Medical Nemesis
2
The Medicalization of Life
Political Transmission of Iatrogenic Disease
Until recently medicine attempted to enhance what occurs in nature. It
fostered the tendency of wounds to heal, of blood to clot, and of
bacteria to be overcome by natural immunity.1 Now medicine tries to
engineer the dreams of reason.2 Oral contraceptives, for instance, are
prescribed "to prevent a normal occurrence in healthy persons."3
Therapies induce the organism to interact with molecules or with
machines in ways for which there is no precedent in evolution. Grafts
involve the outright obliteration of genetically programmed
immunological defenses.4 The relationship between the interest of the
patient and the success of each specialist who manipulates one of his
"conditions" can thus no longer be assumed; it must now be proved, and
the net contribution of medicine to society's burden of disease must be
assessed from without the profession.5 But any charge against medicine
for the clinical damage it causes constitutes only the first step in
the indictment of pathogenic medicine.6 The trail beaten in the harvest
is only a reminder of the greater damage done by the baron to the
village that his hunt overruns.
Social Iatrogenesis
Medicine undermines health not only through direct aggression against
individuals but also through the impact of its social organization on
the total milieu. When medical damage to individual health is produced
by a sociopolitical mode of transmission, I will speak of "social
iatrogenesis," a term designating all impairments to health that are
due precisely to those socio-economic transformations which have been
made attractive, possible, or necessary by the institutional shape
health care has taken.
Social iatrogenesis
designates a category of etiology that encompasses many forms. It
obtains when medical bureaucracy creates ill-health by increasing
stress, by multiplying disabling dependence, by generating new painful
needs, by lowering the levels of tolerance for discomfort or pain, by
reducing the leeway that people are wont to concede to an individual
when he suffers, and by abolishing even the right to self-care. Social
iatrogenesis is at work when health care is turned into a standardized
item, a staple; when all suffering is "hospitalized" and homes become
inhospitable to birth, sickness, and death; when the language in which
people could experience their bodies is turned into bureaucratic
gobbledegook; or when suffering, mourning, and healing outside the
patient role are labeled a form of deviance.
Medical Monopoly
Like its clinical counterpart, social iatrogenesis can escalate from an
adventitious feature into an inherent characteristic of the medical
system. When the intensity7 of biomedical intervention crosses a
critical threshold, clinical iatrogenesis turns from error, accident,
or fault into an incurable perversion of medical practice. In the same
way, when professional autonomy degenerates into a radical monopoly8
and people are rendered impotent to cope with their milieu, social
iatrogenesis becomes the main product of the medical organization.
A radical monopoly goes deeper than that of any one corporation or any
one government. It can take many forms. When cities are built around
vehicles, they devalue human feet; when schools pre-empt learning, they
devalue the autodidact; when hospitals draft all those who are in
critical condition, they impose on society a new form of dying.
Ordinary monopolies corner the market;9 radical monopolies disable
people from doing or making things on their own.10 The commercial
monopoly restricts the flow of commodities; the more insidious social
monopoly paralyzes the output of nonmarketable use-values.11 Radical
monopolies impinge still further on freedom and independence. They
impose a society-wide substitution of commodities for use-values by
reshaping the milieu and by "appropriating" those of its general
characteristics which have enabled people so far to cope on their own.
Intensive education turns autodidacts into unemployables, intensive
agriculture destroys the subsistence farmer, and the deployment of
police undermines the community's self-control. The malignant spread of
medicine has comparable results: it turns mutual care and
self-medication into misdemeanors or felonies. Just as clinical
iatrogenesis becomes medically incurable when it reaches a critical
intensity and then can be reversed only by a decline of the enterprise,
so can social iatrogenesis be reversed only by political action that
retrenches professional dominance.
A radical
monopoly feeds on itself. Iatrogenic medicine reinforces a morbid
society in which social control of the population by the medical system
turns into a principal economic activity. It serves to legitimize
social arrangements into which many people do not fit. It labels the
handicapped as unfit and breeds ever new categories of patients. People
who are angered, sickened, and impaired by their industrial labor and
leisure can escape only into a life under medical supervision and are
thereby seduced or disqualified from political struggle for a healthier
world.12
Social iatrogenesis is not yet accepted as
a common etiology of disease. If it were recognized that diagnosis
often serves as a means of turning political complaints against the
stress of growth into demands for more therapies that are just more of
its costly and stressful outputs, the industrial system would lose one
of its major defenses.13 At the same time, awareness of the degree to
which iatrogenic ill-health is politically communicated would shake the
foundations of medical power much more profoundly than any catalogue of
medicine's technical faults.14
Value-free Cure?
The issue of social iatrogenesis is often confused with the diagnostic
authority of the healer. To defuse the issue and to protect their
reputation, some physicians insist on the obvious: namely, that
medicine cannot be practiced without the iatrogenic creation of
disease. Medicine always creates illness as a social state.15 The
recognized healer transmits to individuals the social possibilities for
acting sick.16 Each culture has its own characteristic perception of
disease17 and thus its unique hygienic mask.18 Disease takes its
features from the physician who casts the actors into one of the
available roles.19 To make people legitimately sick is as implicit in
the physician's power as the poisonous potential of the remedy that
works.20 The medicine man commands poisons and charms. The Greeks' only
word for "drug"—pharmakon— did not distinguish between the power to
cure and the power to kill.21
Medicine is a moral
enterprise and therefore inevitably gives content to good and evil. In
every society, medicine, like law and religion, defines what is normal,
proper, or desirable. Medicine has the authority to label one man's
complaint a legitimate illness, to declare a second man sick though he
himself does not complain, and to refuse a third social recognition of
his pain, his disability, and even his death.22 It is medicine which
stamps some pain as "merely subjective," 23 some impairment as
malingering,24 and some deaths—though not others—as suicide.25 The
judge determines what is legal and who is guilty.26 The priest declares
what is holy and who has broken a taboo. The physician decides what is
a symptom and who is sick. He is a moral entrepreneur,27 charged with
inquisitorial powers to discover certain wrongs to be righted.28
Medicine, like all crusades, creates a new group of outsiders each time
it makes a new diagnosis stick.29 Morality is as implicit in sickness
as it is in crime or in sin.
In primitive societies
it is obvious that in the exercise of medical skill, the recognition of
moral power is implied. Nobody would summon the medicine man unless he
conceded to him the skill of discerning evil spirits from good ones. In
a higher civilization this power expands. Here medicine is exercised by
full-time specialists who control large populations by means of
bureaucratic institutions.30 These specialists form professions which
exercise a unique kind of control over their own work.31 Unlike unions,
these professions owe their autonomy to a grant of confidence rather
than to victory in a struggle. Unlike guilds, which determine only who
shall work and how, they determine also what work shall be done. In the
United States the medical profession owes this supreme authority to a
reform of the medical schools just before World War I. The medical
profession is a manifestation in one particular sector of the control
over the structure of class power which the university-trained elites
have acquired. Only doctors now "know" what constitutes sickness, who
is sick, and what shall be done to the sick and to those whom they
consider at a special risk. Paradoxically, Western medicine, which has
insisted on keeping its power apart from law and religion, has now
expanded it beyond precedent. In some industrial societies social
labeling has been medicalized to the point where all deviance has to
have a medical label. The eclipse of the explicit moral component in
medical diagnosis has thus invested Aesculapian authority32 with
totalitarian power.
The divorce between medicine
and morality has been defended on the ground that medical categories,
unlike those of law and religion, rest on scientific foundations exempt
from moral evaluation.33 Medical ethics have been secreted into a
specialized department that brings theory into line with actual
practice.34 The courts and the law, when they are not used to enforce
the Aesculapian monopoly, are turned into doormen of the hospital who
select from among the clients those who can meet the doctors'
criteria.35 Hospitals turn into monuments of narcissistic scientism,
concrete manifestations of those professional prejudices which were
fashionable on the day their cornerstone was laid and which were often
outdated when they came into use. The technical enterprise of the
physician claims value-free power. It is obvious that in this kind of
context it is easy to shun the issue of social iatrogenesis with which
I am concerned. Politically mediated medical damage is thus seen as
inherent in medicine's mandate, and its critics are viewed as sophists
trying to justify lay intrusion into the medical bailiwick. Precisely
for this reason, a lay review of social iatrogenesis is urgent. The
assertion of value-free cure and care is obviously malignant nonsense,
and the taboos that have shielded irresponsible medicine are beginning
to weaken.
The Medicalization of the Budget
The most handy measure of the medicalization of life is the share taken
out of a typical yearly income to be spent under doctor's orders. In
America before 1950, this was less than a month's income, but by the
mid-seventies, the equivalent of between five and seven weeks of the
typical worker's earnings were spent on the purchase of medical
services. The United States now spends about $95 billion a year for
health care, about 8.4 percent of the gross national product in 1975,
up from 4.5 percent in 1962.36 During the past twenty years, while the
price index in the United States has risen by about 74 percent, the
cost of medical care has escalated by 330 percent. Between 1950 and
1971 public expenditure for health insurance increased tenfold, private
insurance benefits increased eightfold,37 and direct out-of-pocket
payments about three-fold.38 In over-all expenditures other countries
such as France39 and Germany40 kept abreast of the United States. In
all industrial nations—Atlantic, Scandinavian, or East European—the
growth rate of the health sector has advanced faster than that of the
GNP.41 Even discounting inflation, federal health outlays increased by
more than 40 percent between 1969 and 1974.42 The medicalization of the
national budget, moreover, is not a privilege of the rich: in Colombia,
a poor country that notoriously favors its rich, the proportion, as in
England, is more than 10 percent.43
Some of this
has enriched doctors, who until the French Revolution earned their
living as artisans. A few always lived well, but more died poor. The
proverb "Few lawyers die well, few physicians live well" had its
equivalent in most European languages. Now physicians have come to the
top, and in capitalist societies this top is high indeed. Yet it would
be inaccurate to blame the inflation in medicine on the greed of the
medical profession. Much more of the increase has gone to a host of
well-titled medical paper-shufflers whom United States universities
began to graduate in the fifties: to those with masters' degrees in
nursing supervision or with doctorates in hospital administration, and
to all the lower ranks on which the new bureaucrats feed. The cost of
administering the patient, his files, and the checks he writes and
receives can take a quarter out of each dollar on his bill.44 More goes
to the bankers; in some cases the so-called "legitimate" administrative
costs in the medical health insurance business have risen to 70 percent
of the payment made to commercial carriers.
Even
more significant is the new prejudice in favor of high-cost hospital
care. Since 1950 the cost of keeping a patient for one day in a
community hospital in the United States has risen by 500 percent.45 The
bill for patient care in the major university hospitals has risen even
faster, tripling in eight years. Administrative costs have exploded,
multiplying since 1964 by a factor of 7; laboratory costs have risen by
a factor of 5, medical salaries only by a factor of 2.46 The
construction of hospitals now costs in excess of $85,000 per bed, of
which two-thirds buys mechanical equipment that is made obsolete within
less than ten years.47 These rates are almost twice those of the cost
increases and of the obsolescence prevalent in modern weapons systems.
Costs overruns in programs of the Health, Education, and Welfare
Department exceed those in the Pentagon. Between 1968 and 1970 Medicaid
costs increased three times faster than the number of people served. In
the last four years hospital insurance benefits have almost doubled in
cost, and physicians' fees have increased almost twice as fast as had
been planned.48 There is no precedent for a similar sustained expansion
in any other major sector in the civilian economy. It is therefore
ironic that during this unique boom in health care the United States
established another "first." Shortly after the boom started, the life
expectancy for adult American males began to decline and is now
expected to decline even further. The death rate for American males
aged forty-five to fifty-four is comparatively high. Of every 100 males
in the United States who turn forty-five only 90 will see their
fifty-fifth birthday, while in Sweden 95 will survive the decade.49 But
Sweden, Germany, Belgium, Canada, France, and Switzerland are now
catching up with the United States: both their age-specific death rates
for adult males and their global medical costs are shooting up.50
The phenomenal rise in cost of health services in the United States has
been explained in different ways: some blame irrational planning,51
others the higher cost of the new gimmicks that people want in
hospitals.52 The most common interpretation at present relates to the
growing incidence of prepayment of services. Hospitals register
well-insured patients, and rather than providing old products more
efficiently and cheaply, are economically motivated to move towards new
and increasingly expensive ways of doing things. Changing products
rather than higher labor costs, bad administration, or lack of
technological progress are blamed for the rise.53 In this perspective
the change in products seems due precisely to the increased insurance
coverage which encourages hospitals to provide products more expensive
than the customer actually wants, needs, or would have been willing to
pay for directly. His out-of-pocket costs appear increasingly modest,
even though the services offered by the hospital are more costly.
Insurance for high-cost sick-care is thus a self-reinforcing process
which invests the providers of care with the control of increasing
resources.54 As an antidote, some critics recommend enlightened cost
consciousness on the part of consumers;55 others, not trusting the
self-control of laymen, recommend mechanisms to heighten the cost
consciousness of producers.56 Physicians, they argue, would prescribe
more responsibly and less wantonly if they were paid (as are general
practitioners in Britain) on a "capitation" basis that provided a fixed
amount for the maintenance of their clients rather than a fee for
service. But like all other such remedies, capitation enlarges the
iatrogenic fascination with the health supply. People forgo their own
lives to get as much treatment as they can.
In
England the National Health Service has tried, albeit unsuccessfully,
to ensure that cost inflation will be less plagued by conspicuous
flimflam.57 The National Health Service Act of 1946 established access
to health-care resources for all those in need as a human right. The
need was assumed to be finite and quantifiable, the ballot box the best
place to decide the total budget for health, and doctors the only ones
able to determine the resources that would satisfy the need of each
patient. But need as assessed by medical practitioners has proved to be
just as extensive in England as anywhere else. The fundamental hope for
the success of the English health-care system lay in the belief in the
ability of the English to ration supply. Until about 1972 they did so,
in the opinion of an author who surveyed British health economics, "by
means in their way almost as ruthless—but generally held to be more
acceptable—than the ability to pay."58 Until that time health care was
kept below 6 percent of GNP, 10 percent of public spending. Private
practice had shrunk from half of all care to 4 percent. Direct charges
to patients were kept at a phenomenally low 5 percent of the cost. But
this stern commitment to equality prevented only those astounding
misallocations for prestigious gadgetry which provided an easy starting
point for public criticism in the United States. Since 1972 the Health
Service in Britain has undergone a traumatic change, for complex
economic and political reasons. The initial success of the Health
Service and the present unique disarray in the system make predictions
for the future impossible. Demedicalization of health care is as
essential there as elsewhere. Yet curiously, England is also one of the
few industrialized countries where the life expectancy of adult males
has not yet declined, though the chronic diseases of this group have
already shown an increase similar to that observed a decade earlier
across the Atlantic.
Information on costs in the
Soviet Union is more difficult to come by. The number of physicians and
hospital days per capita seems to have doubled between 1960 and 1972,
and costs to have increased by about 260 percent.59 The main claim to
superiority of Soviet medicine is still based on "prophylaxis built
into the social system itself," without this affecting the relative
volume of disease or care in comparison with other industrial countries
of similar development.60 But the theory that therapeutics would wither
away with the state became and has remained heresy since 1932.61
Distinct political systems organize pathologies into different diseases
and thus create distinct categories of demand, supply, and unmet
needs.62 But no matter how disease is perceived, the cost of treatment
rises at comparable rates. The Russians, for instance, limit by decree
mental disease requiring hospitalization: they allow only 10 percent of
all hospital beds for such cases.63 But at a given GNP all industrial
nations generate the same kind of dependence on the physician, and do
so irrespective of their ideology and the nosology these beliefs
engender.64 (Of course, capitalism has proved that it can do so at a
much higher social cost.65) Everywhere in the mid-seventies the main
constraint on professional activity is the necessity to reduce costs.
The proportion of national wealth which is channeled to doctors and
expended under their control varies from one nation to another and
falls somewhere between one-tenth and one-twentieth of all available
funds. But this should lead nobody to believe that health expenditures
on the typical citizen in poor countries are anywhere proportionate to
the countries' per capita average income. Most people get absolutely
nothing. Excepting only the money allocated for treatment of water
supplies, 90 percent of all funds earmarked for health in developing
countries is spent not for sanitation but for treatment of the sick.
From 70 percent to 80 percent of the entire public health budget goes
to the cure and care of individuals as opposed to public health
services.66 Most of this money is spent everywhere on the same kinds of
things.
All countries want hospitals, and many want
them to have the most exotic modern equipment. The poorer the country,
the higher the real cost of each item on their inventories. Modern
hospital beds, incubators, laboratories, respirators, and operating
rooms cost even more in Africa than their counterparts in Germany or
France where they are manufactured: they also break down more easily in
the tropics, are more difficult to service, and are more often than not
out of use. As to cost, the same is true of the physicians who are made
to measure for these gadgets. The education of an open-heart surgeon
represents a comparable capital investment, whether he comes from the
Mexican school system or is the cousin of a Brazilian captain sent on a
government scholarship to study in Hamburg.67 The United States might
be too poor to provide renal dialysis at $15,000 per year to all those
citizens who would claim to need it, but Ghana is too poor to provide
the people equitably with physicians for primary care.68 Socially
critical maximum cost of items that can be equitably shared varies from
one place to another. But whenever tax funds are used to finance
treatment above the critical cost, the system of medical care acts
inevitably as a device for the net transfer of power from the majority
who pay the taxes to the few who are selected because of their money,
schooling, or family ties, or because of their special interest to the
experimenting surgeon.
It is clearly a form of
exploitation when four-fifths of the real cost of private clinics in
poor Latin American countries is paid for by the taxes collected for
medical education, public ambulances, and medical equipment.69 In this
case the concentration of public resources on a few is obviously unjust
because the ability to pay out of pocket a fraction of the total cost
of treatment is a condition for getting the rest underwritten. But the
exploitation is no less in places where the public, through a national
health service, assigns to physicians the sole power to decide who
"needs" their kind of treatment, and then lavishes public support on
those on whom they experiment or practice. The public acquiescence in
the doctor's monopoly on identifying needs only broadens the base from
which doctors can sell their services.70
Indirectly, conspicuous therapies serve as powerful devices to convince
people that they should pay more taxes to get them to all those whom
doctors have declared in need. Once President Frei of Chile had started
on one palace for medical spectator-sports, his successor, Salvador
Allende, was forced to promise three more. The prestige of a puny
national team in the medical Olympics is used to intensify a nationwide
addiction to therapeutic relationships that are pathogenic on a level
much deeper than mere medical vandalism. More health damage is caused
by people's belief that they cannot cope with their illness unless they
call on the doctor than doctors could ever cause by foisting their
ministrations on people.
Only in China—at least, at
first sight—does the trend seem to run in the opposite direction:
primary care is given by nonprofessional health technicians assisted by
health apprentices who leave their regular jobs in the factory when
they are called on to assist a member of their brigade.71 Nutrition,
environmental hygiene, and birth control have improved beyond
comparison. The achievements in the Chinese health sector during the
late sixties have proved, perhaps definitively, a long-debated point:
that almost all demonstrably effective technical health devices can be
taken over within months and used competently by millions of ordinary
people. Despite such successes, an orthodox commitment to Western
dreams of reason in Marxist shape may now destroy what political
virtue, combined with traditional pragmatism, has achieved. The bias
towards technological progress and centralization is reflected already
in the professional reaches of medical care. China possesses not only a
paramedical system but also medical personnel whose educational
standards are known to be of the highest order by their counterparts
around the world, and which differ only marginally from those of other
countries. Most investment during the last four years seems to have
gone towards the further development of this extremely well qualified
and highly orthodox medical profession, which is getting increasing
authority to shape the over-all health goals of the nation. "Barefoot
medicine" is losing its makeshift, semi-independent, grassroots
character and is being integrated into a unitary health-care
technocracy. University-trained personnel instruct, supervise, and
complement the locally elected healer. This ideologically fueled
development of professional medicine in China will have to be
consciously limited in the very near future if it is to remain a
balancing complement rather than an obstacle to high-level self-care.72
Without comparable statistics, statements on Chinese medical economy
remain vague. But there is no reason to believe that cost increases in
pharmaceutical, hospital, and professional medicine in China are less
than in other countries. For the time being, however, it can be argued
that in China modern medicine in rural districts was so scarce that
recent increments contributed significantly to health levels and to
increased equity in access to care.73
In all
countries the medicalization of the budget is related to
well-recognized exploitation within the class structure. No doubt, the
dominance of capitalist oligarchies in the United States,74 the
superciliousness of the new mandarins in Sweden,75 the servility and
ethnocentrism of Moscow professionals,76 and the lobby of the American
Medical and Pharmaceutical Associations,77 as well as the new rise of
union power in the health sector,78 are all formidable obstacles to a
distribution of resources in the interests of the sick rather than of
their self-appointed caretakers. But the fundamental reason why these
costly bureaucracies are health-denying lies not in their instrumental
but in their symbolic function: they all stress delivery of repair and
maintenance services for the human component of the megamachine,79 and
criticism that proposes better and more equitable delivery only
reinforces the social commitment to keep people at work in sickening
jobs. The war between the proponents of unlimited national health
insurance and those who stand up for national health maintenance, as
well as the war between those defending and those attacking all private
practice, shifts public attention from the damage done by doctors who
protect a destructive social order to the fact that doctors do less
than expected in defense of a consumer society.
Beyond a certain encroachment on the budget, money that expands medical
control over space, schedules, education, diet, or the design of
machines and goods will inevitably unleash a "nightmare forged from
good intentions." Money may always threaten health. Too much money
corrupts it. Beyond a certain point, what can produce money or what
money can buy restricts the range of self-chosen "life." Not only
production but also consumption stresses the scarcity of time, space,
and choice.80 Therefore the prestige of medical staples must sap the
cultivation of health, which, within a given environment, to a large
extent depends on innate and inbred mettle.81 The more time, toil, and
sacrifice spent by a population in producing medicine as a commodity,
the larger will be the by-product, namely, the fallacy that society has
a supply of health locked away which can be mined and marketed.82 The
negative function of money is that of an indicator of the devaluation
of goods and services that cannot be bought.83 The higher the price tag
at which well-being is commandeered, the greater will be the political
prestige of an expropriation of personal health.
