You are on page 1of 332

Illich, Ivan (1995 (1976)): Limits to Medicine. Medical Nemesis: The Ex!o!

iation o"
#ealth. $ith a ne% int!od&ction '( the a&tho!. London: Ma!ion )o(a!s.
Innholdsfortegnelse med hyperlinker
Innholds"o!te*nelse med h(e!lin+e! .......................................................................................... 1
Notat om la(o&t ........................................................................................................................... ,
-o!siden ....................................................................................................................................... ,
)a+siden ...................................................................................................................................... .
)o+en sta!te! ............................................................................................................................... /
0ontents .................................................................................................................................. 7
1!e"ace to the 1995 edition ...................................................................................................... 9
1atho*enesis, Imm&nit( and the 2&alit( o" 1&'lic #ealth ................................................. 9
2&alitative 3esea!ch ......................................................................................................... 11
Medical Nemesis ............................................................................................................... 1,
0oin* ............................................................................................................................... 1.
Ethical o! Eistemic 3it&al4 ............................................................................................. 1.
5c+no%led*ments ................................................................................................................. 16
5&tho!6s Note ........................................................................................................................ 17
Int!od&ction ........................................................................................................................... 17
153T I. 0linical Iat!o*enesis ................................................................................................... ,.
1. The Eidemics o" Mode!n Medicine ................................................................................ ,.
7octo!s6 E""ectiveness85n Ill&sion ................................................................................... ,6
9seless Medical T!eatment ............................................................................................... ./
7octo!8In"licted In:&!ies ................................................................................................... .;
7e"enseless 1atients .......................................................................................................... /5
153T II.<ocial Iat!o*enesis ..................................................................................................... /9
,. The Medicali=ation o" Li"e ............................................................................................... /9
1olitical T!ansmission o" Iat!o*enic 7isease .................................................................... /9
<ocial Iat!o*enesis ............................................................................................................ 5>
Medical Monool( ............................................................................................................ 51
?al&e "!ee 0&!e4 ............................................................................................................... 5/
The 1ha!mace&tical Invasion ............................................................................................ 7/
7ia*nostic Ime!ialism ..................................................................................................... ;;
1!eventive <ti*ma ........................................................................................................... 1>>
Te!minal 0e!emonies ...................................................................................................... 1>;
)lac+ Ma*ic .................................................................................................................... 119
1atient Ma:o!ities ............................................................................................................ 1,;
153T III.0&lt&!al Iat!o*enesis ............................................................................................... 1.6
Int!od&ction ......................................................................................................................... 1.6
.. The @illin* o" 1ain .......................................................................................................... 1/.
/. The Invention and Elimination o" 7isease ...................................................................... 16.
5. 7eath 5*ainst 7eath ....................................................................................................... 1;,
7eath as 0ommodit( ....................................................................................................... 1;,
The 7evotional 7ance o" the 7ead ................................................................................. 1;/
The 7anse Maca'!e ........................................................................................................ 1;;
)o&!*eois 7eath .............................................................................................................. 197
0linical 7eath ................................................................................................................. ,>.
T!ade 9nion 0laims to a Nat&!al 7eath .......................................................................... ,>/
7eath 9nde! Intensive 0a!e ............................................................................................ ,>;
153T I?. The 1olitics o" #ealth ............................................................................................ ,15
6. <eci"ic 0o&nte!!od&ctivit( .......................................................................................... ,15
7. 1olitical 0o&nte!meas&!es ............................................................................................... ,,,
0ons&me! 1!otection "o! 5ddicts .................................................................................... ,.,
EA&al 5ccess to To!ts ..................................................................................................... ,.9
1&'lic 0ont!ols ove! the 1!o"essional Ma"ia .................................................................. ,/5
The <cienti"ic B!*Cni=ationDo" Li"e ............................................................................. ,5,
En*inee!in* "o! a 1lastic $om' ..................................................................................... ,57
;. The 3ecove!( o" #ealth .................................................................................................. ,61
Ind&st!iali=ed Nemesis .................................................................................................... ,6,
-!om Inhe!ited M(th to 3esect"&l 1!oced&!e ............................................................... ,66
The 3i*ht to #ealth ......................................................................................................... ,69
#ealth as a ?i!t&e ............................................................................................................ ,71
<&':ect Index ....................................................................................................................... ,7.
Index o" Names ................................................................................................................... ,;6
((5nnonse!)) ............................................................................................................................ .,7
Notat om layout
Sidetall stE! nede!st E sidene. 7e satt i ((do''el a!entes)), o* de e! s+ilt "!a den tilhF!ende
siden med to lin:es+i"t, o* "!a den E"Fl*ende siden med "i!e lin:es+i"t.
Headinger: )o+a ha! headin*e! E t!e nivEe!.
Figurer og tabeller "o!e+omme! i++e i 'o+a
Noter. )o+a ha! e+st!emt man*e "otnote!, o* *odt ove! halva!ten av te+sten e! i notene.
-otntoene "Fl*e! den lFende te+sten. 7e e! lasse!t nede!st E sidene. Notene innledes o*
avsl&ttes med ma!+e!in*ene G"otnote sta!tG o* G"otnote sl&ttG, med t!e x6e! E hve! side av
ma!+e!in*ene. <vH!t man*e "otnote! *E! som "Fl:eton*e! "!a en side til den neste.
##I. >,.>1.,>>6
Forsiden
I?5N ILLI0#
Limits to Medicine
Medical Nemesis: The Ex!o!iation o" #ealth.
Baksiden
JThe medical esta'lishment has 'ecome a ma:o! th!eat to health6
<o 'e*ins Ivan Illich6s si!ited and !easoned attac+ &on the m(thic !esti*e o" contemo!a!(
medicines, examinin* the c&stoms and !it&als cond&cted '( the medical !o"ession.
3elentlessl( and %ith "&ll doc&mentation ta+en "!om !eco*ni=ed medical so&!ces Illich !oves
the imotence o" medical se!vices to chan*e li"e exectanc(, the insi*ni"icance o" most
contemo!a!( clinical ca!e in c&!in* disease, the ma*nit&de o" medicall( in"licted dama*e to
health, and the "&tilit( o" medical and olitical co&nte!8meas&!es.
Illich6s deel( shoc+in* anal(sis into the clinical and social !ealit( o" docto!8made illness
examines the c&lt&!e o" health, sic+ness and s&""e!in* and incl&des an histo!ical examination
o" the concet and ima*e o" death.
Bnl( '( !eco*ni=in* and insistin* &on the essential in*!edients o" e!sonal health, Illich
a!*&es, can individ&als !ecove! the inte*!it( o" thei! 'odies and lives. J1eole need no
'&!ea&c!atic inte!"e!ence to mate, *ive 'i!th, sha!e the h&man condition, and die. Man6s
conscio&sl( lived "!a*ilit(, individ&alit( and !elatedness ma+e the exe!ience o" ain, o"
sic+ness and o" death an inte*!al a!t o" his li"e. The a'ilit( to coe %ith this t!io
a&tonomo&sl( is "&ndamental to his health.6
7octo!s sho&ld !ead this 'oo+ and onde!. <o sho&ld thei! atients6 Times Educational
Supplement
Ivan Illich %as 'o!n in ?ienna in 19,6 and no% lives in Mexico and the 9nited <tates. #is
'oo+s incl&de Celebration of Awareness, Deschooling Society, Tools for Conviviality, Energy
& Equity, The ight to !seful !nemployment, Shadow "or#, $ender, %&' and the "aters of
(orgetfulness and )n the *irror of the +ast, all availa'le "!om Ma!ion )o(a!s 1&'lishe!s.
K1,.95LM17.95
Ma!ion )o(a!s 1&'lishe!s
,/ Lac( 3oad, London <$15 1NL
,.7 E .9th <t!eet, Ne% No!+, NN 1>>16
7ist!i'&ted in the 9<5 '( 0onso!ti&m )oo+ <ales
1>/5 $est*ate 7!ive, <aint 1a&l, MN 5511/81>65
%%%.ma!ion'o(a!s.co.&+
0ove! desi*n: Eleano! 3ose I<)N 18;/,.>8>>785
Boken starter
LIMIT< TB ME7I0INE
((a))
,y the same author
0ele'!ation o" 5%a!eness
7eschoolin* <ociet(
Tools "o! 0onvivialit(
Ene!*( and EA&it(
7isa'lin* 1!o"essions
The 3i*ht to 9se"&l 9nemlo(ment <hado% $o!+
Oende!
#,B and the $ate!s o" -o!*et"&lness
5)0: The 5lha'eti=ation o" the 1o&la! Mind (%ith )a!!( <ande!s)
In the Mi!!o! o" the 1ast
Lect&!es and 5dd!esses 197;8199>
I?5N ILLI0#
LIMIT< TB
ME7I0INE
Medical Nemesis:
The Ex!o!iation o" #ealth
$ith a Ne% Int!od&ction '( the 5&tho!
Ma!ion )o(a!s London P Ne% No!+
(('))
3e!inted in O!eat )!itain and the 9nited <tates in ,>>, '(
M53IBN )BN53< 19)LI<#E3< LT7 ,/ Lac( 3oad, London <$ 15 1 NL
,.7 East .9th <t!eet, Ne% No!+ NN 1>>16
%%%.ma!ion'o(a!s.co.&+
7ist!i'&ted in 5&st!alia and Ne% Qealand '( 1e!i'o 1t( Ltd, 5; )ea&mont 3oad, @&!in*8*ai,
N<$ ,>;>
1&'lishin* #isto!(:
-imits to *edicine is the de"initive ve!sion o" *edical .emesis 8 The E/propriation of
%ealth, o!i*inall( &'lished in Ian&a!( 1975 in the Ma!ion )o(a!s )deas in +rogress se!ies
dealin* %ith alte!natives to ind&st!ial societ(. This %as !e!inted in -e'!&a!( 1975, Bcto'e!
1975 and Ma!ch 1976. -imits to *edicine %as %!itten as a !es&lt o" the %o!ld8%ide !esonse
%hich the a&tho! !eceived &on &'lication o" the o!i*inal d!a"t.
3e!inted 1976, 1977
This edition "i!st &'lished in 1995 '( Ma!ion )o(a!s 1&'lishe!s, London 3e!inted in ,>>1,
,>>,
1> 9 ; 7 6 5 / . ,
(c) Ivan Illich 1976, 1995, ,>>, 0o(!i*ht o%ne!: ?alentina )o!!emans
5ll !i*hts !ese!ved.
No a!t o" this &'lication ma( 'e !e!od&ced, sto!ed in a !et!ieval s(stem o! t!ansmitted in
an( "o!m o! '( an( meansR elect!onic, mechanical, hotoco(in*, !eco!din* o! othe!%ise
excet '!ie" ext!acts "o! the &!oses o" !evie%, %itho&t !io! %!itten e!mission o" the
&'lishe!s.
This 'oo+ is sold s&':ect to the condition that it shall not, '( %a( o" t!ade o! othe!%ise, 'e
lent, !e8sold, hi!ed o&t o! othe!%ise ci!c&lated %itho&t the &'lishe!6s !io! consent in an(
"o!m o" 'indin* o! cove! othe! than that in %hich it is &'lished and %itho&t a simila!
condition incl&din* this condition 'ein* imosed on the s&'seA&ent &!chase!.
The !i*ht o" Ivan Illich to 'e identi"ied as a&tho! o" this %o!+ has 'een asse!ted '( him in
acco!dance %ith the 0o(!i*ht, 7esi*ns and 1atents 5ct 19;;.
5 0I1 catalo*&e !eco!d "o! this 'oo+ is availa'le "!om the )!itish Li'!a!(.
