Fifteen years ago it would have been impossible to get a hearing for the claim that medicine itself might be a danger to health. In the early 1960s, the British National Health Service still enjoyed a worldwide reputation, particularly among American reformers1 The service, created by Albert Beveridge, was based on the assumption that there exists in every population a strictly limited amount of morbidity which, if treated under conditions of equity, will eventually decline2 Thus Beveridge had calculated that the annual cost of the Health Service would fall as therapy reduced the rate of illness3 Health planners and welfare economists never expected that the service's redefinition of health would broaden the scope of medical care and that only budgetary restrictions would keep it from expanding indefinitely. It was not predicted that soon, in a regional screening, only sixty-seven out of one thousand people would be found completely fit and that 50 percent would be referred to a doctor, while according to another study, one in six people screened would be defined as suffering from one to nine serious illnesses4 Nor had the health planners forecast that the threshold of tolerance for everyday reality would decline as fast as the competence for self-care was undermined, and that one-quarter of all visits to the doctor for free service would be for the untreatable common cold. Between 1943 and 1951, 75 percent of the persons questioned claimed to have suffered from illness during the preceding month5 By 1972, 95 percent of those surveyed in one study considered themselves unwell during the fourteen days prior to questioning, and in another study6 in which 5 percent considered themselves free of symptoms, 9 percent claimed to have suffered from more than six different symptoms in the two weeks just past. Least of all did the health planners make provision for the new diseases that would become endemic through the same process that made medicine at least partially effective7 They did not forecast the need for special hospitals dedicated to the soothing of terminal pain, usually suffered by the victims of unsound or ineffective surgery for cancer,8 or the need for other hospital beds for those affected by medicine-induced disease9
The sixties also witnessed the rise and fall of a multinational consortium for the export of optimism to the third world which took shape in the Peace Corps, the Alliance for Progress, Israeli aid to Central Africa, and in the last brush-fires of medical-missionary zeal The Western belief that its medicines could cure the ills of the nonindustrialized tropics was then at its height. International cooperation had just won major battles against mosquitoes, microbes, and parasites, ultimately Pyrrhic victories which were advertised as the beginning of a final solution to tropical disease10 The role that economic and technological development would play in spreading and aggravating sleeping sickness, bilharziasis, and even malaria was not yet suspected11 Those who saw world hunger and new pestilence on the horizon were treated like prophets of doom12 or romantics;13 the Green Revolution was still considered the opening phase of a healthier and more equitable world13 It would have seemed unbelievable that within ten years malnutrition in two forms would become by far the most important threat to modern man,14 The new high-caloric undernourishment of poor populations was not foreseen,15 nor was the fact that overfeeding would be identified as the main cause for the epidemic diseases of the rich[^17] In the United States the new frontiers had not yet been obstructed by competing bureaucratic schemes16 Hopes for better health still focused on equality of access to the agencies that would do away with specific diseases. Iatrogenesis was still an issue for the paranoid.
But by 1975 much of this had changed17 A generation ago, children in kindergarten had painted the doctor as a white-coated father-figure18 Today, however, they will just as readily paint him as a man from Mars or a Frankenstein19 Muckracking feeds on medical charts and doctors' tax returns, and a new mood of wariness among patients has caused medical and pharmaceutical companies to triple their expenses for public relations20 Ralph Nader has made the consumers of health staples money-and quality-conscious. The ecological movement has created an awareness that health depends on the environment---on food and working conditions and housing---and Americans have come to accept the idea that they are threatened by pesticides,21 additives,22 and mycotoxins23 and other health risks due to environmental degradation. Women's liberation has highlighted the key role that the control over one's body plays in health care24 A few slum communities have assumed responsibility for basic health care and have tried to unhook their members from dependence on outsiders. The class-specific nature of body perception,25 language,26 concepts,27 access to health services, 30 infant mortality,28 and actual, specifically chronic, morbidity29 has been widely documented, and the class-specific origins30and prejudices31 of physicians are beginning to be understood. The World Health Organization, meanwhile, is moving to a conclusion that would have shocked most of its founders: in a recent publication WHO advocates the deprofessionalization of primary care as the most important single step in raising national health levels32 Doctors themselves are beginning to look askance at what doctors do33When physicians in New England were asked to evaluate the treatment their patients had received from other doctors, most were dissatisfied. Depending on the method of peer evaluation used, between 134 percent and 63 percent of patients were believed to have received adequate care35 Patients are told ever more frequently by their doctors that they have been damaged by previous medication and that the treatment now prescribed is made necessary by the effects of such prior medication, which in some cases was given in a life-saving endeavor, but much more often for weight control, mild hypertension, flu, or mosquito bite or just to put a mutually satisfactory conclusion to an interview with the doctor36 In 1973 a retiring senior official of the U. S. Department of Health, Education, and Welfare could say that 80 percent of all funds channeled through his office provided no demonstrable benefits to health and that much of the rest was spent to offset iatrogenic damage. His successor will have to deal with these data if he wants to maintain public trust37 Patients are starting to listen, and a growing number of movements and organizations are beginning to demand reform. The attacks are founded on five major categories of criticism and are directed to five categories of reform: (1) Production of remedies and services has become self-serving. Consumer lobbies and consumer control of hospital boards should therefore force doctors to improve their wares. (2) The delivery of remedies and access to services is unequal and arbitrary; it depends either on the patient's money and rank, or on social and medical prejudices which favor, for example, attention to heart disease over attention to malnutrition. The nationalization of health production ought to control the hidden biases of the clinic. (3) The organization of the medical guild perpetuates inefficiency and privilege, while professional licensing of specialists fosters an increasingly narrow and specialized view of disease. A combination of capitation payment with institutional licensing ought to combine control over doctors with the interest of patients. (4) The sway of one kind of medicine deprives society of the benefits competing sects might offer. More public support for alpha waves, encounter groups, and chiropractic ought to countervail and complement the scalpel and the poison. (5) The main thrust of present medicine is the individual, in sickness or in health. More resources for the engineering of populations and environments ought to stretch the health dollar.
