing, and others are all interested in the political genesis of mental illness and its use for political purposes. In order to make their point, they all contrast “unreal” mental with “real” physical disease: in their view the language of natural science, now applied to all conditions that are studied by physicians, really fits physical sickness only. Physical sickness is confined to the body, and it lies in an anatomical, physiological, and genetic context. The “real” existence of these conditions can be  confirmed by measurement and experiment, without any reference to a value-system. None of this applies to mental sickness: its status as a “sickness” depends entirely on psychiatric judgment. The psychiatrist acts as the agent of a social, ethical, and political milieu. Measurements and experiments on these “mental” conditions can be conducted only within an ideological framework which derives its consistency from the general social prejudice of the psychiatrist. The prevalence of sickness is blamed on life in an alienated society, but while political reconstruction might eliminate much psychic sickness, it would merely provide better and more equitable technical treatment for those who are physically ill.
This antipsychiatric stance, which legitimizes the non-political status of physical disease by denying to mental deviance the character of disease, is a minority position in the West, although it seems to be close to an official doctrine in modern China, where mental illness is perceived as a political problem. Maoist politicians are placed in charge of psychotic deviants. Bermann reports that the Chinese object to the revisionist Russian practice of depoliticizing the deviance of class enemies by locking them into hospitals and treating them as if they had a sickness analogous to an infection. They pretend that only the opposite approach can give results: the intensive political re-education of people who are now, perhaps unconsciously, class enemies. Their self-criticism will make them politically active and thus healthy. Here again, the insistence on the primarily nonclinical nature of mental deviance reinforces the belief that another kind of sickness is a material entity.

Advanced industrial societies have a high stake in maintaining the epistemological legitimacy of disease entities. As long as disease is something that takes possession of people, something they “catch” or “get,” the victims of these natural processes can be exempted from responsibility for their condition. They can be pitied rather than blamed for sloppy, vile, or incompetent performance in suffering their subjective reality; they can be turned into manageable and profitable assets if they humbly accept their disease as the expression of “how things are”; and they can be discharged from any political responsibility for having collaborated in increasing the sickening stress of high-intensity industry. An advanced industrial society is sick-making because it disables people from coping with their environment and, when they break down, substitutes a “clinical,” or therapeutic, prosthesis for the broken relationships. People would rebel against such an environment if medicine did not explain their biological disorientation as a defect in their health, rather than as a defect in the way of life which is imposed on them or which they impose on themselves. The assurance of personal political innocence that a diagnosis offers the patient serves as a hygienic mask that justifies further subjection to production and consumption.

The medical diagnosis of substantive disease entities that supposedly take shape in the individual's body is a surreptitious and amoral way of blaming the victim. The physician, himself a member of the dominating class, judges that the individual does not fit into an environment that has been engineered and is administered by other professionals, instead of accusing his colleagues of creating environments into which the human organism cannot fit. Substantive disease can thus be interpreted as the materialization of a politically convenient myth, which takes on substance within the individual's body when this body is in rebellion against the demands that industrial society makes upon it.

In every society the classification of disease—the nosology—mirrors social organization. The sickness that society produces is baptized by the doctor with names that bureaucrats cherish. “Learning disability,” “hyperkinesis,” or “minimal brain dysfunction” explains to parents why their children do not learn, serving as an alibi for school's intolerance or incompetence; high blood pressure serves as an alibi for mounting stress, degenerative disease for degenerating social organization. The more convincing the diagnosis, the more valuable the therapy appears to be, the easier it is to convince people that they need both, and the less likely they are to rebel against industrial growth. Unionized workers demand the most costly therapy possible, if for no other reason than for the perverse pleasure of getting back some of the money they have put into taxes and insurance, and deluding themselves that this will create more equality.

Before sickness came to be perceived primarily as an organic or behavioral abnormality, he who got sick could still find in the eyes of the doctor a reflection of his own anguish and some recognition of the uniqueness of his suffering. Now, what he meets is the gaze of a biological accountant engaged in input/output calculations. His sickness is taken from him and turned into the raw material for an institutional enterprise. His condition is interpreted according to a set of abstract rules in a language he cannot understand. He is taught about alien entities that the doctor combats, but only just as much as the doctor considers necessary to gain the patient's cooperation. Language is taken over by the doctors: the sick person is deprived of meaningful words for his anguish, which is thus further increased by linguistic mystification.

Before scientific slang had come to dominate language about the body, the repertory of ordinary speech in this field was exceptionally rich. Peasant language preserved much of this treasure into our century. Proverbs and sayings kept instructions readily available. The way complaints to the doctor were formulated by Babylonians and Greeks has been compared with the expressions used by German blue-collar workers. As in antiquity the patient stutters, flounders, and speaks about what “grips him” or what he “has caught.” But while the industrial worker refers to his ache as a drab “it” that hurts, his predecessors had many colorful and expressive names for the demons that bit or stung them. Finally, increasing dependence of socially acceptable speech on the special language of an elite profession makes disease into an instrument of class domination. The university-trained and the bureaucrat thus become their doctor's colleague in the treatment he dispenses, while the worker is put in his place as a subject who does not speak the language of his master.