The Pharmaceutical Invasion
Doctors are not needed to medicalize a society's drugs.84 Even without
too many hospitals and medical schools a culture can become the prey of
a pharmaceutical invasion. Each culture has its poisons, its remedies,
its placebos, and its ritual settings for their administration.85 Most
of these are destined for the healthy rather than for the sick.86
Powerful medical drugs easily destroy the historically rooted pattern
that fits each culture to its poisons; they usually cause more damage
than profit to health, and ultimately establish a new attitude in which
the body is perceived as a machine run by mechanical and manipulating
switches.87
In the 1940s few of the prescriptions
written in Houston or Madrid could have been filled in Mexico, except
in the zona rosa of Mexico City, where international pharmacies
flourish alongside boutiques and hotels. Today Mexican village
drugstores offer three times as many items as drugstores in the United
States. In Thailand 88 and Brazil, many items that are elsewhere
outdated, or illegal surplus and duds, are dumped into pharmacies by
manufacturers who sail under many flags of convenience. In the past
decade, while a few rich countries began to control the damage, waste,
and exploitation caused by the licit drug-pushing of their doctors,
physicians in Mexico, Venezuela, and even Paris had more difficulty
than ever before in getting information on the side-effects of the
drugs they prescribed.89 Only ten years ago, when drugs were relatively
scarce in Mexico, people were poor, and most sick persons were attended
by grandmother or the herbalist, pharmaceuticals came packaged with a
descriptive leaflet. Today drugs are more plentiful, more powerful, and
more dangerous; they are sold by television and radio; people who have
attended school feel ashamed of their lingering trust in the Aztec
curer; and the leaflet has been replaced by one standard note which
says "on prescription." The fiction which is meant to exorcise the drug
by medicalizing it in fact only confounds the buyer. The warning to
consult a doctor makes the buyer believe he is incompetent to beware.
In most countries of the world, doctors are simply not well enough
spread out to prescribe double-edged medicine each time it is
indicated, and most of the time they themselves are not prepared, or
are too ignorant, to prescribe with due prudence. As a consequence the
physician's function, especially in poor countries, has become trivial:
he has been turned into a routine prescription machine that is
constantly ridiculed, and most people now take the same drugs, just as
haphazardly, but without his approval.90
Chloramphenicol is a good example of the way reliance on prescription
can be useless for the protection of patients and can even promote
abuse. During the 1960s this drug was packaged as Chloromycetin by
Parke, Davis and brought in about one-third of the company's over-all
profits. By then it had been known for several years that people who
take this drug stand a certain chance of dying of aplastic anemia, an
incurable disease of the blood. Typhoid is almost the only disease
that, with serious qualifications, does justify the taking of this
substance. Through the late fifties and early sixties, Parke, Davis,
notwithstanding strong clinical contraindications, spent large sums to
promote their winner. Doctors in the United States prescribed
chloramphenicol to almost four million people per year to treat them
for acne, sore throat, the common cold, and even such trifles as
infected hangnail. Since typhoid is rare in the United States, no more
than one in 400 of those given the drug "needed" the treatment. Unlike
thalidomide, which disfigures, chloramphenicol kills: it puts its
victims out of sight, and hundreds of them in the United States died
undiagnosed.91
Self-control by the profession on
such matters has never worked,92 and medical memories have proved
particularly short.93 The best one can say is that in Holland or Norway
or Denmark, self-regulation has at certain moments been less
ineffective than in Germany or France94 or Italy,95 and that American
doctors have a particular facility for admitting past mistakes and
jumping on new bandwagons.96 In the United States in the fifties,
control over drugs by regulatory agencies was at a low ebb and
self-control was nominal.97 Then, during the sixties, concerned
newspapermen,98 medical men,99 and politicians100 launched a campaign
that exposed the subservience of physicians and government officials to
pharmaceutical firms and described some of the prevalent patterns of
white-collar crimes in medicine.101 Within two months after the
exposure at a congressional hearing, the use of chloramphenicol in the
United States dwindled. Parke, Davis was forced to insert strict
warnings of hazards and cautionary statements about the use of this
drug into every package. But these warnings did not extend to
exports.102 The drug continued to be used indiscriminately in Mexico,
not only in self-medication but on prescription, thereby breeding a
drug-resistant strain of typhoid bacilli which is now spreading from
Central America to the rest of the world. One doctor in Latin America
who was also a statesman did try to stem the pharmaceutical invasion
rather than just enlist physicians to make it look more respectable.
During his short tenure as president of Chile, Dr. Salvador Allende103
quite successfully mobilized the poor to identify their own health
needs and much less successfully compelled the medical profession to
serve basic rather than profitable needs. He proposed to ban drugs
unless they had been tried on paying clients in North America or Europe
for as long as the patent protection would run. He revived a program
aimed at reducing the national pharmacopeia to a few dozen items, more
or less the same as those carried by the Chinese barefoot doctor in his
black wicker box. Notably, within one week after the Chilean military
junta took power on September 11, 1973, many of the most outspoken
proponents of a Chilean medicine based on community action rather than
on drug imports and drug consumption had been murdered.104
The overconsumption of medical drugs is, of course, not restricted to
areas where doctors are scarce or people are poor. In the United
States, the volume of the drug business has grown by a factor of 100
during the current century:105 20,000 tons of aspirin are consumed per
year, almost 225 tablets per person.106 In England, every tenth night
of sleep is induced by a hypnotic drug and 19 percent of women and 9
percent of men take a prescribed tranquilizer during any one year.107
In the United States, central-nervous-system agents are the
fastest-growing sector of the pharmaceutical market, now making up 31
percent of total sales.108 Dependence on prescribed tranquilizers has
risen by 290 percent since 1962, a period during which the per capita
consumption of liquor rose by only 23 percent and the estimated
consumption of illegal opiates by about 50 percent.109 A significant
quantity of "uppers" and "downers" is obtained in all countries by
circumventing the doctor.110 Medicalized addiction111 in 1975 has
outgrown all self-chosen or more festive forms of creating
well-being.112
It has become fashionable to blame
multinational pharmaceutical firms for the increase in medically
prescribed drug abuse; their profits are high and their control over
the market is unique. For fifteen years, drug industry profits (as a
percentage of sales and company net worth) have outranked those of all
other manufacturing industries listed on the Stock Exchange. Drug
prices are controlled and manipulated: the same bottle that sells for
two dollars in Chicago or Geneva where it is produced, but where it
faces competition, sells for twelve dollars in a poor country where it
does not.113 The markup, moreover, is phenomenal: forty dollars' worth
of diazepam, once stamped into pills and packaged as Valium, sells for
a range of high prices, some as much as 70 times that of phenobarbital,
which, in the opinion of most pharmacologists, has the same
indications, effects, and dangers.114 As commodities, prescription
drugs behave differently from most other items: they are products that
the ultimate consumer rarely selects for himself.115 The producer's
sales efforts are directed at the "instrumental consumer," the doctor
who prescribes but does not pay for the product. To promote Valium,
Hoffmann-LaRoche spent $200 million in ten years and commissioned some
two hundred doctors a year to produce scientific articles about its
properties.116 In 1973, the entire drug industry spent an average of
$4,500 on each practicing physician for advertising and promotion,
about the equivalent of the cost of a year in medical school; in the
same year, the industry contributed less than 3 percent to the budget
of American medical schools.117
Surprisingly,
however, the per capita use of medically prescribed drugs around the
world seems to have little to do with commercial promotion; it
correlates mostly with the number of doctors, even in socialist
countries where the education of physicians is not influenced by drug
industry publicity and where corporate drug-pushing is limited.118
Over-all drug consumption in industrial societies is not fundamentally
affected by the proportion of items sold by prescription, over the
counter, or illegally, and it is not affected by whether the purchase
is paid for out of pocket, through prepaid insurance, or through
welfare funds.119 In all countries, doctors work increasingly with two
groups of addicts: those for whom they prescribe drugs, and those who
suffer from their consequences. The richer the community, the larger
the percentage of patients who belong to both.120
To blame the drug industry for prescribed-drug addiction is therefore
as irrelevant as blaming the Mafia121 for the use of illicit drugs. The
current pattern of overconsumption of drugs—be they effective remedy or
anodyne; prescription item or part of everyday diet; free, for sale, or
stolen—can be explained only as the result of a belief that so far has
developed in every culture where the market for consumer goods has
reached a critical volume. This pattern is consistent with the ideology
of any society oriented towards open-ended enrichment, regardless
whether its industrial product is meant for distribution by the
presumption of planners or by the forces of the market. In such a
society, people come to believe that in health care, as in all other
fields of endeavor, technology can be used to change the human
condition according to almost any design. Penicillin and DDT,
consequently, are viewed as the hors d'oeuvres preceding an era of free
lunches. The sickness resulting from each successive course of miracle
foods is dealt with by serving still another course of drugs. Thus
overconsumption reflects a socially sanctioned, sentimental hankering
for yesterday's progress.
The age of new drugs
began with aspirin in 1899. Before that time, the doctor himself was
without dispute the most important therapeutic agent.122 Besides opium,
the only substances of wide application which would have passed tests
for safety and effectiveness were smallpox vaccine, quinine for
malaria, and ipecac for dysentery. After 1899 the flood of new drugs
continued to rise for half a century. Few of these turned out to be
safer, more effective, and cheaper than well-known and long-tested
therapeutic standbys, whose numbers grew at a much slower rate. In
1962, when the United States Food and Drug Administration began to
examine the 4,300 prescription drugs that had appeared since World War
II, only 2 out of 5 were found effective. Many of the new drugs were
dangerous, and among those that met FDA standards, few were
demonstrably better than those they were meant to replace.123 Fewer
than 98 percent of these chemical substances constitute valuable
contributions to the pharmacopeia used in primary care. They include
some new kinds of remedies such as antibiotics, but also old remedies
which, in the course of the drug age, came to be understood well enough
to be used effectively: digitalis, reserpine, and belladonna are
examples. Opinions vary about the actual number of useful drugs: some
experienced clinicians believe that less than two dozen basic drugs are
all that will ever be desirable for 99 percent of the total population;
others, that up to four dozen items are optimal for 98 percent.
The age of great discoveries in pharmacology lies behind us. According
to the present director of FDA, the drug age began to decline in 1956.
Genuinely new drugs have appeared in decreasing numbers, and many which
temporarily glittered in Germany, England, or France, where standards
are less stringent than in the United States, Sweden, and Canada, were
soon forgotten or are remembered with embarrassment.124 There is not
much territory left to explore. Novelties are either "package
deals"—fixed-dose combinations—or medical "me-toos"125 that are
prescribed by physicians because they have been well promoted.126 The
seventeen-year protection that the patent law gives to significant
newcomers has run out for most. Now anyone can make them, so long as he
does not use the original brand names, which are indefinitely protected
by trademark laws. Considerable research has so far produced no reason
to suspect that drugs marketed under their generic names in the United
States are less effective than their brand-named counterparts, which
cost from 3 to 15 times more.127
The fallacy that
society is caught forever in the drug age is one of the dogmas with
which medical policy-making has been encumbered: it fits industrialized
man.128 He has learned to try to purchase whatever he fancies. He gets
nowhere without transportation or education; his environment has made
it impossible for him to walk, to learn, and to feel in control of his
body. To take a drug, no matter which and for what reason—is a last
chance to assert control over himself, to interfere on his own with his
body rather than let others interfere. The pharmaceutical invasion
leads him to medication, by himself or by others, that reduces his
ability to cope with a body for which he can still care.
Diagnostic Imperialism
In a medicalized society the influence of physicians extends not only
to the purse and the medicine chest but also to the categories to which
people are assigned. Medical bureaucrats subdivide people into those
who may drive a car, those who may stay away from work, those who must
be locked up, those who may become soldiers, those who may cross
borders, cook, or practice prostitution,129 those who may not run for
the vice-presidency of the United States, those who are dead,130 those
who are competent to commit a crime, and those who are liable to commit
one. On November 5, 1766, the Empress Maria Theresa issued an edict
requesting the court physician to certify fitness to undergo torture so
as to ensure healthy, i.e. "accurate," testimony; it was one of the
first laws to establish mandatory medical certification. Ever since,
filling out forms and signing statements have taken up increasingly
more medical time.131 Each kind of certificate provides the holder with
a special status based on medical rather than civic opinion.132 Used
outside the therapeutic process, this medicalized status does two
obvious things: (1) it exempts the holder from work, prison, military
service, or the marriage bond, and (2) it gives others the right to
encroach upon the holder's freedom by putting him into an institution
or denying him work. In addition, the proliferation of medical
certifications can invest school, employment, and politics with
opportunities for new therapeutic functions. In a society in which most
people are certified as deviants, the milieu for such deviant
majorities will come to resemble a hospital. To spend one's life in a
hospital is obviously bad for health.
Once a
society is so organized that medicine can transform people into
patients because they are unborn, newborn, menopausal, or at some other
"age of risk," the population inevitably loses some of its autonomy to
its healers. The ritualization of stages in life is nothing new;133
what is new is their intense medicalization. The sorcerer or medicine
man—as opposed to the malevolent witch—dramatized the progress of an
Azande tribesman from one stage of his health to the next.134 The
experience may have been painful,135 but the ritual was short and it
served society in highlighting its own regenerative powers.136 Lifelong
medical supervision is something else. It turns life into a series of
periods of risk, each calling for tutelage of a special kind. From the
crib to the office and from the Club Mediterranée to the terminal ward,
each age-cohort is conditioned by a milieu that defines health for
those whom it segregates. Hygienic bureaucracy stops the parent in
front of the school and the minor in front of the court, and takes the
old out of the home. By becoming a specialized place, school, work, or
home is made unfit for most people. The hospital, the modern cathedral,
lords it over this hieratic environment of health devotees. From
Stockholm to Wichita the towers of the medical center impress on the
landscape the promise of a conspicuous final embrace. For rich and
poor, life is turned into a pilgrimage through check-ups and clinics
back to the ward where it started.137 Life is thus reduced to a "span,"
to a statistical phenomenon which, for better or for worse, must be
institutionally planned and shaped. This life-span is brought into
existence with the prenatal check-up, when the doctor decides if and
how the fetus shall be born, and it will end with a mark on a chart
ordering resuscitation suspended. Between delivery and termination this
bundle of biomedical care fits best into a city that is built like a
mechanical womb. At each stage of their lives people are
age-specifically disabled. The old are the most obvious example: they
are victims of treatments meted out for an incurable condition.138
Most of man's ailments consist of illnesses that are acute and
benign—either self-limiting or subject to control through a few dozen
routine interventions.139 For a wide range of conditions, those who are
treated least probably make the best progress. "For the sick,"
Hippocrates said, "the least is best." More often than not, the best a
learned and conscientious physician can do is convince his patient that
he can live with his impairment, reassure him of an eventual recovery
or of the availability of morphine at the time when he will need it, do
for him what grandmother could have done, and otherwise defer to
nature.140 The new tricks that have frequent application are so simple
that the last generation of grandmothers would have learned them long
ago had they not been browbeaten into incompetency by medical
mystification. Boy-scout training, good-Samaritan laws, and the duty to
carry first-aid equipment in each car would prevent more highway deaths
than any fleet of helicopter-ambulances. Those other interventions
which are part of primary care and which, though they require the work
of specialists, have been proved effective on a population basis can be
employed more effectively if my neighbor or I feel responsible for
recognizing when they are needed and applying first treatment. For
acute sickness, treatment so complex that it requires a specialist is
often ineffective and much more often inaccessible or simply too late.
After twenty years of socialized medicine in England and Wales, doctors
get to coronary cases on an average of four hours after the beginning
of symptoms, and by this time 50 percent of patients are dead.141 The
fact that modern medicine has become very effective in the treatment of
specific symptoms does not mean that it has become more beneficial for
the health of the patient.
With some
qualifications, the severe limits of effective medical treatment apply
not only to conditions that have long been recognized as
sickness—rheumatism, appendicitis, heart failure, degenerative disease,
and many infectious diseases—but even more drastically to those that
have only recently generated demands for medical care. Old age, for
example, which has been variously considered a doubtful privilege or a
pitiful ending but never a disease,142 has recently been put under
doctor's orders. The demand for old-age care has increased, not just
because there are more old people who survive, but also because there
are more people who state their claim that their old age should be
cured.
The maximum life-span has not changed, but
the average life-span has. Life expectancy at birth has increased
enormously. Many more children survive, no matter how sickly and in
need of a special environment and special care. The life expectancy of
young adults is still increasing in some poorer countries. But in rich
countries the life expectancy of those between fifteen and forty-five
has tended to stabilize because accidents143 and the new diseases of
civilization kill as many as formerly succumbed to pneumonia and other
infections. Relatively more old people are around, and they are
increasingly prone to be ill, out of place, and helpless. No matter how
much medicine they take, no matter what care is given them, a life
expectancy of sixty-five years has remained unchanged over the past
century. Medicine just cannot do much for the illness associated with
aging, and even less about the process and experience of aging
itself.144 It cannot cure cardiovascular disease, most cancers,
arthritis, advanced cirrhosis, not even the common cold. It is
fortunate that some of the pain the aged suffer can be lessened.
Unfortunately, though, most treatment of the old requiring professional
intervention not only tends to heighten their pain but, if successful,
also to protract it.145
Old age has been
medicalized at precisely the historical moment when it has become a
more common occurrence for demographic reasons; 28 percent of the
American medical budget is spent on the 10 percent of the population
who are over sixty-five. This minority is outgrowing the remainder of
the population at an annual rate of 3 percent, while the per capita
cost of their care is rising 5 to 7 percent faster than the over-all
per capita cost. As more of the elderly acquire rights to professional
care, opportunities for independent aging decline. More have to seek
refuge in institutions. Simultaneously, as more of the elderly are
initiated into treatment for the correction of incorrigible impairment
or for the cure of incurable disease, the number of unmet claims for
old-age services snowballs.146 If the eyesight of an old woman fails,
her plight will not be recognized unless she enters the "blindness
establishment"—one of the eight hundred-odd United States agencies
which produce services for the blind, preferably for the young and
those who can be rehabilitated for work.147 Since she is neither young
nor of working age, she will receive only a grudging welcome; at the
same time, she will have difficulty fitting into the old-age
establishment. She will thus be marginally medicalized by two sets of
institutions, the one designed to socialize her among the blind, the
other to medicalize her decrepitude.
As more old
people become dependent on professional services, more people are
pushed into specialized institutions for the old, while the home
neighborhood becomes increasingly inhospitable to those who hang on.148
These institutions seem to be the contemporary strategy for the
disposal of the old, who have been institutionalized in more frank and
arguably less hideous forms by most other societies.149 The mortality
rate during the first year after institutionalization is significantly
higher than the rate for those who stay in their accustomed
surroundings.150 Separation from home contributes to the appearance and
mortality of many a serious disease.151 Some old people seek
institutionalization with the intention of shortening their lives.152
Dependence is always painful, and more so for the old. Privilege or
poverty in earlier life reaches a climax in modern old age. Only the
very rich and the very independent can choose to avoid that
medicalization of the end to which the poor must submit and which
becomes increasingly intense and universal as the society they live in
becomes richer.153 The transformation of old age into a condition
calling for professional services has cast the elderly in the role of a
minority who will feel painfully deprived at any relative level of
tax-supported privilege. From weak old people who are sometimes
miserable and bitterly disappointed by neglect, they are turned into
certified members of the saddest of consumer groups, that of the aged
programmed never to get enough.154 What medical labeling has done to
the end of life, it has equally done to its beginning. Just as the
doctor's power was first affirmed over old age and eventually
encroached on early retirement and climacteric, so his authority over
the delivery room, which dates from the mid-nineteenth century, spread
to the nursery, the kindergarten, and the classroom and medicalized
infancy, childhood, and puberty. But while it has become acceptable to
advocate limits to the escalation of costly care for the old, limits to
so-called medical investments in childhood are still a subject that
seems taboo. Industrial parents, forced to procreate manpower for a
world into which nobody fits who has not been crushed and molded by
sixteen years of formal education, feel impotent to care personally for
their offspring and, in despair, shower them with medicine.155
Proposals to reduce medical outputs in the United States from their
present level of about $100 billion to their 1950 level of $10 billion,
or to close medical schools in Colombia, never turn into controversial
issues because those who make them are soon discredited as heartless
proponents of infanticide or of mass extermination of the poor. The
engineering approach to the making of economically productive adults
has made death in childhood a scandal, impairment through early disease
a public embarrassment, unrepaired congenital malformation an
intolerable sight, and the possibility of eugenic birth control a
preferred theme for international congresses in the seventies.
As for infant mortality, it has indeed been reduced. Life expectancy in
the developed countries has increased from thirty-five years in the
eighteenth century to seventy years today. This is due mainly to the
reduction of infant mortality in these countries; for example, in
England and Wales the number of infant deaths per 1,000 live births
declined from 154 in 1840 to 22 in 1960. But it would be entirely
incorrect to attribute more than one of those lives "saved" to a
curative intervention that presupposes anything like a doctor's
training, and it would be a delusion to attribute the infant mortality
rate of poor countries, which in some cases is ten times that of the
United States, to a lack of doctors. Food, antisepsis, civil
engineering, and above all, a new widespread disvalue placed on the
death of a child,156 no matter how weak or malformed, are much more
significant factors and represent changes that are only remotely
related to medical intervention. While in gross infant mortality the
United States ranks seventeenth among nations, infant mortality among
the poor is much higher than among higher-income groups. In New York
City, infant mortality among the black population is more than twice as
high as for the population in general, and probably higher than in many
underdeveloped areas such as Thailand and Jamaica.157 The insistence
that more doctors are needed to prevent infants from dying can thus be
understood as a way of avoiding income equalization while at the same
time creating more jobs for professionals. It would be equally reckless
to claim that those changes in the general environment that do have a
causal relationship to the presence of doctors represent a positive
balance for health. Although physicians did pioneer antisepsis,
immunization, and dietary supplements, they were also involved in the
switch to the bottle that transformed the traditional suckling into a
modern baby and provided industry with working mothers who are clients
for a factory-made formula.