These proposed remedial policies could control to some degree the social costs created by overmedicalization. By joining together, consumers do have power to get more for their money; welfare bureaucracies do have the power to reduce inequalities; changes in licensing and in modes of financing can protect the population not only against nonprofessional quacks but also, in some cases, against professional abuse; money transferred from the production of human spare parts to the reduction of industrial risks does buy more "health" per dollar. But all these policies, unless carefully qualified, will tend to reduce the externalities created by medicine at the cost of a further increase of medicine's paradoxical counterproduct, its negative effect on health. All tend to stimulate further medicalization. All consistently place the improvement of medical services above those factors which would improve and equalize opportunities, competence, and confidence for self-care; they deny the civil liberty to live and to heal, and substitute promises of more conspicuous social entitlements to care by a professional.
In the following five sections I will deal with some of these possible countermeasures and examine their relative merits.
Consumer Protection for Addicts#
When people become aware of their dependence on the medical industry, they tend to be trapped in the belief that they are already hopelessly hooked. They fear a life of disease without a doctor much as they would feel immobilized without a car or a bus. In this state of mind they are ready to be organized for consumer protection and to seek solace from politicians who will check the high-handedness of medical producers38 The need for such self-protection is obvious, the implicit dangers obscure. The sad truth for consumer advocates is that neither control of cost nor assurance of quality guarantees that health will be served by medicine that measures up to present medical standards.
Consumers who band together to force General Motors to produce an acceptable car have begun to feel competent to look under the hood and to develop criteria for estimating the cost of a cleaner exhaust system. When they band together for better health care, they still believe---mistakenly---that they are unqualified to decide what ought to be done for their bowels and kidneys and blindly entrust themselves to the doctor for almost any repair. Cross-cultural comparison of practices provides no guide. Prescriptions for vitamins are seven times more common in Britain than in Sweden, gamma globulin medication eight times more common in Sweden than in Britain. American doctors operate, on the average, twice as often as Britons; French surgeons amputate almost up to the neck. Median hospital stays vary not with the affliction but with the physician: for peptic ulcers, from six to twenty-six days; for myocardial infarction, from ten to thirty days. The average length of stay in a French hospital is twice that in the United States. Appendectomies are performed and deaths from appendicitis are diagnosed three times more frequently in Germany than anywhere else[^41]
Titmuss39 has summed up the difficulty of cost-benefit accounting in medicine, especially at a time when medical care is losing the characteristics it used to possess when it consisted almost wholly in the personal doctor-patient relationship. Medical care is uncertain and unpredictable; many consumers do not desire it, do not know they need it, and cannot know in advance what it will cost them. They cannot learn from experience. They must rely on the supplier to tell them if they have been well served, and they cannot return the service to the seller or have it repaired. Medical services are not advertised as are other goods, and the producer discourages comparison. Once he has purchased, a consumer cannot change his mind in mid-treatment. By defining what constitutes illness the medical producer has the power to select his consumers and to market some products that will be forced on the consumer, if need be, by the intervention of the police: the producers can even sell forcible internment for the disabled and asylums for the mentally retarded. Malpractice suits have mitigated the layman's sense of impotence on several of these points,40 but basically, they have reinforced the patient's determination to insist on treatment that is considered adequate by informed medical opinion. What further complicates matters is that there is no "normal" consumer of medical services. Nobody knows how much health care will be worth to him in terms of money or pain. In addition, nobody knows if the most advantageous form of health care is obtained from medical producers, from a travel agent, or by renouncing work on the night shift. The family that forgoes a car to move into a Manhattan apartment can foresee how the substitution of rent for gas will affect their available time; but the person who, upon the diagnosis of cancer, chooses an operation over a binge in the Bahamas does not know what effect his choice will have on his remaining time of grace. The economics of health is a curious discipline, somewhat reminiscent of the theology of indulgences which flourished before Luther. You can count what the friars collect, you can look at the temples they build, you can take part in the liturgies they indulge in, but you can only guess what the traffic in remission from purgatory does to the soul after death. Models developed to account for the willingness of taxpayers to foot rising medical bills constitute similar scholastic guesswork about the new world-spanning church of medicine. To give an example: it is possible to view health as durable capital stock used to produce an output called "healthy time."44 Individuals inherit an initial stock, which can be increased by investment in health capitalization through the acquisition of medical care, or through good diet and housing. "Healthy time" is an article in demand for two reasons. As a consumer commodity, it directly enters into the individual's utility function; people usually would rather be healthy than sick. It also enters the market as an investment commodity. In this function, "healthy time" determines the amount of time an individual can spend on work and on play, on earning and on recreation. The individual's "healthy time" can thus be viewed as a decisive indicator of his value to the community as a producer41