As soon as medical effectiveness is assessed in ordinary language, it immediately appears that most effective diagnosis and treatment do not go beyond the understanding that any layman can develop. In fact, the overwhelming majority of diagnostic and therapeutic interventions that demonstrably do more good than harm have two characteristics: the material resources for them are extremely cheap, and they can be packaged and designed for self-use or application by family members. For example, the price of what is significantly health-furthering in Canadian medicine is so low that these same resources could be made available to the entire population of India for the amount of money now squandered there on modern medicine. The skills needed for the application of the most generally used diagnostic and therapeutic aids are so elementary that the careful following of instructions by people who are personally concerned would probably guarantee more effective and responsible use than medical practice ever could. Most of what remains could probably be handled better by “barefoot” nonprofessional amateurs with deep personal commitment than by professional physicians, psychiatrists, dentists, midwives, physiotherapists, or oculists.

When the evidence about the simplicity of effective modern medicine is discussed, medicalized people usually object by saying that sick people are anxious and emotionally incompetent for rational self-medication, and that even doctors call in a colleague to treat their own sick child; and furthermore, that malevolent amateurs could quickly organize into monopoly custodians of scarce and precious medical knowledge. These objections are all valid if raised within a society in which consumer expectations shape attitudes to service, in which medical resources are carefully packaged for hospital use, and in which the mythology of medical efficiency prevails. They would hardly be valid in a world that aimed at the effective pursuit of personal goals that an austere use of technology had put within the range of almost everyone.

5 – Death Against Death

Death as Commodity

In every society the dominant image of death determines the prevalent concept of health. Such an image, the culturally conditioned anticipation of a certain event at an uncertain date, is shaped by institutional structures, deep-seated myths, and the social character that predominates. A society's image of death reveals the level of independence of its people, their personal relatedness, self-reliance, and aliveness. Wherever the metropolitan medical civilization has penetrated, a novel image of death has been imported. Insofar as this image depends on the new techniques and their corresponding ethos, it is supranational in character. But these very techniques are not culturally neutral; they assumed concrete shape within Western cultures and express a Western ethos. The white man's image of death has spread with medical civilization and has been a major force in cultural colonization.

The image of a “natural death,” a death which comes under medical care and finds us in good health and old age, is a quite recent ideal. In five hundred years it has evolved through five distinct stages, and is now ready for a sixth. Each stage has found its iconographic expression: (1) the fifteenth-century “dance of the dead”; (2) the Renaissance dance at the bidding of the skeleton man, the so-called “Dance of Death”; (3) the bedroom scene of the aging lecher under the Ancien Regime; (4) the nineteenth-century doctor in his struggle against the roaming phantoms of consumption and pestilence; (5) the mid-twentieth-century doctor who steps between the patient and his death; and (6) death under intensive hospital care. At each stage of its evolution the image of natural death has elicited a new set of responses that increasingly acquired a medical character. The history of natural death is the history of the medicalization of the struggle against death.

The Devotional Dance of the Dead

From the fourth century onwards, the Church struggled against a pagan tradition in which crowds, naked, frenzied, and brandishing swords, danced on the tombs in the churchyard. Nevertheless, the frequency of ecclesiastical prohibitions testifies that they were of little avail, and for a thousand years Christian churches and cemeteries remained dance floors. Death was an occasion for the renewal of life. Dancing with the dead on their tombs was an occasion for affirming the joy of being alive and a source of many erotic songs and poems.5 By the late fourteenth century, however, the sense of these dances seems to have changed:6 from an encounter between the living and those who were already dead, it was transformed into a meditative, introspective experience. In 1424 the first Dance of the Dead was painted on a cemetery wall in Paris. The original of the Cimetiere des Innocents is lost, but good copies allow us to reconstruct it: king, peasant, pope, scribe, and maiden each dance with a corpse. Each partner is a mirror image of the other in dress and feature. In the shape of his body Everyman carries his own death with him and dances with it through his life. During the late Middle Ages, indwelling death faces man; each death comes with the symbol corresponding to his victim's rank: for the king a crown, for the peasant a pitchfork. From dancing with dead ancestors over their graves, people turned to representing a world in which everyone dances through life embracing his own mortality. Death was represented, not as an anthropomorphic figure, but as a macabre self-consciousness, a constant awareness of the gaping grave. It was not yet the skeleton man of the next century to whose music men and women will soon dance through the autumn of the Middle Ages, but rather each one's own aging and rotting self. At this time the mirror became important in everyday life, and in the grip of the “mirror of death” the “world”  acquired a hallucinating poignancy. With Chaucer and Villon, death becomes as intimate and sensual as pleasure and pain.

