Professor Janice Morse:
I am honored by your invitation to address this second assembly of nurses who have organized as learned watchdogs over the quality of health care. I have been invited as the author of Medical Nemesis (Illich, 1976), a book that was published exactly 20 years ago. I am not a nurse, and, emphatically, I do not care about health. I teach about the history of friendship and the history of the art of suffering.
I am trained as a medieval historian and philosopher. I come here because Professor Carl Mitcham encouraged me. We are associated in research on the symbolic effects of technique: We study what technique says rather than what it does. The predicament that you are facing at this second meeting of your association seems to both of us relevant to our theme.
You study the quality of health care. What is it you focus on? Is it the delivery of services or of messages? I would like to distinguish between those among you who want more, better, cheaper, and less degrading services for more people; and others who want to do research on pathogenic myths and certainties that result from financing and organizing health care rituals. To accomplish this delicate task, I will tell you my own story. I will tell you about my intellectual growth beyond Medical Nemesis, presenting my story as a cautionary tale.
I welcome this occasion to make public amends for something I did when I wrote that book. I wrote Medical Nemesis as one of four essays that examined the symbolic power inherent in modern techniques to shape our basic certainties. In each essay, I used a different method to examine four major institutions, each serving as a screen on which to project my observations. In Nemesis, I took 1970s medicine and studied it with a method that demonstrated the paradoxically counterproductive effectiveness implicit in disproportionate techniques. With my description uncovering clinical, social, and cultural iatrogenesis; namely, the production of multifaceted misery, I did not target the medical establishment for reform. I examined it as an enterprise claiming, in effect, to abolish the need for the art of suffering by a technically engineered pursuit of happiness. I analyzed the development of health care parallel to that of education, transportation, human garaging, and so on, conscious that in the case of institutionalized hygiene, the pursuit of happiness is translated into the pursuit of "health." I see medicine as a paradigm for any megatechnique that promises to transform the conditio humana.
After a quarter of a century, I am still satisfied with the substance and rhetoric of Nemesis. The book opened up a discussion on counter-productivity and the history of needs. But it did something else also: It brought medicine back into the realm of philosophy. My focus on the culture of suffering was the appropriate antidote to the emerging epidemic of bioethics. By reducing each person to "a life," bioethics is helpless to prevent total management of the person, now transformed into a system.
However, I now see a serious flaw in my approach that would vitiate my current intent. I then conceived of health as "the intensity of autonomous coping ability." When I wrote that, I was unaware of the corrupting effect that system-analytic thinking would soon have on perceptions and conceptions. I was unaware that by construing health in this self-referentially cybernetic fashion, I unwittingly prepared the ground for a worldview in which the suffering person would get even further out of touch with the flesh. I neglected the transformation of the experience of body and soul when well-being comes to be expressed by a term that implies functions, feedbacks, and their regulation. Ten years of research with Barbara Duden on the history of the experienced body and several seminars on the history of the gendered self at the Wissenschaftskolleg (Berlin), at Marburg, and at Penn State still lay in the future.
That is the reason why I am worried by the fact that most of the current sales of Medical Nemesis--in several languages--are bulk orders from medical schools. The book is being read as a demonstration of how you can have your cake and eat it too. You can obliterate the experienced sensual body of the past by conceiving of yourself as a self-regulatory, self-constructing system in need of responsible management and, in spite of this disembodiment, claim that you stand within the tradition of the art of suffering and the art of dying. I wrote Nemesis to illustrate what the health care system says, but I did not sufficiently stress its subtle structures that pattern our response, turning us into subsystems.
You are the perfect audience to hear my story and understand it as a cautionary tale. Most of you were once graduate nurses. Those with whom I had breakfast and those with whom I lunched impressed me greatly. Shocked by what you were asked to do as nurses, you went on to graduate schools with the intent to do something about the system. You finished studies in ethnology, sociology, anthropology, and psychology. In the late 1980s, you formed your organization. You did so for mutual support in research on the experience of encounters with the health care system. In medical circles, your initiative was less than welcome. Nevertheless, you had a few fruitful years with some definite institutional impact.
This cannot but change. I can smell that you are on the point of being co-opted. The American Medical Association now spends more than most U.S. industries on public relations. Just consider the glossy 10-page color spreads in Time and Newsweek. Competing for these PR dollars, you win hands down. Grants for each of the 330 papers presented at this meeting can be justified because such studies establish that those professionals who provide care do indeed care for their clients--whether this is true or not.