Orientation on policy and theories on the dollar value of "health" production divide the adherents of squabbling academic factions much as realism and nominalism divided medieval divines42 But to the point that concerns the consumer, they just state in a roundabout way what every Mexican bricklayer knows: only on those days when he is healthy enough to work can he bring beans and tortillas to his children and have a tequila with his friends43 The belief in a causal relationship between doctor's bills and health---which would otherwise be called modernized superstition---is a basic technical assumption for the medical economist44
Different systems have been used to legitimize the economic value of the specific activities in which physicians engage. Socialist nations assume the financing of all care and leave it to the medical profession to define what is needed, how it must be done, who may do it, what it should cost, and who shall get it. More brazenly than elsewhere, input/output calculations of such investments in human capital seem to determine Russian allocations45 Most welfare states intervene with laws and incentives in the organization of their health-care markets, although only the United States has launched a national legislative program under which committees of producers determine what outputs offered on the "free market" the state shall approve as "good care." In late 1973 President Nixon signed Public Law 92-603 establishing mandatory cost and quality controls (by Professional Standard Review Organizations) for Medicaid and Medicare, the tax-supported sector of the health-care industry, which since 1970 has been second in size only to the military-industrial complex. Harsh financial sanctions threaten physicians who refuse to open their files to government inspectors searching for evidence of over-utilization of hospitals, fraud, or deficient treatment. The law requires the medical profession to establish guidelines for the diagnosis and treatment of a long list of injuries, illnesses, and health conditions, mandating the world's most costly program for the medicalization of health production through legislated consumer protection46 The new law guarantees the standard set by industry for the commodity. It does not ask if its delivery is positively or negatively related to the health of people.
Attempts to exercise rational political control over the production of medical health care have consistently failed. The reason lies in the nature of the product now called "medicine," a package made up of chemicals, apparatus, buildings, and specialists, and delivered to the client. The purveyor rather than his clients or political boss determines the size of the package. The patient is reduced to an object---his body---being repaired; he is no longer a subject being helped to heal. If he is allowed to participate in the repair process, he acts as the lowest apprentice in a hierarchy of repairmen47 Often he is not even trusted to take a pill without the supervision of a nurse. The argument that institutional health care (remedial or preventive) ceases after a certain point to correlate with any further "gains" in health can be misused for transforming clients hooked on doctors into clients of some other service hegemony: nursing homes, social workers, vocational counselors, schools48 What started out as a defense of consumers against inadequate medical service, will, first, provide the medical profession with assurance of continued demand and then with the power to delegate some of these services to other industrial branches: to the producers of foods, mattresses, vacations, or training. Consumer protection thus turns quickly into a crusade to transform independent people into clients at all cost.
Unless it disabuses the client of his urge to demand and take more services, consumer protection only reinforces the collusion between giver and taker, and can play only a tactical and a transitory role in any political movement aimed at the health-oriented limitation of medicine. Consumer-protection movements can translate information about medical ineffectiveness now buried in medical journals into the language of politics, but they can make substantive contributions only if they develop into defense leagues for civil liberties and move beyond the control of quality and cost into the defense of untutored freedom to take or leave the goods. Any kind of dependence soon turns into an obstacle to autonomous mutual care, coping, adapting, and healing, and what is worse, into a device by which people are stopped from transforming the conditions at work and at home that make them sick. Control over the production side of the medical complex can work towards better health only if it leads to at least a very sizable reduction of its total output, rather than simply to technical improvements in the wares that are offered.