5 0I1 catalo* !eco!d "o! this 'oo+ is availa'le "!om the Li'!a!( o" 0on*!ess.
I<)N >871/58,99.81 (9<5) I<)N 18;/,.>8>>785 (9@)
1!inted and 'o&nd in O!eat )!itain '( )oo+ma!A&e, London.
((c))
Contents
+reface
)ntroduction 0
153T I. 0linical Iat!o*enesis
The Eidemics o" Mode!n Medicine 1. Doctors1 E,,23ectiveness8an )llusion
!seless *edical Treatment
Doctor4)nflicted )n5uries
Defenseless +atients
153T II. <ocial Iat!o*enesis
The Medicali=ation o" Li"e .9 +olitical Transmission of )atrogenic Disease
Social latrogenesis *edical *onopoly 6alue4(ree Cure7 *edicali8ation of the ,udget
The +harmaceutical )nvasion
Diagnostic )mperialism +reventive Stigma Terminal Ceremonies ,lac# *agic
+atient *a5orities
((d))
153T III. 0&lt&!al Iat!o*enesis
)ntroduction 9&:
The @illin* o" 1ain 1..
The Invention and Elimination o" 7isease 155
7eath 5*ainst 7eath 17/ Death as Commodity
The Devotional Dance of the Dead
The Danse *acabre
,ourgeois Death
Clinical Death
Trade !nion Claims to a .atural Death
Death !nder )ntensive Care
153T I?. The 1olitics o" #ealth
<eci"ic 0o&nte!!od&ctivit( ,11
1olitical 0o&nte!meas&!es ,,1 Consumer +rotection for Addicts Equal Access to Torts
+ublic Controls over the +rofessional *afia
The Scientific 'rgani8ation8of -ift Engineering for a +lastic "omb
The 3ecove!( o" #ealth ,61 )ndustriali8ed .emesis
(rom )nherited *yth to espect +rocedure
The ight to %ealth
%ealth as a 6irtue
)nde/ &::
About the Author ,95
((e))
Preface to the 1! edition
Pathogenesis" Immunity and the #uality of Public Health
5 Lect&!e *iven at the 2&alitative #ealth 3esea!ch 0on"e!ence, #e!she(, 1enns(lvania. I&ne
1.th, 199/
1!o"esso! Ianice Mo!se:
I am hono&!ed '( (o&! invitation to add!ess this second assem'l( o" n&!ses %ho have
o!*ani=ed themselves to act as lea!ned %atchdo*s ove! the A&alit( o" #ealth 0a!e. I have 'een
invited as the a&tho! o" -imits to *edicine 4 *edical .emesis, a 'oo+ that %as &'lished
some t%ent( (ea!s a*o. I am not a n&!se and, emhaticall(, I do not ca!e a'o&t health. I teach
a'o&t the histo!( o" "!iendshi and the histo!( o" the a!t o" s&""e!in*.
I am t!ained as a medieval histo!ian and hilosohe!. I come he!e 'eca&se 1!o"esso! 0a!l
Mitcham enco&!a*ed me. $e a!e associated in !esea!ch on the s(m'olic e""ects o" techniA&e:
%e st&d( %hat techniA&e says !athe! than %hat it does; The !edicament %hich (o& a!e "acin*
at this second meetin* o" (o&! association seems to 'oth o" &s !elevant to o&! theme.
No& st&d( the A&alit( o" health ca!e. $hat is it (o& "oc&s on:
((i))
is it the delive!( o" se!vices o! o" messa*es4 I %o&ld li+e to distin*&ish 'et%een those amon*
(o& %ho %ant mo!e, 'ette!, cheae! and less de*!adin* se!vices "o! mo!e eole, and othe!s
%ho %ant to do !esea!ch on atho*enic m(ths and ce!tainties that !es&lt "!om "inancin* and
o!*ani=in* health ca!e !it&als. To accomlish this delicate tas+, I %ill tell (o& m( o%n sto!(. I
%ill tell (o& a'o&t m( intellect&al *!o%th 'e(ond *edical .emesis, !esentin* m( sto!( as a
ca&tiona!( tale.
I %elcome this occasion to ma+e &'lic amends "o! somethin* I did %hen I %!ote that 'oo+. I
%!ote *edical .emesis as one o" "o&! essa(s %hich examined the s(m'olic o%e! inhe!ent in
mode!n techniA&es to shae o&! 'asic ce!tainties. In each essa(, I &sed a di""e!ent method to
examine "o&! ma:o! instit&tions, each se!vin* as a sc!een on %hich to !o:ect m( o'se!vations.
In .emesis, ) too+ 197>s medicine and st&died it %ith a method %hich demonst!ated the
a!adoxicall( counterproductive e""ectiveness imlicit in dis!oo!tionate techniA&es. $ith
m( desc!ition &ncove!in* clinical, social and c&lt&!al iat!o*enesis, namel(, the !od&ction o"
m&ltile mise!(, I did not ta!*et the medical esta'lishment "o! !e"o!m. I &sed medicine as a
a!adi*m "o! an( me*a8techniA&e that !omises to t!ans"o!m the conditio humana; ) examined
it as a model "o! an( ente!!ise claimin*, in e""ect, to a'olish the need "o! the a!t o" s&""e!in*
'( a technicall( en*inee!ed &!s&it o" hainess. I anal(=ed the Jdeveloment6 o" health ca!e
a!allel to that o" ed&cation, t!anso!tation, h&man *a!a*in*, and so on, conscio&s that in the
case o" instit&tionali=ed h(*iene, the &!s&it o" hainess is t!anslated into the &!s&it o"
6health6.
5"te! nea!l( a A&a!te! o" a cent&!(, I am still satis"ied %ith the s&'stance and !heto!ic o"
.emesis; The 'oo+ oened & a disc&ssion on co&nte!8!od&ctivit( and the histo!( o" needs.
)&t it did somethin* else also: it '!o&*ht medicine 'ac+ into the !ealm o" hilosoh(. M(
"oc&s on the c&lt&!e o" s&""e!in* %as the a!o!iate antidote to the eme!*in* eidemic o"
((ii))
'ioethics. )( !ed&cin* each e!son to Ja li"e6, 'ioethics is helless to !event total
mana*ement o" the e!son, no% t!ans"o!med into a s(stem.
#o%eve!, I no% see a se!io&s "la% in m( a!oach that %o&ld vitiate m( c&!!ent intent. I then
conceived o" health as Jthe intensit( o" a&tonomo&s coin* a'ilit(6. $hen I %!ote that, I %as
&na%a!e o" the co!!&tin* e""ect that s(stem8anal(tic thin+in* %o&ld soon have on
e!cetions and concetions. I %as &na%a!e that '( const!&in* health in this sel"8!e"e!entiall(
c('e!netic "ashion, I &n%ittin*l( !ea!ed the *!o&nd "o! a %o!ldvie% in %hich the s&""e!in*
e!son %o&ld *et even "&!the! o&t o" to&ch %ith the "lesh. I ne*lected the t!ans"o!mation o"
the exe!ience o" 'od( and so&l %hen %ell8'ein* comes to 'e ex!essed '( a te!m that
imlies "&nctions, "eed'ac+s and thei! !e*&lation. Ten (ea!s o" !esea!ch %ith )a!'a!a 7&den
on the histo!( o" the exe!ienced 'od(, and seve!al semina!s on the histo!( o" the *ende!ed
sel" at the "issenschafts#olleg ()e!lin), in Ma!'&!* and in 1enn <tate still la( 'e"o!e me.
That is the !eason %h( I am %o!!ied '( the "act that most o" the c&!!ent sales o" -imits to
*edicine in seve!al lan*&a*es 8 a!e '&l+ o!de!s "!om medical schools. The 'oo+ is 'ein* !ead
as a demonst!ation o" ho% (o& can eat (o&! ca+e and have it too. No& can o'lite!ate the
exe!ienced sens&al 'od( o" the ast '( conceivin* o" (o&!sel" as a sel"8!e*&lato!(, sel"8
const!&ctin* s(stem in need o" !esonsi'le mana*ement and, in site o" this disem'odiment,
claim that (o& stand %ithin the t!adition o" the a!t o" s&""e!in* and the a!t o" d(in*. I %!ote
.emesis to ill&st!ate %hat the health ca!e s(stem says, '&t I did not s&""icientl( st!ess its
s&'tle st!&ct&!es %hich atte!n o&! !esonse, t&!nin* &s into s&'s(stems.
((iii))
#ualitati$e %esearch
No& a!e the e!"ect a&dience to hea! m( sto!( and &nde!stand it as a ca&tiona!( tale. Most o"
(o& a!e *!ad&ate n&!ses. Those %ith %hom I had '!ea+"ast, and those %ith %hom I l&nched,
im!essed me *!eatl(. <hoc+ed '( %hat the( %e!e as+ed to do as n&!ses, the( %ent on to
*!ad&ate schools %ith the intent to do somethin* a'o&t the s(stem. The( "inished st&dies in
ethnolo*(, sociolo*(, anth!oolo*( and s(cholo*(. In the late ;>s, (o& "o!med (o&!
o!*ani=ation. No& did so "o! m&t&al s&o!t in the !esea!ch on the exe!ience o" enco&nte!s
%ith the health ca!e s(stem. In medical ci!cles, (o&! initiative %as less than %elcome.
Neve!theless, (o& had a "e% "!&it"&l (ea!s %ith some de"inite instit&tional imact.
This cannot '&t chan*e. I can smell that (o& a!e on the oint o" 'ein* co8oted. The 5me!ican
Medical 5ssociation no% sends mo!e than most 9.<. ind&st!ies on &'lic !elations. I&st
conside! the *loss( ten8a*e colo&! s!ead in Time and .ewswee#; 0ometin* "o! these
&'lic !elations, (o& %in hands do%n. O!ants "o! each o" the ..> ae!s !esented at this
meetin* can 'e :&sti"ied 'eca&se s&ch st&dies esta'lish that !o"essionals %ho !ovide ca!e do
indeed ca!e "o! thei! clients 8 %hethe! this is t!&e o! not.
-!om m( contacts he!e, I have lea!ned that not all o" (o& le"t act&al n&!sin* to send (o&!
lives oilin* ca!e delive!( %ith *ood %ill, o! doin* en*inee!in* !esea!ch on simle! means that
%o&ld !od&ce hi*he! !ates o" client8e!ceived &tilit(. I have met those o" (o& %ho %ant to
decihe! the melod( that the ca!e s(stem d!&ms into &s. The( a!e the ones %ho intend to t!ain
c(nical hilosohe!s to 'a!+ "ea!lessl( at a contemo!a!( a!adox: the o!*ani=ed &!s&it o"
health has 'ecome the !incial imediment to s&""e!in* exe!ienced as a di*ni"ied,
meaningful, atient, lovin*, 'ea&ti"&l, !esi*ned and even :o("&l em'odiment.
5s lon* as (o& %e!e !otected '( initial liminalit(, it %as
((iv))
ossi'le to envisa*e o&! ca!e s(stem as the instit&tional st!&ct&!e o" a atho*enic &!s&it o"
health. M( host6s semina!s in 1enn <tate on the histo!( o" health8!elated %o!ds and concets is
a *ood examle. )&t once (o& en:o( !o"essional stat&s %ithin the s(stem, (o& lose m&ch o"
this "!eedom. Those %ho %ill then %ant to do !esea!ch on the a!t o" s&""e!in* in o&! c&lt&!e
!athe! than on ostmode!n health %ill have an inc!easin*l( di""ic&lt time. The( a!e the ones to
%hom I eseciall( di!ect m( sto!(. The( a!e the ones %ith %hom I %ant to lead "o! !esea!ch
on the s(m'olic "&nction o" the health ca!e con*lome!ates. $hat does it tell a'o&t who %e
a!e, !athe! than how well %e &!s&e health.