From my contacts here, I have learned that not all of you left actual nursing to spend your lives oiling care delivery with goodwill or doing engineering research on simpler means that would produce higher rates of client-perceived utility. I have met those of you who want to decipher the melody that the care system drums into us. They are the ones who intend to train cynical philosophers to fearlessly bark at a contemporary paradox: The organized pursuit of health has become the principal impediment to suffering experienced as a dignified, meaningful, patient, loving, beautiful, resigned, and even joyful embodiment.
As long as you were protected by initial liminality, it was possible to envisage our care system as the institutional structure of a pathogenic pursuit of health. My host's seminars at Penn State on the history of health-related words and concepts are a good example. But once you enjoy professional status within the system, you lose much of this freedom. Those who will then want to do research on the art of suffering after culture rather than on postmodern health will have an increasingly difficult time. They are the ones to whom I especially direct my story. They are the ones with whom I want to plead for research on the symbolic function of the health care conglomerate. What does it tell about who we are, rather than how well we pursue health?
The opening sentence of Medical Nemesis was an indictment: "The medical establishment has become a major threat to health." It seems strange now that this sentence could shock and anger in 1974. Today, it is trite. I argued "that the layman and not the physician has the potential perspective and effective power to stop the current iatrogenic epidemic." Now the Clintons search for what I called "a conceptual framework within which to assess the seamy side of progress against its more publicized benefits." The same Congress that has effectively fired 2,300 physicists who were working on research for the supercollider now does what I argued for. It "reclaims its own control over medical perception, classification, and decision making." What is it, then, that I now regret?
I am chagrined that I formulated an important and coherent statement about the art of suffering and dying in categories that lend themselves to reductionist disembodiment. In Medical Nemesis, I argued that the fundamental pathogen today is the pursuit of health as this has come to be culturally defined in late-industrial society. I did not understand that in the age of systems management this pathogenic pursuit of health would become universally imposed. I felt free to speak of health in terms of personal autonomy and as the "intensity of coping ability." I conceived of health as "a responsible performance in a social script" that is governed by a "cultural code adapted to a group's genetic make-up, to its history, to its environment." I wanted to make it plausible to a generation committed to the pursuit of health that throughout history the human condition had been "suffered." But I was still under Gregory Bateson's influence, believing that concepts like feedback, pogrom, autopsies, or information--when shrewdly used--could clarify issues. I thought I could equate suffering with the management of my own balance. I was wrong. As soon as you understand suffering as coping, you make the decisive step: From bearing with your flesh, you move towards managing emotions, perceptions, and states of a self conceived as a system.
The use of the English term coping is of very recent coinage. This is a point made at the first international meeting of Historians of Health Care last fall. It is either an abuse or an arbitrary predating to speak about "coping with sickness" in premodern times. Sickness, like pain, disability, tiredness, and fear was suffered, borne, shared, alleviated, dreaded, or cured. Each language has its own rich and precise vocabulary for dealing with woe, discomfort, torture, and all sorts of paroxysms. Great traditions differ from each other fundamentally through their set of notions and practices for dealing with this dark side of the human condition. Within each tradition, the interpretation of discomfort and anguish changes over time and is usually specific to social class. Any attempt to catch this wealth of cultural constellations of suffering in one net by calling it coping is a colonization of the past by imposing a profoundly modern notion.
In the 15th century, the verb to cope meant "to come to blows with someone." By the end of the 17th century, it had been gentled. The Oxford English Dictionary takes an example from Lord Byron: "Brisk confidence is still best with women to cope." After World War II, it entered slang, and kids began to cope with their love life. People learned to cope with husbands, jobs, treatments, unemployment, flu. But in 1967, the Usage Panel of the American Heritage Dictionary (Morris, 1969) still considered it, if not slang, then a kind of newspeak that was permissible in casual writing. Bateson took up the word to introduce systems theory into anthropology. He had a good ear for popular idioms. At just about that time, at least in California, to cope was first used as an intransitive verb. It bespoke a way of existence so new that traditional languages had no word for it. To cope, used without with in formal, written usage, was unacceptable to 75% of the Usage Panel.
Coping flourishes within this epistemic void. The recognition of widespread disorder allows me to chronicle my own growing clarity. It is within this void that words and diagrams have conjured up an emblem that now stands for the self, a new kind of black box.