Equal Access to Torts#
The most common and obvious political issue related to health is based on the charge that access to medical care is inequitable, that it favors the rich over the poor,49 the influential over the powerless. While the level of medical services rendered to the members of technical elites does not vary significantly from one country to another, say from Sweden and Czechoslovakia to Indonesia and Senegal, the value of the services rendered to the typical citizen in different countries varies by factors exceeding the proportion of one to one thousand50 In many poor countries, the few are socially predetermined to get much more than the majority, not so much because they are rich as because they are children of soldiers or bureaucrats or because they live close to the one large hospital. In rich countries members of different minorities are underprivileged, not because, in terms of money per capita, they necessarily get less than their share,51 but because they get substantially less than they have been trained to need. The slum dweller cannot reach the doctor when he needs him, and what is worse, the old, if they are poor and locked in a "home," cannot get away from him. For these and similar reasons, political parties convert the desire for health into demands for equal access to medical facilities52 They usually do not question the goods the medical system produces but insist that their constituents have a right to all that is produced for the privileged53
In the poor countries, the poor majorities clearly have less access to medical services than the rich:58 the services available to the few consume most of the health budget and deprive the majority of services of any kind. In all of Latin America, except Cuba, only one child in forty from the poorest fifth of the population finishes the five years of compulsory schooling;59 a similar proportion of the poor can expect hospital treatment if they become seriously ill. In Venezuela, one day in a hospital costs ten times the average daily income; in Bolivia, about forty times the average daily income54 Everywhere in Latin America, the rich constitute the 3 percent of the population who are college graduates, labor leaders, political party officials, and members of families who have access to services either through money or simply through connections. These few receive costly treatment, often from the doctors of their choice. Most of the physicians, who come from the same social class as their patients, were trained to international standards on government grants55
Notwithstanding unequal access to hospital care, the availability of medical service does not inevitably correlate with personal income. In Mexico about 3 percent of the population has access to the Instituto de Seguridad y Servicios Sociales de las Trabajadores del Estado (ISSSTE), that special part of the social security system which still holds a record for combining personal nursing care with advanced technological sophistication. This fortunate group is made up of government employees who receive truly equal treatment, whether they are ministers or office boys, and can count on high-quality care because they are part of a demonstration model. The newspapers, accordingly, inform the schoolmaster in a remote village that Mexican surgery is as well endowed as its counterpart in Chicago and that the surgeons who operate on him measure up to the standards of their colleagues in Houston. When high-level officials are hospitalized, they may be annoyed because for the first time in their lives they have to share a hospital room with a workman, but they are also proud of the high level of socialist commitment their nation shows in providing the same for boss and custodian. Both kinds of patient tend to overlook the fact that they are equally privileged exploiters. Providing the 3 percent with beds, equipment, administration, and technical care takes one-third of the public-health-care budget of the entire country. To be able to afford to give all of the poor equal access to medicine of uniform quality in poor countries, most of the present training and activity of the health professions would have to be discontinued. However, delivery of effective basic health services for the entire population is cheap enough to be bought for everyone, provided no one could get more, regardless of the social, economic, medical, or personal reasons advanced for special treatment. If priority were given to equity in poor countries and service limited to the basics of effective medicine, entire populations would be encouraged to share in the demedicalization of modern health care and to develop the skills and confidence for self-care, thus protecting their countries from social iatrogenic disease.
In the rich countries, the economics of health are somewhat different56 At first sight, concern for the poor appears to demand further increases in the total health budget57 Yet the more people come to depend on care by service institutions, the more difficult it is to identify equity with equal access and equal benefits58 Is equity realized when equal numbers of dollars are available for the education of rich and poor? Or does it require that the poor get the same "education" although more will have to be spent on their account to achieve equal results? Or must the educational system, in order to be equitable, assure that the poor are not humiliated and hurt more than the rich with whom they compete on the academic ladder? Or is equity in learning opportunities provided only when all citizens share the same kind of learning environment? This battle of equity versus equality in the access to institutional care, already being waged in education, is now shaping up in the medical field59 In contrast to education, however, the issue in health can easily be resolved on available evidence. The per capita expenditure on health care, even for the poorest sector within the United States population, indicates that the base line at which such care turns iatrogenic has long since been passed. In rich countries, the total budget of services for the poor, if used for that which reinforces self-care, is more than ample. More access, even though restricted to those who now receive less, would only equalize the delivery of professional illusions and torts.