&edical Nemesis
The oenin* sentence o" -imits to *edicine %as an indictment: JThe medical esta'lishment
has 'ecome a ma:o! th!eat to health.6 It seems st!an*e no% that this sentence co&ld shoc+ and
an*e! in 1975, Toda(, it6s t!ite. I a!*&ed Jthat the la(man and not the h(sician has the
otential e!sective and e""ective o%e! to sto the c&!!ent iat!o*enic eidemic.6 No% the
0lintons sea!ch "o! %hat I called Ja concet&al "!ame%o!+ %ithin %hich to assess the seam(
side o" !o*!ess a*ainst its mo!e &'lici=ed 'ene"its.6 The same 0on*!ess that has e""ectivel(
"i!ed ,.>> h(sicists %ho %e!e %o!+in* on !esea!ch "o! the s&e!collide! no% does %hat I
a!*&ed "o!. It J!eclaims its o%n cont!ol ove! medical e!cetion, classi"ication and decision8
ma+in*.6 $hat is it, then, that I no% !e*!et4
I am cha*!ined that I "o!m&lated an imo!tant and cohe!ent statement a'o&t the a!t o"
s&""e!in* and d(in* in cate*o!ies that lend themselves to !ed&ctionist disem'odiment. In
-imits to *edicine 44 *edical .emesis, ) a!*&ed that the "&ndamental atho*en toda( is the
&!s&it o" health as this has come to 'e c&lt&!all( de"ined in late8ind&st!ial societ(. I
((v))
did not &nde!stand that in the a*e o" s(stems mana*ement, this atho*enic &!s&it o" health
%o&ld 'ecome &nive!sall( imosed. I "elt "!ee to sea+ o" health in te!ms o" e!sonal
a&tonom(, and as the Jintensit( o" coin* a'ilit(6. I conceived o" health as Ja !esonsi'le
e!"o!mance in a social sc!it6 %hich is *ove!ned '( a Jc&lt&!al code adated to a *!o&6s
*enetic ma+e8&, to its histo!(, to its envi!onment...6 I %anted to ma+e it la&si'le to a
*ene!ation committed to the &!s&it o" health that th!o&*ho&t histo!( the h&man condition had
'een Js&""e!ed.6 )&t I %as still &nde! O!e*o!( )ateson6s in"l&ence, 'elievin* that concets li+e
"eed'ac+, o*!om, a&tosies o! in"o!mation 8 %hen sh!e%dl( &sed 8 co&ld cla!i"( iss&es. I
tho&*ht I co&ld eA&ate s&""e!in* %ith the mana*ement o" m( o%n 'alance. I %as %!on*. 5s
soon as (o& &nde!stand s&""e!in* as coin*, (o& ma+e the decisive ste: "!om 'ea!in* %ith
(o&! "lesh, (o& Jmove to%a!ds mana*in* emotions, e!cetions and states o" the sel"
conceived as a s(stem6.
Coping
The &se o" the En*lish te!m, coin*, is o" ve!( !ecent coina*e. This is a oint made at the "i!st
inte!national meetin* o" #isto!ians o" #ealth 0a!e last "all. It is eithe! an a'&se o! an a!'it!a!(
!edatin* to sea+ a'o&t Jcoin* %ith sic+ness6 in !e8mode!n times. <ic+ness, li+e ain,
disa'ilit(, ti!edness and "ea! %e!e s&""e!ed, 'o!ne, sha!ed, alleviated, d!eaded o! c&!ed. Each
lan*&a*e has its o%n !ich and !ecise voca'&la!( "o! dealin* %ith %oe, discom"o!t, to!t&!e
and all so!ts o" a!ox(sms. O!eat t!aditions di""e! "!om each othe! "&ndamentall( th!o&*h thei!
set o" notions and !actices "o! dealin* %ith this da!+ side o" the h&man condition. $ithin
each t!adition, the inte!!etation o" discom"o!t and an*&ish chan*es ove! time and is &s&all(
seci"ic to social class. 5n( attemt to catch this %ealth o" c&lt&!al constellations o"
((vi))
s&""e!in* in one net '( callin* it coin* is a coloni=ation o" the ast '( imosin* a !o"o&ndl(
modem notion.
<ince the "i"teenth cent&!(, the ve!' Jto coe6 has 'een attested, and means Jto come to 'lo%s
%ith someone6. )( the end o" the seventeenth, it had 'een *entled. The 2E7 ta+es an examle
"!om Lo!d )(!on: J)!is+ con"idence is still 'est %ith %omen to coe.6 5"te! $o!ld $a! II, it
ente!ed slan* and +ids 'e*an to coe %ith thei! love li"e. 1eole lea!ned to coe %ith
h&s'ands, :o's, t!eatments, &nemlo(ment, "l&. )&t in 1967, the 5me!ican #e!ita*e &sa*e
anel still conside!ed it, i" not slan*, then a +ind o" ne%sea+ that is e!missi'le in cas&al
%!itin*. )ateson too+ & the %o!d to int!od&ce s(stems theo!( into anth!oolo*(. #e had a
*ood ea! "o! o&la! idioms. 5t a'o&t :&st that time, at least in 0ali"o!nia, Jto coe6 %as "i!st
&sed as an int!ansitive ve!'. It 'esea+s a %a( o" existence so ne% that t!aditional lan*&a*es
have no %o!d "o! it. The %o!d %as J%elcome 'eca&se it "illed a void in the desc!ition o"
*ene!al disa!!a(6 8 the :&d*ment o" one mem'e! on the &sa*e anel, the one %ho %as a
m&sicolo*ist.
0oin* "lo&!ishes %ithin 8 this eistemic void. The !eco*nition o" %ides!ead diso!de! allo%s
me to ch!onicle m( o%n *!o%in* cla!it(. It is %ithin this void that %o!ds and dia*!ams have
con:&!ed & an em'lem that no% stands "o! the sel", a ne% +ind o" 'lac+ 'ox.
'thical or 'pistemic %itual(
$hen, 'a!el( "i"t(, I de"ined health as Jthe intensit( o" a&tonomo&s coin* a'ilit(6, I did so in
sea!ch o" a contemo!a!( %a( o" !e"e!!in* to a mo!al Je*o6 in a time Ja"te! vi!t&e6.
9n%ittin*l(, ho%eve!, I s&**ested !esonsi'ilit(, a&tooiesis, and sel"8e!cetion in te!ms o"
the e*o6s tole!ances and imm&nities. The!e is no 'ette! o!dina!( ve!' to sa( ho% a e!son
'ehaves, once conceived as a 'lac+ 'ox.
((vii))
No%, nea! sevent(, I !e8!ead m( t!act in a milie& in"ected '( deconst!&ction. I 'ecame ac&tel(
a%a!e that %ithin the s(stem8anal(tic "!ame%o!+ imlied '( the ne%, int!ansitive activit( o"
coin* %ith m( li"e, the t!aditional a!t o" livin* cannot 'e &!s&ed. <el"8e!cetion in s(stems
te!ms dissolves the +ind o" "lesh that co&ld !actice eithe! the a!t o" en:o(ment 8 the s&nn(
hase, o! the a!t o" s&""e!in* 8 the shad( side. *edical .emesis %as an attemt to vindicate
the a!t o" livin*, the a!t o" en:o(ment and s&""e!in*, even %ithin a c&lt&!e shaed '( !o*!ess,
com"o!t, ca!e and ins&!ance !ovidin* entitlement to ain +illin*, no!mali=ation and,
&ltimatel(, e&thanasia. #a=a!do&s medicali=ation, sociall( disa'lin* !o"essionalism and
de'ilitatin* !it&alism en*ende!in* the m(ths o" amnesia, anesthesia and a8mo!talit( %e!e the
themes o" the 'oo+6s th!ee sections. It %as %!itten 'e"o!e !evention and neo8%itchc!a"t had
!eall( ta+en o""R neithe! the accetance o" c&!!ent anti8smo+in* !&les, no! the &'lic "inancin*
o" ac&&nct&!e "o! :ailed d!&* addicts %as then on the a*enda. -!om a histo!ical e!sective, I
indicted a c&lt&!al co!!&tionR I !aised &ltimate A&estions o" ethics.
The iss&e no% "acin* &s is a A&estion o" t!&th. I %ant to indict health ca!e not as a
demo!ali=in* '&t as a nihilist a*enc(. The decisive !es&lt o" eve!( '!&sh %ith the health ca!e
s(stem toda( is eistemic 8 a !ecastin* o" the e*o. -!om T8cell %atch to sa"e sex, "!om &!ine
test to Qen8do, %hat is done in the &!s&it o" health 'oome!an*s as an inte!!etation o" the
sel". In 199/, each o" these !o&tines 'olste!s the coin* a'ilit( o" the sel" as an imm&ne
s(stem.
M( evidence is anecdotal: 7! Qimme!mann, a"te! a da( in he! clinic, "o&nd that th!ee o" he!
eleven visito!s had come "o! !e"e!!al to a T8cell co&nt: one 'eca&se she %as losin* he! hai!R
the second 'eca&se o" imlesR and I "o!*et the s(mtom add&ced '( the thi!d. 7!
Qimme!mann !e"lected on the "o!mation o" h(sicians: the "i!st thin* (o& have to lea!n is a
((viii))
hie!a!ch( o" s&sected etiolo*ies. In 1!otestant Oe!man( in 1;5>, mast&!'ation %as in "i!st
lace "o! men and h(ste!ia "o! %omenR a "e% decades late! it %as t&'e!c&losisR then, s(hilis.
No%, she sees that it6s the s&'sc!ition to a <el"80a!e :o&!nal that t!ansmits s(stem ideolo*(.
Timeta'les, colle*e catalo*&es and com&te! *ames do the same, '&t health ca!e does it %ith
a ven*eance. E*o as an imm&ne s(stem is o" s&ch comlexit( that onl( tests can tell ho% it
sho&ld "eel. $hen the oncolo*ist *ave & "&!the! chemothe!a( on Iim, I as+ed him ho% he
"elt. #e told me to call next da(, '&t onl( a"te! 11 a.m., %hen the la' test %o&ld 'e 'ac+. The
B!hic J+no% th(sel"S now !eads: Jchec+ ho% (o&! s(stem is coin*6.
The te!m Jimm&ne s(stem6 does not aea! in the index o" a sin*le 'iolo*ical text'oo+ 'e"o!e
197,. Ten (ea!s late! it is ha!d to "ind a lea!ned ae! that deals %ith imm&nit( and does not
&se the te!m. 7&!in* the ea!l( ;>s, the concet aea!s in text'oo+s dealin* %ith a ma!+et, a
c&lt&!al &nit, the s(chic constit&tion o" a "amil( 8 as entities endo%ed %ith an imm&ne
s(stem, i" these entities a!e not themselves siml( desc!i'ed as s&ch. 7onna #a!a%a( calls
this thin* Ja otent ol(mo!ho&s o':ect o" 'elie", +no%led*e and !actice ... a *&ide to the
!eco*nition and mis8!eco*nition o" sel" in $este!n 'io8olitics.6
In "act, the =(*ote is on the %a( to%a!d acA&i!in* le*al stat&s as a h&man s&':ect, a!tl(
'eca&se the 1oe and constit&tional :&!ists iml( that its *enome and c(tolasm have the
otential to develo into a sel" '( !eco*ni=in* the Jothe!6 8 in this case, the mothe!.
0onceivin* livin* 'ein*s as imm&ne s(stems !ovides the se&do8le*itimation o" !ed&cin* a
h&man 'ein* to Ja li"e6 &on %hich ethics committees can ass :&d*ments. In a %o!ld made &
o" s(stems, the imm&ne s(stem !elaces %hat %as "o!me!l( called an individ&al o! e!son.
