A Response to Ivan Illich
Abstract and Keywords
The author returns to the challenge presented by Ivan Illich in Medical Nemesis, and the concept of iatrogenesis—the inadvertent harm caused by doctors. The dispute over the numbers: is it the third-highest cause of death (after heart disease and cancer)? Or is this an underestimate? Illich’s book should be seen as a call to action. UK GP Dr Marshall Marinker’s response to Illich’s challenge; the flaws in medical training embodied in the unspoken assumptions guiding the clinical behaviour of its teachers. The inherent power imbalance in the doctor–patient consultation. The profession may have misunderstood Illich, but health systems have improved; medical curricula have been rewritten. The role of society in determining how care is provided, and the influence of health systems. New models of practice altering the person–doctor relationship, incorporating self-management (the ‘third way’ of medical practice). The author’s proposed model (the positive health model) empowers patients, as Illich advocated. The role of medical colleges and governments in positive change.
Keywords: Medical Nemesis, iatrogenesis, call to action, paternalism, reform of medical curriculum, person–doctor relationship, self-management, third way of medical practice, patients, empowerment, positive health model, role of medical colleges, disruptive innovation
In the 1970s, Ivan Illich warned doctors that, by medicalizing the suffering of life which we all experience, doctors were robbing people of the ability to take control of their own lives. He set out his thesis in a book called Medical Nemesis.1 By using medication to give people false hope that the effects of pain, of suffering, and of ageing and death could be mitigated, doctors, he predicted, would become the agents of their own demise. He even provided the evidence that it was happening.
Illich could not have been more provocative. He said that the greatest threat to people’s health is doctors. He called it iatrogenesis2; it begins with the healer.
More than 40 years later, there is still dispute about how much death and disability doctors cause. Some say that to call it the third greatest cause of death after heart disease and cancer is an exaggeration. Others say that’s an underestimate, and that it is actually the number one cause of death in the Western world.
Twenty years after writing Medical Nemesis, Ivan Illich reflected that the book had prompted ‘shock and anger’ when it was published in the 1970s. He reconsidered his views in the 1990s, and decided that, if anything, the assertions he had made were more true. But there was a specific part that he got wrong, he decided. In proposing that the solution was the empowerment of people to take control of their own lives and health, he had completely underestimated the power of the system. In 1994, in the preface to a new edition of the book, he wrote, ‘In Limits to Medicine—Medical Nemesis, I argued that the fundamental pathogen today is the pursuit of health as this has come to be culturally defined in late-industrial society. I did not understand that in the age of systems management, this pathogenic pursuit of health would become universally imposed.’3
The shock and anger of doctors was completely understandable. To them, what Illich was accusing them of was so blatantly wrong, because it flew in the face of everything they had been taught in the heyday of medical science. They (p.152) took a strong defensive position and disagreed with him. They raged against Illich and the other voices in the 1970s who were sounding the alarm bell about the direction in which medicine was heading.
By completely disregarding Illich and others, the medical establishment fought off the challenge. The dogma of the medical model prevailed. But they didn’t know the man; didn’t know what drove him. All they saw was the threat he posed to their view of medicine. They didn’t heed the warning of impending medical nemesis.
For that is what it was, a warning. It was a call to action, a wake-up call for people to see what was really happening. That’s the way Illich worked. Modern medicine was far from his only challenge; he took the same approach with education, work, energy use, transportation, and economic development. In his critique of the modern education system, Deschooling Society, he challenged educationalists to reconsider the formulaic approach to systematizing education, and its contribution to the institutionalization of society.4 He proposed a far more holistic and individual approach to learning which would become life-long. Thank goodness that at least the teachers and educationists listened to him.