Primitive societies conceived of death as the result of an intervention by an alien actor. They did not attribute personality to death. Death is the outcome of someone's evil intention. This somebody who causes death might be a neighbor who, in envy, looks at you with an evil eye, or it might be a witch, an ancestor who comes to pick you up, or the black cat that crosses your path. Throughout the Christian and Islamic Middle Ages, death continued to be regarded as the result of a deliberate personal intervention of God. No figure of “a” death appears at the deathbed, just an angel and a devil struggling over the soul escaping from the mouth of the dying. Only during the fifteenth century were the conditions ripe for a change in this image, and for the appearance of what would later be called a “natural death.” The dance of the dead represents this readiness. Death can now become an inevitable, intrinsic part of human life, rather than the decision of a foreign agent. Death becomes autonomous and for three centuries coexists as a separate agent with the immortal soul, with divine providence, and with angels and demons.

The Danse Macabre

In the morality plays, death appears in a new costume and role. By the end of the fifteenth century, no longer just a mirror image, he assumes the leading role among the “last four things,” preceding judgment, heaven, and hell. Nor is he any longer just one of the four apocalyptic riders from Romanesque bas-reliefs, or the batlike Maegera who picks up souls from the cemetery of Pisa, or a mere messenger executing the orders of God. Death has become an independent figure who calls each man, woman, and child, first as a messenger from God but soon insisting on his own sovereign rights. By 1538 Hans Holbein the Younger had published the first picture-book of death, which was to become a best-seller: woodcuts on the Danse Macabre. The dance partners have shed their putrid flesh and turned into  naked skeletons. The representation of each man as entwined with his own mortality has now changed to show his frenzied exhaustion in the grip of death painted as a force of nature. The intimate mirror-image of the “self” which had been colored by the “new devotion” of the German mystics has been replaced by a death painted as the egalitarian executioner of a law that whirls everyone along and then mows them down. From a lifelong encounter, death has turned into the event of a moment.

During the Middle Ages eternity, together with God's presence, had been immanent in history. Now death becomes the point at which linear clock-time ends and eternity meets man. The world has ceased to be a sacrament of this presence; with Luther it became the place of corruption that God saves. The proliferation of clocks symbolizes this change in consciousness. With the predominance of serial time, concern for its exact measurement, and the recognition of the simultaneity of events, a new framework for the recognition of personal identity is manufactured. The identity of the person is sought in reference to a sequence of events rather than in the completeness of one's life span. Death ceases to be the end of a whole and becomes an interruption in the sequence.

Skeleton men predominate on the title pages of the first fifty years of the woodcut, as naked women now predominate on magazine covers. Death holds the hourglass or strikes the tower clock. Many a bell clapper was shaped like a bone. The new machine, which can make time of equal length, day and night, also puts all people under the same law. By the time of the Reformation, postmortem survival has ceased to be a transfigured continuation of life here below, and has become either a frightful punishment in the form of hell or a totally unmerited gift from God in heaven. Indwelling grace has been turned into justification by faith alone. Thus during the sixteenth century, death ceases to be conceived of primarily as a transition into the next world, and the accent is placed on the end of this life. The open grave looms much larger than the doors of heaven or hell and the encounter with death has become more certain than immortality, more just than king, pope, or even God. Rather than life's aim, it has become the end of life.

The finality, imminence, and intimacy of personal death were not only part of the new sense of time but also of the emergence of a new sense of individuality. On the pilgrim's path from the Church Militant on earth to the Church Triumphant in heaven, death was experienced very much as an event that concerned both communities. Now each man faced his own and final death. Of course, once death had become such a natural force, people wanted to master it by learning the art or the skill of dying. Ars Moriendi, one of the first printed do-it-yourself manuals on the market, remained a best-seller in various versions for the next two hundred years. Many people learned to read by deciphering it. The most widely circulated version was published by Caxton at the Westminster press in 1491: over one hundred incunabula editions were made before 1500 from woodblocks and from movable type, under the title Art and Craft to knowe ye well to dye. The small folio printed in neat Gothic letters was part of a series to instruct the “complete gentleman” in “behaviour, gentle and devout,” from manipulating a table knife to conducting a conversation, from the art of weeping and blowing the nose to the art of playing chess, of praying, and of dying.

This was not a book of remote preparation for death through a virtuous life, nor a reminder to the reader of an inevitable steady decline of physical forces and the constant danger of death. It was a “how-to” book in the modern sense, a complete guide to the business of dying, a method to be learned while one was in good health and to be kept at one's fingertips for use in that inescapable hour. The book is not written for monks and ascetics but for “carnall and secular” men for whom the ministrations of the clergy were not available. It served as a model for similar instructions, often written in much less matter-of-fact spirit, by people like Savonarola, Luther, and Jeremy Taylor. Men felt responsible for the expression their face would show in death. Kunstler has shown that about this very time an unprecedented approach was developed in the painting of human faces: the Western portrait of countenance, which tries to represent much more than just the likeness of facial traits. The first portraits, in fact, represent princes and were executed immediately after their death, from memory, in order to render the individual, atemporal personality of the deceased ruler present at his state funeral. Early Renaissance humanists wanted to remember their dead, not as ghouls or ghosts, saints or symbols, but as a continuing, personal, historical presence.