$hile the ea!l( t%entieth cent&!( !acticed animism '( accetin* homo economicus
((ix))
as a nat&!al "act, %hich le*itimated seein* 'acte!ia Jcometin*6 "o! sca!ce ox(*en, so the late
t%entieth cent&!( !actices its nec!omanc( '( *ivin* s&'stance to s(stem concets, and '(
!ed&cin* e!sons 'o!n "o! s&""e!in* and deli*ht to !ovisionall( sel"8s&stainin* in"o!mation
loos.
$hen I %!ote -imits to *edicine 8 *edical .emesis, the 'oo+ that (o& have !ead in
!ea!ation "o! this meetin*, all this I did not +no%.
Ivan Illich
((x))
LIMIT< TB ME7I0INE
((xi))
((xii))
)ckno*ledgments
M( thin+in* on medical instit&tions %as shaed ove! seve!al (ea!s in e!iodic conve!sations
%ith 3osl(n Lind8heim and Iohn Mc@ni*ht. M!s. Lindheim, 1!o"esso! o" 5!chitect&!e at the
9nive!sit( o" 0ali"o!nia at )e!+ele(, is sho!tl( to &'lish The %ospitali8ation of Space, and
Iohn Mc@ni*ht, 7i!ecto! o" 9!'an <t&dies at No!th%este!n 9nive!sit(, is %o!+in* on The
Serviced Society; $itho&t the challen*e "!om these t%o "!iends, I %o&ld not have "o&nd the
co&!a*e to develo m( last conve!sations %ith 1a&l Ooodman into this 'oo+.
<eve!al othe!s have 'een closel( connected %ith the *!o%th o" this text: Iean 3o'e!t and Iean
1. 7&&(, %ho ill&st!ated the economic thesis stated in this 'oo+ %ith examles "!om time8
oll&tin* and sace8disto!tin* t!anso!tation s(stemsR 5nd!T Oo!=, %ho has 'een m( !incial
t&to! in the olitics o" healthR Ma!ion )o(a!s, %ho %ith admi!a'le cometence &'lished the
d!a"t o" this 'oo+ in London and th&s ena'led me to 'ase m( "inal ve!sion on a %ide sect!&m
o" c!itical !eaction. To them and to all m( c!itics and hele!s, and eseciall( to those %ho
have led me to val&a'le !eadin*, I o%e dee *!atit&de.
This 'oo+ %o&ld neve! have 'een %!itten %itho&t ?alentina )o!!emans. <he has atientl(
assem'led the doc&mentation on %hich it is 'ased, and !e"ined m( :&d*ment and so'e!ed m(
lan*&a*e %ith he! constant
c!iticism. The chate! on the ind&st!iali=ation o" death is a s&mma!( o" the notes she has
assem'led "o! he! o%n 'oo+ on the histo!( o" the "ace o" death.
I?5N ILLI0h
0&e!navaca, Mexico
Ian&a!( 1976
((xiii))
)uthor+s Note
I %!ote *edical .emesis as a d!a"t "o! the )deas )n +rogress se!ies and !e%!ote this d!a"t 'oth
in -!ench "o! the a!allel se!ies Techno4Critique and in Oe!man "o! 3o%ohlt ?e!la*. Bthe!
t!anslations aea!ed in Italian, <anish, 7&tch, <%edish, No!%e*ian and <e!'o80!oat.
The c!iticism, advice and doc&mentation that I have !eceived as a !es&lt o" the ci!c&lation o"
m( d!a"t have ena'led me to comlete this 'oo+. I dedicate it in *!atit&de to m( c!itics.
I?5N ILLI0#
,7 -e'!&a!( 1976
((1))
((,))
Introduction
The medical esta'lishment has 'ecome a ma:o! th!eat to health. The disa'lin* imact o"
!o"essional cont!ol ove! medicine has !eached the !oo!tions o" an eidemic. latrogenesis,
the name "o! this ne% eidemic, comes "!om iatros, the O!ee+ %o!d "o! Gh(sician,G and
genesis, meanin* Go!i*in.G 7isc&ssion o" the disease o" medical !o*!ess has moved & on the
a*endas o" medical con"e!ences, !esea!che!s concent!ate on the sic+8ma+in* o%e!s o"
dia*nosis and the!a(, and !eo!ts on a!adoxical dama*e ca&sed '( c&!es "o! sic+ness ta+e
& inc!easin* sace in medical doe8sheets. The health !o"essions a!e on the '!in+ o" an
&n!ecedented ho&secleanin* camai*n. G0l&'s o" 0os,G named a"te! the O!ee+ Island o"
7octo!s, have s!&n* & he!e and the!e, *athe!in* h(sicians, *lo!i"ied d!&**ists, and thei!
ind&st!ial sonso!s as the 0l&' o" 3ome has *athe!ed Ganal(stsG &nde! the ae*is o" -o!d, -iat,
and ?ol+s%a*en. 1&!ve(o!s o" medical se!vices "ollo% the examle o" thei! collea*&es in
othe! "ields in addin* the stic+ o" Glimits to *!o%thG to the ca!!ot o" eve! mo!e desi!a'le
vehicles and the!aies. Limits to !o"essional health ca!e a!e a !aidl( *!o%in* olitical iss&e.
In %hose inte!est these limits %ill %o!+ %ill deend to a la!*e extent on %ho ta+es the
initiative in "o!m&latin* the need "o! them: eole o!*ani=ed "o! olitical action that
challen*es stat&s8A&o !o"essional o%e!, o! the health
((.))
!o"essions intent on exandin* thei! monool( even "&!the!.
The &'lic has 'een ale!ted to the e!lexit( and &nce!taint( o" the 'est amon* its h(*ienic
ca!eta+e!s. The ne%sae!s a!e "&ll o" !eo!ts on volte8"ace mani&lations o" medical leade!s:
the ionee!s o" (este!da(6s so8called '!ea+th!o&*hs %a!n thei! atients a*ainst the dan*e!s o"
the mi!acle c&!es the( have onl( :&st invented. 1oliticians %ho have !oosed the em&lation
o" the 3&ssian, <%edish, o! En*lish models o" sociali=ed medicine a!e em'a!!assed that !ecent
events sho% thei! et UUs(stems to 'e hi*hl( e""icient in !od&cin* the same atho*enic8that
is, sic+enin*8c&!es and ca!e that caitalist medicine, al'eit %ith less eA&al access, !od&ces. 5
c!isis o" con"idence in mode!n medicine is &on &s. Me!el( to insist on it %o&ld 'e to
cont!i'&te "&!the! to a sel"8"&l"illin* !ohec(, and to ossi'le anic.
This 'oo+ a!*&es that anic is o&t o" lace. Tho&*ht"&l &'lic disc&ssion o" the iat!o*enic
andemic, 'e*innin* %ith an insistence &on dem(sti"ication o" all medical matte!s, %ill not
'e dan*e!o&s to the common%eal. Indeed, %hat is dan*e!o&s is a assive &'lic that has come
to !el( on s&e!"icial medical ho&secleanin*s. The c!isis in medicine co&ld allo% the la(man
e""ectivel( to !eclaim his o%n cont!ol ove! medical e!cetion, classi"ication, and decision8
ma+in*. The laici=ation o" the 5esc&laian temle co&ld lead to a dele*itimi=in* o" the 'asic
!eli*io&s tenets o" mode!n medicine to %hich ind&s8t!ial societies, "!om the le"t to the !i*ht,
no% s&'sc!i'e.
M( a!*&ment is that the la(man and not the h(sician has the otential e!sective and
e""ective o%e! to sto the c&!!ent iat!o*enic eidemic. This 'oo+ o""e!s the la( !eade! a
concet&al "!ame%o!+ %ithin %hich to assess the seam( side o" !o*!ess a*ainst its mo!e
&'lici=ed 'ene"its.
((/))
It &ses a model o" social assessment o" technolo*ical !o*!ess that I have selled o&t
else%he!e6 and alied !evio&sl( to ed&cation, and t!anso!tation,. and that I no% al( to
the c!iticism o" the !o"essional monool( and o" the scientism in health ca!e that !evail in
all nations that have o!*ani=ed "o! hi*h levels o" ind&st!iali=ation. In m( oinion, the
sanitation o" medicine is a!t and a!cel o" the socio8economic inve!sion %ith %hich 1a!t I?
o" this 'oo+ deals.
The "ootnotes !e"lect the nat&!e o" this text. I asse!t the !i*ht to '!ea+ the monool( that
academia has exe!cised ove! all small !int at the 'ottom o" the a*e. <ome "ootnotes
doc&ment the in"o!mation I have &sed to ela'o!ate and to ve!i"( m( o%n !econceived
a!adi*m "o! otimall( limited health ca!e, a e!sective that did not necessa!il( have an(
lace %ithin the mind o" the e!son %ho collected the co!!esondin* data. Bccasionall(, I
A&ote m( so&!ce onl( as an e(e%itness acco&nt that is incidentall( o""e!ed '( the exe!t
author, %hile !e"&sin* to accet %hat he sa(s as exe!t testimony on the *!o&nds that it is
hea!sa( and the!e"o!e o&*ht not to in"l&ence the !elevant &'lic decisions.
Man( mo!e "ootnotes !ovide the !eade! %ith the +ind o" 'i'lio*!ahical *&idance that I
%o&ld have a!eciated %hen I "i!st 'e*an, as an o&tside!, to delve into the s&':ect o" health
ca!e and t!ied to acA&i!e cometence in the olitical eval&ation o" medicine6s e""ectiveness.
These notes !e"e! to li'!a!( tools and !e"e!ence %o!+s that I have lea!ned to a!eciate in
(ea!s o" sin*le8handed exlo!ation. The( also list !eadin*s, "!om technical mono*!ahs to
novels, that have 'een o" &se to me.
-inall(, I have &sed the "ootnotes to deal %ith m( o%n
xxx "otnote! sta!t xxx
9 Tools for 0onvivialit( (London: 0alde! V )o(a!s, 197.).
& &schooling Society, 3&th N. 5nshen, ed. (London: 0alde! V )o(a!s, 1971).
. Energ, and Equity (London: 0alde! V )o(a!s, 197/).
xxx "otnote! sl&tt xxx
((5))
a!enthetical, s&lementa!(, and tan*ential s&**estions and A&estions, %hich %o&ld have
dist!acted the !eade! i" +et in the main text. The la(man in medicine, "o! %hom this 'oo+ is
%!itten, %ill himsel" have to acA&i!e the cometence to eval&ate the imact o" medicine on
health ca!e. 5mon* all o&! contemo!a!( exe!ts, h(sicians a!e those t!ained to the hi*hest
level o" seciali=ed incometence "o! this &!*entl( needed &!s&it.
The !ecove!( "!om societ(8%ide iat!o*enic disease is a olitical tas+, not a !o"essional one. It
m&st 'e 'ased on a *!ass!oots consens&s a'o&t the 'alance 'et%een the civil li'e!t( to heal
and the civil !i*ht to eA&ita'le health ca!e. 7&!in* the last *ene!ations the medical monool(
ove! health ca!e has exanded %itho&t chec+s and has enc!oached on o&! li'e!t( %ith !e*a!d
to o&! o%n 'odies. <ociet( has t!ans"e!!ed to h(sicians the excl&sive !i*ht to dete!mine %hat
constit&tes sic+ness, %ho is o! mi*ht 'ecome sic+, and %hat shall 'e done to s&ch eole.