Or did they? One of the most watched TED talks of all time, Sir Ken Robinson’s 2006 talk ‘Do schools kill creativity?’ echoes many of Illich’s themes in relation to the flaws of modern education. Again, decades after Illich sounded the warning.5
I personally recognize Illich as a disruptor. I recognize him, because I have to own that I am a disruptor too. Here’s a dictionary definition of disruptor: ‘Someone or something that interrupts an event, activity, or process by causing a disturbance or problem.’ But there’s a level of meaning beyond that. What the establishment didn’t realize was that Illich was deliberately disrupting to prompt a response that would lead to a better outcome. In modern terminology, he was a positive disruptor: ‘Someone who challenges current organizational habits and works to find positive alternatives; uprooting and changing how we think, behave, do business, learn and go about our day-to-day.’6
Illich’s solution was for people to rise up and seize control of their own lives and health, collectively. People should change the system, should rise up against the expropriation of their health, and the removal of their ability to manage their own health by their subjugation to doctors. What he came to realize was that the power of the medical and pharmaceutical system negated any possibility of that being the solution. The patient–doctor relationship in the 1970s was inherently power-based, and the power imbalance between doctor (p.153) and patient was based on knowledge. Under that paternalistic approach, doctors said, essentially, ‘I know your health better than you do.’
In the 1970s, Dr Marshall Marinker wrote a response to Medical Nemesis. Marinker was already an influential GP when I did my GP training in the mid 1980s. By the time of his death in 2019, he was described as ‘one of the notable GPs of the past half century in the UK’.7 Of Medical Nemesis he wrote, ‘I shall need to acknowledge and celebrate much of the analysis of the medical profession which Ivan Illich makes, and yet to challenge what seem to me to be unsatisfactory conclusions.’8
Marinker was a positive disruptor too. He also saw the flaws in the training of doctors, stating, ‘There is a hidden curriculum in medical education that is based not on the medical school’s declared intentions, but on the clinical behaviour of its teachers.’9
But I believe that he missed the point of Illich’s conclusions, which he saw as idealistic and utopian. ‘I suggest a society without unhealth would not be a utopia but a particular type of hell.’ Contradicting his own assessment, he still concluded powerfully:
Medical Nemesis, whatever its author intends, must become part of the text for a reform of the medical curriculum. That some contemporary students, confronted with the model of medical care which their teachers present, can say, ‘I am no longer sure that I want to be a doctor. I don’t want to be like you’ provides some evidence that the reform may be already upon us.10
Marinker’s prediction of imminent reform was wrong, but only in timing. It took decades before that reform occurred. The modern medical curriculum, certainly here in New Zealand, is very different from the one that I and my contemporaries were taught. The doctor of the future will be far more like the doctor that Illich saw, and the person–doctor partnership will redress the power imbalance he warned against.
My overwhelming conclusion is that, in their fear of threat of change, doctors didn’t hear Illich. If anyone could have heard, it was Marshall Marinker, but even he missed the point. In accusing Illich of painting a utopian future, he had not registered the conclusion to the summary of Medical Nemesis which Illich wrote for The Lancet, in which he explicitly stated:
The recovery of a health attitude towards sickness is neither Luddite nor Romantic nor Utopian: it is a guiding ideal which can never be fully achieved, (p.154) which can be achieved with modern devices as never before in history, and which must orient politics to avoid encroaching Nemesis.11
Illich wanted doctors to avoid their nemesis. He saw there was a solution that was best for society, but he was also protective of the scarce (and expensive) resource that are doctors. He brought in the concepts of equity, empowerment, and responsibility. In truth, the model he presented meets all the requirements for being disruptive innovation: both better and cheaper than the established way. Illich wrote:
The level of public health corresponds to the degree to which the means and responsibility for coping with illness are distributed among the total population. This ability to cope can be enhanced but never replaced by medical intervention or the hygienic characteristics of the environment. That society which can reduce professional intervention to the minimum will provide the best conditions for health. The greater the potential for autonomous adaptation to self, to others, and to the environment, the less management of adaptation will be needed or tolerated.12
Illich was overtly calling for health systems to move towards health enhancement, to achieve greater population health as well as individual control over life and health. He even saw health as the ability to adapt to changing circumstances: the new definition of positive health which was only realized by doctors nearly four decades later.