The damage this switch
does to natural immunity mechanisms fostered by human milk and the
physical and emotional stress caused by bottle feeding are comparable
to if not greater than the benefits that a population can derive from
specific immunizations.158 Even more serious is the contribution the
bottle makes to the menace of worldwide protein starvation. For
instance, in 1960, 96 percent of Chilean mothers breast-fed their
infants up to and beyond the first birthday. Then, for a decade,
Chilean women underwent intense political indoctrination by both
right-wing Christian Democrats and a variety of left-wing parties. By
1970 only 6 percent breast-fed beyond the first year and 80 percent had
weaned their infants before the second full month. As a result, 84
percent of potential human breast milk now remains unproduced. The milk
of an additional 32,000 cows would have to be added to Chile's
overgrazed pastures to compensate—as far as possible—for this loss.159
As the bottle became a status symbol, new illnesses appeared among
children who had been denied the breast, and since mothers lack
traditional know-how to deal with babies who do not behave like
sucklings, babies became new consumers of medical attention and of its
risks.160 The sum total of physical impairment due just to this
substitution of marketed baby food for mother's milk is difficult to
balance against the benefits derived from curative medical intervention
in childhood sickness and from surgical correction of birth defects
ranging from harelip to heart defects.
It can, of
course, be argued that the medical classification of age groups
according to their diagnosed need for health commodities does not
generate ill-health but only reflects the health-denying breakdown of
the family as a cocoon, of the neighborhood as a network of gift
relationships, and of the environment as the shelter of a local
subsistence community. No doubt, it is true that a medicalized social
perception reflects a reality that is determined by the organization of
capital-intensive production, and that it is the corresponding social
pattern of nuclear families, welfare agencies, and polluted nature that
degrades home, neighborhood, and milieu. But medicine does not simply
mirror reality; it reinforces and reproduces the process that
undermines the social cocoons within which man has evolved. Medical
classification justifies the imperialism of standard staples like baby
food over mother's milk and of old-age homes over a corner at home. By
turning the newborn into a hospitalized patient until he or she is
certified as healthy, and by defining grandmother's complaint as a need
for treatment rather than for patient respect, the medical enterprise
creates not only biologically formulated legitimacy for
man-the-consumer but also new pressures for an escalation of the
megamachine.161 Genetic selection of those who fit into that machine is
the logical next step of medicosocial control.
Preventive Stigma
As curative treatment focuses increasingly on conditions in which it is
ineffectual, expensive, and painful, medicine has begun to market
prevention. The concept of morbidity has been enlarged to cover
prognosticated risks. Along with sick-care, health care has become a
commodity, something one pays for rather than something one does. The
higher the salary the company pays, the higher the rank of an
aparatchik, the more will be spent to keep the valuable cog well oiled.
Maintenance costs for highly capitalized manpower are the new measure
of status for those on the upper rungs. People keep up with the Joneses
by emulating their "check-ups," an English word which has entered
French, Serbian, Spanish, Malay, and Hungarian dictionaries. People are
turned into patients without being sick. The medicalization of
prevention thus becomes another major symptom of social iatrogenesis.
It tends to transform personal responsibility for my future into my
management by some agency.
Usually the danger of
routine diagnosis is even less feared than the danger of routine
treatment, though social, physical, and psychological torts inflicted
by medical classification are no less well documented. Diagnoses made
by the physician and his helpers can define either temporary or
permanent roles for the patient. In either case, they add to a
biophysical condition a social state created by presumably
authoritative evaluation.162 When a veterinarian diagnoses a cow's
distemper, it doesn't usually affect the patient's behavior. When a
doctor diagnoses a human being, it does.163 In those instances where
the physician functions as healer he confers on the person recognized
as sick certain rights, duties, and excuses which have a conditional
and temporary legitimacy and which lapse when the patient is healed;
most sickness leaves no taint of deviance or disorderly conduct on the
patient's reputation. No one is interested in ex-allergies or
ex-appendectomy patients, just as no one will be remembered as an
ex-traffic offender. In other instances, however, the physician acts
primarily as an actuary, and his diagnosis can defame the patient, and
sometimes his children, for life. By attaching irreversible degradation
to a person's identity, it brands him forever with a permanent
stigma.164 The objective condition may have long since disappeared, but
the iatrogenic label sticks. Like ex-convicts, former mental patients,
people after their first heart attack, former alcoholics, carriers of
the sickle-cell trait, and (until recently) ex-tuberculotics are
transformed into outsiders for the rest of their lives. Professional
suspicion alone is enough to legitimize the stigma even if the
suspected condition never existed. The medical label may protect the
patient from punishment only to submit him to interminable instruction,
treatment, and discrimination, which are inflicted on him for his
professionally presumed benefit.165
In the past,
medicine labeled people in two ways: those for whom cures could be
attempted, and those who were beyond repair, such as lepers, cripples,
oddities, and the dying. Either way, diagnosis could lead to stigma.
Medicalized prevention now creates a third way. It turns the physician
into an officially licensed magician whose prophecies cripple even
those who are left unharmed by his brews.166 Diagnosis may exclude a
human being with bad genes from being born, another from promotion, and
a third from political life. The mass hunt for health risks begins with
dragnets designed to apprehend those needing special protection:
prenatal medical visits; well-child-care clinics for infants; school
and camp check-ups and prepaid medical schemes.167 Recently genetic and
blood pressure "counseling" services were added. The United States
proudly led the world in organizing disease-hunts and, later, in
questioning their utility.168
In the past decade,
automated multiphasic health-testing became operational and was
welcomed as the poor man's escalator into the world of Mayo and
Massachusetts General. This assembly-line procedure of complex chemical
and medical examinations can be performed by paraprofessional
technicians at a surprisingly low cost. It purports to offer uncounted
millions more sophisticated detection of hidden therapeutic needs than
was available in the sixties even for the most "valuable" hierarchs in
Houston or Moscow. At the outset of this testing, the lack of
controlled studies allowed the salesmen of mass-produced prevention to
foster unsubstantiated expectations. (More recently, controlled
comparative studies of population groups benefitting from maintenance
service and early diagnosis have become available; two dozen such
studies indicate that these diagnostic procedures—even when followed by
high-level medical treatments—have no positive impact on life
expectancy.169) Ironically, the serious asymptomatic disorders which
this kind of screening alone can discover among adults are frequently
incurable illnesses in which early treatment only aggravates the
patient's physical condition. In any case, it transforms people who
feel healthy into patients anxious for their verdict.
In the detection of sickness medicine does two things: it "discovers"
new disorders, and it ascribes these disorders to concrete individuals.
To discover a new category of disease is the pride of the medical
scientist.170 To ascribe the pathology to some Tom, Dick, or Harry is
the first task of the physician acting as member of a consulting
profession.171 Trained to "do something" and express his concern, he
feels active, useful, and effective when he can diagnose disease.172
Though, theoretically, at the first encounter the physician does not
presume that his patient is affected by a disease, through a form of
fail-safe principle he usually acts as if imputing a disease to the
patient were better than disregarding one. The medical-decision rule
pushes him to seek safety by diagnosing illness rather than health.173
The classic demonstration of this bias came in an experiment conducted
in 1934.174 In a survey of 1,000 eleven-year-old children from the
public schools of New York, 61 percent were found to have had their
tonsils removed. "The remaining 39 percent were subjected to
examination by a group of physicians, who selected 45 percent of these
for tonsillectomy and rejected the rest. The rejected children were
re-examined by another group of physicians, who recommended
tonsillectomy for 46 percent of those remaining after the first
examination. When the rejected children were examined a third time, a
similar percentage was selected for tonsillectomy so that after three
examinations only sixty-five children remained who had not been
recommended for tonsillectomy. These subjects were not further examined
because the supply of examining physicians ran out."175 This test was
conducted at a free clinic, where financial considerations could not
explain the bias.
Diagnostic bias in favor of
sickness combines with frequent diagnostic error. Medicine not only
imputes questionable categories with inquisitorial enthusiasm; it does
so at a rate of miscarriage that no court system could tolerate. In one
instance, autopsies showed that more than half the patients who died in
a British university clinic with a diagnosis of specific heart failure
had in fact died of something else. In another instance, the same
series of chest X-rays shown to the same team of specialists on
different occasions led them to change their mind on 20 percent of all
cases. Up to three times as many patients will tell Dr. Smith that they
cough, produce sputum, or suffer from stomach cramps as will tell Dr.
Jones. Up to one-quarter of simple hospital tests show seriously
divergent results when done from the same sample in two different
labs.176 Nor do machines seem to be any more infallible. In a
competition between diagnostic machines and human diagnosticians in 83
cases recommended for pelvic surgery, pathology showed that both man
and machine were correct in 22 instances; in 37 instances the computer
correctly rejected the doctor's diagnosis; in 11 instances the doctors
proved the computer wrong; and in 10 cases both were in error.177
In addition to diagnostic bias and error, there is wanton
aggression.178 A cardiac catheterization, used to determine if a
patient is suffering from cardiomyopathy—admittedly, this is not done
routinely—costs $350 and kills one patient in fifty. Yet there is no
evidence that a differential diagnosis based on its results extends
either the life expectancy or the comfort of the patient.179 Most tests
are less murderous and much more commonly performed, but many still
involve known risks to the individual or his offspring which are high
enough to obscure the value of whatever information they can provide.
Many routine uses of X-rays and fluoroscope on the young, the injection
or ingestion of reagents and tracers, and the use of Ritalin to
diagnose hyperactivity in children are examples.180 Attendance in
public schools where teachers are vested with delegated medical powers
constitutes a major health risk for children.181 Even simple and
otherwise benign examinations turn into risks when multiplied. When a
test is associated with several others, it has considerably greater
power to harm than when it is conducted by itself. Often tests provide
guidance in the choice of therapy. Unfortunately, as the tests turn
more complex and are multiplied, their results frequently provide
guidance only in selecting the form of intervention which the patient
may survive, and not necessarily that which will help him. Worst of
all, when people have lived through complex positive laboratory
diagnosis, unharmed or not, they have incurred a high risk of being
submitted to therapy that is odious, painful, crippling, and expensive.
No wonder that physicians tend to delay longer than laymen before going
to see their own doctor and that they are in worse shape when they get
there.182
Routine performance of early diagnostic
tests on large populations guarantees the medical scientist a broad
base from which to select the cases that best fit existing treatment
facilities or are most useful in the attainment of research goals,
whether or not the therapies cure, rehabilitate, or soothe. In the
process, people are strengthened in their belief that they are machines
whose durability depends on visits to the maintenance shop, and are
thus not only obliged but also pressured to foot the bill for the
market research and the sales activities of the medical establishment.
Diagnosis always intensifies stress, defines incapacity, imposes
inactivity, and focuses apprehension on nonrecovery, on uncertainty,
and on one's dependence upon future medical findings, all of which
amounts to a loss of autonomy for self-definition. It also isolates a
person in a special role, separates him from the normal and healthy,
and requires submission to the authority of specialized personnel. Once
a society organizes for a preventive disease-hunt, it gives epidemic
proportions to diagnosis. This ultimate triumph of therapeutic
culture183 turns the independence of the average healthy person into an
intolerable form of deviance.
In the long run the
main activity of such an inner-directed systems society leads to the
phantom production of life expectancy as a commodity. By equating
statistical man with biologically unique men, an insatiable demand for
finite resources is created. The individual is subordinated to the
greater "needs" of the whole, preventive procedures become
compulsory,184 and the right of the patient to withhold consent to his
own treatment vanishes as the doctor argues that he must submit to
diagnosis, since society cannot afford the burden of curative
procedures that would be even more expensive.185
Terminal Ceremonies
Therapy reaches its apogee in the death-dance around the terminal
patient.186 At a cost of between $500 and $2,000 per day,187 celebrants
in white and blue envelop what remains of the patient in antiseptic
smells.188 The more exotic the incense and the pyre, the more death
mocks the priest.189 The religious use of medical technique has come to
prevail over its technical purpose, and the line separating the
physician from the mortician has been blurred.190 Beds are filled with
bodies neither dead nor alive.191 The conjuring doctor perceives
himself as a manager of crisis.192 In an insidious way he provides each
citizen at the last hour with an encounter with society's deadening
dream of infinite power.193 Like any crisis manager of bank, state, or
couch, he plans self-defeating strategies and commandeers resources
which, in their uselessness and futility, seem all the more grotesque.
At the last moment, he promises to each patient that claim on absolute
priority for which most people regard themselves as too unimportant.
The ritualization of crisis, a general trait of a morbid society, does
three things for the medical functionary. It provides him with a
license that usually only the military can claim. Under the stress of
crisis, the professional who is believed to be in command can easily
presume immunity from the ordinary rules of justice and decency. He who
is assigned control over death ceases to be an ordinary human. As with
the director of a triage, his killing is covered by policy.194 More
important, his entire performance takes place in the aura of crisis.195
Because they form a charmed borderland not quite of this world, the
time-span and the community space claimed by the medical enterprise are
as sacred as their religious and military counterparts. Not only does
the medicalization of terminal care ritualize macabre dreams and
enlarge professional license for obscene endeavors: the escalation of
terminal treatments removes from the physician all need to prove the
technical effectiveness of those resources he commands.196 There are no
limits to his power to demand more and ever more. Finally, the
patient's death places the physician beyond potential control and
criticism. In the last glance of the patient and in the life-long
perspective of the "morituri" there is no hope, but only the
physician's last expectation.197 The orientation of any institution
towards "crisis" justifies enormous ordinary ineffectiveness.198
Hospital death is now endemic.199 In the last twenty-five years the
percentage of Americans who die in a hospital has grown by a third.200
The percentage of hospital deaths in other countries has grown even
faster. Death without medical presence becomes synonymous with romantic
pigheadedness, privilege, or disaster. The cost of a citizen's last
days has increased by an estimated 1,200 percent, much faster than that
of over-all health care. Simultaneously, at least in the United States,
funeral costs have stabilized; their growth rate has come in line with
the rise of the general consumer-price index. The most elaborate phase
of the terminal ceremonies now surrounds the dying patient and has been
separated, under medical control, from the removal exequies and the
burial of what remains. In a switch of lavish expenditure from tomb to
ward, reflecting the horror of dying without medical assistance,201 the
insured pay for participation in their own funeral rites.202
Fear of unmedicated death was first felt by eighteenth-century elites
who refused religious assistance and rejected belief in the
afterlife.203 A new wave of this fear has now swept rich and poor, and
has combined with egalitarian pathos to create a new category of goods:
those which are "terminally" scarce, because they are commandeered by
the physician in high-cost death chambers. To distribute these goods, a
new branch of legal 204 and ethical literature has arisen to deal with
the question how to exclude some, select others, and justify choices of
life-prolonging techniques and ways of making death more comfortable
and acceptable.205 Taken as a whole, this literature tells a remarkable
story about the mind of the contemporary jurist and philosopher. Most
of the authors do not even ask whether the techniques that sustain
their speculations have in fact proved to be life-prolonging. Naively,
they go along with the delusion that ongoing rituals that are costly
must be useful. In this way law and ethics bolster belief in the value
of policies that regulate politically innocuous medical equality at the
point of death.
The modern fear of unhygienic death
makes life appear like a race towards a terminal scramble and has
broken personal self-confidence in a unique way.206 It has fostered the
belief that man today has lost the autonomy to recognize when his time
has come and to take his death into his own hands.207 The doctor's
refusal to recognize the point at which he has ceased to be useful as a
healer208 and to withdraw when death shows on his patient's face209 has
made him into an agent of evasion or outright dissimulation.210 The
patient's unwillingness to die on his own makes him pathetically
dependent. He has now lost his faith in his ability to die, the
terminal shape that health can take, and has made the right to be
professionally killed into a major issue.211
Several unexamined expectations are interwoven in the cultural
orientation towards death in the wards. People think that
hospitalization will reduce their pain or that they will probably live
longer in the hospital. Neither is likely to be true. Of those admitted
with a fatal condition to the average British clinic, 10 percent died
on the day of arrival, 30 percent within a week, 75 percent within a
month, and 97 percent within three months.212 In homes for terminal
care, 56 percent were dead within a week of admission. In terminal
cancer, there is no difference in life expectancy between those who end
in the home and those who die in the hospital. Only a quarter of
terminal cancer patients need special nursing at home, and then only
during their last weeks. For more than half, suffering will be limited
to feeling feeble and uncomfortable, and what pain there is can usually
be relieved.213 But by staying at home they avoid the exile,
loneliness, and indignities which, in all but exceptional hospitals,
await them.214 Poor blacks seem to know this and upset the hospital
routine by taking their dying home. Opiates are not available on
demand. Patients who have severe pains over months or years, which
narcotics could make tolerable, are as likely to be refused medication
in the hospital as at home, lest they form a habit in their incurable
but not directly fatal condition.215 Finally, people believe that
hospitalization increases their chances of surviving a crisis. With
some clear-cut exceptions, on this point too, more often than not, they
are wrong. More people die now because crisis intervention is
hospital-centered than can be saved through the superior techniques the
hospital can provide. In the poor countries many more children have
died of cholera or diarrhea during the last ten years because they were
not rehydrated on time with a simple solution forced down their
throats: care was centered on sophisticated intravenous rehydration at
a distant hospital.216 In rich countries the deaths caused by the use
of evacuation equipment are beginning to balance the number of lives
thus saved. Hospital "worship" is unrelated to the hospital's
performance.
Like any other growth industry, the
health system directs its products where demand seems unlimited: into
defense against death. An increasing percentage of newly acquired tax
funds is allocated towards life-extension technology for terminal
patients. Complex bureaucracies sanctimoniously select for dialysis
maintenance one in six or one in three of those Americans who are
threatened by kidney failure. The patient-elect is conditioned to
desire the scarce privilege of dying in exquisite torture.217 As a
doctor observes in an account of the treatment of his own illness, much
time and effort must go into preventing suicide during the first and
sometimes the second year that the artificial kidney may add to
life.218 In a society where the majority die under the control of
public authority, the solemnities formerly surrounding legalized
homicide or execution adorn the terminal ward. The sumptuous treatment
of the comatose takes the place of the doomed man's breakfast in other
cultures.219
Public fascination with
high-technology care and death can be understood as a deep-seated need
for the engineering of miracles. Intensive care is but the culmination
of a public worship organized around a medical priesthood struggling
against death.220 The willingness of the public to finance these
activities expresses a desire for the nontechnical functions of
medicine. Cardiac intensive-care units, for example, have high
visibility and no proven statistical gain for the care of the sick.
They require three times the equipment and five times the staff needed
for normal patient care; 12 percent of all graduate hospital nurses in
the United States work in this heroic medicine. This gaudy enterprise
is supported, like a liturgy of old, by the extortion of taxes, by the
solicitation of gifts, and by the procurement of victims. Large-scale
random samples have been used to compare the mortality and recovery
rates of patients served by these units with those of patients given
home treatment. So far they have demonstrated no advantage. The
patients who have suffered cardiac infarction themselves tend to
express a preference for home care; they are frightened by the
hospital, and in a crisis would rather be close to people they know.
Careful statistical findings have confirmed their intuition: the higher
mortality of those benefitted by mechanical care in the hospital is
usually ascribed to fright.221
Black Magic
Technical intervention in the physical and biochemical make-up of the
patient or of his environment is not, and never has been, the sole
function of medical institutions.222 The removal of pathogens and the
application of remedies (effective or not) are by no means the sole way
of mediating between man and his disease. Even in those circumstances
in which the physician is technically equipped to play the technical
role to which he aspires, he inevitably also fulfills religious,
magical, ethical, and political functions. In each of these functions
the contemporary physician is more pathogen than healer or just anodyne.
Magic or healing through ceremonies is clearly one of the important
traditional functions of medicine.223 In magic the healer manipulates
the setting and the stage. In a somewhat impersonal way he establishes
an ad hoc relationship between himself and a group of individuals.
Magic works if and when the intent of patient and magician
coincides,224 though it took scientific medicine considerable time to
recognize its own practitioners as part-time magicians. To distinguish
the doctor's professional exercise of white magic from his function as
engineer (and to spare him the charge of being a quack), the term
"placebo" was created. Whenever a sugar pill works because it is given
by the doctor, the sugar pill acts as a placebo. A placebo (Latin for
"I will please") pleases not only the patient but the administering
physician as well.225
In high cultures, religious
medicine is something quite distinct from magic.226 The major religions
reinforce resignation to misfortune and offer a rationale, a style, and
a community setting in which suffering can become a dignified
performance. The opportunities offered by the acceptance of suffering
can be differently explained in each of the great traditions: as karma
accumulated through past incarnations; as an invitation to Islam, the
surrender to God; or as an opportunity for closer association with the
Savior on the Cross. High religion stimulates personal responsibility
for healing, sends ministers for sometimes pompous and sometimes
effective consolation, provides saints as models, and usually provides
a framework for the practice of folk medicine. In our kind of secular
society religious organizations are left with only a small part of
their former ritual healing roles. One devout Catholic might derive
intimate strength from personal prayer, some marginal groups of recent
arrivals in Săo Paolo might routinely heal their ulcers in Afro-Latin
dance cults, and Indians in the valley of the Ganges still seek health
in the singing of the Vedas. But such things have only a remote
parallel in societies beyond a certain per capita GNP. In these
industrialized societies secular institutions run the major myth-making
ceremonies.227
The separate cults of education,
transportation, and mass communication promote, under different names,
the same social myth which Voeglin228 describes as contemporary gnosis.