7eviance is no% Gle*itimateG onl( %hen it me!its and &ltimatel( :&sti"ies medical
inte!!etation and inte!vention. The social commitment to !ovide all citi=ens %ith almost
&nlimited o&t&ts "!om the medical s(stem th!eatens to dest!o( the envi!onmental and c&lt&!al
conditions needed '( eole to live a li"e o" constant a&tonomo&s healin*. This t!end m&st 'e
!eco*ni=ed and event&all( 'e !eve!sed.
Limits to medicine m&st 'e somethin* othe! than !o"essional sel"8limitation. I %ill
demonst!ate that . the insistence o" the medical *&ild on its &niA&e A&ali"ications to c&!e
medicine itsel" is 'ased on an ill&sion. 1!o"essional o%e! is the !es&lt o" a olitical
dele*ation o" a&tonomo&s a&tho!it( to the health occ&ations %hich %as enacted d&!in* o&!
cent&!( '( othe! secto!s o" the &nive!sit(8t!ained 'o&!*eoisie: it cannot no% 'e !evo+ed '(
those %ho conceded itR it can onl( 'e dele*itimi=ed '( o&la!
((6))
a*!eement a'o&t the mali*nanc( o" this o%e!. The sel"8medication o" the medical s(stem
cannot '&t "ail. I" a &'lic, anic+ed '( *o!( !evelations, %e!e '!o%'eaten into "&!the!
s&o!t "o! mo!e exe!t cont!ol ove! exe!ts in health8ca!e !od&ction, this %o&ld onl(
intensi"( sic+enin* ca!e. It m&st no% 'e &nde!stood that %hat has t&!ned health ca!e into a
sic+8ma+in* ente!!ise is the ve!( intensit( o" an en*inee!in* endeavo! that has t!anslated
h&man s&!vival "!om the e!"o!mance o" o!*anisms into the !es&lt o" technical mani&lation.
G#ealth,G a"te! all, is siml( an eve!(da( %o!d that is &sed to desi*nate the intensit( %ith
%hich individ&als coe %ith thei! inte!nal states and thei! envi!onmental conditions. In %omo
sapiens, Ghealth(G is an ad:ective that A&ali"ies ethical and olitical actions. In a!t at least,
the health o" a o&lation deends on the %a( in %hich olitical actions condition the milie&
and c!eate those ci!c&mstances that "avo! sel"8!eliance, a&tonom(, and di*nit( "o! all,
a!tic&la!l( the %ea+e!. In conseA&ence, health levels %ill 'e at thei! otim&m %hen the
envi!on8ment '!in*s o&t a&tonomo&s e!sonal, !esonsi'le coin* a'ilit(. #ealth levels can
onl( decline %hen s&!vival comes to deend 'e(ond a ce!tain oint on the hete!onomo&s
(othe!8di!ected) !e*&lation o" the o!*anism6s homeostasis. )e(ond a c!itical level o" intensit(,
instit&tional health ca!e8no matte! i" it ta+es the "o!m o" c&!e, !evention, o! envi!onmental
en*inee!in*8is eA&ivalent to s(stematic health denial.
The th!eat %hich c&!!ent medicine !e!esents to the health o" o&lations is analo*o&s to the
th!eat %hich the vol&me and intensit( o" t!a""ic !e!esent to mo'ilit(, the th!eat %hich
ed&cation and the media !e!esent to lea!nin*, and the th!eat %hich &!'ani=ation !e!esents to
cometence in homema+in*. In eaeh case a ma:o! instit&tional endeavo! has t&!ned
co&nte!!od&ctive. Time8con
((7))
s&min* accele!ation in t!a""ic, nois( and con"&sin* comm&nications, ed&cation that t!ains eve!
mo!e eole "o! eve! hi*he! levels o" technical cometence and seciali=ed "o!ms o"
*ene!ali=ed incometence: these a!e all henomena a!allel to the !od&ction '( medicine o"
iat!o*enic disease. In each case a ma:o! instit&tional secto! has !emoved societ( "!om the
seci"ic &!ose "o! %hich that secto! %as c!eated and technicall( inst!&mented.
Iat!o*enesis cannot 'e &nde!stood &nless it is seen as the
seci"icall( medical mani"estation o" specc counterproductivity; <eci"ic o! a!adoxical
co&nte!!od&ctivit( is a ne*ative social indicato! "o! a diseconom( %hich !emains loc+ed
%ithin the s(stem that !od&ces it. It is a meas&!e o" the con"&sion delive!ed '( the ne%s
media, the incometence "oste!ed '( ed&cato!s, o! the time8loss !e!esented '( a mo!e
o%e!"&l ca!. <eci"ic co&nte!!od&ctivit( is an &n%anted side8e""ect o" inc!easin*
instit&tional o&t&ts that !emains inte!nal to the s(stem %hich itsel" o!i*inated the seci"ic
val&e. It is a social meas&!e "o! o':ective "!&st!ation. This st&d( o" atho*enic medicine %as
&nde!8ta+en in o!de! to ill&st!ate in the health8ca!e "ield the va!io&s asects o"
co&nte!!od&ctivit( that can 'e o'8se!ved in all ma:o! secto!s o" ind&st!ial societ( in its
!esent sta*e. 5 simila! anal(sis co&ld 'e &nde!ta+en in othe! "ields o" ind&st!ial !od&ction,
'&t the &!*enc( in the "ield o" medicine, a t!aditionall( !eve!ed and sel"8con*!at&lato!( se!vice
!o"ession, is a!tic&la!l( *!eat.
)&ilt8in iat!o*enesis no% a""ects all social !elations. it is the !es&lt o" inte!nali=ed coloni=ation
o" li'e!t( '( a""l&ence. In !ich co&nt!ies medical coloni=ation has !eached sic+enin*
!oo!tionsR oo! co&nt!ies a!e A&ic+l( "ollo%in* s&it. (The si!en o" one am'&lance can
dest!o( <ama!itan attit&des in a %hole 0hilean to%n.) This !ocess, %hich I shall call the
Gmedicali=ation o" li"e,G dese!ves a!tic&late olitical !eco*nition. Medicine co&ld
((;))
'ecome a !ime ta!*et "o! olitical action that aims at an inve!sion o" ind&st!ial societ(. Bnl(
eole %ho have !ecove!ed the a'ilit( "o! m&t&al sel"8ca!e and have lea!ned to com'ine it
%ith deendence on the alication o" contemo!a!( technolo*( %ill 'e !ead( to limit the
ind&st!ial mode o" !od&ction in othe! ma:o! a!eas as %ell.
5 !o"essional and h(sician8'ased health8ca!e s(stem that has *!o%n 'e(ond c!itical 'o&nds
is sic+enin* "o! th!ee !easons: it m&st !od&ce clinical dama*e that o&t%ei*hs its otential
'ene"itsR it cannot '&t enhance even as it o'sc&!es the olitical conditions that !ende! societ(
&nhealth(R and it tends to m(sti"( and to ex!o!iate the o%e! o" the individ&al to heal
himsel" and to shae his o! he! envi!onment. 0ontemo!a!( medical s(stems have o&t*!o%n
these tole!a'le 'o&nds. The medical and a!amedical monool( ove! h(*ienic methodolo*(
and technolo*( is a *la!in* examle o" the olitical mis&se o" scienti"ic achievement to
st!en*then ind&st!ial !athe! than e!sonal *!o%th. <&ch medicine is '&t a device to convince
those %ho a!e sic+ and ti!ed o" societ( that it is the( %ho a!e ill, imotent, and in need o"
technical !eai!. I %ill deal %ith these th!ee levels o" sic+enin* medical imact in the "i!st
th!ee a!ts o" this 'oo+.
The 'alance sheet o" achievement in medical technolo*( %ill 'e d!a%n & in the "i!st chate!.
Man( eole a!e al!ead( a!ehensive a'o&t docto!s, hositals, and the d!&* ind&st!( and
onl( need data to s&'stantiate thei! mis*ivin*s. 7octo!s al!ead( "ind it necessa!( to 'olste!
thei! c!edi'ilit( '( demandin* that man( t!eatments no% common 'e "o!mall( o&tla%ed.
3est!ictions on medical e!"o!mance %hich !o"essionals have come to conside! mandato!(
a!e o"ten so !adical that the( a!e not accet8a'le to the ma:o!it( o" oliticians. The lac+ o"
e""ectiveness o" costl( and hi*h8!is+ medicine is a no% %idel( disc&ssed "act "!om %hich I
sta!t, not a +e( iss&e I %ant to d%ell on.
((9))
1a!t II deals %ith the di!ectl( health8den(in* e""ects o" medicine6s social o!*ani=ation, and
1a!t III %ith the disa'lin* imact o" medical ideolo*( on e!sonal stamina: &nde! th!ee
sea!ate headin*s I desc!i'e the t!ans"o!mation o" ain, imai!ment, and death "!om a
e!sonal challen*e into a technical !o'lem.
1a!t I? inte!!ets health8den(in* medicine as t(ical o" the co&nte!!od&ctivit( o"
ove!ind&st!iali=ed civili=ation and anal(=es "ive t(es o" olitical !esonse %hich constit&te
tacticall( &se"&l !emedies that a!e all st!ate*icall( "&tile. It distin*&ishes 'et%een t%o modes
in %hich the e!son !elates and adats to his envi!onment: a&tonomo&s (i.e., sel"8*ove!nin*)
coin* and hete!onomo&s (i.e., ad8ministe!ed) maintenance and mana*ement. It concl&des '(
demonst!atin* that onl( a olitical !o*!am aimed at the limitation o" !o"essional
mana*ement o" health %ill ena'le eole to !ecove! thei! o%e!s "o! health ca!e, and that s&ch
a !o*!am is inte*!al to a societ(8%ide c!iticism and !est!aint o" the ind&st!ial mode o"
!od&ction.
((1>))
P)%, I. Clinical Iatrogenesis
((11))
1. ,he 'pidemics of &odern &edicine
7&!in* the ast th!ee *ene!ations the diseases a""lictin* $este!n societies have &nde!*one
d!amatic chan*es.6 1olio, dihthe!ia, and t&'e!c&losis a!e vanishin*R one shot o" an anti'iotic
o"ten c&!es ne&monia o! s(hilisR and so man( mass +ille!s have come &nde! cont!ol that
t%o8thi!ds o" all deaths a!e no% associated %ith the diseases o" old a*e. Those %ho die (o&n*
a!e mo!e o"ten than not victims o" accidents, violence, o! s&icide.,
These chan*es in health stat&s a!e *ene!all( eA&ated %ith a dec!ease in s&""e!in* and
att!i'&ted to mo!e o! to 'ette! medical ca!e. 5ltho&*h almost eve!(one 'elieves that at least
one o" his "!iends %o&ld not 'e alive and %ell excet "o! the s+ill o" a docto!, the!e is in "act
no evidence o" an( di!ect !elationshi 'et%een this m&tation o" sic+ness and the so8called
!o*!ess o" medicine.. The chan*es a!e
xxx "otnote! sta!t xxx
1 E!%in #. 5c+e!+necht, %istory and $eography of *e *ost )mportant Diseases 2.ew <or#=
%afner, 9>?@A;
, Bdin $. 5nde!son and Mon!oe Le!ne!, *easuring %ealth -evels in the !nited States,
9*B49>@C, #ealth In"o!mation -o&ndation 3esea!ch <e!ies no. 11 (Ne% No!+: -o&ndation,
196>). Ma!c Lalonde, 5 .ew +erspedive on the %ealth of 0anadians: A "or#ing Document
(Btta%a: Oove!nment o" 0anada, 5!il 197/). This co&!a*eo&s -!ench8En*lish !eo!t '( the
0anadian -ede!al <ec!eta!( "o! #ealth contains a m&lticolo!ed cente!"old doc&mentin* the
chan*e in mo!talit( "o! 0anada in a se!ies o" *!ahs.