There are two aspects to health: freedom and rights. Above all, health designates the range of autonomy within which a person exercises control over his own biological states and over the conditions of his immediate environment. In this sense, health is identical with the degree of lived freedom. Primarily the law ought to guarantee the equitable distribution of health as freedom, which, in turn, depends on environmental conditions that only organized political efforts can achieve. Beyond a certain level of intensity, health care, however equitably distributed, will smother health-as-freedom. In this fundamental sense, health care is a matter of well-ordered liberty. Implicit in this concept is a preferred position of inalienable freedoms to do certain things, and here civil liberty must be distinguished from civil rights. The liberty to act without restraint from government has a wider scope than the civil rights the state may enact to guarantee that people will have equal powers to obtain certain goods or services.
Civil liberties ordinarily do not force others to carry out my wishes; a person may publish his or her opinion freely as far as the government is concerned, but this does not imply a duty for any one newspaper to print that opinion. A person may need to drink wine in his kind of worship, but no mosque has to welcome him to do so within its walls. At the same time, the state as a guarantor of liberties can enact laws that protect equal rights without which its members would not enjoy their freedoms. Such rights give meaning to equality, while liberties give shape to freedom. One sure way to extinguish freedom to speak, to learn, or to heal is to delimit them by transmogrifying civil rights into civic duties. The freedoms of the self-taught will be abridged in an overeducated society just as the freedom to health care can be smothered by overmedication. Any sector of the economy can be so expanded that for the sake of more costly levels of equality, freedoms are extinguished.
We are concerned here with movements that try to remedy the effects of socially iatrogenic medicine through political and legal control of the management, allocation, and organization of medical activities. Insofar as medicine is a public utility, however, no reform can be effective unless it gives priority to two sets of limits. The first relates to the volume of institutional treatment any individual can claim: no person is to receive services so extensive that his treatment deprives others of an opportunity for considerably less costly care per capita if, in their judgment (and not just in the opinion of an expert), they make a request of comparable urgency for the same public resources. Conversely, no services are to be forcibly imposed on an individual against his will: no man, without his consent, shall be seized, imprisoned, hospitalized, treated, or otherwise molested in the name of health. The second set of limits relates to the medical enterprise as a whole. Here the idea of health-as-freedom has to restrict the total output of health services within subiatrogenic limits that maximize the synergy of autonomous and heteronomous modes of health production. In democratic societies, such limitations are probably unachievable without guarantees of equity---without equal access. In that sense, the politics of equity is probably an essential element of an effective program for health. Conversely, if concern with equity is not linked to constraints on total production, and if it is not used as a countervailing force to the expansion of institutional medical care, it will be futile60
Public Controls over the Professional Mafia#
A third category of political remedies for unhealthy medicine focuses directly on how doctors do their work. Like consumer advocacy and legislation of access, this attempt to impose lay control on the medical organization has inevitable health-denying effects when it is changed from an ad hoc tactic into a general strategy.
Four and a half million men and women in two hundred occupations are employed in the production and delivery of medically approved health services in the United States. (Only 8 percent are physicians, whose net income after deductions for rent, personnel, and supplies represents 15 percent of total health expenditures and whose average income in 1973 was $50,000.67) The total does not include osteopaths, chiropractors, and others who might have specialized university training and require a license to practice, but who, unlike pharmacists, optometrists, laboratory technicians, and similar physicians' underlings, do not produce health care of the same prestige61 Even further removed from the establishment, and therefore excluded from these statistics, are thousands of purveyors of nonconventional health care, ranging from mail-order herbalists and masseurs to teachers of yoga62 Of the many claimants to competence who are more or less integrated into the official establishment, about thirty categories are licensed in the United States63 In no state of the union is a license required for fewer than fourteen kinds of practitioners64 These licenses are issued on completion of formal educational programs and sometimes on the evidence of a successful examination; in rare instances, proficiency or experience is a prerequisite for admission to independent practice65 Competent or successful work is nowhere a condition for continuing in practice. Renewal is automatic, usually upon payment of a fee; only fifteen out of fifty states permit a physician's license to be challenged on grounds of incompetence66 While claims to specialist standing come and go on the fringes, the specialties recognized by the American Medical Association have steadily increased, doubling in the last fifteen years: half the practicing American physicians are specialists in one of sixty categories, and the proportion is expected to increase to 55 percent before 198067 Within each of these fields a fiefdom has developed with specialized nurses, technicians, journals, congresses, and sometimes organized groups of patients pressing for more public funds68 The cost of coordinating the treatment of the same patient by several specialists grows exponentially with each added competence, as does the risk of mistakes and the probability of damage due to the unexpected combination of different therapies. As the number of patient relationships outgrows the elements in the total population, the occupations dealing with medical information, insurance, and patient defense multiply unchecked. Of course, physicians lord it over these fiefs and determine what work these pseudo-professions shall do. But with the recognition of some autonomy many of these specialized groups of medical pages, ushers, footmen, and squires have also gained some power to evaluate how well they do their own work. By gaining the right to self-evaluation according to special criteria that fit its own view of reality, each new specialty generates for society at large a new impediment to evaluating what its work actually contributes to the health of patients. Organized medicine has practically ceased to be the art of healing the curable, and consoling the hopeless has turned into a grotesque priesthood concerned with salvation and has become a law unto itself. The policies that promise the public some control over the medical endeavor tend to overlook the fact that to achieve their purpose they must control a church, not an industry.
