[Marxism] re: Medical Issues and the Emotions of Taking One's Medicine
paul_illich at hotmail.com
Fri May 7 08:01:55 MDT 2004
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
- 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
"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."
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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