[Marxism] re: Medical Issues and the Emotions of Taking One's Medicine

paul illich paul_illich at hotmail.com
Fri May 7 08:01:55 MDT 2004

Hi Tony,

Have you read Ivan Illich's Medical Nemesis?

I epect you have, or know of it, but in case not:

This looks in detail at the institutionalization of medical
"expertise" and it's effect on individuals and communities
from a Marxist perspective.

I wrote an obit for Ivan [on BlueGreenEarth's archive
at http://www.bluegreenearth.us/index.html]
- he is no relation BTW - and am very interested
in his work, especially Tools For Conviviality.

"In the early nineties, he was diagnosed with cancer. True to his belief 
that "the medical establishment has become a major threat to health" 
[Medical Nemesis, 1975], he stayed steadfastly in charge of all aspects of 
his own medication. Naturally, the establishment medical profession had 
recommended a sedative regime that would have undoubtedly led Illich quickly 
into an institutionalized quiescent zombie state. As it is, he held to his 
own, and continued to be active until the end, successfully completing his 
final work [on pain], to be published in 2003. He passed away on December 
2nd, 2002."

Paul Illich

"Here is a brief review of some of his most important ideas:

The corrupting impact of institutions:

Ivan Illich's critique of institutionalization is concerned at the tendency 
of modern institutions to become oversized, dehumanizing and alienating. 
They undermine confidence and stifle creativity, yet are often set up in the 
first place to fulfill positive goals and to realize humanly creative ends. 
Beyond a certain scale, however, they lose the capability to reach these 
goals, indeed often increasing pressure away from them.

The factors that make this inevitable include schooling, the "expert" 
culture, commodification and counterproductivity, all of which are 

Schooling / Education

The education establishment of the seventies was increasingly centralized, 
with nationalized curricula, government interference and a 
"bureaucratization of accreditation". Little has changed, and the 
requirement in our culture for paper proof of formal education has if 
anything worsened. The rise of institutionalized education, obscuring as it 
does everyday / vernacular / apprenticed forms of learning, is a part of the 
devaluing commodification of knowledge.

Illich's ideas for deinstitutionalizing education – "deschooling" – and for, 
instead, creating humanizing, or "convivial", forms of education were part 
of a radical tradition of alternative schooling ideals.

"Many students, especially those who are poor, intuitively know what the 
schools do for them. They school them to confuse process and substance. Once 
these become blurred, a new logic is assumed: the more treatment there is, 
the better are the results; or, escalation leads to success. The pupil is 
thereby "schooled" to confuse teaching with learning, grade advancement with 
education, a diploma with competence, and fluency with the ability to say 
something new. His imagination is "schooled" to accept service in place of 
value." – Deschooling Society

Illich's failure to be taken up by the establishment in no way reduces his 
relevance and importance, and indeed was a predictable consequence of the 
other factors that Illich critiqued.

"Expert" power / culture

The bureaucratization of accreditation does not merely affect the youth in 
education. It becomes enshrined in academia as a method of keeping one up on 
the [Professor] Joneses. More PhD's, more citations, more publications. This 
quantative valuing of expertise is an inextricable part of the reversal of 
the education establishments nominal purpose.

In creating this culture of "expertise", power becomes expropriated from 
ordinary individuals, whose empowerment to shape their own lives and 
environment is negated. The only opinion on a given subject to be granted 
any credence by the state and other institutions is the opinion that comes 
from the recognized "expert". However, this "expert" has to daily prove his 
expertise through time-consuming rituals, such as rehashing the last decent 
work he/she did another twenty times, in different guises, to ensure maximum 
citations, and to work towards yet another post-graduate qualification.

The "expert" must create increasingly baroque obstacles to the next 
generation of wannabe "experts" in order to maintain tenure. They become the 
gatekeepers, controlling the production of knowledge, controlling how 
knowledge is "legitimately" acquired, and creating a cartel. This is obvious 
in all spheres of the knowledge economy. Those who have been active in 
environmental campaigns, for example, will be familiar with the "argument" 
that you don't know what you are talking about because you don't have 
letters after your name / a piece of paper saying you have a ratified 
quantity of pre-packaged knowledge. And you will know this for the crock 
that it is, as you will often be better read than half [at least!] of the 
company lackeys that are devaluing your contribution. Illich is as concerned 
as we are to demythologize science.