Dozens of concrete strategies are now being discussed and proposed to make the health industry more health-serving and less self-serving: decentralization of delivery; universal public insurance; group practice by specialists; health-maintenance programs rather than sick-care; payment of a fixed amount per patient per year (capitation) rather than fee-for-service; elimination of present restrictions on the use of health manpower; more rational organization and utilization of the hospital system; replacement of the licensing of individuals by the licensing of institutions held to performance standards; and the organization of patient cooperatives to balance or support a professional medical power.
Each of these proposals would indeed improve medical efficiency, but at the cost of a further decline in society's effective health care. To increase efficiency by upward mobility of personnel and downward assignment of responsibility could not but tighten the integration of the medical-care industry and with it social polarization.
As the training of middle-level professionals becomes more expensive, nursing personnel in the lower ranks is becoming scarce. Poor salaries, growing disdain for servant and housekeeping roles, an increase in chronic patients (and consequent growing tedium in their care), disappearance of the religious motivation for nuns and deacons, and new opportunities for women in other fields all contribute to a manpower crisis. In England nearly ⅔ of all low-level hospital personnel come from overseas, usually from former colonies; in Germany, from Turkey and Yugoslavia; in France, from North Africa; in the U. S., from the ranks of racial minorities. The creation of new ranks, titles, curricula, roles, and specialties at the bottom level is a doubtfully effective remedy. The hospital only reflects the labor economy of a high-technology society: transnational specialization on the top, bureaucracies in the middle, and at the bottom, a new subproletariat made up of migrants and the professionalized client69
The multiplication of paraprofessional specialists further decreases what the diagnostician does for the person who seeks his help, while the multiplication of generalist auxiliaries tends to reduce what uncertified people may do for each other or for themselves70 Institutional licensing71 would indeed permit a more efficient deployment of personnel, a more rational health-manpower mix, and greater opportunity for advancement: it would no doubt greatly improve the delivery of medical staples such as dental work, bonesetting, and the delivery of babies. But if it became the model for over-all health care, it would be equivalent to the creation of a medical Ma Bell72 Lay control over an expanding medical technocracy is not unlike the professionalization of the patient: both enhance medical power and increase its nocebo effect. As long as the public bows to the professional monopoly in assigning the sick-role, it cannot control hidden health hierarchies that multiply patients73 The medical clergy can be controlled only if the law is used to restrict and disestablish its monopoly on deciding what constitutes disease, who is sick, and what ought to be done to him or her74
Misdirection of blame for iatrogenesis is the most serious political obstacle to public control over health care. To turn doctor-baiting into radical chic would be the surest way to defuse any political crisis fueled by the new health consciousness. If physicians were to become conspicuous scapegoats, the gullible patient would be relieved from blame for his therapeutic greed. School-baiting did save the institutional enterprise when crisis last hit in education. The same strategy could now save the medical system and keep it essentially as it is.
Quite suddenly in the 1970s the schools lost their status as sacred cows. Driven by Sputnik, racial conflict, and new frontiers, the school bubble had outgrown all nonmilitary budgets and had burst. For a short while, the hidden curriculum of the school system lay exposed. It became conventional wisdom that after a certain point in its expansion, the school system inevitably reproduces a meritocratic class society and neatly arranges people according to levels of highly specialized torpor for which they are trained in graded, age-specific, competitive, and compulsory rituals. Frustration of an expensive dream had led many people to grasp that no amount of compulsory learning could equitably prepare the young for industrial hierarchies, and that all effective preparation of children for an inhuman socio-economic system constituted systematic aggression against their persons. At this point a new vision of reality could have grown into a radical revolt against a capital-intensive system of production and the beliefs that bolster it. But instead of blaming the hubris of pedagogues, the public conceded to pedagogues more power to do precisely as they pleased. Disgruntled teachers focused criticism on their peers, the methods, the organization of schooling, and the financing of institutions, all of which were defined as obstacles to effective education.