. 3enT 7&'os, The *irage of %ealth= !topian +rogress and ,iological Change 2.ew <or#=
Anchor ,oo#s, 9>@>A, was the first to effectively e/pose the delusion of producing Dbetter
healthD as a dangerous and infectious medically sponsored disease; Thomas *cEeown and
$ordon *c-achlan, eds;,1 *edical %istory and
xxx "otnote! "o!tsette! neste sixde xxx
((1.))
deendent va!ia'les o" olitical and technolo*ical t!ans8"o!mations, %hich in t&!n a!e
!e"lected in %hat docto!s do
and sa(R the( a!e not si*ni"icantl( !elated to the ,activities that !eA&i!e the !ea!ation, stat&s,
and costl( eA&iment in %hich the health !o"essions ta+e !ide./ In addition, an exandin*
!oo!tion o" the new '&!den o" disease o" the last "i"teen (ea!s is itsel" the !es&lt o" medical
inte!vention in "avo! o" eole %ho a!e o! mi*ht 'ecome sic+. It is
docto!8made, o! iatrogenic;s
5"te! a cent&!( o" &!s&it o" medical &toia,6 and cont!a!( to c&!!ent conventional %isdom,7
medical se!vices
xxx "otnote! "o!tsette! "!a "o!!i*e side xxx
*edical Cara A <(mosi&m of +erspectives (Ne% No!+: Bx"o!d 9niv. 1!ess, 1971,),
int!od&ce the sociolo*( o" medical se&do8!o*!ess. Iohn 1o%les, GBn the Limitations o"
Mode!n Medicine,G in Science, *edicine and *an (London: 1e!*an on, 197.), 1:18.>, *ives a
c!itical selection o" !ecent En*lish8lan*&a*e lite!at&!e on this s&':ect. -o! the 9.<. sit&ation
cons&lt 3ic+ 0a!lson, 77m End of *edicine (Ne% No!+: $ile( Inte!acience, 1975). #is essa(
is Gan emi!icall( 'ased '!ie"R theo!etical in nat&!e.G -o! his indictment o" 5me!ican medicine
he has chosen those dimensions "o! %hich he had comlete evidence o" a nat&!e he co&ld
handle. Iean80la&de 1olac+, -a *Fdecine dis caital (1a!is: Mase!o,197>). 5 c!itiA&e o" the
olitical t!ends that see+ to endo% medical technolo*( %ith an e""ective imact on health
levels '( a Gdemoc!ati=ation o" medical cons&me! !od&cts.G The a&tho! discove!s that these
!od&cts themselves a!e shaed '( a !e!essive and alienatin* 'o&!*eois class st!&ct&!e. To
&se medicine "o! olitical li'e!ation it %ill 'e necessa!( to G"ind in sic+ness, even %hen it is
disto!ted '( medical inte!vention, a !otest a*ainst the existin* social o!de!.G
/ 7aniel O!een'e!*, GThe J$a! on 0ance!6: B""icial -iction and #a!sh -acts,G Science and
Oove!nment eport, vol. / (7ecem'e! 1, 197/). This %ell8!esea!ched !eo!t to the la(man
s&'stantiates the vie% that 5me!ican 0ance! <ociet( !oclamations that cance! is c&!a'le and
!o*!ess has 'een made a!e G!eminiscent o" ?ietnam otimism !io! to the del&*e.G
s DorlaFd1s )llustrated *edical Dictionary, ,5th ed. (1hiladelhia: <a&nde!s, 197/):
GIat!o*enic (iat!s88O!. h(sician, *ant ae8O!. to !od&ce). 3es&ltin* "!om the activit( o"
h(sicians. B!i*inall( alied to diso!de!s ind&ced in the atient '( a&tos&**estion 'ased on
the h(sician6s examination, manne!, o! disc&ssion, the te!m is no% alied to an( adve!se
condition in a atient occ&!!in* as the !es&lt o" t!eatment '( a h(sician o! s&!*eon.G
6 #ein!ich <chie!*es, !topias der *edi8in= $ttt#ialite und Eriti# der iirt8tlic#m )deologie
des 9>; 5 #; 2Sal8burg= *Gller, 9>??A; A useful guide to the historical literature is ichard *;
,ur#e, An %istorical Chronology of Tuberad s, &nd ed; 2Springfield, )ll;= Thomas, 9>@@A;
7 -o! an anal(sis o" the a*ents and atte!ns that dete!mine the eidemic s!ead o" mode!n
misin"o!mation th!o&*ho&t a scienti"ic comm&nit(, see 7e!e+ I. de <ella 1!ice, -isle <cience,
,ig Sciage 2.ew <or#= Columbia !niv; +ress, 9>?0A;
xxx "otnote! sl&tt xxx
((1/))
have not 'een imo!tant in !od&cin* the chan*es in li"e exectanc( that have occ&!!ed. 5
vast amo&nt o" contemo!a!( clinical ca!e is incidental to the c&!in* o" disease, '&t the
dama*e done '( medicine to the health o" individ&als and 8o&lations is ve!( si*ni"icant.
These "acts a!e o'vio&s, %ell doc&mented, and %ell !e!essed.
-octors+ 'ffecti$eness.)n Illusion
The st&d( o" the evol&tion o" disease atte!ns !ovides evidence that d&!in* the last cent&!(
docto!s have a""ected eidemics no mo!e !o"o&ndl( than did !iests d&!in* ea!lie! times.
Eidemics came and %ent, im!ecated '( 'oth '&t to&ched '( neithe!. The( a!e not modi"ied
an( mo!e decisivel( '( the !it&als e!"o!med in medical clinics than '( those c&stoma!( at
!eli*io&s sh!ines .9 7isc&ssion o" the "&t&!e o" health ca!e mi*ht &se"&ll( 'e*in %ith the
!eco*nition o" this "act.
The in"ections that !evailed at the o&tset o" the ind&st!ial a*e ill&st!ate ho% medicine came
'( its !e&tation.9 T&'e!c&losis, "o! instance, !eached a ea+ ove! t%o *ene!ations. In Ne%
No!+ in 1;1,, the death !ate %as estimated to 'e hi*he! than 7>> e! 1>,>>>R '( 1;;,, %hen
@och "i!st isolated and c&lt&!ed the 'acill&s, it had al!ead( declined to .7> e! 1>,>>>. The
!ate %as do%n to 1;> %hen the "i!st sanato!i&m %as oened in 191>, even though
Gcons&mtionG still held second lace in the mo!talit( ta'les.1) 5"te! $o!ld $a! II, '&t
'e"o!e anti'i
xxx "otnote! sta!t xxx
; Bn the cle!ical nat&!e o" medical !actice, see G0lT!icalisme de la "onction mTdicale4
MTdecine et olitiA&e. Le 6<ace!doce6 mTdical. La 3elation thT!ae&tiA&e. 1s(chanal(se et
ch!istianisme,G -e Sana, s&l. , (1966867).
9 I. N. $eis"e!t, G7as 1!o'lem des <ch%inds&chts+!an+en in 7!ama &nd 3oman,G 7 :o&ma
"ist%&e*el . (19,7): 5798;,. 5 *&ide to t&'e!c&losis as a lite!a!( motive in 19th8cent&!(
d!ama and novel. E. E'stein, G7ie L&n*ensch%inds&cht in de! $eltlite!at&!,G Q!i eHfir Diishe
rands 5 (191.).
1> 3enT and Iean 7&'os, Tlis *Is 1he% Tislm!mhs s, *ae and Sod ()oston: Little, )!o%n,
195.). Bn the social, lite!a!(, and scienti"ic asects o" 19th8cent&!( t&'e!c&losisR an anal(sis
o" its incidence.
xxx "otnote! sl&tt xxx
((15))
otics 'ecame !o&tine, it had slied into eleventh lace %ith a !ate o" /;. 0hole!a,G
d(sente!(,6, and t(hoid simila!l( ea+ed and d%indled o&tside the h(sician6s cont!ol. )(
the time thei! etiolo*( %as &nde!stood and thei! the!a( had 'ecome seci"ic, these diseases
had lost m&ch o" thei! vi!&lence and hence thei! social imo!tance. The com'ined death !ate
"!om sca!let "eve!, dihthe!ia, %hooin* co&*h, and measles amon* child!en & to "i"teen
sho%s that nea!l( 9> e!cent o" the total decline in mo!talit( 'et%een 1;6> and 1965 had
occ&!!ed 'e"o!e the int!od&ction o" anti'iotics and %ides!ead imm&ni=ation.1. In a!t this
!ecession ma( 'e att!i'&ted to im!oved ho&sin* and to a dec!ease in the vi!&lence o" mic!o8
o!*anisms, '&t '( "a! the most imo!tant "acto! %as a hi*he! host8!esistance d&e to 'ette!
n&t!ition. In oo! co&nt!ies toda(, dia!!hea and &e!8!esi!ato!(8t!act in"ections occ&! mo!e
"!eA&entl(, last lon*e!, and lead to hi*he! mo!talit( %he!e n&t!ition is oo!, no matte! ho%
m&ch o! ho% little medical ca!e is availa'le.1/ In En*land, '( the middle o" the nineteenth
cent&!(, in"ectio&s eidemics had 'een !elaced '( ma:o! maln&t!ition s(nd!omes, s&ch as
!ic+ets and ella*!a. These in t&!n ea+ed and vanished, to 'e !elaced '( the diseases o"
ea!l( childhood and, some%hat late!, '( an inc!ease in d&odenal &lce!s in
xxx "otnote! sta!t xxx
11 0ha!les E. 3osen'e!*, The Cholera <ears= The !nited States in 9C0&, 9CJ>, and 9C??
(0hica*o: 9niv. o" 0hica*o 1!ess, 196,). The Ne% No!+ eidemic o" 1;., %as a mo!al
dilemma "!om %hich delive!ance %as so&*ht in "astin* and !a(e!. )( the time o" the
eidemics o" 1;66, the c&lt&!e that had !od&ced Ne% No!+ sl&ms had as %ell !od&ced
chlo!ide o" lime.
1, $.I. van Qi:l, G<t&dies on 7ia!!heal 7isease in <even 0o&nt!ies,G ,ulletin of the "orld
%ealth 'rgani8ation .5 (1966): ,/9861. 3ed&ction in dia!!heal diseases is '!o&*ht a'o&t '( a
'ette! %ate! s&l( and sanitation, neve! '( c&!ative inte!vention.
1. 3. 3. 1o!te!, The 0ont!i'&tion of the ,iological and *edical <ciences to %arman "elfare,
1!esidential 5dd!ess to the )!itish 5ssociation "o! the 5dvancement o" <cience, <%ansea
Meetin*, 1971 (London: the 5ssociation, 197,), . 95.
1/ N. <. <c!imsha%, 0. E. Ta(lo!, and Iohn E. Oo!don, Intnac"ions of N&t!ition and )nfection
(Oeneva: $o!ld #ealth B!*ani=ation, 196;).
xxx "otnote! sl&tt xxx
229?AA
(o&n* men. $hen these declined, the mode!n eidemics too+ ove!: co!ona!( hea!t disease,
emh(sema, '!onchitis, o'esit(, h(e!tension, cance! (eseciall( o" the l&n*s), a!th!itis,
dia'etes, and so8called mental diso!de!s. 7esite intensive !esea!ch, %e have no comlete
exlanation "o! the *enesis o" these chan*es.15 )&t t%o thin*s a!e ce!tain: the !o"essional
!actice o" h(sicians cannot 'e c!edited %ith the elimination o" old "o!ms o" mo!talit( o!
mo!'idit(, no! sho&ld it 'e 'lamed "o! the inc!eased exectanc( o" li"e sent in s&""e!in* "!om
the ne% diseases. -o! mo!e than a cent&!(, anal(sis o" disease t!ends has sho%n that the
envi!onment is the !ima!( dete!minant o" the state o" *ene!al health o" an( ,o&lation.Ws
Medical *eo*!ah(,G
xxx "otnote! sta!t xxx
15 Iohn 0assel, G1h(sical Illness in 3esonse to <t!ess,G 5ntolo*ia 57, mimeo*!ahed
(0&e!navaca: 0I7B0 (0ent!o Inte!c&lt&!al de 7oc&menta8don), 1971).