"This new mythology of governance by the manipulation of knowledge-stock 
inevitably erodes reliance on government by people." – Celebration of 

Despite his early formal education being to a high level, and in a variety 
of subject areas, Illich himself fell foul of this "expert" establishment. 
All of us can, if sufficiently astute, become, say, "citizen scientists". 
But with no paper ratification of the fact [and with all the formalizing and 
straitjacketing the institution we'd need to suck up to would impose if we 
chose the established route to this paper ratification], we are all prone to 
attack on the same grounds Illich was: we will be accused of being 
intellectual mavericks; of not being "properly" read with regard to related 
works; of relying on "intuition"; and of working in a theoretical vacuum.

Indeed, in so far as the institutions concerned "must" be the ones to define 
what is appropriate in an argument, all these things may be true. But 
granted a modicum of rationality and self-critique, there is truly no reason 
why the informed citizen should not have an opinion just as valid as that of 
the "expert", and indeed he/she may have fresh perspectives to bring to the 
feast, as a result of not having been institutionalized into the same 
specialized rut as those whose opinions are nominally more worthwhile.


In creating a society where the institution can control what is perceived as 
"needs", and thus control what is considered the "satisfaction" of those 
needs, institutions can more fully control the factors they need to in order 
to achieve their goals. However, in so doing they not only dehumanize and 
disempower real individuals by positing a more "useful" conception [the 
theoretical "average citizen"], they also thereby create a warped view of 
the very reality they seek to control.

In making everything and everyone cohere to their theoretical construct, 
they make everything and everyone into a static unit to be moved around 
their intellectual chess-board. That is to say, they create a mere 
commodity. In education this phenomenon mutates learning from a healthful 
and voluntaristic activity into a measured and weighed object / thing. The 
acquisition of more of this object gives the individual greater social value 
than someone who has acquired less of it. Qualitative measurement falls by 
the wayside, as quantitative value [ie: commodification] becomes paramount.

At the same time, the "professionals" monopolize the production of the 
commodity, control [restrict] the distribution of the commodity and raise 
the market price of the commodity in order to keep their "club" exclusive. 
The self-taught individual will be discriminated against, and in order to be 
allowed into the club, he/she must gain a "recognized" quantity of learning 
via the consumption of services through the industrialized / planned / 
professional institution. That is, he/she must learn to approach learning as 
the acquisition of a form of capital, and, as Karl Marx or Erich Fromm would 
note, conspire in his own alienation / dehumanization.


All the above points lead inexorably to a position wherein a basically 
positive and beneficial process is turned into a negative and harmful 
process. It is clear that, beyond a certain scale, institutions are forced 
through their own internal logic, in combination with the external 
straitjacket of the market economy [whether free-market or state 
capitalist], to cross a threshold past which their action becomes frequently 
counterproductive. At this point the person, or consumer as he/she has now 
become, will feel the full force of their disempowerment.

"The growing impotence of people to decide for themsleves affects the 
structure of their expectations. [...] No longer can each person make his or 
her own contribution to the constant renewal of society. Recourse to better 
knowledge produced by science not only voids personal decisions of the power 
to contribute to an ongoing historical and social process, it also destroys 
the rules of evidence by which experience is traditionally shared. The 
knowledge-consumer depends on getting packaged programs funneled into him. 
He finds security in the expectation that his neighbor and his boss have 
seen the same programs and read the same columns. The procedure by which 
personal certainties are exchanged is eroded by the increasing recourse to 
exceptionally qualified knowledge produced by a science, profession, or 
political party. Mothers poison their children on the adman's of the M.D.'s 
advice. Even in the courtroom and in parliament, scientific hearsay – well 
hidden under the veil of expert testimony – biases juridical and political 
decisions [eg: look at the way in which so-called DNA "evidence" and the 
laws of statistical probability are abused in the courtroom]. Judges, 
governments, and voters abdicate thier own evidence about the necessity of 
resolving conflicts in a situation of defined and permanent scarcity and opt 
for further growth on the basis of data which they admittedly cannot fully 
understand." – Celebration of Awareness

Illich in no way embraces a nihilistic opposite to institutions existing at 
all. Rather, he sees it as necessary to seek human-scaled institutions; to 
learn where the thresholds of scale lie in order to avoid crossing over to 
counterproductive leviathan institutions such as both welfare states and 
corporatized states offer. To the extent that Capital is the driving force 
behind such growth, Illich's position is by definition "radical" and 
dangerous to both Left and Right.