When, barely 50, I defined health as "the intensity of autonomous coping ability," I did so in search of a contemporary way of referring to a moral "ego" in a time "after virtue." Unwittingly, however, I suggested responsibility, autopoiesis, and self-perception in terms of the ego's tolerances and immunities. There is no better ordinary verb to say how a person behaves, once conceived as a black box.
Now, nearly 70, I re-read my tract in a milieu infected by desconstruction. I became acutely aware that within the system-analytic framework implied by the new, intransitive activity of coping (with my life), the traditional art of living cannot be pursued. Self-perception in systems terms dissolves the kind of flesh that could practice either the art of enjoyment--the sunny phase--or the art of suffering--the shady side.
Medical Nemesis was an attempt to vindicate the art of living, the art of enjoyment and suffering, even within a culture shaped by progress, comfort, care, and insurance providing entitlement to pain killing, normalization, and, ultimately, euthanasia. Hazardous medicalization, socially disabling professionalism, and debilitating ritualism engendering the myths of amnesia, anaesthesia, and a-mortality were the themes of the book's three sections. It was written before prevention and neo-witchcraft had really taken off; neither the acceptance of current antismoking rules, nor the public financing of acupuncture for jailed drug addicts was then on the agenda. From a historical perspective, I indicted a cultural corruption; I raised ultimate questions of ethics.
The issue now facing us is a question of truth. I want to indict health care not as a demoralizing but as a nihilist activity. The decisive result of every brush with the health care system today is epistemic--a recasting of the ego. From T-cell watch to safe sex, from urine test to Zendo, what is done in the pursuit of health boomerangs as an interpretation of the self. In 1994, each of these routines bolsters the coping ability of the self as an immune system.
My evidence is anecdotal: Dr. Zimmermann, after a day in her clinic. Three of her 11 visitors had come for referral to a T-cell count: one because she was losing her hair; the second because of pimples; and I forget the symptom adduced by the third. Dr. Zimmermann reflected on the formation of physicians: The first thing you have to learn is a hierarchy of suspected aetiologies. In Protestant Germany in 1850, masturbation was first for men and hysteria first for women; a few decades later it was tuberculosis; then, syphilis. Now, she sees that it's the subscription to a self-care journal that transmits system ideology.
Timetables, college catalogs, and computer games do the same, but health care does it with a vengeance. Ego as an immune system is of such complexity that only tests can tell how it should feel. When the oncologist gave up further chemotherapy on Jim, I asked him how he felt. He told me to call next day, but only after 11 a.m., when the lab test would be back. The Orphic "Know thyself" now reads "Check how your system is coping."
The term immune system does not appear in the index of a single biological textbook before 1972. Ten years later it is hard to find a learned paper that deals with immunity and does not use the term. During the early 1980s, the concept appeared in textbooks dealing with a market, a cultural unit, the psychic constitution of a family--as entities endowed with an immune system, if these entities are not themselves simply described as such. Donna Harroway calls this thing, "a potent and polymorphous object of belief, knowledge, and practice . . . a map drawn to guide recognition and misrecognition of self and other in the dialectics of western biopolitics" (Harroway, 1989).
In fact, the zygote is on the way toward acquiring legal status as a human subject; partly because the Pope and constitutional jurists imply that its genome and cytoplasm have the potential to develop into a self by recognizing the "other"--in this case, the mother. Conceiving living beings as immune systems provides the pseudo-legitimation of reducing a human being to "a life," upon which ethics committees can pass judgments. In a world made up of systems, the immune system replaces what was formerly called an individual or person. Although the early 20th century practiced animism by accepting homo economicus as a natural fact--which legitimated seeing bacteria "competing" for scarce oxygen--so the late 20th century practices its necromancy by giving substance to system concepts and by reducing persons born for suffering and delight to provisionally self-sustaining information loops.
Most of this I did not know at the time I wrote Medical Nemesis.
Author's Note: An earlier version of this article was presented as "Against Coping" at the Second International Interdisciplinary Conference, Hershey, PA, June 1994.
Harroway, D. (1989). The biopolitics of postmodern bodies: Determination of self in immune system discourse. Differences: A Journal of Feminist Cultural Studies, 1(1), 3-43.
Illich, I. (1976) Medical nemesis: The expropriation of health. New York: Pantheon.
Morris, W. (Ed.). (1969). American heritage dictionary of the English language. Boston: Houghton-Mifflin.
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By Ivan Illich
Ivan Illich, Ph.D., is a professor of science, technology, and society at Pennsylvania State University, University Park.
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Source: Qualitative Health Research, Feb95, Vol. 5 Issue 1, p7, 8p