In popular devotion a new kind of curiosity about the afterlife developed. Fantastic horror stories about dead bodies and artistic representations of purgatory both multiplied. The grotesque concern of the seventeenth century with ghosts and souls underscores the growing anxiety of a culture faced with the call of death rather than the judgment of God. In many parts of the Christian world the dance of death became a standard decoration in the entrance of parish churches. The Spaniards brought the skeleton man to America, where he fused with the Aztec idol of death. Their mestizo offspring, on its rebound to Europe, influenced the face of death throughout the Hapsburg Empire from Holland to the Tyrol. After the Reformation, European death became and remained macabre.

Simultaneously, medical folk-practices multiplied, all designed to help people meet their death with dignity as individuals. New superstitious devices were developed so that one might recognize whether one's sickness required the acceptance of approaching death or some kind of treatment. If the flower thrown into the fountain of the sanctuary drowned, it was useless to spend money on remedies. People tried to be ready when death came, to have the steps well learned for the last dance. Remedies against a painful agony multiplied, but most of them were still to be performed under the conscious direction of the dying, who played a new role and played it consciously. Children could help a mother or father to die, but only if they did not hold them back by crying. A person was supposed to indicate when he wanted to be lowered from his bed onto the earth which would soon engulf him, and when the prayers were to start. But bystanders knew that they were to keep the doors open to make it easy for death to come, to avoid noise so as not to frighten death away, and finally to turn their eyes respectfully away from the dying man in order to leave him alone during this most personal event.

 Neither priest nor doctor was expected to assist the poor man in typical fifteenth- and sixteenth-century death. In principle, medical writers recognized two opposite services the physician could perform. He could either assist healing or help the coming of an easy and speedy death. It was his duty to recognize the facies hippocratica, the special traits which indicated that the patient was already in the grip of death. In healing as in withdrawal, the doctor was anxious to work hand-in- glove with nature. The question whether medicine ever could “prolong” life was heatedly disputed in the medical schools of Palermo, Fez, and even Paris. Many Arab and Jewish doctors denied this power outright, and declared such an attempt to interfere with the order of nature to be blasphemous.

Vocational zeal tempered by philosophical resignation comes through clearly in the writings of Paracelsus. “Nature knows the boundaries of her course. According to her own appointed term, she confers upon each of her creatures its proper life span, so that its energies are consumed during the time that elapses between the moment of its birth and its predestined end. . . . A man's death is nothing but the end of his daily work, an expiration of air, the consummation of his innate balsamic self-curing power, the extinction of the rational light of nature, and a great separation of the three: body, soul, and spirit. Death is a return to the womb.” Without excluding transcendence, death has become a natural phenomenon, no longer requiring that blame be placed on some evil agent.

The new image of death helped to reduce the human body to an object. Up to this time, the corpse had been considered something quite unlike other things: it was treated almost like a person. The law recognized its standing: the dead could sue and be sued by the living, and criminal proceedings against the dead were common. Pope Urban VIII, who had been poisoned by his successor, was dug up, solemnly judged a simonist, had his right hand cut off, and was thrown into the Tiber. After being hanged as a thief, a man might still have his head cut off for being a traitor. The dead could also be called to witness. The widow could still repudiate her husband by putting the keys and his purse on his casket. Even today the executor acts in the name of the dead, and we still speak of the “desecration” of a grave or the secularization of a public cemetery when it is turned into a park. The appearance of natural death was necessary for the corpse to be deprived of much of its legal standing.

The arrival of natural death also prepared the way for new attitudes towards death and disease which became common in the late seventeenth century. During the Middle Ages, the human body had been sacred; now the physician's scalpel had access to the corpse itself. Its dissection had been considered by the humanist Gerson to be “a sacrilegious profanation, a useless cruelty exercised by the living against the dead.” But at the same time that Everyman's Death began to emerge in person in the morality plays, the corpse first appeared as a teaching object in the amphitheater of the Renaissance university. When the first authorized public dissection took place in Montpellier in 1375, this new learned activity was declared obscene, and the performance could not be repeated for several years. A generation later, permission was given for one corpse a year to be dissected within the borders of the German Empire. At the University of Bologna, also, one body was dissected each year just before Christmas, and the ceremony was inaugurated by a procession, accompanied by exorcisms, and took three days. During the fifteenth century, the University of Lerida in Spain was entitled to the corpse of one criminal every three years, to be dissected in the presence of a notary assigned by the Inquisition. In England in 1540, the faculties of the universities were authorized to claim four corpses a year from the hangman. Attitudes changed so rapidly that by 1561 the Venetian Senate ordered the hangman to take instruction from Dr. Fallopius in order to provide him with corpses well suited for “anatomizing.” Rembrandt painted “Dr. Tulp's Lesson” in 1632. Public dissection became a favored subject for paintings and, in the Netherlands, a common event at carnivals. The first step towards surgery on television and in the movies had been taken. The physician had advanced his knowledge of anatomy and his power to exhibit his skill, but both were disproportionate to an advance in his ability to heal. Medical rituals helped to orient, repress, or allay the fear and anguish generated by a death that had become macabre. The anatomy of Vesalius rivaled Holbein's Danse Macabre somewhat as scientific sex-guides now rival Playboy and Penthouse magazines.