Common to a gnostic world-view and its cult are six characteristics:
(1) it is practiced by members of a movement who are dissatisfied with
the world as it is because they see it as intrinsically poorly
organized. Its adherents are (2) convinced that salvation from this
world is possible (3) at least for the elect and (4) can be brought
about within the present generation. Gnostics further believe that this
salvation depends (5) on technical actions which are reserved (6) to
initiates who monopolize the special formula for it. All these
religious beliefs underlie the social organization of technological
medicine, which in turn ritualizes and celebrates the
nineteenth-century ideal of progress.
Among the
important nontechnical functions of medicine, a third one is ethical
rather than magical, secular rather than religious. It does not depend
on a conspiracy into which the sorcerer enters with his adept, nor on
myths to which the priest gives form, but on the shape which medical
culture gives to interpersonal relations. Medicine can be so organized
that it motivates the community to deal in a more or less personal
fashion with the frail, the decrepit, the tender, the crippled, the
depressed, and the manic. By fostering a certain type of social
character, a society's medicine could effectively lessen the suffering
of the diseased by assigning an active role to all members of the
community in the compassionate tolerance for and the selfless
assistance of the weak.229 Medicine could regulate society's gift
relationships.230 Cultures where compassion for the unfortunate,
hospitality for the crippled, leeway for the troubled, and respect for
the old have been developed can, to a large extent, integrate the
majority of their members into everyday life.
Healers can be priests of the gods, lawgivers, magicians, mediums,
barber-pharmacists, or scientific advisers.231 No common name with even
the approximate semantic range covered by our "doctor" existed in
Europe before the fourteenth century.232 In Greece the repairman, used
mostly for slaves, was respected early, though he was not on a level
with the healing philosopher or even with the gymnast for the free.233
Republican Rome considered the specialized curers a disreputable lot.
Laws on water supply, drainage, garbage removal, and military training,
combined with the state cult of healing gods, were considered
sufficient; grandmother's brew and the army sanitarian were not
dignified by special attention. Until Julius Caesar gave citizenship to
the first group of Asclepiads in 46 B.C., this privilege was refused to
Greek physicians and healing priests.234 The Arabs honored the
physician;235 the Jews left health care to the quality of the ghetto
or, with a bad conscience, brought in the Arab physician.236 Medicine's
several functions combined in different ways in different roles. The
first occupation to monopolize health care is that of the physician of
the late twentieth century.
Paradoxically, the more
attention is focused on the technical mastery of disease, the larger
becomes the symbolic and nontechnical function performed by medical
technology. The less proof there is that more money increases survival
rates in a given branch of cancer treatment, the more money will go to
the medical divisions deployed in that special theater of operations.
Only goals unrelated to treatment, such as jobs for the specialists,
equal access by the poor, symbolic consolation for patients, or
experimentation on humans, can explain the expansion of lung-cancer
surgeries during the last twenty-five years. Not only white coats,
masks, antiseptics, and ambulance sirens but entire branches of
medicine continue to be financed because they have been invested with
nontechnical, usually symbolic power.
Willy-nilly
the modern doctor is thus forced into symbolic, nontechnical roles.
Nontechnical functions prevail in the removal of adenoids: more than 90
percent of all tonsillectomies performed in the United States are
technically unnecessary, yet 20 to 30 percent of all children still
undergo the operation. One in a thousand dies directly as a consequence
of the operation and 16 in a thousand suffer from serious
complications. All lose valuable immunity mechanisms. All are subjected
to emotional aggression: they are incarcerated in a hospital, separated
from their parents, and introduced to the unjustified and more often
than not pompous cruelty of the medical establishment.237 The child
learns to be exposed to technicians who, in his presence, use a foreign
language in which they make judgments about his body; he learns that
his body may be invaded by strangers for reasons they alone know; and
he is made to feel proud to live in a country where social security
pays for such a medical initiation into the reality of life.238
Physical participation in a ritual is not a necessary condition for
initiation into the myth which the ritual is organized to generate.
Medical spectator sports cast powerful spells. I happened to be in Rio
de Janeiro and in Lima when Dr. Christiaan Barnard was touring there.
In both cities he was able to fill the major football stadium twice in
one day with crowds who hysterically acclaimed his macabre ability to
replace human hearts. Medical-miracle treatments of this kind have
worldwide impact. Their alienating effect reaches people who have no
access to a neighborhood clinic, much less to a hospital. It provides
them with an abstract assurance that salvation through science is
possible. The experience in the stadium at Rio prepared me for the
evidence I was shown shortly afterwards which proved that the Brazilian
police have so far been the first to use life-extending equipment in
the torture of prisoners. Such extreme abuse of medical techniques
seems grotesquely coherent with the dominant ideology of medicine.
The unintended nontechnical influence that medical technique exercises
on society's health can, of course, be positive.239 An unnecessary shot
of penicillin can magically restore confidence and appetite.240 A
contraindicated operation can solve a marriage problem and reduce
symptoms of disease in both partners.241 Not only the doctor's sugar
pills but even his poisons can be powerful placebos. But this is not
the prevailing result of the nontechnical side-effects of medical
technology. It can be argued that in precisely those narrow areas in
which high-cost medicine has become more specifically effective, its
symbolic side-effects have become overwhelmingly health-denying:242 the
traditional white medical magic that supported the patient's own
efforts to heal has turned black.243
To a large
extent, social iatrogenesis can be explained as a negative placebo, as
a nocebo effect.244 Overwhelmingly the nontechnical side-effects of
biomedical interventions do powerful damage to health. The intensity of
the black-magic influence of a medical procedure does not depend on its
being technically effective. The effect of the nocebo, like that of the
placebo, is largely independent of what the physician does.
Medical procedures turn into black magic when, instead of mobilizing
his self-healing powers, they transform the sick man into a limp and
mystified voyeur of his own treatment. Medical procedures turn into
sick religion when they are performed as rituals that focus the entire
expectation of the sick on science and its functionaries instead of
encouraging them to seek a poetic interpretation of their predicament
or find an admirable example in some person—long dead or next door—who
learned to suffer.
Medical procedures multiply
disease by moral degradation when they isolate the sick in a
professional environment rather than providing society with the motives
and disciplines that increase social tolerance for the troubled.
Magical havoc, religious injury, and moral degradation generated under
the pretext of a biomedical pursuit are all crucial mechanisms
contributing to social iatrogenesis. They are amalgamated by the
medicalization of death.
When doctors first set up
shop outside the temples in Greece, India, and China, they ceased to be
medicine men. When they claimed rational power over sickness, society
lost the sense of the complex personage and his integrated healing
which the sorcerer-shaman or curer had provided.245 The great
traditions of medical healing had left the miracle cure to priests and
kings. The caste that had an "in" with the gods could call for their
intervention. To the hand that wielded the sword was attributed the
power to subdue not only the enemy but also the spirit. Up to the
eighteenth century the king of England laid his hands every year upon
those afflicted with facial tuberculosis whom physicians knew they were
unable to cure.246 Epileptics, whose ills resisted even His Majesty's
touch, took refuge in the healing strength that flowed from the hands
of the executioner.247
With the rise of medical
civilization and healing guilds, the physicians distinguished
themselves from the quacks and the priests because they knew the limits
of their art. Today the medical establishment is about to reclaim the
right to perform miracles. Medicine claims the patient even when the
etiology is uncertain, the prognosis unfavorable, and the therapy of an
experimental nature. Under these circumstances the attempt at a
"medical miracle" can be a hedge against failure, since miracles may
only be hoped for and cannot, by definition, be expected. The radical
monopoly over health care that the contemporary physician claims now
forces him to reassume priestly and royal functions that his ancestors
gave up when they became specialized as technical healers.
The medicalization of the miracle provides further insight into the
social function of terminal care. The patient is strapped down and
controlled like a spaceman and then displayed on television. These
heroic performances serve as a rain-dance for millions, a liturgy in
which realistic hopes for autonomous life are transmuted into the
delusion that doctors will deliver health from outer space.
Patient Majorities
Whenever medicine's diagnostic power multiplies the sick in excessive
numbers, medical professionals turn over the surplus to the management
of nonmedical trades and occupations. By dumping, the medical lords
divest themselves of the nuisance of low-prestige care and invest
policemen, teachers, or personnel officers with a derivative medical
fiefdom. Medicine retains unchecked autonomy in defining what
constitutes sickness, but drops on others the task of ferreting out the
sick and providing for their treatment. Only medicine knows what
constitutes addiction, though policemen are supposed to know how it
should be controlled. Only medicine can define brain damage, but it
allows teachers to stigmatize and manage the healthy-looking cripples.
When the need for a retrenchment of medical goals is discussed in
medical literature, it now usually takes the shape of planned
patient-dumping. Why should not the newborn and the dying, the
ethnocentric, the sexually inadequate, and the neurotic, plus any
number of other uninteresting and time-consuming victims of diagnostic
fervor, be pushed beyond the frontiers of medicine and be transformed
into clients of nonmedical therapeutic purveyors: social workers,
television programmers, psychologists, personnel officers, and sex
counselors?248 This multiplication of enabling jobs that hold reflected
medical prestige has created an entirely new setting for the role of
the sick.
Any society, to be stable, needs
certified deviance. People who look strange or who behave oddly are
subversive until their common traits have been formally named and their
startling behavior slotted into a recognized pigeonhole. By being
assigned a name and a role, eerie, upsetting freaks are tamed, becoming
predictable exceptions who can be pampered, avoided, repressed, or
expelled. In most societies there are some people who assign roles to
the uncommon ones; according to the prevalent social prescription, they
are usually those who hold special knowledge about the nature of
deviance:249 they decide whether the deviant is possessed by a ghost,
ridden by a god, infected by poison, being punished for his sin, or the
victim of vengeance wrought by a witch. The agent who does this
labeling does not necessarily have to be comparable to medical
authority: he may hold juridical, religious, or military power. By
naming the spirit that underlies deviance, authority places the deviant
under the control of language and custom and turns him from a threat
into a support of the social system. Etiology is socially
self-fulfilling: if the sacred disease is believed to be caused by
divine possession, then the god speaks in the epileptic fit.250
Each civilization defines its own diseases.251 What is sickness in one
might be chromosomal abnormality, crime, holiness, or sin in another.
Each culture creates its response to disease. For the same symptom of
compulsive stealing one might be executed, treated to death, exiled,
hospitalized, or given alms or tax money. Here thieves are forced to
wear special clothes; there, to do penance; elsewhere, to lose a
finger, or again, to be conditioned by magic or by electric shock. To
postulate for every society a specifically "sick" kind of deviance with
even minimal common characteristics252 is a hazardous undertaking. The
contemporary assignation of sick-roles is of a unique kind. It
developed not much more than a generation before Henderson and Parsons
analyzed it.253 It defines deviance as the special legitimate behavior
of officially selected consumers within an industrial milieu.254 Even
if there were something to say for the thesis that in all societies
some people are, so to speak, temporarily put out of service and
pampered while being repaired, the context within which this exemption
operates elsewhere cannot be compared to that of the welfare state.
When he assigns sick-status to a client, the contemporary physician
might indeed be acting in some ways similar to the sorcerer or the
elder; but in belonging also to a scientific profession that invents
the categories it assigns when consulting, the modern physician is
totally unlike the healer. Medicine men engaged in the occupation of
curing and exercised the art of distinguishing evil spirits from each
other. They were not professionals and had no power to invent new
devils. Enabling professions in their annual assemblies create the
sick-roles they assign.
The roles available for an
individual have always been of two kinds: those which are standardized
by cultural tradition and those which are the result of bureaucratic
organization. Innovation at all times meant a relative increase of the
latter, rationally created roles. No doubt, engineered roles could be
recovered by cultural tradition. No doubt a neat distinction between
the two kinds of roles is difficult to make. But on the whole, the
sick-role tended until recently to be of the traditional kind.255 In
the last century, however, what Foucault has called the new clinical
vision has changed the proportions. The physician has increasingly
abandoned his role as moralist and assumed that of enlightened
scientific entrepreneur. To exonerate the sick from accountability for
their illness has become a predominant task, and new scientific
categories of disease have been shaped for the purpose. Medical school
and clinic provide the doctor with the atmosphere in which disease, in
his eyes, may become a task for biological or social technique; his
patients still carry their religious and cosmic interpretations into
the ward, much as the laymen once carried their secular concerns into
church for Sunday service.256 But the sick-role described by Parsons
fits modern society only as long as doctors act as if treatment were
usually effective and while the general public is willing to share
their rosy view.257 The mid-twentieth-century sick-role has become
inadequate for describing what happens in a medical system that claims
authority over people who are not yet ill, people who cannot reasonably
expect to get well, and those for whom doctors have no more effective
treatment than that which could be offered by their uncles or aunts.
Expert selection of a few for institutional pampering was a way to use
medicine for the purpose of stabilizing an industrial society:258 it
entailed the easily regulated entitlement of the abnormal to abnormal
levels of public funds. Kept within limits, during the early twentieth
century the pampering of deviants "strengthened" the cohesion of
industrial society. But after a critical point social control exercised
through the diagnosis of unlimited needs destroyed its own base.259
Until proved healthy, the citizen is now presumed to be sick.260 In a
triumphantly therapeutic society, everybody can make himself into a
therapist and someone else into his client.
The
role of the doctor has now become blurred.261 The health professions
have come to combine clinical service, public-health engineering, and
scientific medicine. The doctor deals with clients who are
simultaneously cast in several roles during every contact they have
with the health establishment. They are turned into patients whom
medicine tests and repairs, into administered citizens whose healthy
behavior a medical bureaucracy guides, and into guinea pigs on whom
medical science constantly experiments. The Aesculapian power of
conferring the sick-role has been dissolved by the pretensions of
delivering totalitarian health care. Health has ceased to be a native
endowment each human being is presumed to possess until proven ill, and
has become an ever-receding goal to which one is entitled by virtue of
social justice.
The emergence of a conglomerate
health profession has rendered the patient role infinitely elastic. The
doctor's certification of the sick has been replaced by the
bureaucratic presumption of the health manager who arranges people
according to degrees and categories of therapeutic need, and medical
authority now extends to supervised health care, early detection,
preventive therapies, and increasingly, treatment of the incurable.
Previously modern medicine controlled only a limited market; now this
market has lost all boundaries. Unsick people have come to depend on
professional care for the sake of their future health. The result is a
morbid society that demands universal medicalization and a medical
establishment that certifies universal morbidity.
In a morbid society262 the belief prevails that defined and diagnosed
ill-health is infinitely preferable to any other form of negative label
or to no label at all. It is better than criminal or political
deviance, better than laziness, better than self-chosen absence from
work. More and more people subconsciously know that they are sick and
tired of their jobs and of their leisure passivities, but they want to
hear the lie that physical illness relieves them of social and
political responsibilities. They want their doctor to act as lawyer and
priest. As a lawyer, the doctor exempts the patient from his normal
duties and enables him to cash in on the insurance fund he was forced
to build. As a priest, he becomes the patient's accomplice in creating
the myth that he is an innocent victim of biological mechanisms rather
than a lazy, greedy, or envious deserter of a social struggle for
control over the tools of production. Social life becomes a giving and
receiving of therapy: medical, psychiatric, pedagogic, or geriatric.
Claiming access to treatment becomes a political duty, and medical
certification a powerful device for social control.
With the development of the therapeutic service sector of the economy,
an increasing proportion of all people come to be perceived as
deviating from some desirable norm, and therefore as clients who can
now either be submitted to therapy to bring them closer to the
established standard of health or concentrated into some special
environment built to cater to their deviance. Basaglia263 points out
that in the first historical stage of this process, the diseased are
exempted from production. At the next stage of industrial expansion, a
majority come to be defined as deviant and in need of therapy. When
this happens, the distance between the sick and the healthy is again
reduced. In advanced industrial societies the sick are once more
recognized as possessing a certain level of productivity which would
have been denied them at an earlier stage of industrialization. Now
that everybody tends to be a patient in some respect, wage labor
acquires therapeutic characteristics. Lifelong health education,
counseling, testing, and maintenance are built right into factory and
office routine. Therapeutic dependencies permeate and color productive
relations. Homo sapiens, who awoke to myth in a tribe and grew into
politics as a citizen, is now trained as a lifelong inmate of an
industrial world.264 The medicalization of industrial society brings
its imperialistic character to ultimate fruition.
-------------------------------------------
1 Judith P. Swazey and Renée Fox, "The Clinical Moratorium: A Case
Study of Mitral Valve Surgery," in Paul A. Freund, ed., Experimentation
with Human Subjects (New York: Braziller, 1970), pp. 315-57.
2 Francisco Goya, in Los Caprichos, the series of etchings of 1786,
shows a man asleep at his desk with his head on his crossed arms, while
monsters surround him. The inscription on the desk reads, "El sueno de
la razon produce monstruos." Rene Dubos uses this picture as
frontispiece of his book The Mirage of Health (see above, note 3, p.
13). It encapsulates his thesis, on which I try to elaborate in the
present book.
3 Morton Mintz, The Pill: An Alarming
Report (Boston: Beacon Press, 1970). Model for a study of medicine by a
newspaper reporter who knows how to combine studies in medicine with
information that is significant but has been overlooked, repressed, or
veiled in medical literature.
4 Francis D. Moore,
"The Therapeutic Innovation: Ethical Boundaries in the Initial Clinical
Trials of New Drugs and Surgical Procedures," in Freund, ed.,
Experimentation with Human Subjects, pp. 358-78.
5
One example of the need for such outside control over professional
progress might be useful. Peter R. Breggin, "The Return of Lobotomy and
Psychosurgery," Congressional Record 118 (February 24, 1972): 5567-77,
presents a truly shocking review of the vast literature on the current
resurgence of lobotomy in the U.S. and around the world. The first wave
was aimed mostly (2/3) at female state hospital patients, and claimed
50,000 persons in the U.S. alone before 1964. New methods are available
to destroy parts of the brain by ultrasonic waves, electric
coagulation, and implantation of radium seeds. The technique is
promoted for the sedation of the elderly, to render their
institutionalization less expensive; for the control of hyperactive
children; and to reduce erotic fantasies and the tendency to gamble.
6 Each society has its characteristic "nosology," or classification of
diseases. Both the extent of conditions classified as disease and the
number and kinds of diseases listed change with history. The official
or medical nosology recognized in a society can be to a very high
degree out of gear with the perception of the disease shared by one or
several of the society's classes. See Michel Foucault, The Birth of the
Clinic, trans. A. M. Sheridan Smith (New York: Pantheon, 1973). In our
society nosology is almost totally medicalized; ill-health that is not
labeled by the physician is written off either as malingering or as
illusion. As long as iatrogenic disease is treated as one small
category within the established nosology, its contribution to the total
volume of recognized diseases will not be appreciated.
7I use the term "intensity" to designate an increase that can be marked
by numbers but not measured directly. Paralyzing fear is by no means
superior to a lesser fear that drives to flight. Fernand Renoitre,
Éleménts de critique des sciences et de cosmologie, course published by
the Institut Superieur de Philosophic, Louvain, 1947, pp. 129-30.
8 For a more systematic analysis of the term "radical monopoly" as
applied to professional institutions, see Ivan Illich, Tools for
Conviviality (New York: Harper & Row, 1973), chap. 3, sec. 2, pp.
51-7.
9 An example: Until about 1969, penicillin G
tablets were available in Mexican pharmacies under their generic name
at a very low price. They have since disappeared from the market. The
Farmacopea Mexicana does not list any oral penicillin G even in
trademark preparations. Only considerably more expensive preparations
are available.
10 John Blake, ed., Safeguarding the
Public: Historical Aspects of Medical Drug Control, Papers from a
Conference Sponsored by the National Library of Medicine (Baltimore:
Johns Hopkins, 1970). On the process by which the medical profession
developed its self-image of benevolent caretaker, see L. Edelstein, The
Hippocratic Oath (Baltimore: Johns Hopkins, 1943).
11 For the classic distinction between exchange-value and use-value
consult Karl Marx, Capital (Chicago: Kerr, 1912), vol. 1, chap. 1,
especially sec. 4.
12 Michel Bosquet, "Quand la
médecine rend malade: La Terrible Accusation d'un groupe d'experts," Le
Nouvel Observateur, no. 519 (1974), pp. 84-118, and no. 520 (1974), pp.
90-130. This article shows how social iatrogenesis is fundamentally the
result of the alibi function played by the professional monopoly of the
sick-role.
13 Paul Ramsey, Fabricated Man: The
Ethics of Genetic Control (New Haven, Conn.: Yale Univ. Press, 1970),
argues that there are things we can do which ought not to be done. To
exclude these things is a necessary condition for safeguarding man from
total abasement by technical control. Ramsey reaches this conclusion
about specific kinds of medical techniques. I make the same argument,
but about the global intensity of the medical endeavor.
14 P. M. Brunetti, "Health in Ecological Perspective," Acta
Psychiatrica Scandinavica 49, fasc. 4 (1973): 393-404. Brunetti argues
that the concentration of power and the dependence on extrametabolic
energy can make the vital milieu uninhabitable for beings whose
integration depends on the exercise of their autonomy. Medicine is used
to rationalize this transfer.
15 Renée Fox,
"Illness," in International Encyclopedia of the Social Sciences (1968),
7: 90-6. An excellent introduction to the evolution of this concept.
l6 Talcott Parsons, The Social System (New York: Free Press, 1951), pp.
428 ff., contains the classic formulation of the sick-role. Miriam
Siegler and Humphrey Osmond, Models of Madness, Models of Medicine (New
York: Macmillan, forthcoming) compare several models for disabling
deviance and plead, for political reasons, for the relative expansion
of the Parsonian sick role on the grounds that it alone creates a claim
to therapy. For the contrary plea see Niels Christie's still untitled
forthcoming book on the counterproductivity of therapy. (For
manuscript, write to Niels Christie, Faculty of Law and Jurisprudence,
University of Oslo.)
l7 Forrest E. Clements,
"Primitive Concepts of Disease," University of California Publications
in American Archaeology and Ethnology 32, no. 2 (1932): 185-252. Common
etiologies fall into four main categories: (1) sorcery, (2) breach of
taboo, (3) intrusion of foreign object, (4) loss of soul.