As opposed to traditional establishment forms of learning, Illich has 
promoted a more free-form approach to learning, where it is seen as a 
positive virtue to be eclectic and knowledgeable across a wide and 
self-determined field of facts and ideas. This very approach leads to a 
disinclination to bequeath a monolithic set of "answers" behind. Viable 
alternatives must needs be flexible. This means that Illich's alternative is 
less a guidebook saying "and then you go out into the world with this 
material tool and do this material thing and then you'll find yourself in 
utopia", than a set of techniques to approach whatever material 
circumstances you choose with a rational but open, reflective, and creative 
mind-set, hopefully backed-up by an affinity group that suits your own free 

"I believe that a desirable future depends on our deliberately choosing a 
life of action over a life of consumption, on our engendering a lifestyle 
which will enable us to be spontaneous, independent, yet related to each 
other, rather than maintaining a lifestyle which only allows us to make and 
unmake, produce and consume - a style of life which is merely a way station 
on the road to the depletion and pollution of the environment. The future 
depends more upon our choice of institutions which support a life of action 
than on our developing new ideologies and technologies. We need a set of 
criteria which will permit us to recognize those institutions which support 
personal growth rather than addiction, as well as the will to invest our 
technological resources preferentially in such institutions of growth." – 
Deschooling Society

Thus Illich supports the creation of what he calls "convivial" institutions, 
rather than bureaucratic and manipulative ones. These will be used 
spontaneously and voluntarily by any and all members of society as required, 
and will be in service to the community, rather than seeking to make the 
community cohere to the controlling logic of the institution. Education, 
work and society should all evolve as a whole in line with human needs, 
starting with the "decommodification", "deinstitutionalization", and 
"deprofessionalization" of social relations.

Nonetheless, he does offer some tentative concrete ideas. In education, 
Illich suggests the development of what he calls "learning webs". These 
would give access to knowledge, and encourage the sharing of knowledge 
through forums for public presentation of ideas learnt. That these should 
not be required to work through a limited, controlling and monolithic nexus 
of institutions may be taken as read. Access would be through numerous small 
libraries, showrooms, agencies that are reserved for the purpose, and 
through freely shared facilities - the corner shop, local factory, farms, 
airports, perhaps even the chill-out room at the local nightclub [you'll 
always find them in the kitchen at parties]. Vernacular skills could be 
passed on at "skill exchanges", where there are appropriate facilities, and 
where those with specific areas of knowledge may leave a CV and a phone 
number / email address. Such loci might become communications networks that 
allow extensive "peer-matching". Learning would partake of the 
characteristics of distributed cognition.

In no way would Illich advocate such trends as a positive alternative in 
education, without altering the wider social context too. He saw it as 
possible that freeing educators from restraint in such a manner might make 
negative control and conditioning [locally] more, rather than less, 
effective. A full flowering of the ethical and political concepts in 
"conviviality" is, therefore, required in order to make changes in one area 
lead to positive outcomes in that area, let alone in others. 
De-commodification must also be sought in order to achieve positive change - 
a message that is too radical for the free-market politician or 
industrialist. Not only that, but a recognition of scarcity and the limits 
to growth is required in order for a convivial and human future to exist.

"To formulate a theory about a future society both very modern and not 
dominated by industry, it will be necessary to recognize natural scales and 
limits. We must come to admit that only within limits can machines take the 
place of slaves; beyond these limits they lead to a new kind of serfdom. 
Only within limits can education fit people into a man-made environment: 
beyond these limits lies the universal schoolhouse, hospital ward, or 
prison. Only within limits ought politics be concerned with the distribution 
of maximum industrial outputs, rather than with equal inputs of either 
energy or information. Once these limits are recognized, it becomes possible 
to articulate the triadic relationship between persons, tools, and a new 
collectivitity. Such a society, in which modern technologies serve 
politically interrelated individuals rather than managers, I will call 
"convivial"." – Celebration of Awareness

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