School-baiting enabled liberal schoolmasters to mutate into a new breed of adult educators. School-baiting not only saved but---momentarily---upgraded the salary and prestige of the teacher. Whereas before the crisis point the schoolmaster had been restricted in his pedagogical aggression to an age-specific group below sixteen years of age, which was exposed to him during class hours in the school building to be initiated into a limited number of subjects, the new knowledge-merchant now considers the world his classroom. While the curricular teacher could disqualify only those nonstudents who dared to learn a curricular matter on their own, the new manager of lifelong and recurrent "education," "conscientization," "sensitivity training," or "politicization" presumes to degrade in the eyes of the public any behavioral patterns that he has not approved. The school-baiting of the sixties could easily set the pattern for the coming medical war. Following the lead of the teachers who declare that the world is their classroom, some chic crusading physicians75 now jump onto the bandwagon of medicine-baiting and channel public frustration and anger at curative medicine into a call for a new elite of scientific guardians who would control the world as their ward76
The Scientific Organization---of Life#
Belief in medicine as an applied science generates a fourth kind of countermeasure to iatrogenesis which inevitably increases the irresponsible power of the health profession---and thereby the damage medicine does. The proponents of higher scientific standards in medical research and social organization argue that pathogenic medicine is due to the overwhelming number of bad doctors let loose on society. Fewer decision-makers, more carefully screened, better trained, more tightly supervised by their peers, and more effectively in command over what is done for whom and how, would ensure that the powerful resources now available to medical scientists would be applied for the benefit of the people77 Such idolatry of science overlooks the fact that research conducted as if medicine were an ordinary science, diagnosis conducted as if patients were specific cases and not autonomous persons, and therapy conducted by hygienic engineers are the three approaches which coalesce into the present endemic health-denial.
As a science, medicine lies on a borderline. Scientific method provides for experiments conducted on models. Medicine, however, experiments not on models but on the subjects themselves. But medicine tells us as much about the meaningful performance of healing, suffering, and dying as chemical analysis tells us about the aesthetic value of pottery78
In the pursuit of applied science the medical profession has largely ceased to strive towards the goals of an association of artisans who use tradition, experience, learning, and intuition, and has come to play a role reserved to ministers of religion, using scientific principles as its theology and technologists as acolytes79 As an enterprise, medicine is now concerned less with the empirical art of healing the curable and much more with the rational approach to the salvation of mankind from attack by illness, from the shackles of impairment, and even from the necessity of death80 By turning from art to science, the body of physicians has lost the traits of a guild of craftsmen applying rules established to guide the masters of a practical art for the benefit of actual sick persons. It has become an orthodox apparatus of bureaucratic administrators who apply scientific principles and methods to whole categories of medical cases. In other words, the clinic has turned into a laboratory. By claiming predictable outcomes without considering the human performance of the healing person and his integration in his own social group, the modern physician has assumed the traditional posture of the quack.
As a member of the medical profession the individual physician is an inextricable part of a scientific team. Experiment is the method of science, and the records he keeps---if he likes it or not---are part of the data for a scientific enterprise. Each treatment is one more repetition of an experiment with a statistically known probability of success. As in any operation that constitutes a genuine application of science, failure is said to be due to some sort of ignorance: insufficient knowledge of the laws that apply in the particular experimental situation, a lack of personal competence in the application of method and principles on the part of the experimenter, or else his inability to control that elusive variable which is the patient himself. Obviously, the better the patient can be controlled, the more predictable will be the outcome in this kind of medical endeavor. And the more predictable the outcome on a population basis, the more effective will the organization appear to be. The technocrats of medicine tend to promote the interests of science rather than the needs of society81 The practitioners corporately constitute a research bureaucracy. Their primary responsibility is to science in the abstract or, in a nebulous way, to their profession82 Their personal responsibility for the particular client has been resorbed into a vague sense of power extending over all tasks and clients of all colleagues. Medical science applied by medical scientists provides the correct treatment, regardless of whether it results in a cure, or death sets in, or there is no reaction on the part of the patient. It is legitimized by statistical tables, which predict all three outcomes with a certain frequency. The individual physician in a concrete case may still remember that he owes nature and the patient as much gratitude as the patient owes him if he has been successful in the use of his art. But only a high level of tolerance for cognitive dissonance will allow him to carry on in the divergent roles of healer and scientist83 The proposals that seek to counter iatrogenesis by eliminating the last vestiges of empiricism from the encounter between the patient and the medical system are latter-day crusaders of an inquisitorial kind84 They use the religion of scientism to devalue political judgment. While operational verification in the laboratory is the measure of science, the contest of adversaries appealing to a jury that applies past experience to a present issue, as this issue is experienced by actual persons, constitutes the measure of politics. By denying public recognition to entities that cannot be measured by science, the call for pure, orthodox, confirmed medical practice shields this practice from all political evaluation.