18 Eliot Freidson, "Disability as Deviance," in M. B. Sussman, ed.,
Sociology and Rehabilitation (Washington: American Sociological
Association, 1966), pp. 71-99. Professional diagnosis tends merely to
give validity to lay perceptions of the value attributed to certain
individuals.
19 Harold Garfinkel, "Conditions of
Successful Degradation Ceremonies," American Journal of Sociology 61
(March 1956): 420-44. In our society public degradation ceremonies
outside the courts are rather rare. But medicine even today puts public
evaluation on characteristics considered as essential as self-control
or sexuality.
20 Louis Lewin, The Untoward Effects
of Drugs, trans. W. T. Alexandre (Detroit: Davis, 1883).
Notwithstanding its early date, this remains a fascinating book to
read, full of historical footnotes. It lists victims of medicine from
Nero's guard captain (Spanish fly) to Otto II (aloes), and Avicenna
(pepper enema).
21 On the double meaning of this
term from archaic texts to the Hippocratic corpus, see Walter Artelt,
Studien zur Geschichte der Begriffe "Heilmittel" und "Gift":
Urzeit-Homer-Corpus Hippocraticum (Darmstadt: Wissenschaftliche
Buchgesell-schaft, 1968). John D. Gimlette, Malay Poisons and Charm
Cures (Kuala Lumpur: Oxford Univ. Press, 1971); John D. Gimlette and H.
W. Thompson, A Dictionary of Malayan Medicine (Kuala Lumpur: Oxford
Univ. Press, 1971): both volumes form a fascinating introduction to the
same ambiguity in an entirely different world.
22
Judith Lorber, "Deviance as Performance: The Case of Illness," in Eliot
Freidson and Judith Lorber, eds., Medical Men and Their Work (Chicago:
Aldine, 1972), pp. 414-23. Discusses the attempts of the deviant person
to convey the impression which he hopes will lead to the imposition of
a certain label rather than another.
23 Thomas S.
Szasz, "The Psychology of Persistent Pain: A Portrait of l'Homme
Douloureux," in A. Soulairac, J. Cahn, and J. Charpentier, eds. Pain,
Proceedings of the International Symposium Organized by the Laboratory
of Psychophysiology, Faculty of Sciences, Paris, April 11-13, 1967 (New
York: Academic Press, 1968), pp. 93-113.
24 Mark G.
Field, "Structured Strain in the Role of the Soviet Physician,"
American Journal of Sociology, 58 (1953): 493-502. Describes a
situation in which the government rationed sick passes, which were in
great demand by overstrained workers. Physicians were forced to
readjust the definition of sickness to balance the interest of the
workers against the demands of the production process. Thomas S. Szasz,
"Malingering: Diagnosis or Social Condemnation?" in Freidson, and
Lorber, eds., Medical Mm and Their Work, pp. 353-68.
25 Edwin S. Shneidman, "Orientations Towards Death: A Vital Aspect of
the Study of Lives," in Robert W. White, ed., The Study of Lives:
Essays on Personality in Honor of A. Murray (New York: Atherton, 1963).
For the classification of death by intention and legitimacy and further
literature on the subject, see Gregory Zilboorg, "Suicide Among
Civilized and Primitive Races," American Journal of Psychiatry 92 (May
1936): 1347-69.
26 Pharmacists, for instance, will
not be condemned for poisoning their clients. See Earl R. Quinney,
"Occupational Structure and Criminal Behavior: Prescription Violation
by Retail Pharmacists," Social Problems 11 (1963): 179-85.
27 Howard S. Becker, Outsiders: Studies in the Sociology of Deviance
(New York: Free Press, 1963). Clarifies the connection between the
therapeutic orientation of an occupation or profession and
"entrepreneur-ship."
28 Joseph R. Gusfield, "Social
Structure and Moral Reform: A Study of the Woman's Christian Temperance
Union," American Journal of Sociology 61 (November 1955): 221-32. Moral
crusaders are always obsessed with improving those whom they set out to
benefit.
29 Frank Tannenbaum, Crime and the Community (New York: Columbia Univ. Press, 1938).
30 Wilbert Moore and Gerald W. Rosenblum, The Professions: Roles and
Rules (New York: Russell Sage, 1970). See especially chap. 3 of this
comprehensive guide to the literature, "The Professionalization of
Occupations."
31 William J. Goode, "Encroachment,
Charlatanism, and the Emerging Professions: Psychology, Medicine, and
Sociology," American Sociological Review 25 (December 1960): 902-14.
32 See Miriam Siegler and Humphrey Osmond, "Aesculapian Authority," Hastings Center Studies 1, no. 2 (1973): 41-52.
33 Eliot Freidson, Profession of Medicine: A Study of the Sociology of
Applied Knowledge (New York: Dodd, Mead, 1971), pp. 208 ff.
34 June Goodfield, "Reflections on the Hippocratic Oaths," Hastings Center Studies 1, no. 2 (1973): 79-92.
35 The law has had little experience with the problem of selecting one
individual to live and thereby dooming others to die. Seamen have been
convicted of manslaughter for having helped to throw 14 of 41
passengers out of a leaking lifeboat into the sea (U.S. vs. Holmes,
1842). So far the silence of the U.S. judiciary, combined with the
silence of the legislature, seems to imply a preference for leaving
decisions involving selection for survival to processes not subject to
legal analysis. But increasing demands are made to create a rule of law
to protect individuals seeking so-called life-prolonging treatment
against the prejudices and arbitrariness of professional men. See
below, note 204, p. 102.
36 Seymour E. Harris, The
Economics of American Medicine (New York: Macmil-lan, 1964). A detailed
survey of the cost of services, drugs, various levels of manpower, and
hospitals; of historical value for the period between 1946 and 1961,
during which health-care costs rose by 380%.
37
Robert W. Hetherington, Carl E. Hopkins, and Milton I. Roemer, Health
Insurance Plans: Promise and Performance (New York: Wiley 1975). The
U.S. is dominated by a galaxy of autonomous and often competing health
plans that are sometimes commercial, sometimes provider-sponsored, and
sometimes organized along the lines of group practice. For most
citizens all this is supplemented by some coverage through national
health insurance. This evaluation of clients' reactions to different
choices shows how little they really differ.
38
Martin S. Feldstein, The Rising Cost of Hospital Care (Washington,
D.C.: Information Resources, 1971). Hospital costs have outstripped by
far the rise in physicians' fees. The over-all cost of medical care has
gone up faster than the average cost of all goods and services in the
consumer price index. Prescription and drug costs have risen the least.
Over-the-counter drug prices have actually fallen, but the drop is more
than made up for by prescription costs.
39 CREDOC
(Centre de recherches et de documentation sur la consommation),
Évolution de la structure des soins médicaux, 1959-1972 (Paris, 1973).
40 "Krankheitskosten: 'Die bombe tickt'; Das westdeutsche
Gesundheitswesen," 1. "Der Kampf um die Kassen-Milliarden"; 2. "Die
Phalanx der niedergelassenen Ärzte," Der Spiegel, no. 19 (1975), pp.
54-66; no. 20 (1975), pp. 126-42.
41 An excellent
general introduction to the cost explosion in health care is R.
Maxwell, Health Care: The Proving Dilemma; Needs vs. Resources in
Western Europe, the U.S., and the U.S.S.R. (New York: McKinsey &
Co., 1974). lan Douglas-Wilson and Gordon McLachlan, eds., Health
Service Projects: An International Survey (Boston: Little, Brown,
1973). This international comparison shows "the extreme heterogeneity
in organization and ideology" of different systems. Everywhere "the
rationalization is motivated, not by politics of the left or the right,
but by the sheer necessity to secure more effective use of scarce and
expensive resources." No country can indefinitely sustain unchecked
increases in funds allocated for the treatment of illness.
42 Louise Russell et al., Federal Health Spending, 1969-74 (Washington,
D.C.: Center for Health Policy Studies, National Planning Association,
1974). For comparison check B. Able Smith, An International Study of
Health Expenditures and Its Relevance for Health Planning, Public
Health Paper no. 32 (Geneva: World Health Organization, 1967). Based on
a questionnaire to ministries, this supersedes the author's earlier
Paying for Health Services and provides data for the study of trends.
Herbert E. Klarman, The Economics of Health (New York: Columbia Univ.
Press, 1965), gives a qualitative analysis of demand, supply, and
organization in the U.S., with ample bibliographical guidance.
43John Bryant, Health and the Developing World (Ithaca, N.Y.: Cornell
Univ. Press, 1969). A picture of health care in countries receiving
international aid.
44 For documentation assembled
by professional administrators, see Bruce Balfe et al., Resource
Materials on the Socio-economic and Business Aspects of Medicine
(Chicago: Center for Health Services R & D., American Medical
Association, 1971). For orientation on current, mostly U.S., materials
on medical economics ranging from research reports to articles in Time
magazine, see American Medical Association, Medical Socioeconomic
Research Sources, 12 issues per year since 1970.
45 Feldstein, Rising Cost of Hospital Care.
46 John H. Knowles, "The Hospital," Scientific American 229 (September
1973): 128-37. Contains charts and graphs on the evolution of hospital
expenditures.
47 Martin S. Feldstein, "Hospital
Cost Inflation: Study of Nonprofit Price Dynamics," American Economic
Review 61 (December 1971): 853-76. For a complementary prediction of a
further increase in capital-intensive medicine see Dale L. Hiestand,
"Research into Manpower for Health Services," Milbank Memorial Fund
Quarterly 44 (October 1966): 146-81.
48 Robert
Rushmer, Medical Engineering: Projections for Health Care Delivery (New
York: Academic Press, 1972), p. 115.
49 Victor R. Fuchs, Who Shall Live? Health, Economics and Social Choice (New York: Basic Books, 1974), p. 15.
50 W. H. Forbes, "Longevity and Medical Costs," New England Journal of
Medicine 277 (1967): 71-8. Longevity is measured as "average remaining
lifetime" (ARL). It has remained nearly constant for 1947-1965, but the
U.S. rate compared with other industrialized countries has fallen
sharply for men and slightly for women. "There is no longer any
significant relationship [in 30 countries studied] between the money
spent on health and the longevity of the population." See also P.
Longone, "Mortalité et morbidité," Population et Société, no. 43
(January 1972).
51 Victor Cohen, "More Hospitals To Fill: Abuses Grow," Technology Review, October-November 1973, pp. 14-16.
52 Robert F. Rushmer, Medical Engineering: Projections for Health Care
Delivery (New York: Academic Press, 1972), expresses the hope that the
forthcoming increase in federal funding will create a new market for
spare parts, from breast-enhancers to artificial hearts.
53 Feldstein, Rising Cost of Hospital Care.
54 William A. Glaser, Paying the Doctor: Systems of Remuneration and
Their Effects (Baltimore: Johns Hopkins, 1970). Consult this
cross-national comparative analysis for the impact of different methods
of payment on the costliness of the physician.
55
John and Sylvia Jewkes, Value for Money in Medicine (Oxford: Blackwell,
1963), pp. 30-7, argue: "It may be that, as electorates become more
sophisticated, they will recognize they have in fact to pay (or free
services"; also that relatively cheap prevention through more healthy
everyday habits is more effective than purchase of repairs.
56 Fuchs, in Who Shall Live?, chap. 3, argues for institutional
licensing as a substitute for the licensing of individuals. Under such
a system, medical-care institutions would be licensed by the state and
would then be free to hire and use personnel as each saw fit. This
system would deploy resources more efficiently and provide more upward
job mobility. But the physician's control over care produced and
delivered by others would be weakened.
57 For a bibliography on socialized medicine in Britain, consult Freidson, Profession of Medicine, p. 34, n. 9.
58 Michael H. Cooper, Rationing Health Care (London: Halsted Press,
1975). A sober, critical, and lively attempt at an over-all economic
review of the nature and problems of the first 26 years of the British
National Health Service.
59 Y. Lisitsin, Health Protection in the USSR (Moscow: Progress Publishers, 1972).
60 Mark G. Field, Soviet Socialized Medicine: An Introduction (New
York: Free Press, 1967). A standard introduction (now 12 years out of
date) to the Soviet medical system. Pp. ix-xii provide a critical
orientation to German, English, and French literature, and chap. 5,
references to the return from social to curative priorities.
61 See below, note 64.
62 John Frey, Medicine in Three Societies (MTP, Aylesbury, England, 1974).
63 Mark G. Field, "Soviet and American Approaches to Mental Illness: A
Comparative Perspective," Review of Soviet Medical Sciences 1 (1964):
1-36.
64 Joachim Israel, "Humanisierung oder
Bürokratisierung der Medizin?" Neue Gesellschaft 21 (1974): 397-404.
Provides an inventory of 15 strong tendencies towards the
bureaucratization of life, which takes specifically health-related
forms in medicine and menaces people equally in the Federal Republic of
Germany and in the U.S.S.R.
65 Odin W. Anderson,
Health Care: Can There Be Equity? The United States, Sweden, and
England (New York: Wiley, 1972). All three systems grow towards the
same kind of bureaucracy, at comparable costs, but equity in access is
much lower in the U.S.A.
66 International Bank for Reconstruction and Development, Health Sector Policy Paper, Washington, D.C., March 1975.
67 It must not be overlooked that medical schools in poor countries
constitute one of the most effective means for the net transfer of
money to the rich countries. O. Ozlak and D. Caputo, "The Migration of
Medical Personnel from Latin America to the U.S.: Towards an
Alternative Interpretation," paper presented at the Pan-American
Conference on Health and Manpower Planning, Ottawa, Canada, September
10-14, 1973. The authors estimate that the annual net loss for the
whole of Latin America due to the flow of physicians to the U.S. is
$200 million, a figure equal to the total medical aid given by the U.S.
to Latin America during the first development decade, i.e., the period
that started with the "Alliance for Progress." Hossain A. Ronaghy,
Kathleen Cahill, and Timothy D. Baker, "Physician Migration to the
United States: One Country's Transfusion Is Another Country's
Hemorrhage," Journal of the American Medical Association 227 (1974):
538-42, provides information on outmigration of Iranian students by the
university from which they graduated. Oscar Gish, ed., Doctor Migration
and World Health, Occasional Papers on Social Administration no. 43,
Social Administration Research Trust (London: Bell, 1971). Stephen S.
Mick, "The Foreign Medical Graduate," Scientific American 232 (February
1975): 14-22. There are 58,000 imported physicians now practicing in
the U.S.; fully licensed practitioners have quadrupled. In the Middle
Atlantic, North Central, and New England regions, they outnumber native
physicians. India, the Philippines, Italy, and Canada each paid for the
full education of more than 3,000 of these; Argentina, South Korea, and
Thailand, among others, for more than 1,000 each. N.B.: The training of
a Peruvian physician costs about six thousand times as much as the
education of a typical Peruvian peasant.
68 In
Ghana, the Central Hospital absorbed 149 of the 298 physicians
available to the official health services, yet only about 1% of the
patients had been officially referred by medical personnel outside the
hospital. M. J. Sharpston, "Uneven Geographical Distribution of Medical
Care, a Ghanaian Case Study," Journal of Development Studies 8 (January
1972): 205-22.
69 For a useful survey of social
science research on health in Latin America, see Arthur Rubel, "The
Role of Social Science Research in Recent Health Programs in Latin
America," Latin American Research Review 2 (1966): 37-56. Dieber
Zschock, "Health Planning in Latin America: Review and Evaluation,"
Latin American Research Review 5 (1970): 35-56.
70
Victor R. Fuchs, "The Contribution of Health Services to the American
Economy," Milbank Memorial Fund Quarterly 44 (October 1966): 65-103.
Fuchs drives this point home.
71 For orientation
see Joshua Horn, Away with All Pests: An English Surgeon in People's
China, 1954-1969 (New York: Monthly Review Press, 1971). Victor W. and
Ruth Sidel, "Medicine in China: Individual and Society," Hastings
Center Studies 2, no. 3 (1974): 23-36. Victor Sidel, "The Barefoot
Doctors of the People's Republic of China," New England Journal of
Medicine 286 (1972): 1292-1300. A. J. Smith, "Medicine in China" (5
articles), British Medical Journal, 1974, 2:367-70, and the following
four issues. Carl Djerassi, "The Chinese Achievement in Fertility
Control," Bulletin of the Atomic Scientists, June 1974, pp. 17-24. Paul
T. K. Lin, "Medicine in China," Center Magazine (Santa Barbara, Calif),
May-June, 1974. M. H. Liang et al., "Chinese Health Care: Determinants
of the System," American Journal of Public Health 63 (February 1973):
102-10. Horn's is still the best first-person report. Sidel's and
Smith's are reports from traveling colleagues to the profession.
Djerassi gives valuable insights into the status of contraception. Lin
calls attention to the new challenges created by the recent prevalence
of degenerative disease. See also Ralph C. Croizier, Traditional
Medicine in Modem China: Science, Nationalism, and the Tension of
Cultural CJiange (Cambridge: Harvard Univ. Press, 1968).
72 David Lampton, Health, Conflict, and the Chinese Political System,
Michigan Papers in Chinese Studies no. 18 (Ann Arbor: Univ. of
Michigan, Center for Chinese Studies, 1974). Since 1971 competing
interest groups, each trying to maximize realization of its values,
have helped to re-establish the pre-1968 bureaucratic model in medicine.
73 Instruments for the further study of contemporary Chinese health
care: Joseph Quinn, Medicine and Public Health in the People's Republic
of China, U.S. Department of Health, Education, and Welfare no. NIH
73-67. Fogarty International Center, A Bibliography of Chinese Sources
on Medicine and Public Health in the People's Republic of China:
1960-1970, Department of Health, Education, and Welfare publication no.
NIH 73-439. American Journal of Chinese Medicine, P.O. Box 555, Garden
City, N.Y. 11530.
74 Vicente Navarro, "The
Underdevelopment of Health or the Health of Underdevelopment: An
Analysis of the Distribution of Human Health Resources in Latin
America," International Journal of Health Services 4, no. 1 (1974):
5-27. Scarcity of health care is consistent with the general scarcity
of industrial outputs that favors an urban, entrepreneurial
lumpen-bourgeoisie dependent on its foreign counterparts. This paper is
based on a presentation at the Pan-American Conference on Health and
Manpower Planning in Ottawa, Canada, September 10-14, 1973. A modified
version appears in the spring 1974 issue of Politics and Society.
75 B. Shenkin, "Politics and Medical Care in Sweden: The Seven Crowns
Reform," New England Journal of Medicine 288 (1973): 555-59. For
background consult Ronald Huntford, The New Totalitarians (New York:
Stein & Day, 1972).
76 Roy A. and Zhores
Medvedev, A Question of Madness (New York: Knopf, 1972), complain that
the nature of society is such that at least two professions, medicine
and law, are not part of the state system. The totalitarian
centralization of medical services, while it has introduced the
progressive principle of free health care for all, has also made it
possible to use medicine as a means of government control and political
regulation.
77 David R. Hyde et al., "The American
Medical Association: Power, Purpose, and Politics in Organized
Medicine," Yale Law Journal 63 (May 1954): 938-1022. Hyde is an early,
dated, but still valuable critic. Richard Harris, A Sacred Trust
(Baltimore: Penguin, 1969). A history of the American Medical
Association's clever and costly battle against public health
legislation in the sixties. Elton Rayack, Professional Power and
American Medicine: The Economics of the American Medical Association
(Cleveland: World Pub., 1967), describes blackmail and conspiracy by
the American Medical Association lobby to maintain tight control over
licensing and the setting of standards for every product that
physicians perceive as health-related. This control removes all limits
from their power.
78 On the reasons that foreshadow
the unionization of doctors, see S. Kelman, "Towards a Political
Economy of Medical Care," Inquiry 8, no. 3 (1971): 30-8; also note 79,
p. 248.
79 Lewis Mumford, The Pentagon of Power,
vol. 2, The Myth of the Machine (New York: Harcourt Brace, 1970),
elaborates on the concept of society as megamachine.
80 Beyond a certain point of intensity, consumption produces a scarcity
of time: Staffan B. Linder, Harried Leisure Class (New York: Columbia
Univ. Press, 1970); acceleration produces a penury of space: Jean
Robert, "Essai sur 1'accélération des dons," L'Arc (Aix-en-Provence),
fall 1975; and planning destroys the possibilities for choice: Herbert
Marcuse, Eros and Civilization (Boston: Beacon Press, 1955).
81 René Dubos, Man and His Environment: Biomedical Knowledge and Social
Action, Pan-American Health Organization, Scientific Publication no.
131 (Washington, D.C., March 1966). "The kind of health that men desire
most is ... the condition best suited to reach goals that each
individual formulates for himself." See also Heinz von Foerster,
Molecular Ethology: An Immodest Proposal (New York: Plenum Press,
1970), for a demonstration from theoretical biology that nontrivial
"life" can be extinguished by overprogramming.
82
Victor Fuchs, "Some Economic Aspects of Mortality in Developed
Countries," paper presented at the Conference on the Economy of Health
and Medical Care, Tokyo, 1973, mimeographed. Fuchs assumes that "life
is primarily produced by nonmarket activities, and that the female
tends to specialize in such activities." The attempt to replace rather
than to complement these "nonmarket activities" with commodities is
literally unhealthy. See Alan Berg, The Nutrition Factor: Its Role in
National Development (Washington, D.C.: Brookings Institution, 1973),
app. C, p. 229, on the sickening effects of the substitution of various
formulas for breast milk.
83 The medicalization of
the budget is a measure of the professional disseizin of health and of
the acquiescence of people in their own disendowment by therapeutic
caretakers. Disseizin: "the wrongful putting out of him from that which
is actually seized as a freehold": P. G. Osborn, Concise Law Dictionary
(London: Sweet & Maxwell, 1964).
84 For a first
orientation: Alfred M. Ajami, Jr., Drugs: An Annotated Bibliography and
Guide to the Literature (Boston: Hall, 1973). Ajami selects and
annotates more than 500 references on psychopharmacology for an
interdisciplinary course on the U.S. "scene" of the late sixties. U.S.
