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 has taken up increasingly more medical time108 Each kind of certificate provides the holder with a special status based on medical rather than civic opinion109 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 next110 The experience may have been painful,135 but the ritual was short and it served society in highlighting its own regenerative powers111 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 started112 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 condition113
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 interventions114 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 nature115 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 dead116 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 itself117 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 it118
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 snowballs119 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 work120 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 on121 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 societies122 The mortality rate during the first year after institutionalization is significantly higher than the rate for those who stay in their accustomed surroundings123 Separation from home contributes to the appearance and mortality of many a serious disease124 Some old people seek institutionalization with the intention of shortening their lives125 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 richer126 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 enough127 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 medicine128 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 Jamaica129 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 immunizations130 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 loss131 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 risks132 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 megamachine133 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 does134 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-allergics 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 stigma135 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 benefit136
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 brews137 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 schemes138 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 utility139
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 scientist140 To ascribe the pathology to some Tom, Dick, or Harry is the first task of the physician acting as member of a consulting profession141 Trained to "do something" and express his concern, he feels active, useful, and effective when he can diagnose disease142 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 health143 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 labs144 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 error145
In addition to diagnostic bias and error, there is wanton aggression146 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 examples147 Attendance in public schools where teachers are vested with delegated medical powers constitutes a major health risk for children148 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 there149
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 expensive150
Terminal Ceremonies#
Therapy reaches its apogee in the death-dance around the terminal patient151 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 smells152 The more exotic the incense and the pyre, the more death mocks the priest153 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 blurred154 Beds are filled with bodies neither dead nor alive155 The conjuring doctor perceives himself as a manager of crisis156 In an insidious way he provides each citizen at the last hour with an encounter with society's deadening dream of infinite power157 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 policy158 More important, his entire performance takes place in the aura of crisis159 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 commands160 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 expectation161 The orientation of any institution towards "crisis" justifies enormous ordinary ineffectiveness[^198]
Hospital death is now endemic162 In the last twenty-five years the percentage of Americans who die in a hospital has grown by a third163 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 rites164
Fear of unmedicated death was first felt by eighteenth-century elites who refused religious assistance and rejected belief in the afterlife165 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 legal204 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 acceptable166 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. Naïvely, 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 way167 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 hands168 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 dissimulation169 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 issue170 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 months171 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 relieved172 But by staying at home they avoid the exile, loneliness, and indignities which, in all but exceptional hospitals, await them173 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 condition174 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 life175 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 cultures176
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 death177 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 fright178
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 institutions179 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 medicine180 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 well181
In high cultures, religious medicine is something quite distinct from magic182 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 São 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 ceremonies183
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 weak184 Medicine could regulate society's gift relationships185 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 advisers186 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 free187 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 priests188 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 physician189 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 establishment190 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 life191
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 positive192 An unnecessary shot of penicillin can magically restore confidence and appetite193 A contraindicated operation can solve a marriage problem and reduce symptoms of disease in both partners194 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 black195
To a large extent, social iatrogenesis can be explained as a negative placebo, as a nocebo effect196 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 provided197 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 cure198 Epileptics, whose ills resisted even His Majesty's touch, took refuge in the healing strength that flowed from the hands of the executioner199
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 fit200
Each civilization defines its own diseases201 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 it202 It defines deviance as the special legitimate behavior of officially selected consumers within an industrial milieu203 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 kind204 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 service205 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 view206 The mid-nineteenth-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 base207 Until proved healthy, the citizen is now presumed to be sick208 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 blurred209 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.