The Disestablishment of the Medical Priesthood

Ivan Illich's Medical Nemesis and the supernatural power erroneously ascribed to doctors of medicine

“The medical clergy can be controlled only if the law is used to restrict and disestablish its monopoly on deciding what constitutes disease, who is sick, and what ought to be done to him or her.” - Ivan Illich

In 1976, Ivan Illich wrote what is perhaps the most comprehensive critique of contemporary medicine: Medical Nemesis: The Expropriation of Health. This book coined the term iatrogenesis (yat-ro-genesis) to refer to the harm caused by medical treatments, the collateral damage of contemporary medicine. It is astonishing to me that this had not been recognised before, except perhaps in that quaint horror we have for the beliefs of doctors past, like blood-letting or the four humours.

To Illich’s despair, his book was taken up immediately by medical schools as a coursebook, whereupon its main title was softened to Limits to Medicine. What had been intended as a savage critique of the self-thwarting institution of ‘modern medicine’ was being absorbed into the very practices that Illich was opposing. But now, half a century later, this slight speed bump has been ironed out: it is not that iatrogenesis has been eliminated - it is far worse now than it has ever been before. We have simply moved beyond caring about it.

Medical Nemesis takes a far-sighted view of the history of our relationship with death. We have gone from our dying being an acknowledged inevitability that everyone has to face when their time comes, to something treated as capable of infinite postponement, provided ‘correct treatments’ are provided. We are entrenched in a belief that our bodies are machines whose durability can be maintained indefinitely, provided we put ourselves in for appropriate maintenance from time to time. As Illich shrewdly observed, this bizarre metaphysical viewpoint also puts us all under an obligation to foot the bill for both the market research and the advertising endeavours of the medical establishment.

Neither is Illich the only one to mount such a critique. The economist Milton Friedman savaged the idea of medical licensure, which he saw primarily as a means of establishing and maintaining a monopoly. By controlling the number of practicing physicians, licensure limits competition and brings about an inflation of the associated wages. The result of this guild system can be clearly witnessed in the United States, a nation that has access to the most potent medical technology, offers the most expensive medical services through mandatory subscriptions, yet has among the worst health outcomes of anywhere on the planet.

Mary Midgley noted that medical doctors have inherited the power once possessed by priests, and this was also Illich’s accusation. We have reserved vast authority over human life to a medical establishment whose political influence now far outstrips anything the Vatican achieved in the Middle Ages. At that time, people would turn to their parish priests for advice on all life’s problems - no doubt including a great many for which the clergy were unable to offer much assistance. Our secular priesthood, on the other hand, considers nothing off limits for its manufactured solutions, and the harms that it inflicts in its forever war against disease are increasingly absolved as ‘necessary sacrifices’.

At the same time that the Enlightenment heralded our religious freedom we were unknowingly enshrining a new godless theocracy, a metaphysical faith in magical medicine that is the epitome of the technological zeitgeist. Its practices now have very little to do with scientific process, and the ancient principle of ‘first do no harm’ is long forgotten. The field of medicine has become rather disinterested in the art of healing what can be cured, and committed instead to the salvation of humanity from the perpetual attack of illness. Meanwhile, techno-medicine’s most dedicated zealots cling to their naïve faith that immortality of the flesh will soon be granted to them...

Oh, but the horror that accompanies the suggestion that we should disestablish our secular priesthood! We are appalled at the idea that we might disband the medical guild and permit people to practice medicine for themselves. We dare not let medical practitioners justify their fees by offering demonstrably superior healthcare, for we are committed to deploying the law in order to compel everyone to fund the ever-expanding crusade against diabolical disease. Yet now, as euthanasia is added to the list of tools for ‘curing’ disease, what plausibility remains for the status quo? If your doctor is permitted to kill you, what exactly is it that we fear the unlicensed healer could do that would be any worse...?