National Clearing House for Mental Health, Bibliography of Drug
Dependence and Abuse 1928-1966 (Chevy Chase, Md., J969). Indispensable
for historical research. Alice L. Brunn, How to Find Out in Pharmacy: A
Guide to Sources of Pharmaceutical Information (Oxford: Pergamon Press,
1969). A simple reference guide. R. H. Blum et al., Society and Drugs,
2 vols. (Berkeley, Calif.: Jossey-Bass, 1970). A portable library on
society and drugs.
85 G. E. Vaillant, "The Natural
History of Narcotic Drug Addiction," in Seminars in Psychiatry 2
(November 1970): 486-98. Drugs depend both for their desirability and
their effect on the milieu in which they are taken. The choice of the
drug is a function of the culture, but the abuse of the drug is a
function of the man. The ritualization of drug-taking creates its
subculture: thus the history of drug addiction as that of society must
be rewritten every few years. Samuel Proger, ed., The Medicated Society
(New York: Macmillan, 1968), provides documents showing the kind of
drug culture that prevailed in the U.S. long before LSD.
The extent to which addicts are forced into a ghetto of their own
depends upon the community that rejects them. For instance, Puerto
Ricans in New York do not reject their addicts in the way middle-class
Americans do: J. P. Fitzpatrick, "Puerto Rican Addicts and Nonaddicts:
A Comparison," unpublished report, Institute for Social Research,
Fordham University, 1975.
86 Hans Wiswe,
Kulturgeschichte der Kochkunst: Kochbücher und Rezepte aus zwei
Jahrtausenden (Munich: Moos, 1970). Most societies cannot distinguish
clearly between their pharmacopeia and their diet. This survey of
cookbooks shows that many were written by physicians, with a frequent
insistence that the best medicine comes from the kitchen and not from
the pharmacy. Most contain "recipes" for the care of the sick.
87 For the present information available on drug action, see Louis S.
Goodman and Alfred Gilman, The Pharmacological Basis of Therapeutics,
4th ed. (New York: Macmillan, 1970). On prescribing patterns, see Karen
Dunnell and Ann Cartwright, Medicine Takers, Prescribers and Hoarders
(London: Routledge, 1972). Who takes which sort of medicines for what
types of conditions and symptoms? How do doctors encourage or
discourage this pattern? What kinds of medicines are kept in the home
and for how long? Detailed information about England. Also see John P.
Morgan and Michael Weintraub, "A Course on the Social Functions of
Prescription Drugs: Seminar Syllabus and Bibliography," Annals of
Internal Medicine 77 (August 1972): 217-22; Paul Stolley and Louis
Lasagna, "Prescribing Patterns of Physicians," Journal of Chronic
Diseases 22 (December 1969): 395-405.
88 Business in Thailand, special issue on the pharmaceutical industry, August 1974.
89 The American physician can easily gain access to this information
from such sources as Medical Letter on Drugs and Therapeutics, Medical
Library Association, 919 N. Michigan Avenue, Chicago, 111. This is an
unbiased source of drug information mailed fortnightly. Nothing
comparable is available in French, German, or Spanish. Also see Richard
Burack, The New Handbook of Prescription Drugs: Official Names, Prices,
and Sources for Patient and Doctor, rev. ed. (New York: Pantheon,
1970). (See below, note 99, p. 67, for description of this book.)
90 Arturo Aldama, "Establecimiento de un laboratorio farmacéutico
nacional," Higiene: Organo oficial de la Sociedad Mexicana de Higiene
11 (January-February 1959). This sounded the alarm.
91 The information on Cloromycetin is taken from U.S. Senate, Select
Committee on Small Business, Subcommittee on Monopoly, Competitive
Problems in the Drug Industry, 90th Congress, 1st and 2nd Sessions,
1967-68, pt. 2, p. 565.
92 On the mechanisms that
turn self-regulation into license for performance of the maximum
publically tolerated abuse, see Eliot Freidson and Buford Rhea,
"Process of Control in a Company of Equals," Social Problems 9 (1963):
119-131. They show that, though much abuse goes unobserved, even if
observed it is not communicated to colleagues, and even if communicated
it is treated by "talking to the offender" and remains uncontrolled.
Self-regulation principally protects the profession by eliminating the
incompetent butcher and the brazen moral leper. William J. Goode, "The
Protection of the Inept," American Sociological Review 32 (February
1967): 5-19. Goode describes how self-regulation consists to a large
degree in the protection of the inept within the group and the
protection of the group's self-interest from the excesses of the inept.
Modernization consists in the more efficient utilization of the inept
in the self-interest of the group. Eliot Freidson and Buford Rhea,
"Knowledge and Judgment in Professional Evaluations," Administrative
Science Quarterly 10 (June 1965): 107-24.
93 Memory
is no guide to which drugs have been prescribed or consumed in the
past. A search in the national registry of prescriptions in England and
Wales shows that 8 out of 10 women who had borne a defective child
after taking thalidomide on prescription denied that they had taken the
drug, and that their physicians denied having ordered it. See A. L.
Speirs, "Thalidomide and Congenital Abnormalities," Lancet, 1962, 1:303.
94 Henri Pradal, Guide des médicaments les plus courants (Paris: Seuil,
1974). In November 1973 my French publisher, Seuil, brought out a
paperback original of this book by a physician with many years'
experience as a toxicologist. It is a list of the 100 best-selling
pharmaceuticals, including prescription drugs, explaining what each one
is, what it is indicated for, how it tends to be used or prescribed,
and with what consequences. On publication day 57 drug firms started
separate legal actions to have the book withdrawn and sued for
reimbursement for probable damages.
95 A. del
Favero and G. Loiacono, Farmaci, salute e profitti in Italia (Milan:
Feltrinelli, 1974), describe the dependence and servility of the
Italian physician in his relations with the drug industry, and the
exploitative integration of the Italian drug firms among transnational
companies. Full of documentation and detail.
96
James H. Young, Medical Messiahs: A Social History of Health Quackery
in Twentieth-Century America (Princeton, N.J.: Princeton Univ. Press,
1967). Historical background for the cavalier confidence of U.S.
organized medicine based on its protection of the public against
free-lance healers and self-medication. For the earlier history see
James H. Young, The Toadstool Millionaires: A Social History of Patent
Medicines in America Before Federal Regulation (Princeton, N.J.:
Princeton Univ. Press, 1961).
97 Robert S.
McCleery, One Life—One Physician: An Inquiry into the Medical
Profession's Performance in Self-Regulation, A Report to the Center for
the Study of Responsive Law (Washington, D.C.: Public Affairs Press,
1971). This report to a study group initiated by Ralph Nader concludes
that there is a total lack of internal quality control within the
medical profession.
98 Morton Mintz, By
Prescription Only: A Report on the Roles of the United States Food and
Drug Administration, the American Medical Association, Pharmaceutical
Manufacturers and Others in Connection with the Irrational and Massive
Use of Prescription Drugs that May Be Worthless, Injurious, or Even
Lethal, 2nd ed. (Boston: Beacon Press, 1967). Originally published as
The Therapeutic Nightmare (Boston: Houghton Mifflin, 1965), this
masterpiece of investigative journalism by a staff reporter of the
Washington Post has done more than any other book to change the focus
of the U.S. discussion of medicine. For ten years a benevolent minority
had worried about the damage done by capitalist medicine to the poor.
Now the pill-swallowing majority became aware of what it was doing to
them.
99 Richard Burack, M.D., The New Handbook of
Prescription Drugs: Official Names, Prices and Sources for Patient and
Doctor (New York: Pantheon, 1970). Published at a time when judicial
evidence for the undue bias of regulatory commissions, conspiracy for
the dissemination of misleading information on poisonous drugs, and the
venality of not a few professors of medicine was still difficult to
obtain this book provides information and evaluation of the efficiency,
usefulness, side-effects, and application of the 200 most prescribed
drugs, comments on brand-name prices in comparison with generic
equivalents (for which suppliers are listed with addresses), and adds
spicy anecdotes on many trademarked nostrums.
100 James L. Goddard, "The Drug Establishment," Esquire, March 1969. A readable and well-researched report.
101 Edwin Sutherland, While-Collar Crime (New York: Holt, 1961), uses
this term to designate a wide variety of serious offenses involving
recognized social harm that either are not prosecuted or are confined
to civil courts. The medical variety has epidemic consequences and
might be called "white-coat crime."
102 Herbert
Schreier and Lawrence Berger, "On Medical Imperialism: A Letter,"
Lancet, 1974, 1:1161: "Under pressure from the US Food and Drug
Administration, Parke-Davis inserted strict warnings of hazards and
cautionary statements about indications for the use of the drug in the
USA. The warning did not extend to the same drug abroad." Also see John
F. Hellegers, "Chloramphenicol in Japan: Let It Bleed," Bulletin of
Concerned Asia Scholars 5 (July 1973): 37-45. The expansion of federal
controls over the export of drugs would only partially remedy this form
of imperialism. Federal authority, which now does cover the $6 billion
pharmaceutical drug industry, does not yet extenc over the $3 billion
medical device industry. It cannot, for example, stop the A. H. Robins
company from supplying foreign companies with a model of a
contraceptive shield which has been withdrawn from the U.S. market
because of its high infection rate; see Hastings Center Studies 5, no.
3 (1975): 2.
103 On medicine in Chile under Allende
consult Howard Waitzkin and Hilary Modell, "Medicine, Socialism, and
Totalitarianism: Lesson from Chile," New England Journal of Medicine
291 (1974): 171-7; Vicente Navarro, "What Does Chile Mean? An Analysis
of Events in the Health Sector Before, During, and After Allende's
Administration," Milbank Memorial Fund Quarterly 52 (spring 1974):
93-130. This article is based on a paper presented at the International
Health Seminar at Harvard University, February 1974. For an eyewitness
report, see Ursula Bernauer and Elisabeth Freitag, Poder popular in
Chile am Beispiel Gesundtieit: Dokumente ata Elendsvierteln
(Stein/Nuremberg: Laetere/Imba, 1974).
104 Albert
Jonsen et al., "Doctors in Politics: A Lesson from Chile," New England
Journal of Medicine 291 (1974): 471-2. Describes the particular
violence with which physicians were persecuted by the junta.
105John M. Firestone, Trends in Prescription Drug Prices (Washington,
D.C.: Enterprise Institute for Public Policy Research, 1970). Drug
expenditures account for only about 10% of health expenditures. The
moderate rise in the cost of each prescription during the last years is
due mainly to an increase in the size of the average prescription.
106 Edward M. Brecher and Consumer Reports Editors, Licit and Illicit
Drugs: The Consumers Union Report on Narcotics, Stimulants,
Depressants, Inhalants, Hallucinogens and Marijuana—Including Caffeine,
Nicotine and Alcohol (Boston: Little, Brown, 1973).
107 D. M. Dunlop, "The Use and Abuse of Psychotropic Drugs," in
Proceedings of the Royal Society of Medicine 63 (1970): 1279. G. L.
Klerman, "Social Values and the Consumption of Psychotropic Medicine,"
in Proceedings of the First World Congress on Environmental Medicine
and Biology (Haarlem: North-Holland, 1974). For a particularly
pernicious form of medically prescribed drug addiction see Dorothy
Nelkin, Methadone Maintenance: A Technological Fix (New York:
Braziller, 1973).
108 James L. Goddard, "The
Medical Business," Scientific American 229 (September 1973): 161-6.
Contains graphs and charts showing U.S. sales of prescription and
nonprescription drugs by category, 1962-71; breakdown by sales dollar
estimated in 1968 for 17 leading pharmaceutical houses; introduction of
new drugs, combinations, and dosage forms, 1958-72. Also identifies 8
classes of prescription drugs. Within the category "nervous system
drugs" alone, sales aggregate more than $1 billion per year. This
compares with three other categories each aggregating about $500
million, and the rest, each less than $350 million. For a breakdown, by
age, sex, and type, of medicines prescribed to nonhospitalized patients
in the course of one year in the U.S., see B. S. H. Harris and J. B.
Hallan, "The Number and Cost of Prescribed Medicines: Selected
Diseases," Inquiry 7 (1970): 38-50.
109 Drug Use in
America: Problem in Perspective, Second Report of the National
Commission on Marihuana and Drug Abuse, 1972, 1973, 1974, 4 vols.
(Washington, D.C.: Government Printing Office; stock no. 5266-0003).
National Commission for the Study of Nursing and Nursing Education, An
Abstract for Action (New York: McGraw-Hill, 1970).
110 Mitchell Baiter et al., "Cross-national Study of the Extent of
Anti-Anxiety/Sedative Drug Use," New England Journal of Medicine 290
(1974): 769-74.
111 Michael Balint, Treatment or
Diagnosis: A Study of Repeat Prescriptions in General Practice, Mind
and Medicine Monographs (Philadelphia: Lippincott, 1970). Prescription
provides luster and seeming rationality to the belief that progress
consists in buying one's way out of everything, including reality
itself. Balint points out that in two-thirds of cases in which drugs
were repeatedly prescribed without any technical justification, the
physician himself took the initiative to offer the drug. Harry Dowling,
"How Do Practicing Physicians Use New Drugs?" Journal of the American
Medical Association 185 (1963): 233-36. Out of fear of "doing nothing"
the practitioner is led to prescribe more than is indicated by
instructions on the package. On the pattern according to which
prescription abuses spread, see Leighton E. duff et al., "Studies in
the Epidemiology of Adverse Drug Reactions," Journal of the American
Medical Association 188 (1964): 976-83.
l12Philippe
de Felice, Poisons sacrés: Ivresses divines; Essai sur quelques formes
inferieures de la mystique (Paris: Albin, 1936; reprinted 1970). The
traditional, usually religious setting and goal for drug consumption
are contrasted with present-day laicized use of mind-altering
substances.
113 Charles Levinson, Valium zum
Beispiel: Die multinational Konzeme der pharmazeutischen Industrie
(Hamburg: Rowohlt, 1974). The prices charged in India by Glaxo, Pfizer,
Hoechst, CIBA-Geigy, and Hofftnann-LaRoche are on the average 357%
higher than those listed in the Western countries where these firms
have their home offices.
114 See also Burack, New Handbook of Prescription Drugs.
115 In most countries, most information on drugs for the physician
comes from industry-sponsored manuals such as Physicians' Desk
Reference to Pharmaceutical Specialities and Biologicals, published
since 1946 by Medical Economics, Rutherford, NJ. This annual
publication, known as PDR, is supported by the pharmaceutical industry.
The drug descriptions are written by the companies themselves, which
pay $115 per column-inch for the space; see John Pekkanen, The American
Connection: Profiteering and Politicking in the "Ethical" Drug Industry
(Chicago: Follett, 1973), p. 106. The French Vidal contains
descriptions which suppress the warnings that are obligatory in the
leaflet that comes with the drug. In contrast to these, the U.S. has
two semiofficial pharmacological compendia, the Pharmacopeia of the
United States of America (USP) and the National Formulary (NF). The USP
has consistently given consideration to therapeutic worth and toxicity.
These compendia are not written for the guidance of physicians, but to
provide drug manufacturers with technical standards that preparations
must meet to be marketed legally in interstate commerce in the U.S.
116 For an idea of the number of physicians at the service of a single
manufacturer in the decision to promote just one product consult
Librium: Worldwide Bibliography, published yearly since 1959 by Roche
Laboratories. The first four years contain 832 entries. See also
Science 180 (1973): 1038, for a report of a study conducted by the
Federal Drug Administration on the ethics of physicians who conduct
field research with new drugs. One-fifth of those investigated had
invented the data they sent to the drug companies, and pocketed the
fees.
117 Selig Greenberg, The Quality of Mercy: A
Report on the Critical Condition of Hospital and Medical Care in
America (New York: Atheneum, 1971).
118 H. Friebel,
"Arzneimittelverbrauchs-Studien," in H. J. Dengler and W. Wirth, eds.,
Seminar für Klinische Pharmakologie auf Schloss Reisenberg bei
Günzburg/ Donau, vom 25-29. Oktober, 1971, Uberreicht von der
Medizinisch-Pharmazeu-tischen Studiengesellschaft E.V., Frankfurt am
Main, pp. 228-40. Short, valuable statement on the lack of useful
measurements, which makes such a broad statement the best that can be
responsibly offered. The author is a director of the Drug Efficacy and
Safety Division of the World Health Organization.
119 World Health Organization, Regional Office for Europe, Consumption
of Drugs: Report on a Symposium, Oslo, November 3-7, 1969. Limited
edition, available only to persons with official professional standing
through the WHO regional office in Copenhagen. This study is the first
of its kind. It compares 22 countries, noting significant differences
in drug-consumption patterns but enormous difficulties in establishing
precise comparisons. Therapeutic categories, cost evaluations, and
measurements for pharmacological units differ. From the information it
is legitimate to deduce that total consumption of medicine is largely
independent of cost or of the kind of practice that is prevalent, i.e.,
private or socialized. The consumption in a given country of those
drugs that require a prescription is positively related to the density
of prescribing physicians.
120 Alfred M. Freedman,
"Drugs and Society: An Ecological Approach," Comprehensive Psychiatry
13 (September-October 1972): 411-20.
121 Alvin
Moscow, Merchants of Heroin (New York: Dial Press, 1968). This can
serve as an introduction to one branch of underworld business.
122 For the history of the conscious use of the placebo effect, see
Arthur K. Shapiro, "A Contribution to a History of the Placebo Effect,"
Behavioral Science 5 (April 1960): 109-35; Gerhard Kienle,
Arzneimittelsicherheit und Gesellschaft: Eine kritische Untersuchung
(Stuttgart: Schattauer, 1974). The ability of the placebo to provoke
symptoms of a specific kind, even when given in a double-blind
situation, is discussed by Kienle in chap. 7. A mine of international
literature on drug safety.
123 See the statements
by Henry Simmons, director of the Food and Drug Administration's Bureau
of Drugs, in Nicholas Wade, "Drug Regulation: Food and Drug
Administration Replies to Charges by Economists and Industry," Science
179 (1973): 775-7.
124 Ibid.
125 Fuchs, Who Shall Live?
126 William M Wardell, "British Usage and American Awareness of Some
New Therapeutic Drugs," Clinical Pharmacology and Therapeutics 14
(November-December 1973): 1022-34. Studies new drugs which became
available in England and were widely discussed in the literature to
which U.S. doctors subscribe. Wardell finds that the American
specialist is not aware of the existence of these drugs unless they are
marketed in the U.S. and that he is therefore subject to enlightment by
detail men.
127 Medizinisch-Pharmazeutischen
Studiengesellschaft E.V., Bioverfügbarkeit van Arzneistoffen,
Schriftenreihe der Medizinisch-Pharmazeutischen Studiengesellschaft
E.V., vol. 6 (Frankfurt: Umschau, 1974). Joint public-relations
campaigns conducted by otherwise competing firms deserve special
attention. At present, they focus on extolling the superiority of
trademarked products over generic equivalents—e.g., of Bayer Aspirin
over the generic drug aspirin—on the grounds of "bio-availability," a
higher and more controlled biological availability of the drug once it
is incorporated into the organism. For any unprejudiced mind, ten
years' research has proved that with the one exception of a generic
preparation of chloramphenicol (see Burack, A New Handbook of
Prescription Drugs, p. 85), generic drugs are in no way inferior to
those produced under trade names. This conclusion has been incorporated
into U.S. federal policy-making. Nevertheless, for the last 5 years the
drug companies have sponsored several hundred "research papers" per
year on differences in "bio-availability," spending on the author of
each paper an average of $6,000 in honoraria, expenses, and costs of
attending professional conferences. Many of these authors are
department heads of major universities. The conclusions of most papers
show no medically significant difference. But the total impact of this
phantom research is the mystification of the prescribing general
practitioner, who will often recommend the drug advertised for its high
"bio-availability," irrespective of its cost.
128
J. P. Dupuy and A. Letourmy, Déterminants et coűts sociaux de
I'innovation en matičre de santé, report by the OCDE, 1974. The authors
support this thesis. The refinement of those criteria by which a
specialist measures the effectiveness of his specialized intervention,
after a certain threshold, will ensure the appearance of generically
predictable unwanted side-effects. If, in their turn, the specific
diagnosis and treatment of these side-effects were attempted, this
further medical intervention would only reinforce iatrogenesis.
129 On the certification of prostitutes, see William W. Sanger, The
History of Prostitution (New York: American Medical Press, 1858).
130 For history of medical death certificates, see U.S. National Office
of Vital Statistics, First Things and Last: The Story of Birth and
Death Certificates, U.S. Public Health Service Publication no. 724
(Washington, D.C., I960).
131 Office of Health
Economics, Off Sick, January 1971, p. 17. It is estimated that between
15 and 30% of all visits to the doctor have no other purpose than
obtaining a certificate. In 58% of the cases, the final day of
incapacity noted on certificates justifying sick leave is Saturday.
132 The encroachment of expertise on the rule against hearsay is of
course not limited to medicine. It is a common feature of
secularization and of the rise of the professions. Inside and outside
the courtroom, it whittles away confidence in what the common man sees
and hears, and thus undermines both the judicial and the political
process. On the author's view of professional expropriation of
language, science, and legal procedures, see Ivan Illich, Tools for
Conviviality (New York: Harper & Row, 1973), pp. 85-99.
133 Franz Boll, "Die Lebensalter: Ein Beitrag zur antiken Ethologie und
zur Geschichte der Zahlen," Neue Jahrbucher für das klassische
Altertum, Geschichte und deutsche Literatur 16, no. 31 (1913): 89-145.
134 See E. E. Evans-Pritchard, Witchcraft, Oracles, and Magic Among the
Azande (New York: Oxford Univ. Press, 1937), for the distinction of the
sorcerer from the witch. This distinction is refined and applied to
Western culture by Jeffrey B. Russell, Witchcraft in the Middle Ages
(Ithaca, N.Y.: Cornell Univ. Press, 1972). The demonological element
that transforms the sorceress into a heretic is usually grafted on at
the level of the courts.