Recently, I was presenting to a group of doctors about the concepts in this book and the science behind the connection between medicine, health, and wellbeing. When they realized the book was still being written, they asked that I include two additional points. First, they pointed out that there is much being said about the harm (iatrogenesis) caused by doctors, and much ‘doctor-bashing’. They felt badly done by. They pointed out that doctors are only fulfilling the role set for them by society, and in delivering medical care to patients they are providing the service that is expected. In other words, patients are complicit in the wrongs of the current model. Their second point was that the practice that doctors provide is decided by the healthcare system. The system is designed around a particular model of practice, so it is extremely hard to do anything but provide that model of care. To my mind, there is an even stronger third point: that senior doctors in particular are delivering only what they were trained to deliver. Like our parents in raising us, they are doing their best with their current level of knowledge.
• Life course theory demonstrates that not only does our health affect our life, but life affects our health.
• There is new scientific evidence that identifies the role that environment and our choices have on our health (and sickness), including epigenetics and positive psychology.
• If we can develop the belief that we can take control of own lives and destiny, self-efficacy, we can improve our health and live longer and happier lives.
• The way that doctors have been trained during the era of advances in medical science has limited the evolution of the practice of medicine.
Our medical students are now being taught new science and new models of practice with compassion, but if we don’t create the environment in which they can work to new models, it will be a long time before the new models are incorporated into practice. The dogma of the medical model from senior doctors is entrenched. It withstands logical and evidential challenge.
The field of psychology is changing, with two models of practice running in parallel. Traditional psychology deals with mental ill health, while positive psychology takes people from a state of coping to one in which they can flourish.
The definition of health has evolved. A new definition is that health is the ability to adapt and self-manage in the face of life’s challenges. The proposal is for the new definition to be known as positive health. Life’s challenges affect us all, at all stages of our life. Our body responds to challenge with defence systems developed through millennia of human evolution. The body’s defence systems are mediated through the nervous and immune systems, under the central control of primitive parts of the brain which are not under conscious control, but influenced by our higher centres. Under states of unrelenting threats or challenges, particularly when primed by adverse childhood experiences, our nervous system and immune systems are unable to return to a normal state of balance, or ease in the system (homeostasis). Instead, a low-grade inflammatory state of allostasis, or dis-ease develops. This has the propensity to turn into illness or disease. Increasingly, this is being seen as the root of the majority of sickness in our society.
A model of medical practice is proposed which does not substitute for the medical model, but rather goes beyond it. It is meta medicine. It is not alternative or complementary, but mainstream. It is the third way. It is a model based (p.156) on traditional Māori cultural views of health being an integrated whole: physical, psychological, whānau (family) or emotional health, and spiritual health. In order to present a concept that is universally acceptable, in the model I propose, ‘spiritual’ is added to ‘existential’ health. Maslow’s hierarchy of needs, and theory of motivation, identifies that we are all driven by a desire to become the best we can be, which also coincides with those parts of life that bring purpose and meaning. The ultimate goal of humans is described by Maslow as self-actualization: becoming the person we were meant to be. In positive psychology, the ultimate state of being is known as flourishing. If the terms ‘self-actualization’ and ‘flourishing’ are not precisely synonymous, they are at the very least complementary.
Because the model relies on accurate diagnosis and prognosis, with the application of the medical model as a first stage, this model of practice is a truly medical model because doctors are uniquely qualified to practise it, even though it goes beyond their current training. Reaching a diagnosis will rely on the ability to distinguish conditions for which a specific pathological diagnosis can be reached from those for which investigations are negative and have been termed ‘medically unexplained symptoms’. The new term of bodily distress disorder has now given these conditions a specific diagnostic label. It provides a mechanistic explanation for the symptom complexes being due to disorders of physiological function in the interaction between brain, nervous system, and immune system, at the dis-ease end of the spectrum. This allows for positive diagnosis, rather than diagnosis by exclusion after a myriad of tests have been conducted. It prevents people from feeling they are being labelled as having something that’s ‘all in your head’. The potential association between these conditions and the pre-existence of adverse childhood experiences and other traumatic circumstances is now being established.