The religious preference given to scientific language over the language of the layman is one of the major bulwarks of professional privilege. The imposition of this specialized language upon political discourse about medicine easily voids it of effectiveness.
The deprofessionalization of medicine does not imply the proscription of technical language any more than it calls for the exclusion of genuine competence, nor does it oppose public scrutiny and exposure of malpractice. But it does imply a bias against the mystification of the public, against the mutual accreditation of self-appointed healers, against the public support of a medical guild and of its institutions, and against the legal discrimination by, and on behalf of, people whom individuals or communities choose and appoint as their healers. The deprofessionalization of medicine does not mean denial of public funds for curative purposes, but it does mean a bias against the disbursement of any such funds under the prescription or control of guild members. It does not mean the abolition of modern medicine. It means that no professional shall have the power to lavish on any one of his patients a package of curative resources larger than that which any other could claim for his own. Finally, it does not mean disregard for the special needs that people manifest at special moments in their lives: when they are born, break a leg, become crippled, or face death. The proposal that doctors not be licensed by an in-group does not mean that their services shall not be evaluated, but rather that this evaluation can be done more effectively by informed clients than by their own peers. Refusal of direct funding to the more costly technical devices of medical magic does not mean that the state shall not protect individual people against exploitation by ministers of medical cults; it means only that tax funds shall not be used to establish any such rituals. Deprofessionalization of medicine means the unmasking of the myth according to which technical progress demands the solution of human problems by the application of scientific principles, the myth of benefit through an increase in the specialization of labor, through multiplication of arcane manipulations, and the myth that increasing dependence of people on the right of access to impersonal institutions is better than trust in one another.
Engineering for a Plastic Womb#
So far I have dealt with four categories of criticism directed at the institutional structure of the medical-industrial complex. Each gives rise to a specific kind of political demand, and all of them become reinforcements for the dependence of people on medical bureaucracies because they deal with health care as a form of therapeutic planning and engineering85 They indicate strategies for surgical, chemical, and behavioral intervention in the lives of sick people or people threatened with sickness. A fifth category of criticism rejects these objectives. Without relinquishing the view of medicine as an engineering endeavor, these critics assert that medical strategies fail because they concentrate too much effort on sickness and too little on changing the environment that makes people sick.
Most research on alternatives to clinical intervention is directed towards program engineering for the professional systems of man's social, psychological, and physical environment. "Non-health-service health determinants" are largely concerned with planned intervention in the milieu86 Therapeutic engineers shift the thrust of their interventions from the potential or actual patient towards the larger system of which he is imagined to be a part. Instead of manipulating the sick, they redesign the environment to ensure a healthier population87
Health care as environmental hygienic engineering works within categories different from those of the clinical scientist. Its focus is survival rather than health in its opposition to disease; the impact of stress on populations and individuals rather than the performance of specific persons; the relationship of a niche in the cosmos to the human species with which it has evolved rather than the relationship between the aims of actual people and their ability to achieve them88 In general, people are more the product of their environment than of their genetic endowment. This environment is being rapidly distorted by industrialization. Although man has so far shown an extraordinary capacity for adaptation, he has survived with very high levels of sublethal breakdown. Dubos[^96] fears that mankind will be able to adapt to the stresses of the second industrial revolution and overpopulation just as it survived famines, plagues, and wars in the past. He speaks of this kind of survival with fear because adaptability, which is an asset for survival, is also a heavy handicap: the most common causes of disease are exacting adaptive demands. The health-care system, without any concern for the feelings of people and for their health, simply concentrates on the engineering of systems that minimize breakdowns.
Two foreseeable and sinister consequences of a shift from patient-oriented to milieu-oriented medicine are the loss of the sense of boundaries between distinct categories of deviance, and a new legitimacy for total treatment89 Medical care, industrial safety, health education, and psychic reconditioning are all different names for the human engineering needed to fit populations into engineering systems. As the health-delivery system continually fails to meet the demands made upon it, conditions now classified as illness may soon develop into aspects of criminal deviance and asocial behavior. The behavioral therapy used on convicts in the United States90 and the Soviet Union's incarceration of political adversaries in mental hospitals91 indicate the direction in which the integration of therapeutic professions might lead: an increased blurring of boundaries between therapies administered with a medical, educational, or ideological rationale92
The time has come not only for public assessment of medicine but also for public disenchantment with those monsters generated by the dream of environmental engineering. If contemporary medicine aims at making it unnecessary for people to feel or to heal, eco-medicine promises to meet their alienated desire for a plastic womb.