135 Victor W. Turner,
"Betwixt and Between: The Liminal Period in Rites de Passage," in
American Ethnological Society, Symposium on New Approaches to the Study
of Religion: Proceedings, 1964 (Seattle: Univ. of Washington Press,
1965), pp. 4-20. By medicalization of life, what appeared to be
"liminal" in past societies has been made the everyday situation of
administered man.
136 Arnold van Gennep, The Rites
of Passage (London: Routledge, 1960 [French original, 1909]). The
recent critique of the author by Levy-Strauss has not called into
question his basic idea that periods of initiation affirm and symbolize
the continuing health-maintaining function of culture.
137 For literature on the subtle penetration of the hospital into the
interstices of the modern city consult Gerald F. Pyle. "The Geography
of Health Care," in John Melton Hunter, The Geography of Health and
Disease, Studies in Geography no. 6 (Chapel Hill, N.C.: Univ. of North
Carolina Press, 1974), a spatial analysis at the service of health
planners. For a book-length treatment of the architectonic impact of
hospitals on our society, see Roslyn Lindheim, The Hospitalization of
Space (London: Calder & Boyars, 1976). Lindheim demonstrates how
the reorganization of spatial patterns at the service of physicians has
impoverished the nonmedical, health-supporting, and healing aspects of
the social and physical environment for modern man.
138 For orientation on the social science literature on the old and
aging, see James E. Birren, Yonina Talmon and Earl F. Cheit, "Aging: 1.
Psychological Aspects; 2. Social Aspects; 3. Economic Aspects,"
International Encyclopedia of the Social Sciences (1968), 1:176-202.
For orientation on German literature, see Volkmar Boehlau, ed., Wege
zur Erforschung des Alterns, Wege der Forschung, vol. 189 (Darmstadt:
Wissenschaftliche Buchgesellschaft, 1973), an anthology. On French
contemporary aging, Michel Philibert, L'Echelle des âges (Paris: Seuil,
1968).
139John H. Dingle, "The Ills of Man,"
Scientific American 229 (September 1973): 77-82. The study that comes
to this "conclusion" is broadly based. It distinguishes four
perspectives on "ailment": (1) people, (2) physicians, (3) patients,
(4) compilers of vital statistics. From all four points of view this
conclusion seems to hold.
140 Max Neuburger, The
Doctrine of the Healing Power of Nature Throughout the Course of Time,
trans. L. J. Boyd (New York: privately printed, 1932). For more recent
referencees, Joseph Schumacher, Antike Medizin: Die naturphilosophischm
Grundlagen der Medizin in der griechischen Antike (Berlin: Gruyter,
1963).
141 J. F. Partridge and J. S. Geddes, "A
Mobile Intensive-Care Unit in the Management of Myocardial Infarction,"
Lancet, 1967, 2:271.
142 Simone de Beauvoir, The
Coming of Age: The Study of the Aging Process, trans. Patrick O'Brian
(New York: Putnam, 1972). A monumental treatment of old age throughout
history in the perspective of contemporary aging. See also Jean Amery,
Über das Alter: Revolte und Resignation (Stuttgart: Klette, 1968), an
exceptionally sensitive contemporary phenomenology of aging.
143 World Health Statistics Report 27, September 1974. An international
comparison of 27 industrialized countries shows that for the age group
15-44 years old, accidents were the leading cause of death in 1971
(except for England and Wales). In half of these countries they
accounted for more than 30% of all deaths.
144 David Jutman, "The Hunger of Old Men," Trans-Action, November 12, 1971, pp. 55-66.
145 A. N. Exton-Smith, "Terminal Illness in the Aged," Lancet, 1961,
2:305-8. Most pain and suffering are associated with processes that
lead indirectly to death. Although the use of antibiotics may avert or
delay complications such as bronchopneumonia, which would otherwise be
fatal, this often adds little time and much pain to a life.
146 Rick Carlson, in The End of Medicine (New York: Wiley Interscience,
1975), develops this whole point very well. See also H. Harmsen, "Die
sozialmedizin-ische Bedeutung der Erhöhung der Lebenserwartung und der
Zunahme des Anteils der Bejahrten bis 1980," Physikalische Medizin und
Rehabilitation 9, no. 5 (1968): 119-21.
147 Robert
A. Scott, The Making of Blind Mm (New York: Russell Sage, 1969). Being
accepted among the blind and behaving like a blind person are to a
great extent independent of the degree of optical impairment. For most
of the "blind," it is above all the result of their successful client
relationship to an agency concerned with "blindness."
148 Roslyn Lindheim, "Environments for the Elderly: Future-Oriented
Design for Living?" February 20, 1974, mimeographed. Describes the way
the old experience space.
149 On the social
elimination of the old the main source remains John Koty, Die
Behandlung der Alien und Kranken bei dm Naturvölkem (Stuttgart:
Hirschfeld, 1934). I have not seen Fritz Paudler, Die Alien- und
Krankentötung als Situ bei dm indogermanischen Völkern (Heidelberg,
1936). Complete reference to the literature in Will-Eich Peuckert, ed.,
"Altentotung," in Handwörterbuch der Sage (Gottingen: Vandenhoeck &
Ruprecht, 1961).
150 A. Jores and H. G. Puchta,
"Der Pensionierungstod: Untersuchungen an Hamburger Beamten,"
Medizinische Klinik 54, no. 25 (1959): 1158-64.
151
David Bakan, Disease, Pain and Sacrifice: Toward a Psychology of
Suffering (Boston: Beacon Press, 1971). These diseases include asthma,
cancer, congestive heart failure, diabetes mellitus, disseminated
lupus, functional uterine bleeding, Raynaud's disease, rheumatoid
arthritis, thyrotoxicosis, tuberculosis and ulcerative colitis. See
ibid, for literature on each.
152 Elisabeth
Markson, "A Hiding Place To Die," Trans-Action, November 12, 1972, pp.
48-54. A pathetic and sensitive report. See also Jutman, "The Hunger of
Old Men." The old have always obliged by dying on request: David
Lester, "Voodoo Death: Some New Thoughts on an Old Phenomenon,"
American Anthropologist 74 (June 1972): 386-90; Walter B. Cannon,
"Voodoo Death," American Anthropologist 44 (April-June 1942): 169-81.
There were always ways of driving them to suicide: J. Wisse, Selbstmord
und Todesfarcht bei den Naturvölkern (Zutphen: Thieme, 1933).
153 Peter Townsend, The Last Refuge: A Survey of Residential
Institutions and Homes for the Aged in England and Wales (London:
Routledge, 1962). Complements previous work done by the author.
Evaluates residential accommodations as provided under the British
National Assistance Act of 1948 and points to the lack of equity in
treatment. Anne-Marie Guillemard, La Retraite, one mart sociale:
Sociologie des conduites en situation de retraite (Paris: Mouton,
1972). A socio-economic study which shows that class discrimination is
strongly accentuated in French retirement.
154 A.
Eardley and J. Wakefield, What Patients Think About the Christie
Hospital, University Hospital of South Manchester, 1974. From year to
year the demands made by people at a certain age above 70 become more
specific and costly.
155 The "baby" is a rather
recently developed social category: the first stage in the development
of man-the-consumer. On the process by which the suckling was slowly
turned into a baby and the assistance that medicine provided in this
process, see Luc Boltanski, "Prime education et morale de classe,"
Cahiers du Centre de sociologie européenne (The Hague/Paris: Mouton,
1969).
156 The culture of childhood as that
characteristic for an age group distinct from the adult and the infant
is of social origin, like that of the "baby." See Philippe Aries,
Centuries of Childhood: A Social History of Family Life (New York:
Knopf, 1962), especially on the profound change the attitude towards
the death of a child underwent between the 17th and the 19th centuries.
157 John Bryant, M.D., Health and the Developing World (Ithaca, N.Y.: Cornell Univ. Press, 1969).
158 About the relatively much higher resistance to malaria, infections,
and deficiency diseases of breast-fed babies, see "Milk and Malaria,"
British Medical Journal, 1952, 2:1405, and 1953, 2:1210. O. Mellander
and B. Vahlquiest, "Breast Feeding and Artificial Feeding," Acta
Paediatrica 2, suppl. (1958): 101. For a survey of literature, the
editorial "Breast Feeding and Polio Susceptibility," Nutrition Review,
May 1965, pp. 131-3. Leonardo J. Mata and Richard Wyatt, "Host
Resistance to Infection," American Journal of Clinical Nutrition 24
(August 1971): 976-86.
159 For more data on the
impact of the bottle on world nutrition, see Alan Berg, The Nutrition
Factor: Its Role in National Development (Washington, D.C.: Brookings
Institution, 1973). A child nursed through the first two years of its
life receives the nutritional equivalent of 461 quarts of cow's milk,
which costs the equivalent of the average yearly income of an Indian.
160 The pattern of worldwide modern malnutrition is reflected in the
two forms that infant malnutrition takes. The switch from the breast to
the bottle introduces Chilean babies to a life of endemic
undernourishment; the same switch initiates British babies into a life
of sickening, addictive overalimentation: see R. K. Gates, "Infant
Feeding Practices," British Medical Journal, 1973, 2:762-4.
161 On life as a constant training for survival in the megamachine, see
Lewis Mumford, The Pentagon of Power: The Myth of the Machine, Volume 2
(New York: Harcourt Brace, 1970).
162 Thomas J.
Scheff, Being Mentally III: A Sociological Theory (Chicago: Aldine,
1966). Though he deals primarily with psychiatric issues, Scheff does
stress the analytic difference between mental illness that is part of
the social system and the corresponding behavior.
163 Freidson, Profession of Medicine, p. 223.
164 Erving Goffman, Stigma: Notes on the Management of Spoiled Identity
(Engle-wood Cliffs, N.J.: Spectrum 1963). See also Richard Sennett,
"Two on the Aisle," New York Review of Books, November 1, 1973, who
underlines that for Goffman the central task is a description of the
consciousness induced by living in a modern city. Contemporary life
inevitably stigmatizes; on the mechanisms see H. P. Dreitzel, Die
gesellschaftlichen Leiden und das Leiden an der Gesellschaft:
Vorstudien zu einer Pathologic des Rollenverhaltens (Stuttgart: Enke,
1972).
165 Wilhelm Aubert and Sheldon Messinger,
"The Criminal and the Sick," Inquiry 1 (1958): 137-60. Discusses the
different forms social control can take, depending on the special way
in which stigma impinges on moral identity.
166
Fred Davis, Passage Through Crisis: Polio Victims and Their Families
(Indianapolis: Bobbs-Merrill, 1963). Davis relates transitoriness not
only to seriousness but also to social class. The poor will be
diagnosed as "permanently impaired" much sooner than the rich.
167 C. M. Wylie, "Participation in a Multiple Screening Clinic with
Five-Year Follow-up," Public Health Reports 76 (July 1961): 596-602.
Report indicates disappointing results.
168 G. S.
Siegel, "The Uselessness of Periodic Examination," Archives of
Environmental Health 13 (September 1966): 292-5. "Periodic health
examination of adults, as originally conceived and currently practiced,
remains, after 50 years of vigorous American promotion, a
scientifically unproven medical procedure. We do not have conclusive
evidence that a population receiving such care lives longer, better,
healthier, or happier because of it, nor do we have evidence to the
contrary."
169 Paul D. Clote, "Automated
Multiphasic Health Testing: An Evaluation," independent study with John
McKnight, Northwestern University, 1973; reproduced in Antologia A8
(Cuernavaca: CIDOC, 1974). Reviews the available literature.
170 J. Schwartz and G. L. Baum, "The History of Histoplasmosis," New
England Journal of Medicine 256 (1957): 253-8. Describes the costly
discovery of an incurable "disease" that neither kills nor impairs and
seems to be endemic wherever people come in contact with chickens,
cattle, cats, or dogs.
171 Freidson, Profession of
Medicine, pp. 73 ff., makes the distinction I here apply. As a
scholarly professional, the medical scientist need contend only with
his colleagues and their acceptance of his "invention" of a new
disease. As a consulting professional, the practicing physician depends
on an educated public that accepts his exclusive right to diagnose.
172 Parsons, The Social System, pp. 466 ff. The author makes this point commenting on Pareto.
173 Thomas J. Scheff, "Decision Rules, Types of Error, and Their
Consequences in Medical Diagnosis," Behavioral Science 8 (1963): 97-107.
174 American Child Health Association, Physical Defects: The Pathway to
Correction (New York, 1934), chap. 8, pp. 80-96.
175 Harry Bakwin, "Pseudodoxia Pediatrica," New England Journal of Medicine 232 (1945): 691-97.
176 For references and further bibliography see L. H. Garland, "Studies
on the Accuracy of Diagnostic Procedures," American Journal of
Rontgenology, Radium Therapy, and Nuclear Medicine 82 (July 1959):
25-38. See also A. L. Cochrane and L. H. Garland, "Observer Error in
the Interpretation of Chest Films: An International Comparison," Lancet
263 (1952): 505-9. Suggests that American diagnosticians might have a
stronger penchant for positive findings than their British
counterparts. A. L. Cochrane, P. J. Chapman, and P. D. Oldham,
"Observers' Errors in Taking Medical Histories," Lancet 260 (1951):
1007-9.
177 Osier Peterson, Ernest M. Barsamian,
and Murray Eden, "A Study of Diagnostic Performance: A Preliminary
Report," Journal of Medical Education 41 (August 1966): 797-803.
178 Maurice Pappworth, Human Guinea Pigs: Experimentation on Man
(Boston: Beacon Press, 1968). In 1967 Dr. Pappworth published a report
on experimental diagnostic procedures that involved high risks of
permanent damage or death, which had recently been described in the
most respectable medical journals and were often performed on
nonpatients, infants, pregnant women, mental defectives, and the old.
He has been attacked for rendering a disservice to his profession, for
undermining the trust lay people have in doctors, and for publishing in
a paperback what could "ethically" be told only in literature written
for doctors. Perhaps most surprising in these reports is the relentless
repetition of identical high-risk procedures for the sole purpose of
earning academic promotions.
179 "Such a procedure
is as informative as recording a patient's blood pressure once in a
lifetime, or examining his urine once every 20 years. This practice is
ridiculous, absurd and unnecessary . . . and of absolutely no value in
diagnosis or treatment." Maurice Pappworth, "Dangerous Head That May
Rule the Heart," Perspective, pp. 67-70.
180
Minimal brain damage in children is as often as not a creation of
Ritalin; it is a diagnosis determined by the treatment. See Roger D.
Freeman, "Review of Medicine in Special Education: Medical-Behavioral
Pseudorelationships," Journal of Special Education 5 (winter-spring
1971): 93-99.
181 Alexander R. Lucas and Morris
Weiss, "Methylphenidate Hallucinosis," Journal of the American Medical
Association 217 (1971): 1079-81. Ritalin is used for the control of
minimal brain dysfunction in schoolchildren. The author questions the
ethics of using a powerful agent with serious side-effects, some well
defined and others suspected, for mass therapy of a condition that is
ill-defined. See^lso Barbara Fish, "The One-Child-One-Drug Myth of
Stimulants in Hyperkinesis," Archives of General Psychiatry 25
(September 1971): 193-203. Considerable permanent damage has probably
been done to hyperactive children treated with amphetamines for a
condition possibly due to biochemical stress from lead poisoning: D.
Bryce-Smith and H. A. Waldron, "Lead, Behavior, and Criminality,"
Ecologist 4, no. 10 (1975).
182 Barbara Blackwell,
The Literature of Delay in Seeking Medical Care for Chronic Illnesses,
Health Education Monograph no. 16 (San Francisco: Society for Public
Health Education, 1963).
183 Philip Rieff, Triumph
of the Therapeutic: Uses of Faith after Freud (New York: Harper
Torchbook, 1968), argues that the hospital has succeeded the church and
the parliament as the archetypical institution of Western culture.
184 Like policemen in pursuit of crime prevention, doctors are now
given the benefit of the doubt if they harm the patient. William A.
Westley, "Violence and the Police," American Journal of Sociology 59
(July 1953): 34-41, found that one-third of all people in a small
industrial city, asked, "When do you think a policeman is justified in
roughing up a man?" said they believed it was legitimate to use
violence just to coerce respect for the police.
185
Joseph Cooper, "A Non-Physician Looks at Medical Utopia," Journal of
the American Medical Association 197 (1966): 697-9.
186 Orville Brim et al., eds., The Dying Patient (New York: Russell
Sage, 1960). An anthology with a bibliography for each contribution.
First deals with the spectrum of technical analysis and decision-making
in which health professionals engage when they are faced with the task
of determining the circumstances "under which an individual's death
should occur." Provides a series of recommendations about what might be
done to make this engineering process "somewhat less graceless and less
distasteful for the patient, his family and, most of all, the attending
personnel."
187 Though the cost of intensive
terminal care has easily doubled just in the last 4 years, it is still
useful to consult Robert J. Glaser, "Innovation and Heroic Acts in
Prolonging Life," in Brim et al., The Dying Patient, chap. 6, pp.
102-28.
188 Richard A. Kalish, "Death and Dying: A
Briefly Annotated Bibliography," in Brim et al., The Dying Patient, pp.
327-80. An annotated bibliographic survey of English-language
literature on dying, limited mainly to items which deal with
contemporary professional activity, decision-making, and technology in
the hospital. This is an extract from a much larger list by the same
author. For complementing items see Austin H. Kutscher, Jr., and Austin
H. Kutscher, A Bibliography of Books on Death, Bereavement, Loss and
Grief, 1953-68 (New York: Health Sciences Publishing Corp., 1969).
189 Increase in medical expenditures can add no more to the average
life expectancy of entire populations in rich countries, from the U.S.
to China. It can add significantly only to the life-span of the very
young in most of the poorer countries. This has been dealt with in the
first chapter. The ability of medicine to affect the survival rates of
small groups of people selected by medical diagnosis is something else.
Antibiotics have enormously increased the chances of surviving
pneumonia; oral rehydration, the probability of surviving dysentery or
cholera. Such effective interventions are overwhelmingly of the cheap
and simple kind. Their administration under the control of a
professional physician may have become a cultural must for Americans,
but it is not yet so for Mexicans. A third issue is the ability of
medical treatment to increase the chances for survival among an even
smaller proportion of people: those affected by acute conditions that
can be cured thanks to speedy and complex hospital care, and those
affected by degenerative conditions in which complex technology can
obtain remissions. For this group the rule applies: the more expensive
the treatment, the less its value in terms of added life expectancy. A
fourth group are the terminally ill: money tends to prolong dying only
by starting it earlier.
190 For the language with
which Americans referred to the corpse just before physicians intruded
into the mortician's business, see Jessica Mitford, The American Way of
Death (New York: Simon & Schuster, 1963).
191
Under new names the "zombie" has become an important subject in
medicolegal disputations, to judge from the inflation of literature on
conflicting claims of death and life over the body. Institute of
Society, Ethics, and the Life Sciences, Research Group on Ethical,
Social, and Legal Issues in Genetic Counseling and Genetic Engineering,
"Ethical and Social Issues in Screening for Genetic Disease," New
England Journal of Medicine 286 (1972): 1129-32. A good summary of
current opinions on the criteria for determining that death has
occurred. The authors carefully separate this issue from any attempt to
define death. Alexandre Capron and Leon R. Kass, "A Statutory
Definition of the Standards for Determining Human Death: An Appraisal
and a Proposal," University of Pennsylvania Law Review 121 (November
1972): 87-118. An introduction to the legal aspects of the physician's
intrusion into the gravedigger's domain.
192 This
spread of legitimacy for the institutional management of crisis has
enormous political potential because it prepares for irreversible
crisis government. Just as Weber could argue that Puritan wealth was an
unintended consequence of the anxiety aroused by the doctrine of
predestination, so a moralist historian of Tawney's fiber might argue
that readiness for technofascism is the unintended consequence of a
society that voted for terminal care to be paid for by national
insurance.
193 By "ritualization" crisis is
transformed from an urgent occasion for personal integration (Erikson)
into a stress situation (Robinson, for some discussion) in which a
bureaucratic apparatus is forced into action in pursuit of a goal for
which, by its very nature, it cannot be organized. Under such
circumstances, the institution's make-believe functions will take the
upper hand. This must happen when medicine pursues a "dying policy."
The confusion is enhanced by the use of a word such as "dying" or
"decision," which designates action that springs from intimacy in a
context devoid of it. Erik Erikson, "Psychoanalysis and Ongoing
History: Problems of Identity, Hatred, and Nonviolence," American
Journal of Psychiatry 122 (September 1965): 241-53. James Robinson, The
Concept of Crisis in Decision-Making, Symposi Studies Series no. 11
(Washington, D.C.: National Institute of Social and Behavioral Science,
1962).
194 Leonard Lewin, Triage (New York: Dial
Press, 1972), raises the issue of society committed to dying policy in
a novel which, unfortunately, does not compare with his previous Report
from Iron Mountain.
195 Valentina Borremans and
Ivan Illich, "Dying Policy," manuscript prepared for Encyclopedia of
Bio-Ethics, Kennedy Institute, Washington, D.C., to be published in
1976. The authors have agreed to contribute the entry under the title
proposed by the editors of the encyclopedia precisely to highlight the
fact that the combination of the intransitive verb "to die" and the
bureaucratic term "policy" constitutes the supreme attack on language
and reason.
196 He who successfully claims power in
an emergency suspends and can destroy rational evaluation. The
insistence of the physician on his exclusive capacity to evaluate and
solve individual crises moves him symbolically into the neighborhood of
the White House.
197 For the author's view on the
distinction between hope and expectation as two opposed future-oriented
attitudes, see Ivan Illich, "The Dawn of Epithimethean Man," paper
prepared for a symposium in honor of Erich Fromm. Expectation is an
optimistic or pessimistic reliance on institutionalized technical
means; hope, a trusting readiness to be surprised by another person.
198 "Crisis" thus becomes the red herring used by the executive to
heighten his power in inverse proportion to the services he renders. It
also becomes, in ever new combinations (energy crisis, authority
crisis, East-West crisis), an inexhaustible subject for well-financed
research by scientists paid to give to "crisis" the scholarly content
that justifies the grantor. See Renzo Tomatis, La ricerca illimitaia
(Milan: Feltrinelli, 1975).