To distinguish this new model of practice from traditional medicine, and to align it with the new definition of positive health and the science of positive psychology, I propose that it be called ‘positive medicine’. The application of the model to form an individualized health plan (Life and Health Integration Plan) involves the incorporation of the habits of positive health into all aspects of the life of the individual, together with specification of what brings meaning and purpose (and therefore motivation) uniquely for that person.
What does this mean for patients?
The first part of the answer to this question is to go back to what patients want. Patients tell us they want to be upskilled to understand their own (p.157) health; to be treated like an individual, not a collection of symptoms; and to be empowered to manage their own health. They want holistic care that recognizes the importance of the many facets of their life, including the existential questions about what gives their life meaning and purpose. They want to be able to talk about belief systems and about sexuality.
With empowerment comes responsibility. In the positive medicine model, patients become the experts in their own health, with support from their doctors. Empowerment comes with a sense of control and agency, a belief that you can take control of your circumstances. But there’s no going back from that position. You can’t blame the doctor if you don’t do the things that you and your doctor have worked out will help you move forward with your life. In the person–doctor partnership, the requirement to own the end result rests with the patient.
Working through life’s opportunities opens up choices. It may be that you reach a realization that things need to change in your life to move forward and experience life to the full. These can be difficult choices, with the rewards on the other side, but they are ‘the road less travelled’. Many people settle for where they’re at and don’t make the tough calls. That’s OK, particularly if it’s a conscious choice. If you choose not to make tough calls, the most important thing is that you take control of the things that are within your power to control and enjoy life anyway.
One caution. There is a strong evidence base which demonstrates that taking control of one’s life and applying the habits of positive health improves health, happiness, and length of life, and decreases illness and disease. However, that is a statistical finding that holds true for groups of people. I’m not proposing this model as a panacea, but I am saying it goes beyond what currently exists. The current medical model is losing the battle against illness and disease. What if the positive medicine process doesn’t actually reduce your personal markers of disease (for instance, if it doesn’t return the blood sugar of a type 2 diabetic to normal), but nonetheless the end result is understanding your own health better? What if the result is that you have more control of your life and a clearer sense of its purpose and meaning? What if the end result is that you feel happier?
Is that not a better outcome than the current deficit model of disease care, where the goal is to avoid a negative outcome?
Because this is a positive health model for health enhancement rather than a disease management model, it means that it applies to you whether you’re fit and healthy and want to stay so (primary prevention), stressed and in a state of dis-ease with illness or disease waiting to happen (secondary prevention), or have already developed a condition or conditions (tertiary prevention). At any (p.158) of these tiers, you are likely to benefit and be able to take control of your life and health.
What does this mean for doctors?
The RCGP in the UK is clear what general practice in the UK in 2030 needs to look and feel like, having undertaken extensive consultation. It will need new models of practice: ‘Our vision is that by 2030, general practice will have the skills and resources it needs to meet the healthcare needs of the population by preventing more illness, diagnosing and treating disease and empowering patients to live healthy, fulfilling lives.’13 The College describes more holistic, patient-centred models of care, focused more on prevention, adopting a partnership approach so that GPs can have more fulfilling relationships with their patients.
The RCGP foresees a team approach, with doctors providing just part of the picture, and incorporating other skills into the team, including helping people address the social determinants of health. There will be more flexibility and more use of technology, such as remote consultations (by phone or videoconference). As I work through their 2030 wish list, all the angles are covered by positive medicine. It ticks all the boxes. A model of practice such as positive medicine is the future of general practice in the UK by 2030, by my analysis.
This person–doctor partnership achieves a number of benefits for doctors as well as patients: because of the partnership approach, there is far more involvement from the patient in making management choices. This means more likelihood of therapeutic success and less inappropriate prescribing and risk of side effects. Greater levels of explanation and informed consent means lower utilization of treatment modalities lacking evidence, lower levels of dissatisfaction, and fewer patient complaints. It’s safer for both patients and doctors.