16 Bne o" the clea!est ea!l( statements on the a!amo&nt imo!tance o" the envi!onment is I.
1. -!an+, A#ademische eds vom 6ol#selend als der *uer der Eran#heiten (1avia, 179>R
!e!int ed., Lei=i*: )a!th, 196>). Thomas *cEeown and 3. O. 3eco!d, G3easons "o! thT
7ecline in Mo!talit( in En*land and $ales 7&!in* the Nineteenth 0ent&!(,G +opulation
Studies 16 (196,): 9/81,,. Ed%in 0had%ic+, eport on the Sanitary Condition of the
-abouring +opulation of $reat ,ritain, 9CJ&, ed. M. $. -linn (0hica*o: 5ldine, 1965),
cond&ded a cent&!( and a hal" a*o that Gthe !ima!( and most imo!tant meas&!es and at the
same time the most !actical, and %ithin the !eco*ni=ed !ovidence o" &'lic administ!ation,
a!e d!aina*e, the !emoval o" all !e"&se "!om ha'itations, st!eets, and !oads, and the
im!ovement o" the s&lies o" %ate!.G Max von 1ette!+o"e!, The 6alue of %ealth to a 0it(
Two -ectures Delivered in 9C:0, t!ans. #en!( E. <i*e!ist ()altimo!e: Iohns #o+ins, 19/1),
calc&lated a cent&!( a*o the cost o" health to the cit( o" M&nich in te!ms o" ave!a*e %a*es
lost and medical costs c!eated. 1&'lic se!vices, eseciall( 'ette! %ate! and se%a*e disosal,
he a!*&ed, %o&ld lo%e! the death !ate, mo!'idit(, and a'senteeism and this %o&ld a( "o!
itsel". Eidemiolo*ical !esea!ch has enti!el( con"i!med these h&manistic convictions: 7elit8
Mo!ando, 3adenac, and ?ilain, DisparitFs rFgionales en motiFrs de santT, )&lletin de
<tatistiA&e d& MinistX!e de la <antT et de la <Tc&!itT <ociale No. ., 197.R $a!!en
$in+elstein, I!., GEidemiolo*ical 0onside!ations 9nde!l(in* the 5llocation o" #ealth and
7isease 0a!e 3eso&!ces,G )nternational 3ournal ofEpidemiolog< 1, no. 1 (197,): 6987/R -.
-a*nani, SantF, comonvnation mFdicale et envi!onnement: +roblKmes et mTthodes (1a!is:
Mo&ton, 197.).
17 N. 7. McOlashan, ed., *edical $eography= Techniques and (ield <t&dies (Ne% No!+:
)a!nes V No'le, 197.). IacA&es Ma( and 7onna McLelland, eds., <t&dies be *edical
$eography, 1> vols. (Ne% No!+: #a"ne!, 1961871). 7aniel Noin, -a $Fographie
dFmographique de la (rance (1a!is: 19-, 197.). I. ?allin, -a *ortalitF en
/// fotnoter fortsetter neste side ///
((17))
the histo!( o" diseases, 1; medical anth!oolo*(,19 and the social histo!( o" attit&des to%a!ds
illness,> have sho%n that "ood,,1 %ate!,,, and ai!,,6 in co!!elation %ith the level o"
xxx "otnote! "o!tsette! "!a "o!!i*e side xxx
(rance par tranches depuis 1699 (1a!is: 19-, 197.). L. 7. <tam, The $eography of -ife
and Death (Ithaca, N.N.: 0o!nell 9niv. 1!ess, 1965). E. 3oden%aldt et al., $eltse&chenatlas
(#am'&!*, 19.6). Iohn Melton #&nte!, The $eography of %ealth and Disease, <t&dies in
$eography no; ? 2Chapel %ill= !niv; of .orth Carolina +ress, 9>:JA;
1; E!%in #. 5c+e!+necht, Therepeutics= (rom the +rimitives to the Twentieth Century (Ne%
No!+: #a"ne!, 9>:0A; A simle ove!vie%. I. -. 7. <h!e%s'&!(, 5 #isto!( o" the )&'onic
+lague in the )!itish hies (0am'!id*e: 0am'!id*e 9niv. 1!ess, 9>:BA; 5n o&tstandin*
examle o" histo!( %!itten '( a 'acte!iolo*ist and eidemiolo*ist.
19 -o! an int!od&ction to the lite!at&!e, see <teven 1ol*a!, G#ealth and #&man )ehavio&!:
5!eas o" Inte!est 0ommon to the <ocial and Medical <ciences,G Current Anthropology 0
(5!il 196,): 1598,>5. 1ol*a! *ives a c!itical eval&ation o" each item and the !esonses o" a
la!*e n&m'e! o" collea*&es to his eval&ation. <ee also <teven 1ol*a!, G#ealth,G in
)nternational Encyclopedia of the Social Sciences (196;), 6:..>86R Eliot -!eidson, GThe
<ocilo*( o" Medicine: 5 T3end 3eo!t and )i'lio*!ah(,G Current Sociology, 196186,, nos.
1>811, . 1,.89,.
,> 1a&l <lac+, G7isease and the <ocial #isto!ian,G Times -itterary Supplement, *arch C,
197/, ,..8/. 5 critical review article; Catherine elict and AgnKs Souriac, DLpidFmies , et
mentalitFs= -e CholFra de 9C0& en Seine4et4'ise,D Annales Lconomies, SociFtFs,
Civilisations, 197/, no; J, pp; >0@4?@;
,1 5lan )e!*, The N&t!ition (actor; )ts ole in .ational Daft ($ashin*ton, 7.0.: )!oo+in*s
Instit&tion, 197.). #ans I. Te&te'e!* and OYnte! $ie*elmann, 7e! $endel der
Nah!&n*s*e%ohnheiten &nde! dem Ein"l&ss de! Ind&st!ialisie!&n* (OZttin*en: ?andenhoec+
V 3&!echt, 197,), deal %ith the imact o" ind&st!iali=ation on the A&antit(, A&alit(, and
dist!i'&tion o" "ood in 19th8cent&!( E&!oe. $ith the t!ansition "!om s&'sistence on limited
stales to eithe! mana*ed o! chosen men&s, the t!aditional !e*ional c&lt&!es o" eatin*, "astin*,
and s&!vivin* h&n*e! %e!e dest!o(ed. 5 'adl( o!*ani=ed !ich mine o" 'i'lio*!ahic
in"o!mation. In the %a+e o" Ma!c )loch and L&cien -e'v!e, some o" the most val&a'le
!esea!ch on the si*ni"icance o" "ood to o%e! st!&ct&!es and health levels %as done. -o! an
o!ientation on the method &sed, cons&lt O&( Th&illie!, GNote s&! les so&!ces de l6histoi!e
!T*ionale de l6alimentation a& [I[e siXcle,G Annales Lconomies, SociFtFs, Civilisations, 196;,
no. 6, . 1.>1819R O&( Th&illie!, G5& [I[e siXcle: L65limentation en Nive!nais,G Annales,
1965, no. 6, . 116.8;/. -o! a maste!iece cons&lt -!an\ois Le'!&n, -es %ommes et la mo!t
a& 5n:o& a& 9:e et 9Ce siKcles; Essai de dFmographie et psychologie historiques (1a!is:
Mo&ton, 1971AM 5. 1oit!inea&, D-1Alimentation o&lai!e en 5&ve!*ne a& [?IIIe siXcle,G in
EnquNtes, . .,.8.1; B%sei Tem+in, .utrition from Classical 5ntiA&it( to the ,aroque,
#&man N&t!ition Mono*!ah 0, Ne% No!+, 9>?&; (or the t!ans"o!mation o" '!ead into a
s&'stance machines can !od&ce, see <ie*"!ied Oiedion, *echani8ation Ta#es Command= A
Contribution to Anonymous %istory (Ne% No!+: No!ton, 1969), eseciall( ts. /:,, J=0 (on
meat). 5lso -e!nand )!a&del, GLe <&e!"l& et l6o!dinai!e: No&!!it&!e et 'oissons,G in
Civilisation matFrielle et captalisme (1a!is: 0olin, 1967), . 1./89;.
,, L 7. 0a!!&the!s, )mpact and Economics of Community "ater Supply= A Study of ural
"ater )nvestment in Eenya, "ye College, Ashford, Eent, 9>:0M on the impact
xxx "otnote! "o!tsette! E neste side xxx
((1;))
socioolitical eA&alit(,/ and the c&lt&!al mechanisms that ma+e it ossi'le to +ee the
o&lation sta'le,,5 la( the
xxx "otnote! "o!tsette! "!a "o!!i*e side xxx
o" %ate! s&l( on health. Bn the im!ovement o" !&!al %ate! s&lies d&!in* the 19th
cent&!(: O&( Th&illie!, :To&! &ne histoi!e !T*ionale de l6ea& en Nive!nais a& [I[e siXcle,G
Annales Economies, SociFtFs, 0ivilisations, 196;, no. 1, . /9 "". The im!ovement o" %ate!
s&lies chan*ed eole6s attit&de to%a!ds thei! o%n 'odies: O&( Th&illie!, G1o&! &ne histoi!e
de l6h(*iXne co!o!elle. 9n exemle !T*ional: le Nive!nais,G evue d1histoire Fconomique d
sociale /6, no. , (196;): ,.,85.R La%!ence $!i*ht, 0lean and Decent= The (ascinating
%istory >f the ,athroom and the "ater Closet and of Sundry %abits, (ashions and
Accessories of the Toilet, +rincipally in $reat ,ribe, (rance and America 2Toronto= !niv; of
Toronto +reis, 9>?:A; .ew patterns for laundry developed= $uy Thuillier, D+our &ne histoi!e
de la lessive a& [I[e siXcle,G 5nnales, 1969, no. ,, . .5589>.
,. Leste! ). Lave and E&*ene 1. <es+in, G5i! 1oll&tiZn and #&man #ealth,G Science 169
(197>): 7,.8... Iean81a&l 7eaeaive et al., MTdecins, chiasse et FpidFmies O la fin d& P6)))e
siKcle (1a!is: Mo&ton, 197,).
,/ 5 s(nthetic, %ell8doc&mented a!*&ment to this oint is Eman&el de @adt, GIneA&alit( and
#ealth,G 9niv. o" <&ssex, Ian&a!( 1975. The o!i*inal and lon*e! ve!sion o" this ae! %as
%!itten in 197, as the int!od&cto!( chate! o" a 'oo+, Solid y 'iennia, %hich sho&ld have 'een
&'lished in <antia*o, 0hile, in 197.. Iohn 1o%les, G#ealth and Ind&st!ialisation in )!itain:
The Inte!action o" <&'stantive and Ideolo*ical 0han*e,G !ea!ed "o! a 0olloA&i&m on the
5data'ilit( o" Man to 9!'an Li"e, -i!st $o!ld 0on*!ess on Envi!onmental Medicine and
)iolo*(, 1a!is, I&l( 185, 197/. 0. -e!!e!o, G#ealth and Levels of Livin* in Latin 5me!ica,G
*ilban# *anorial -&nd (hoa!sel( /. (Bcto'e! 1965): ,;1895. 5 decline in mo!talit( is not to
'e anticiated "!om mo!e exendit&!es on health ca!e '&t "!om a di""e!ent allocation o" "&nds
%ithin the health secto! com'ined %ith social chan*e.