Bourgeois Death

Baroque death counterpointed an aristocratically organized heaven. The church vault might depict a last judgment with separate spaces reserved for savages, commoners, and nobles, but the Dance of Death beneath depicted the mower who used his scythe regardless of post or rank. Precisely because macabre equality belittled worldly privilege, it also made it more legitimate. However, with the rise of the bourgeois family, equality in death came to an end: those who could afford it began to pay to keep death away.

Francis Bacon was the first to speak about the prolongation of life as a new task for physicians. He divided medicine into three offices: “First, the preservation of health, second, the cure of disease, and third, the prolongation of life,” and extolled the “third part of medicine, regarding the prolongation of life: this is a new part, and deficient, although the most noble of all.“ The medical profession did not even consider facing this task, until, some one hundred and fifty years later, there appeared a host of clients who were anxious to pay for the attempt. This was a new type of rich man who refused to die in retirement and insisted on being carried away by death from natural exhaustion while still on the job. He refused to accept death unless he was in good health in an active old age. Montaigne had already ridiculed such people as exceptionally conceited: “ ‘Tis the last and extreme form of dying . . . what an idle conceit is it to expect to die of a decay of strength which is the effect of the extremest age, and to propose to ourselves no shorter lease on life . . . as if it were contrary to nature to see a man break his neck with a fall, be drowned by shipwreck, be snatched away with pleurisy or the plague . . . we ought to call natural death that which is general, common and universal.” Such people were few in his time; soon their numbers would increase. The preacher expecting to go to heaven, the philosopher denying the existence of the soul, and the merchant wanting to see his capital double once more were all in agreement that the only death that accorded with nature was one which would overtake them at their desks.
There is no evidence to show that the age-specific life expectancy of most people in their sixties had increased by the middle of the eighteenth century, but there is no doubt that new technology had made it possible for the old and rich to hang on while doing what they had done in middle age. The pampered could stay on the job because their living and working conditions had eased. The Industrial Revolution had begun to create employment opportunities for the weak, sickly, and old. Sedentary work, hitherto rare, had come into its own. Rising entrepreneurship and capitalism favored the boss who had had the time to accumulate capital and experience. Roads had improved: a general affected by gout could now command a battle from his wagon, and decrepit diplomats could travel from London to Vienna or Moscow. Centralized nation-states increased the need for scribes and an enlarged bourgeoisie. The new and small class of old men had a greater chance of survival because their lives at home, on the street, and at work had become physically less demanding. Aging had become a way of capitalizing life. Years at the desk, either at the counter or the school bench, began to bear interest on the market. The young of the middle class, whether gifted or not, were now for the first time sent to school, thus allowing the old to stay on the job. The bourgeoisie who could afford to eliminate “social death” by avoiding retirement, created “childhood” to keep their young under control.

Along with the economic status of the old, the value of their bodily functions increased. In the sixteenth century “a young wife is death to an old man,” and in the seventeenth, “old men who play with young maids dance with death.” At the court of Louis XIV the old lecher was a laughingstock; by the time of the Congress of Vienna he had turned into an object of envy. To die while courting one's grandson's mistress became the symbol of a desirable end.

A new myth about the social value of the old was developed. Primitive hunters, gatherers, and nomads had usually killed them, and peasants had put them into the back room, but now the patriarch appeared as a literary ideal. Wisdom was attributed to him just because of his age. It first became tolerable and then appropriate that the elderly should attend with solicitude to the rituals deemed necessary to keep up their tottering bodies. No physician was yet in attendance to take on this task, which lay beyond the competence claimed by apothecary or herbalist, barber or surgeon, university-trained doctor or traveling quack. But it was this peculiar demand that helped to create a new kind of self-styled healer.

Formerly, only king or pope had been under an obligation to remain in command until the day of his death. They alone consulted the faculties: the Arabs from Salerno in the Middle Ages, or the Renaissance men from Padua or Montpellier. Kings, however, kept court physicians to do what barbers did for the commoner: bleed them and purge them, and in addition, protect them from poisons. Kings neither set out to live longer than others, nor expected their personal physicians to give special dignity to their declining years. In contrast, the new class of old men saw in death the absolute price for absolute economic value. The aging accountant wanted a doctor who would drive away death; when the end approached, he wanted to be formally “given up” by his doctor and to be served his last repast with the special bottle reserved for the occasion. The role of the “valetudinarian” was thereby created, and with genteel decrepitude, the eighteenth- century groundwork was laid for the economic power of the contemporary physician.

The ability to survive longer, the refusal to retire before death, and the demand for medical assistance in an incurable condition had joined forces to give rise to a new concept of sickness: the type of health to which old age could aspire. In the years just before the French Revolution this had become the health of the rich and the powerful; within a generation chronic disease became fashionable for the young and pretentious, consumptive features the sign of premature wisdom, and the need for travel into warm climates a claim to genius. Medical care for protracted ailments, even though they might lead to untimely death, had become a mark of distinction.