My experience is of the privilege of spending time with people, hearing their stories, their hopes, and their fears. The fact that I can contribute and make a difference brings a huge degree of satisfaction. At our last session, my client Glyn said to me, ‘I really look forward to our meetings. It feels as though I’m the focus of everything we’re doing. It feels like a partnership.’
Again, I need to be clear that I don’t see this model being for all doctors. I see it being ideal for GPs and some specialist doctors, such as occupational physicians, rehabilitation physicians, palliative care physicians (who practise to similar models in any case), and paediatricians. An obstetrician has just (p.159) expressed interest in hearing more. I expect that some doctors will reject the approach as being too far removed from their training and their understanding of health and disease. My job is not to persuade them. Rather, I want to empower the doctors who tell me they are already aware of the need for more holistic and patient-centred models and want to practise to those models.
Where do the medical colleges fit in?
It is clear that the RCGP in the UK is taking a leadership role and seeking to positively influence the health of the population of the UK by new models of general practice. But 2030 is still a long way off. I suspect that the future vision it paints is so far off because of the inertia of the system, and the big change of emphasis required to move away from disease care to healthcare. I’m sure that the RCGP is already advocating for change at a system level. But it needs the strength of patient views and public opinion behind it in order to influence the political will to expedite change.
Here in New Zealand and Australia, the medical colleges have been under attack and accused of being simply a professional guild, established purely for the purpose of supporting their members; that the colleges are self-serving and not fit for purpose in the modern world of healthcare. Professor Des Gorman put forward this notion in the journal of the RACP.14
I see this challenge in the same light as that of Ivan Illich, and consider Professor Gorman to be a positive disruptor. He accuses the medical colleges of not responding to health system failings, of not reducing medical error, and asks the question:
Is the future college role to be constrained to professional and technical evaluation of doctor competence and up-skilling? Can the medical guilds become effective socially beyond intrinsic guild-need and play a role in preventing and mitigating, and in responding to health system failures?15
As an active and proud member of the RACP, my answer to Professor Gorman is a resounding ‘Yes! I believe we can.’
As well as training and evaluating specialist physicians, the RACP is active in advocating for positive healthcare system change. Its EVOLVE project provides leadership in identifying the myriad of medical treatments and interventions with no proven value, and instead proven harm, and advocates for (p.160) their use by doctors to be stopped. The Aotearoa New Zealand Committee of the RACP has been active in promoting action on healthy housing, good work, and family wellbeing. Employment, Poverty and Health, the statement of principles on the role of doctors to influence the social determinants of health, sets out the ways that doctors can move beyond traditional roles to have societal influence. And my own faculty has led the charge in developing the Consensus Statement on the Health Benefits of Work. The progression of the College’s annual conference, Congress, shows how progressive its thinking is around health and practice. The RACP is active in health advocacy in its most holistic sense.
The medical colleges can be voices of advocacy for societal change and, in particular, addressing the challenges put to us by Ivan Illich. Illich saw patient pressure as the solution. That didn’t work effectively against the system. The answer to iatrogenesis lies not with patients, but with doctors. Not just individual doctors, but the medical colleges. I personally challenge every board member of every medical college to read Medical Nemesis and, rather than reacting defensively, to critically appraise the case Illich puts forward for patient empowerment and new models of medical practice which reduce patient harm and increase people’s ability to face life’s challenges. If the argument was strong in the 1970s, I see it now as incontrovertible.
How is your college preparing to avoid impending nemesis?
Other key players
An underlying flaw in the system is the historical training of doctors. To achieve the future state, our medical students and junior doctors must able to practise the new principles and models of medical practice they are being taught. It follows that the universities and medical schools need to be influencing medical education, by communicating with the medical colleges which provide continuing professional development to doctors. I have been surprised talking to my own son and other medical students and junior doctors by just how different their training has been to my own, and the different concepts they are being taught. Yet these concepts are foreign to many senior doctors. This is a state of affairs which must not be allowed to continue.