199 The term "hospital
death" is used here to designate all deaths that happen in a hospital,
and not only that 10% of the total which are "associated with a
diagnostic or therapeutic procedure which is considered a contributing,
precipitating or primary cause of obitus." Elihu Schimmel, "The Hazards
of Hospitalization," Annals of Internal Medicine 60 (January 1964):
100-16.
200 Monroe Lerner, "When, Why, and Where
People Die," in Brim et al., The Dying Patient, pp. 5-29. Gives
breakdowns of this evolution between 1955 and 1967 by cause of death,
color, and region of the U.S.
201 Erwin H.
Ackerknecht, "Death in the History of Medicine," Bulletin of the
History of Medicine 42 (1968): 19-23. For the elites of the
Enlightenment, death became different and far more frightening than it
had been for earlier generations. Apparent death became a kind of
secularized hell and a major medical concern. "Live tests" by
trumpet-blowing (Professor Hufeland) and electric shock (Creve) were
introduced. Bichat's Recherches physiologiques sur la vie et la mart
(1800) ended the anti-apparent-death movement in medicine as suddenly
as Lancisi's work had started it in 1707.
202 All
societies seem to have distinguished stages by which the living pass
into the grave. I will deal with these in chapter 9, and show how the
renewed concern with the taxonomy of decay is consistent with other
contemporary regressions to primitive fascinations.
203 Margot Augener, "Scheintod als medizinisches Problem im 18.
Jahrhundert," Mitteilungen zur Geschichte der Medizin und der
Naturwissenschafien, nos. 6-7 (1967). The secularized fear of hell on
the part of the enlightened rich focused on the horror of being buried
alive. It also led to the creation of philanthropic foundations
dedicated to the succor of the drowning or the burning.
204 "Scarce Medical Resources," editorial, Columbia Law Review 69
(April 1969): 690-2. A review article based on interviews with several
dozen U.S. experts. Describes and evaluates the current policies of
exclusion and selection from a legal point of view. Uncritically
accepts the probable effectiveness of the techniques supposed to be in
extreme demand.
205 Shannon Sollito and Robert M.
Veatch, Bibliography of Society, Ethics and the Life Sciences, a
Hastings Center Publication (Hastings-on-Hudson, N.Y., 1974). J. R.
Elkinton, "The Literature of Ethical Problems in Medicine," pts. 1, 2,
3, Annals of Internal Medicine 73 (September 1970): 495-8; (October
1970): 662-6; (November 1970): 863-70. These are mutually complementary
introductions to the ethical literature.
206
Hermann Feifel, "Physicians Consider Death," in Proceedings of the
American Psychological Association Convention (Washington, D.C.: the
Association, 1967), pp. 201-2. Physicians seem significantly more
afraid of death than either the physically sick or the normal healthy
individual. The argument could lead to the thesis that physicians are
now carriers of infectious fright.
207 Euthanasia: An Annotated Bibliography, Euthanasia Educational Fund, 250 West 57th Street, New York, N.Y. 10019.
208 The right to heal as an intransitive activity that must be
exercised by the patient can enter into conflict with the assertion of
the physician's right to heal, a transitive activity. For the origins
of a medical right to heal, which would correspond to a professional
duty, see Ludwig Edelstein, "The Professional Ethics of the Greek
Physician," Bulletin of the History of Medicine 30 (September-October
1956): 391-419. Walter Reich raises the contemporary issue about the
substance in the physician-patient contract when the disease turns from
curable to terminal and therefore a "healer contract" comes to an end.
Walter Reich, "The Physician's 'Duty' to Preserve Life," Hastings
Center Report 5 (April 1975): 14-15.
209 The
recognition of the facies hippocratica, the signs of approaching death
that indicated to the physician the point at which curative efforts had
to be abandoned, was part of medical curricula until the end of the
19th century. On this subject, see chapter 8.
210
Fred Davis, "Uncertainty in Medical Prognosis, Clinical and
Functional," American Journal of Sociology 66 (July 1960): 41-7. Davis
examines the doctor's behavior when an unfavorable prognosis of
impairment or death becomes certain, and finds widespread cultivation
of uncertainty by dissimulation or evasion. Dissimulation feeds Dr.
Slop or Dr. Knock, who proffers clinically unsubstantiated diagnoses to
curry favorable opinion by selling unwarranted placebos. Evasion, or
the failure to communicate a clinically substantiated prognosis, keeps
the patient and his family in the dark, lets them find out "in a
natural sort of way," allows the doctor to avoid loss of his time—and
scenes, and permits the doctor to pursue treatments the patient would
have rejected had he known they cannot cure. Uncertainty is often
cultivated as a conspiracy between doctor and patient to avoid
acceptance of the irreversible, a category which does not fit their
ethos.
211 Sissela Bok et al., "The Dilemmas of
Euthanasia," Bioscience 23 (August 1973): 461-78. It is often
overlooked that euthanasia, or the medical termination of human life,
could not have been an important issue before terminal care was
medicalized. At present, most legal and ethical literature dealing with
the legitimacy and the moral status of such professional contributions
to the acceleration of death is of very limited value, because it does
not call in question the legal and ethical status of medicalization,
which created the issue in the first place. H. L. Hart, Law, Liberty
and Morality (Stanford, Calif.: Stanford Univ. Press, 1963). By arguing
that the law ought to take a neutral position, Hart goes perhaps
furthest in this discussion. On one side the travesty of ethics takes
the form of forced sale of medical products at literally any cost.
Freeman states that "the death of an unoperated patient is an
unacceptable means of alleviating sufferings" not only for the patient
but also for his family: John M. Freeman, "Whose Suffering?" and Robert
E. Cooke, "Is There a Right To Die—Quickly?" Journal of Pediatrics 80
(May 1972): 904-8. On the other hand, even the spokesmen in favor of
terminal self-medication with pain-killers proceed on the assumption
that in this as in any other consumption of drugs, the patient must buy
what another selects for him.
212 John Hinton, Dying (Baltimore: Penguin Books, 1974).
213 Institute of Medicine of Chicago, Terminal Care for Cancer Patients
(Chicago: Central Service for the Chronically Ill, 1950).
214 David Sudnow, Passing On: The Social Organization of Dying
(Englewood Cliffs, N.J.: Prentice-Hall, 1967). Described in its
introduction as "salutary reading for the layman whose contact with the
terminal phase of human life is limited to occasional encounters," this
book should cure one of any desire for professional assistance.
215 Exton-Smith, "Terminal Illness in the Aged."
216 For a summary of several studies, see International Bank for
Reconstruction and Development, Health Sector Policy Paper (Washington,
D.C., March 1975), p. 34.
217 "Improvements in
artificial kidneys are needed, as borne out by the fact that uremic
patients often are subjectively worse for a period after dialysis even
though their blood chemistry is apparently near normal. Possible
explanations are the nonremoval of an unknow 'uremic factor' or more
likely the unwanted removal of a needed factor from the blood, or
perhaps some subtle injury to the blood by the kidney machine."
Rushmer, Medical Engineering, p. 314.
218 C. H.
Calland, "Iatrogenic Problems in End-Stage Renal Failure," New England
Journal of Medicine 287 (1972): 334-8. An autobiographical account of a
medical doctor in such terminal treatment.
219 Hans
von Hentig, Vom Ursprung der Henkersmahlzeit (Tübingen: Mohr, 1958).
The medicalization of death has enormously increased the percentage of
people whose death happens under bureaucratic control. In his
encyclopedic study of the breakfast offered a condemned man by his
executioner, Hentig concludes that there exists a deep-felt need to
lavish favors on persons who die in a publicly determined way. Usually
this favor takes the form of a sumptuous meal. Even during World War I
soldiers still exchanged cigarettes, and the firing-squad commander
offered a last cigarette. Terminal treatment in war, prison, and
hospital has now been depersonalized. Intensive care for the dying can
also be seen as a funeral gift for the unburied.
220 Stephen P. Strickland, Politics, Science and Dread Disease: A Short
History of the United States Medical Research Policy, Commonwealth Fund
Series (Cambridge: Harvard Univ. Press, 1972). Strickland describes how
the U.S. government medical research policy got under way with the 1927
proposal by a senator to post a $5 million reward for the person who
collared the worst killer, namely cancer. Gives the history of the boom
in cancer research. The U.S. government now spends more than $500
million per year on it.
221 H. G. Mather et al.,
"Acute Myocardial Infarction: Home and Hospital Treatment," British
Medical Journal, 1971, 3:334-8.
222 John Powles has
made this argument; see "On the Limitations of Modern Medicine," in
Science, Medicine and Man (London: Pergamon, 1973), 1:1-30. An
increasingly large proportion of the contemporary disease burden is
man-made; engineering intervention in sickness is not making much
progress as a strategy. The continued insistence on this strategy can
be explained only if it serves nontechnical purposes. Diminishing
returns within medicine are a specific instance of a wider crisis in
industrial man's relationship to his environment.
223 M. Bartels, Die Medizin der Naturvölker (Leipzig: Grieben, 1893). A
classic on the magical element in the medicine of primitive peoples.
224 William J. Goode, "Religion and Magic," in Goode, ed, Religion
Among the Primitives (New York: Free Press, 1951), pp. 50-4.
225 On the history of medical studies of the placebo effect and the
evolution of the term, see Arthur K. Shapiro, "A Contribution to a
History of the Placebo Effect," Behavioral Science 5 (April 1960):
109-35.
226 The distinction between the magical
elimination, religious interpretation, or ethical socialization of
suffering and its technical manipulation and legal control deserves
much more detailed analysis. I introduce these distinctions only to
clarify that (1) medical technique does have nontechnical effects (2)
some of which cannot be considered economic or social externalities (3)
because they specifically influence health levels. (4) These
health-related latent functions do have a complex, multilayered
structure and (5) more often than not spoil health.
227 By myths I here mean set behavior patterns which have the ability
to generate among the participants a blindness to or tolerance for the
divergence between the rationalization reinforced by the celebration of
the ritual and the social consequences produced by this same
celebration, which are in direct contradiction to the myth. For an
analysis see Max Gluckman, Order and Rebellion in Tribal Africa (New
York: Free Press, 1963).
228 Eric Voeglin, Science, Politics and Gnosticism, trans. William Fitzpatrick (Chicago: Regnery, 1968).
229 The social ordering of compassion, nurture, and celebration has
been the most effective aspect of primitive medicine; see Erwin H.
Ackerknecht, "Natural Diseases and Rational Treatment in Primitive
Medicine," Bulletin of the History of Medicine 19 (May 1946): 467-97.
230 Richard M. Titmuss, The Gift Relationship (New York: Pantheon,
1971), compares the market for human blood under U.S. commercial and
British socialized medical systems, shows the immense superiority of
British blood transfusions, and argues that the greater effectiveness
of the British approach is due to the lower level of commercialization.
231 Only in Chaucer's time did a common name for all healers appear:
Vern L. Bullough, "Medical Study at Medieval Oxford," Speculum 36
(1961): 600-12.
232 "The Term 'Doctor,' " Journal of the History of Medicine and Allied Sciences 18 (1963): 284-7.
233 Louis Conn-Haft, The Public Physician of Ancient Greece (Northampton, Mass.: Smith College, 1956).
234Adalberto Pazzini, Storia delta medidna, 2 vols. (Milan: Societa editrice libraria, 1947).
235 For Arab medicine in general, consult Lucien Leclerc, Histoire de
la médicine arabe: Exposé complet des traductions du grec: Les Sciences
en Orient, leur transmission ŕ I'Occident par les traductions latines,
2 vols. (1876; reprint ed., New York: Franklin, 1971); Manfred Ullmann,
Die Medizin im Islam (Leiden: Brill, 1970), an exhaustive guide. But
see also the judgment of Ibn Khaldun, The Muqaddimak: An Introduction
to History, trans. Franz Rosenthal, Bollingen Series XLIII, 3 vols.
(Princeton, N.J.: Princeton Univ. Press, 1967). For a critical review
of Arabic contributions to the Western image of the doctor, see
Heinrich Schipperges, "Ideologic und Historiographie des Arabismus,"
Sudhoffs Archiv, suppl. 1, 1961.
236 Jacob Marcus,
Communal Sick-Care in the German Ghetto (Cincinnati: Hebrew Union
College Press, 1947). This book provides reasons for bad conscience for
relying on outsiders.
237 S. D. Lipton, "On
Psychology of Childhood Tonsillectomy," in R. S. Eissler et al., eds.,
Psychoanalytic Study of the Child (New York: International Univs.
Press, 1962), 17:363-417; reprinted in Anthología A8 (Cuernavaca:
CIDOC, 1974).
238 Julius A. Roth, "Ritual and Magic
in the Control of Contagion," American Sociological Review 22 (June
1957): 310-14. Describes how doctors come to believe in magic. Belief
in the danger of contagion from tuberculosis patients leads to
ritualized procedures and irrational practices. For instance, the rules
compelling patients to wear protective masks are strictly enforced when
they go to X-ray services but not when they go to movies or socials.
239 Arthur K. Shapiro, "Factors Contributing to the Placebo Effect:
Their Implications for Psychotherapy," American Journal of
Psychotherapy 18, suppl. 1 (March 1964): 73-88.
240
Otto Lippross, Logik und Magie in der Medizin (Munich: Lehmann, 1969),
pp. 198-218. Lippross argues, and documents his belief, that most
effective healing depends on the physician's choice of the method that
most suits his personality. For bibliography, see pp. 196-218.
241 Henry K. Beecher, "Surgery as Placebo: A Quantitative Study of
Bias," Journal of the American Medical Association 176 (1961): 1102-7.
It has been long known that surgery can have placebo effects on the
patient. I argue here that similar effects can be sociopolitically
transmitted by highly visible interventions.
242
Gerhard Kienle, Arzneimittelsicherheit and Gesellschaft: Eine kritische
Untersuchung (Stuttgart: Schattauer, 1974), makes this point but deals
only with the pharmacology-related sector of medical technology.
243 Henry K. Beecher, "Nonspecific Forces Surrounding Disease and the
Treatment of Disease," Journal of the American Medical Association 179
(1962): 437-40. "Any fear can kill, but fearful diagnosis can almost
guarantee death from diagnosis." Walter B. Cannon, "Voodoo Death,"
American Anthropologist 44 (April-June 1942): 169-81. Victims of
Haitian magic have ominous and persistent fears, which cause intense
action of the sympatico-adrenal system and a sudden fall of blood
pressure resulting in death.
244 R. C. Pogge, "The
Toxic Placebo," Medical Times 91 (August 1963): 778-81. S. Wolf,
"Effects of Suggestion and Conditioning on the Action of Chemical
Agents in Human Subjects: The Pharmacology of P\a.cebos," Journal of
Clinical Investigation 29 (January 1950): 100-9. G. Herzhaft, "L'Effet
nocebo," Encéphale 58 (November-December 1969): 486-503.
245 Erwin Ackerknecht, "Problems of Primitive Medicine," in William A.
Lessa and Evon Z. Vogt, Reader in Comparative Religion (New York:
Harper & Row, 1965), chap. 8, pp. 394-402. Ackerknecht offers an
important corrective to the Parsonian prejudice that all societies
incorporate a specific kind of power in the healer. He shows that
medicine man and modern physician are antagonists rather than
colleagues: both take care of disease, but in all other ways they are
different.
246 Marc Bloch, The Royal Touch: Sacred
Monarchy and Scrofula in England and France, trans. J. E. Anderson
(Montreal: McGill-Queens Univ. Press, 1973).
247Werner Danckert, Unehrliche Leute: Die verfemten Berufe (Bern:
Francke, 1963). Deals with the healing powers traditionally attributed
to outcastes and marginals such as executioners, gravediggers,
prostitutes, and millers.
248 Dominique Wolton, Le
Nouvel Ordre sexuel (Paris: Seuil, 1974), describes the outcome of the
French sexual revolution: a new "sexocracy" made up of physicians,
militants, educators, and pharmacists has secularized and schooled
French sexuality and "by subjecting body awareness to orthopedic
management has reproduced the welfare receiver even in this intimate
domain."
249 Henry E. Sigerist, Civilization and Disease (Chicago: Univ. of Chicago Press, 1970).
250 For complementary references, refer to notes 15-18, p. 44 above.
251 T. F. Troels-Lund, Gesundheit and Krankheit in der Ansctumung alter
Zeiten (Leipzig, 1901), is an early study of the shifting frontiers of
sickness in different cultures. Walther Riese, The Conception of
Disease: Its History, Its Versions and Its Nature (New York:
Philosophical Library, 1953), attempts a philosophical epistemology.
For orientation on the evolution of recent discussion see David
Mechanic, Medical Sociology: A Selective View (New York: Free Press,
1968), especially pp. 33 ff.
252 As just one
example of a society without the Aesculapian role, see Charles O.
Frake, "The Diagnosis of Disease Among the Subanun of Mindanao,"
American Anthropologist 63 (1961): 113-32. In the sphere of making
decisions about disease, differences in individual skill and knowledge
receive recognition, but there is no formal status of diagnostician or
even, by Subanun conception, of curer.
253 Lawrence
J. Henderson, "Physician and Patient as a Social System," New England
Journal of Medicine 212 (1935): 819-23, was perhaps the first to
suggest that the physician exonerates the sick from moral
accountability for their illness. For the classical formulation of the
modern, almost morality-free sick-role, see Talcott Parsons, "Illness
and the Role of the Physician" (orig. 1948), in Clyde Kluckhohn and
Henry Murray, eds., Personality in Nature, Society and Culture, rev.
ed. (New York: Knopf, 1953).
254 David Robinson,
The Process of Becoming Ill (London: Routledge, 1971), discovers a
fundamental weakness in most studies done so far on the sick-role: they
are based on people who finally did become patients, and deal with the
person who feels ill but does not see the doctor as somebody who
delays. He rejects the notion that illness starts with the presentation
of symptoms to a professional. Most people are not patients most of the
time they feel ill. Robinson studies empirically the sick behavior of
nonpatients.
255 The distinction between the
intransitive healing by the patfent and the transitive healing provided
for him must be further refined. The latter, a service to the patient,
can be provided in two profoundly distinct ways. It can be the output
of an institution and its functionaries executing policies, or it can
be the result of personal, spontaneous interaction within a cultural
setting. The distinction has been elaborated by Jacques Ellul, The
Technological Society (New York: Random House, 1964). Ellul's concept
of "institutionalized values" has been subjected to the analysis of a
symposium: Katallagete [Be Reconciled]: Journal of the Committee of
Southern Churchmen 2 (winter-spring 1970): 1-65. The phenomenology of
personal care has been developed by Milton Mayeroff, On Caring (New
York: Harper & Row, 1971).
256 Renée Fox,
Experiment Perilous: Physicians and Patients Facing the Unknown
(Glencoe, Ill.: Free Press, 1959), studies terminal patients who have
consented to be used as subjects for medical experiment.
Notwithstanding the prevailing logical and rational explanations for
their sickness, they too grapple with it in religious, cosmic, and
especially moral terms.
257 Sickness becomes
associated with high living standards and high expectations. In the
first six months of 1970, 5 million working days were lost in Britain
owing to industrial disputes. This has been exceeded in only 2 years
since the general strike in 1926. In comparison, over 300 million
working days were lost through absence due to certified sickness.
Office of Health Economics, Off Sick (London, 1971).
258 Clarence Karier, "Testing for Order and Control in the Corporate
Liberal State," Educational Theory 22 (spring 1972), shows the role the
Carnegie Foundation played in developing educational testing materials
that can be used for social control in situations where the ability of
schools to perform this task has broken down. According to Karier,
tests given outside the schools are a more powerful device for
discrimination than tests given within a pedagogical situation. In the
same way, it can be argued that medical testing becomes an increasingly
powerful means for classification and discrimination, as the number of
test results accumulate for which no significant treatment is feasible.
Once the patient role becomes universal, medical labeling turns into a
tool for total social control.
259 Siegler and
Osmond, "Aesculapian Authority." According to the authors, Aesculapian
authority was first mentioned in T. T. Paterson, "Notes on Aesculapian
Authority," unpublished manuscript, 1957. It comprises three roles:
sapiential authority to advise, instruct, and direct; moral authority,
which makes medical actions the right thing and not just something
good; and charismatic authority, by which the doctor can appeal to some
supreme power and which often outranks the patient's conscience and the
ration d'etat. Pedagogues, psychologists, movement leaders, and
nonconventional healers tend increasingly to appeal to this
three-tiered authority in the name of their peculiar technique, thus
joining the ranks of the scientific doctors and contributing to a
cancerous expansion of the Aesculapian role.
260
Franco Basaglia, La maggioranza deviante: L'ideologia del contralto
sociale totale, Nuovo Politecnico no. 43 (Turin: Einaudi, 1971). Since
the sixties a citizen without a medically recognized status has come to
constitute an exception. A fundamental condition of contemporary
political control is the conditioning of people to believe they need
such a status for the sake not only of their own but of other people's
health.
261 Nils Christie, "Law and Medicine: The
Case Against Role Blurring," Law and Society Review 5 (February 1971):
357-66. A case study by a criminologist of the conflict between two
monopolistic professional empires. Medicine converges with education
and law enforcement. The medicalization of all diagnosis denies the
deviant the right to his own values: he who accepts the patient role
implies by this submission that, once restored to health (which is just
a different kind of patient role in our society), he will conform. The
medicalization of his complaint results in the political castration of
his suffering. For this see Jesse R. Pitts, "Social Control: The
Concept," International Encyclopedia of the Social Sciences (1968),
14:391.
262 H. Huebschmann, "La Notion d'une société malade," Présence, no. 94 (1966), pp. 25-40.
263 Basaglia, La maggioranza deviante.
264 Michel Foucault, Surveiller et punir: Naissance de la prison
(Paris: Gallimard, 1975). On the rise of the pan-therapeutic society in
which morality-charged roles are extinguished. English translation to
be published by Pantheon Books, New York.