By contrast, a reverse judgment now could be made on the ailments of the poor, and the ills from which they had always died could be defined as untreated sickness. It did not matter at all if the treatment doctors could provide for these ills had any effect on the progress of the sickness; the lack of such treatment began to mean that they were condemned to die an unnatural death, an idea that fitted the bourgeois image of the poor as uneducated and unproductive. From now on the ability to die a “natural” death was reserved to one social class: those who could afford to die as patients.

Health became the privilege of waiting for timely death, no matter what medical service was needed for this purpose. In an earlier epoch, death had carried the hourglass. In woodcuts, both skeleton and onlooker grin when the victim refuses death. Now the middle class seized the clock and employed doctors to tell death when to strike. The Enlightenment attributed a new power to the doctor, without being able to verify whether or not he had acquired any new influence over the outcome of dangerous sickness.

Clinical Death

The French Revolution marked a short interruption in the medicalization of death. Its ideologues believed that untimely death would not strike in a society built on its triple ideal. But the doctor's newly acquired clinical eyeglasses made him look at death in a new perspective. Whereas the merchants of the eighteenth century had determined the outlook on death with the help of the charlatans they employed and paid, now the clinicians began to shape the public's vision. We have seen death turn from God's call into a “natural” event and later into a “force of nature“; in a further mutation it had turned into an “untimely” event when it came to those who were not both healthy and old. Now it had become the outcome of specific diseases certified by the doctor.

 Death had paled into a metaphorical figure, and killer diseases had taken his place. The general force of nature that had been celebrated as “death” had turned into a host of specific causations of clinical demise. Many “deaths” now roamed the world. A number of book plates from private libraries of late nineteenth-century physicians show the doctor battling with personified diseases at the bedside of his patient. The hope of doctors to control the outcome of specific diseases gave rise to the myth that they had power over death. The new powers attributed to the profession gave rise to the new status of the clinician.

While the city physician became a clinician, the country physician became first sedentary and then a member of the local elite. At the time of the French Revolution he had still belonged to the traveling folk. The surplus of army surgeons from the Napoleonic wars came home with a vast experience, looking for a living. Military men trained on the battlefield, they soon became the first resident healers in France, Italy, and Germany. The simple people did not quite trust their techniques and staid burghers were shocked by their rough ways, but still they found clients because of their reputation among veterans of the Napoleonic wars. They sent their sons to the new medical schools springing up in the cities, and these upon their return created the role of the country doctor, which remained unchanged up to the time of World War II. They derived a steady income from playing the family doctor to the middle class who could well afford them. A few of the city or town rich acquired prestige by living as patients of famous clinicians, but in the early nineteenth century a much more serious competition for the town doctor still came from the medical technicians of old — the midwife, the tooth-puller, the veterinarian, the barber, and sometimes the public nurse. Notwithstanding the newness of his role and resistance to it from above and below, the European country doctor, by mid-century, had become a member of the middle class. He earned enough from playing lackey to a squire, was family friend to other notables, paid occasional visits to the lowly sick, and sent his complicated cases to his clinical colleague in town. While “timely” death had originated in the emerging class consciousness of the bourgeois, “clinical” death originated in the emerging professional consciousness of the new, scientifically trained doctor. Henceforth, a timely death with clinical symptoms became the ideal of middle-class doctors, and it was soon to become incorporated into the aspirations of trade unions.

Trade Union Claims to a Natural Death

In our century a valetudinarian's death while undergoing treatment by clinically trained doctors came to be perceived, for the first time, as a civil right. Old-age medical care was written into union contracts. The capitalist privilege of natural extinction from exhaustion in a director's chair gave way to the proletarian demand for health services during retirement. The bourgeois hope of continuing as a dirty old man in the office was ousted by the dream of an active sex life on social security in a retirement village. Lifelong care for every clinical condition soon became a peremptory demand for access to a natural death. Lifelong institutional medical care had become a service that society owed all its members.

“Natural death” now appeared in dictionaries. One major German encyclopedia published in 1909 defines it by means of contrast: “Abnormal death is opposed to natural death because it results from sickness, violence, or mechanical and chronic disturbances.” A reputable dictionary of philosophical concepts states that “natural death comes without previous sickness, without definable specific cause.” It was this macabre hallucinatory death-concept that became intertwined with the concept of social progress. Legally valid claims to equality in clinical death spread the contradictions of bourgeois individualism among the working class. The right to a natural death was formulated as a claim to equal consumption of medical services, rather than as a freedom from the evils of industrial work or as a new liberty and power for self-care. This unionized concept of an “equal clinical death” is thus the inverse of the ideal proposed in the National Assembly of Paris in 1792: it is a deeply medicalized ideal.
First of all, this new image of death endorses new levels of social control. Society has become responsible for preventing each man's death: treatment, effective or not, can be made into a duty. Any fatality occurring without medical treatment is liable to become a coroner's case. The encounter with a doctor becomes almost as inexorable as the encounter with death. I know of a woman who tried, unsuccessfully, to kill herself. She was brought to the hospital in a coma, with a bullet lodged in her spine. Using heroic measures the surgeon kept her alive, and he considers her case a success: she lives, but she is totally paralyzed; he no longer has to worry about her ever attempting suicide again.