The hospital system and those who design healthcare systems will be pricking their ears up. The potential for positive medicine as disruptive innovation leading to more effective, safer, and cheaper healthcare should be viewed as an opportunity for complete system redesign and revolutionary advances in (p.161) healthcare, not the evolutionary improvement in disease care which is so obviously failing us. The opportunity for revolutionary change extends to hospital and local systems too, where innovative approaches can be taken.
Nurses and allied health professionals see the principles I espouse as obvious, because they reflect their own training. They completely understand the flaws of the medical model. That means there is an important role for the professional bodies of these non-doctor healthcare professionals to influence change and challenge the reductionist status quo of the medical model.
Others with a vested interest in getting this right include insurers, workers’ or injury compensation bodies, lawyers, and employers. I see all these players as potentially adding to the flaws of the system. (In the thousands of cases where patients have been let down by the system, all of them have at times been contributory.) But being part of the problem always opens up the possibility of being part of the solution. I am seeing many large employers making great advances in looking after the health and wellbeing of their workers. I am seeing insurance companies taking a far more positive and health-promoting approach to insurance policies and claims management.
Ultimately, though, the solution does rest with the people, and specifically the representatives of the people. That power rests with government. As hard as it sometimes is to realize it, governments exist to deliver the will of the people and what is best for our communities and societies. That includes the departments and ministries of health, their chief scientists and chief medical advisors, and the civil servants who advise ministers and run government services. It is the political will which will ultimately decide the funding for new healthcare systems.
As patients, we do have a say, by making it clear to our politicians that we want positive change.
My response to Ivan Illich
Dear Ivan Illich,
In belated response to your 1974 warning of Medical Nemesis, I would like to apologize that we perceived your message as a threat, rather than the opportunity for change you intended.
As I write, 47 years later, patients are still asking for the empowerment and control over their lives and health that you warned was being taken from them by the medical system. You saw the root of the problem as being doctors. Iatrogenesis—it begins with the healer.
(p.162) Ultimately, as you saw, the solution does rest with patients and their ability to influence political will and change systems. But there is a more elegant and powerful agent of change, and that is to go to the root of the problem, namely, doctors.
I propose that doctors provide the thought leadership for the revolutionary change to positive medicine in order to deliver the positive health that people are asking for. For doctors to go beyond the medical model to a holistic empowerment model means that the meaning of iatrogenesis can also be extended to reflect the shift in role—to positive iatrogenesis. Once again, it begins with the healer.
But here’s the final twist. As we once again see doctors as the healers that society needs them to be, we also realize that we are all healers. Our body is the ultimate healer. Working together, the partnership creates the circumstances of ease to allow the body to heal. Since doctors are people too, and doctors are patients too, we all benefit. We are one.
(1.) Illich, Ivan. Limits to Medicine: Medical Nemesis. London: Calder & Boyars, 1974.
(2.) Iatrogenesis, from the Greek iatros (doctor), meaning ‘inadvertent harm caused by doctors’. Illich defined three levels: firstly, clinical iatrogenesis, which includes the harm done directly by doctors, including ineffective, unsafe, and erroneous treatments; secondly, social iatrogenesis, the medicalization of normal life events such as ageing; and thirdly, cultural iatrogenesis, the destruction of traditional ways of dealing with death, suffering, and sickness.
(3.) Illich, Ivan. Limits to Medicine: Medical Nemesis, 2nd ed. London: Calder & Boyars, 1995, pp. v–vi.
(4.) Illich, Ivan. Deschooling Society. London: Marion Boyars, 1971.
(7.) Marshall Marinker’s obituary: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31729-5/fulltext.
(9.) Marshall Marinker’s obituary, https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31729-5/fulltext.
(11.) Illich, Ivan. ‘Medical nemesis’. The Lancet, 1974, 303(7863): 918–921.
(12.) Illich, Ivan. Limits to Medicine: Medical Nemesis, 2nd ed. London: Calder & Boyars, 1995, p. 274.
(14.) Gorman, Des. ‘Medical colleges: whose purpose, if any, do they serve?’ Internal Medicine Journal, 2017, 47(3): 245–247.