Our new image of death also befits the industrial ethos. The good death has irrevocably become that of the standard consumer of medical care. Just as at the turn of the century all men were defined as pupils, born into original stupidity and standing in need of eight years of schooling before they could enter productive life, today they are stamped from birth as patients who need all kinds of treatment if they want to lead life the right way. Just as compulsory educational consumption came to be used as a device to obviate concern about work, so medical consumption became a device to alleviate unhealthy work, dirty cities, and nerve-racking transportation. What need is there to worry about a murderous environment when doctors are industrially equipped to act as life-savers!
Finally, “death under compulsory care” encourages the re-emergence of the most primitive delusions about the causes of death. As we have seen, primitive people do not die of their own death, they do not carry finitude in their bones, and they are still close to the subjective immortality of the beast. Among them, death always requires a supernatural explanation, somebody to blame: the curse of an enemy, the spell of a magician, the breaking of the yarn in the hands of the Parcae, or God dispatching his angel of death. In the dance with his or her mirror-image, European death emerged as an agent independent of another's will, an inexorable force of nature that men and women had to face on their own. The imminence of death was an exquisite and constant reminder of the fragility and tenderness of life. During the late Middle Ages, the discovery of “natural” death became one of the mainsprings of European lyric and drama. But the same imminence of death, once perceived as an extrinsic threat coming from nature, became a major challenge for  the emerging engineer. If the civil engineer had learned to manage earth, and the pedagogue-become-educator to manage knowledge, why should the biologist- physician not manage death? When the doctor contrived to step between humanity and death, the latter lost the immediacy and intimacy gained four hundred years earlier. Death that had lost face and shape had lost its dignity.

The change in the doctor-death relationship can be well illustrated by following the iconographic treatment of this theme. In the age of the Dance of Death, the physician is rare. In the only picture I have located in which death treats the doctor as a colleague, he has taken an old man by one hand, while in the other he carries a glass of urine, and seems to be asking the physician to confirm his diagnosis. In the age of the Dance of Death, the skeleton man makes the doctor the main butt of his jokes. In the earlier period, while death still wore some flesh, he asks the doctor to confirm in the latter's own mirror-image what he thought he knew about man's innards. Later, as a fleshless skeleton, he teases the doctor about his impotence, jokes about or rejects his honoraria, offers medicine as pernicious as that the physician dispensed, and treats the doctor as just one more common mortal by snatching him into the dance. Baroque death seems to intrude constantly into the doctor's activities, making fun of him while he sells his wares at a fair, interrupting his consultation, transforming his medicine bottles into hourglasses, or taking the doctor's place on a visit to the pesthouse. In the eighteenth century a new motif appears: death seems to enjoy teasing the physician about his pessimistic diagnoses, abandoning those sick persons whom the doctor has condemned, and dragging the doctor off to the tomb while leaving the patient alive. Until the nineteenth century, death deals always with the doctor or with the sick, usually taking the initiative in the action. The contestants are at opposite ends of the sickbed. Only after clinical sickness and clinical death had developed considerably do we find the first pictures in which the doctor assumes the initiative and interposes himself between his patient and death. We have to wait until after World War I before we see physicians wrangling with the skeleton, tearing a young woman from its embrace, and wresting the scythe from death's hand. By 1930 a smiling white-coated man is rushing against a whimpering skeleton and crushing it like a fly with two volumes of Marle's Lexicon of Therapy. In other pictures, the doctor raises one hand and wards off death while holding up the arms of a young woman whom death grips by the feet. Max Klinger represents the physician clipping the feathers of a winged giant. Others show the physician locking the skeleton into prison or even kicking its bony bottom. Now the doctor rather than the patient struggles with death. As in primitive cultures, somebody can again be blamed when death triumphs. This somebody is no longer a person with the face of a witch, an ancestor, or a god, but the enemy in the shape of a social force. Today, when defense against death is included in social security, the culprit lurks within society. The culprit might be the class enemy who deprives the worker of sufficient medical care, the doctor who refuses to make a night visit, the multinational concern that raises the price of medicine, the capitalist or revisionist government that has lost control over its medicine men, or the administrator who partly trains physicians at the University of Delhi and then drains them off to London. The witch-hunt that was traditional at the death of a tribal chief is being modernized. For every premature or  clinically unnecessary death, somebody or some body can be found who irresponsibly delayed or prevented a medical intervention.

Much of the progress of social legislation during the first half of the twentieth century would have been impossible without the revolutionary use of such an industrially graven death-image. Neither the support necessary to agitate for such legislation nor guilt feelings strong enough to enforce its enactment could have been aroused. But the claim to equal medical nurturing towards an equal kind of death has also served to consolidate the dependence of our contemporaries on a limitlessly expanding industrial system.

Death Under Intensive Care

We cannot fully understand the deeply rooted structure of our social organization unless we see in it a multifaceted exorcism of all forms of evil death. Our major institutions constitute a gigantic defense program waging war on behalf of “humanity“ against death-dealing agencies and classes. This is a total war. Not only medicine but also welfare, international relief, and development programs are enlisted in this struggle. Ideological bureaucracies of all colors join the crusade. Revolution, repression, and even civil and international wars are justified in order to defeat the dictators or capitalists who can be blamed for the wanton creation and tolerance of sickness and death.

Curiously, death became the enemy to be defeated at precisely the moment at which megadeath came upon the scene. Not only the image of “unnecessary” death is new, but also our image of the end of the world. Death, the end of my world, and apocalypse, the end of the world, are intimately related; our attitude towards both has clearly been deeply affected by the atomic situation. The apocalypse has ceased to be just a mythological conjecture and has become a real contingency. Instead of being due to the will of God, or man's guilt, or the laws of nature, Armageddon has become a possible consequence of man's direct decision. Cobalt, like hydrogen bombs, creates an illusion of control over death. Medicalized social rituals represent one aspect of social control by means of the self-frustrating war against death.

Malinowski has argued that death among primitive people threatens the cohesion and therefore the survival of the whole group. It triggers an explosion of fear and irrational expressions of defense. Group solidarity is saved by making out of the natural event a social ritual. The death of a member thereby becomes an occasion for an exceptional celebration. The dominance of industry has disrupted and often dissolved most traditional bonds of solidarity. The impersonal rituals of industrialized medicine create an ersatz unity of mankind. They tie all its members into a pattern of “desirable” death by proposing hospital death as the goal of economic development. The myth of progress of all people towards the same kind of death diminishes the feeling of guilt on the part of the “haves” by transforming the ugly deaths that the “have-nots” die into the result of present underdevelopment, which ought to be remedied by further expansion of medical institutions.

Of course, medicalized death has a different function in highly industrialized societies than it has in mainly rural nations. Within an industrial society, medical intervention in everyday life does not change the prevailing image of health and death, but rather caters to it. It diffuses the death-image of the medicalized elite among the masses and reproduces it for future generations. But when “death prevention” is applied outside of a cultural context in which consumers religiously prepare themselves for hospital deaths, the growth of hospital-based medicine inevitably constitutes a form of imperialist intervention. A sociopolitical image of death is imposed; people are deprived of their traditional vision of what constitutes health and death. The self-image that gives cohesion to their culture is dissolved, and atomized individuals can now be incorporated into an international mass of highly “socialized” health consumers. The expectation of medicalized death hooks the rich on unlimited insurance payments and lures the poor into a gilded deathtrap. The contradictions of bourgeois individualism are corroborated by the inability of people to die with any possibility of a realistic attitude towards death. The customs man guarding the frontier between Upper Volta and Mali explained to me this importance of death in relation to health. I wanted to know from him how people along the Niger could understand each other, though almost every village spoke a different tongue. For him this had nothing to do with language: “As long as people cut the prepuce of their boys the way we do, and die our death, we can understand them well.”

In many a village in Mexico I have seen what happens when social security arrives. For a generation people continue in their traditional beliefs; they know how to deal with death, dying, and grief. The new nurse and the doctor, thinking they know better, teach them about an evil pantheon of clinical deaths, each one of which can be banned, at a price. Instead of modernizing people's skills for self-care, they preach the ideal of hospital death. By their ministration they urge the peasants to an unending search for the good death of international description, a search that will keep them consumers forever.
Like all other major rituals of industrial society, medicine in practice takes the form of a game. The chief function of the physician becomes that of an umpire. He is the agent or representative of the social body, with the duty to make sure that everyone plays the game according to the rules. The rules, of course, forbid leaving the game and dying in any fashion that has not been specified by the umpire. Death no longer occurs except as the self-fulfilling prophecy of the medicine man.

Through the medicalization of death, health care has become a monolithic world religion whose tenets are taught in compulsory schools and whose ethical rules are applied to a bureaucratic restructuring of the environment: sex has become a subject in the syllabus and sharing one's spoon is discouraged for the sake of hygiene. The struggle against death, which dominates the life-style of the rich, is translated by development agencies into a set of rules by which the poor of the earth shall be forced to conduct themselves.

Only a culture that evolved in highly industrialized societies could possibly have called forth the commercialization of the death-image that I have just described. In its extreme form, “natural death” is now that point at which the human organism refuses any further input of treatment. People63 die when the electroencephalogram indicates that their brain waves have flattened out: they do not take a last breath, or die because their heart stops. Socially approved death happens when man has become useless not only as a producer but also as a consumer. It is the point at which a consumer, trained at great expense, must finally be written off as a total loss. Dying has become the ultimate form of consumer resistance.

Traditionally the person best protected from death was the one whom society had condemned to die. Society felt threatened that the man on Death Row might use his tie to hang himself. Authority might be challenged if he took his life before the appointed hour. Today, the man best protected against setting the stage for his own dying is the sick person in critical condition. Society, acting through the medical system, decides when and after what indignities and mutilations he shall die. The medicalization of society has brought the epoch of natural death to an end. Western man has lost the right to preside at his act of dying. Health, or the autonomous power to cope, has been expropriated down to the last breath. Technical death has won its victory over dying. Mechanical death has conquered and destroyed all other deaths.

Politics of Health

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