,5 Emil( 3. 0oleman, GL6In"anticide dans le ha&t mo(en "i*e,G t!ans. 5. 0hamo&x, 5nnales
Economies, <ociTtTs, 0ivilisations, 197/, no. ,, . .158.5. <&**ests that in"anticide in the
Middle 5*es %as demo*!ahicall( si*ni"icant. 5nsle( I. 0oo+, GThe 7ecline o" -e!tilit( in
E&!oe "!om the -!ench 3evol&tion to $o!ld $a! II,G in <. I. )eh!man et al., (ertility and
(amily 1lannin* (5nn 5!'o!: 9niv. of Michi*an 1!ess, 197>). Ma!ital "e!tilit( declined
eve!(%he!e 'e"o!e the !oo!tion o" the o&lation %ho ma!!ied inc!eased. 7isc!imination
a*ainst the ille*itimate com'ined %ith !est!icted access to ma!!ia*e ma( have se!ved to
cont!ol o&lation. This h(othesis is !ein"o!ced in I.8L. -land!in, G0ont!acetion, ma!ia*e et
!elations amo&!e&ses dans l6Bccident ch!Ttien,G Annales, 1969, no. 6, . 1.7>89>.
7emo*!ahic data s&**est no cont!acetion %ithin ma!!ia*e "o! 17th and 1;th8cent&!(
-!ance, '&t ve!( lo% !ates o" ille*itimac(. 0ont!acetion in ma!!ia*e %as nea! he!es(,
concetion o&tside ma!!ia*e a scandal. -land!in s&**ests that d&!in* the 19th cent&!( sex&al
'ehavio! 'et%een so&ses 'e*an to 'e modeled on t!aditional 'ehavio! o&tside ma!!ia*e.
0ont!acetion seems to have 'ecome acceta'le "i!st amon* easant "amilies !ich eno&*h to
+ee in"ant mo!talit( lo%: see M. Le!idon, G-TconditT et mo!talitT in"antile dans t!ois villa*es
'ava!ois: 9ne 5nal(se de donnTs individ&alisTes d& [I[e 6siXcle,G 1o&lation 5 (1969): 9978
1>>,. 5ltho&*h h(sicians in En*land oosed its s!ead, the( seemin*l( alied it
e""ectivel( in
xxx "otnote! "o!tsette! E neste side xxx
((19))
decisive !ole in dete!minin* ho% health( *!o%n8&s "eel and at %hat a*e ad&lts tend to die.
5s the olde! ca&ses o" disease !ecede, a ne% +ind o" maln&t!ition is 'ecomin* the most
!aidl( exandin* mode!n eidemic.,6 Bne8thi!d o" h&manit( s&!vives on a level o"
&nde!no&!ishment %hich %o&ld "o!me!l( have 'een lethal, %hile mo!e and mo!e !ich eole
a'so!' eve! *!eate! amo&nts o" oisons and m&ta*ens in thei! "ood.,7
<ome mode!n techniA&es, o"ten develoed %ith the hel o" docto!s, and otimall( e""ective
%hen the( 'ecome a!t o" the c&lt&!e and envi!onment o! %hen the( a!e alied
indeendentl( o" !o"essional delive!(, have also e""ected chan*es in *ene!al health, '&t to a
lesse! de*!ee. 5mon* these can 'e incl&ded cont!acetion, smallox vaccination o" in"ants,
and s&ch nonmedical health meas&!es as the t!eatment o" %ate! and se%a*e, the &se o" soa
and scisso!s '( mid%ives, and some anti'acte!ial and insecticidal !oced&!es. The imo!tance
o" man( o" these !actices %as "i!st !eco*ni=ed and stated '( docto!s8o"ten co&!a*eo&s
dissidents %ho s&""e!ed "o! thei! !ecommendations,;
xxx "otnote! "o!tsette! "!a "o!!i*e side xxx
thei! o%n lives: I. 5. )an+s, G-amil( 1lannin* and )i!th 0ont!ol in ?icto!ian Times,G ae!
!ead at the <econd 5nn&al 0on"e!ence, o" the <ociet( "o! the #isto!( o" Medicine, Leiceste!
9niv., 197,. The 0atholic 0h&!ch seems to have made cont!acetion an iss&e onl( inso"a! as
it a""ected the ind&st!ial middle classes: see Iohn Thomas Noonan, Contraception= A %istory
of )ts Treatment by the Catholic Theologians and 0anoeists (0am'!id*e: #a!va!d 9niv. 1!ess,
1965). 1hilie 5!iXs, GLes TechniA&es de la mo!t,G in %istoire des populations franQaises et
de lours attitudes demnt la vie depuis le P 6llh siecle (1a!is: <e&il, 1971), . .7..
,6 <o "a!, %o!ld h&n*e! and %o!ld maln&t!ition have inc!eased %ith ind&st!ial develoment.
GBne thi!d to one hal" o" h&manit( a!e said to 'e *oin* to 'ed h&n*!( eve!( ni*ht. In the
<tone 5*e the "!action m&st have 'een m&ch smalle!. This is the e!a o" &n!ecedented h&n*e!.
No%, in the time o" the *!eatest technical o%e!, sta!vation is an instit&tion.G Ma!shall
<ahlins, Stone Age Economics (0hica*o: 5ldine, 197,), . ,..
,7 I. E. 7avies and $. -. Edm&ndson, Epidemiology of DDT (Mo&nt @isco, N.N.: -&t&!e,
197,). 5 *ood examle o" a!adoxical disease cont!ol "!om )o!neo: Insecticides &sed in
villa*es to cont!ol mala!ia vecto!s also acc&m&lated in coc+!oaches, most o" %hich a!e
!esistant. Oec+oes "ed on these, 'ecame letha!*ic, and "ell !e( to cats. The cats died, !ats
m&ltilied, and %ith !ats came the th!eat o" eidemic '&'onic la*&e. The a!m( had to
a!ach&te cats into the
:&n*le villa*e 2Conservation .ews, I&l( 197.).
,; 5 *ood examle o" medical e!sec&tion o" innovato!s is *iven '( O. Oo!tva( and I.
Qoltan, ); <immel%eis, %is -ife and "or# 2,udapest= A#ademiai Eiado,
xxx "otnote! "o!tsette! E neste side xxx
((,>))
8'&t this does not consi*n soa, ince!s, vaccination needles, delo&sin* !ea!ations, o!
condoms to the cate*o!( o" Gmedical eA&iment.G The most !ecent shi"ts in mo!talit( "!om
(o&n*e! to olde! *!o&s can 'e exlained '( the inco!o!ation o" these !oced&!es and
devices into the la(man6s c&lt&!e.
In cont!ast to envi!onmental im!ovements and mode!n non!o"essional health meas&!es, the
seci"icall( medical t!eatment o" eole is neve! si*ni"icantl( !elated to a decline in the
como&nd disease '&!den o! to a !ise in li"e exectanc(.G Neithe! the !oo!tion o" docto!s in
a o&lation no! the clinical tools at thei! disosal no! the n&m'e! o" hosital 'eds is a ca&sal
"acto! in the st!i+in* chan*es in ove!8all atte!ns o" disease. The ne% tech8niA&es "o!
!eco*ni=in* and t!eatin* s&ch conditions as e!nicio&s anemia and h(e!tension, o! "o!
co!!ectin* con*enital mal"o!mations '( s&!*ical inte!vention, !e8de"ine '&t do not !ed&ce
mo!'idit(. The "act that the docto! o&lation is hi*he! %he!e ce!tain diseases have 'ecome
!a!e has little to do %ith the docto!s6 a'ilit( to cont!ol o! eliminate them..> It siml( means
that docto!s
xxx "otnote! "o!tsette! "!a "o!!i*e side xxx
196;), a c!itical 'io*!ah( o" the "i!st *(necolo*ist to &se antisetic !oced&!es in his %a!ds.
In 1;/; he !ed&ced mo!talit( "!om &e!e!al "eve! '( a "acto! o" 15 and %as the!e&on
dismissed and ost!aci=ed '( his collea*&es, %ho %e!e o""ended at the idea that h(sicians
co&ld 'e ca!!ie!s o" death. Mo!ton Thomson6s novel The Cry and the Covenant 2.ew No!+:
Ne% 5me!ican Li'!a!(, 197.) ma+es <emmel%eis come alive.
,9 0ha!les T. <te%a!t, I!., G5llocation o" 3eso&!ces to #ealth,G 5ournal of %uman esources
?, no; 1 (1971): 1>.8,1. <te%a!t classi"ies !eso&!ces devoted to health as t!eatment,
!evention, in"o!mation, and !esea!ch. In all nations o" the $este!n #emishe!e, !evention
(e.*., ota'le %ate!) and ed&cation a!e si*ni"icantl( !elated to li"e exectanc(, '&t none o" the
Gt!eatment va!ia'lesG a!e so !elated.
.> 3e&el 5. <tallones, in Envi!onment, Ecology, and Epidemiology, 1an85me!ican #ealth
B!*ani=ation <cienti"ic 1&'lication no. ,.1 ($ashin*ton, <etem'e! .>, 1971), sho%s the!e
is a st!on* ositive co!!elation in the 9.<.5. 'et%een a hi*h !oo!tion o" docto!s in the
*ene!al o&lation and a hi*h !ate o" co!ona!( disease, %hile the co!!elation is st!on*l(
ne*ative "o! ce!e'!al vasc&la! disease. <tallones oints o&t that this sa(s nothin* a'o&t a
ossi'le in"l&ence o" docto!s on eithe!. Mo!'idit( and mo!talit( a!e an inte*!al a!t o" the
h&man envi!onment and &n!elated to the e""o!ts made to cont!ol an( seci"ic disease.
xxx "otnote! sl&tt xxx
((,1))
delo( themselves as the( li+e, mo!e so than othe! !o"essionals, and that the( tend to *athe!
%he!e the climate is health(, %he!e the %ate! is clean, and %he!e eole a!e emlo(ed and
can a( "o! thei! se!vices.sl
/seless &edical ,reatment
5%e8insi!in* medical technolo*( has com'ined %ith e*alita!ian !heto!ic to c!eate the
im!ession that contemo!a!( medicine is hi*hl( e""ective. 9ndo&'tedl(, d&!in* the last
*ene!ation, a limited n&m'e! o" seci"ic !oced&!es have 'ecome ext!emel( &se"&l. )&t %he!e
the( a!e not monooli=ed '( !o"essionals as tools o" thei! t!ade, those %hich a!e alica'le
to %ides!ead diseases a!e &s&all( ve!( inexensive and !eA&i!e a minim&m o" e!sonal s+ills,
mate!ials, and c&stodial se!vices "!om hositals. In cont!ast, most o" toda(6s s+(!oc+etin*
medical exendit&!es a!e destined "o! the +ind o" dia*nosis and t!eatment %hose e""ectiveness
at 'est is do&'t"&l.., To ma+e this oint I %ill distin*&ish 'et%een in"ectio&s and
nonin"ectio&s diseases.
In the case o" in"ectio&s diseases, chemothe!a( has la(ed a si*ni"icant !ole in the cont!ol o"
ne&monia, *ono!!hea, and s(hilis. 7eath "!om ne&monia, once the Gold man6s "!iend,G
declined (ea!l( '( 5 to ; e!cent a"te! s&lhonamides and anti'iotics came on the ma!+et.
<(hilis, (a%s, and man( cases o" mala!ia and t(hoid can 'e c&!ed A&ic+l( and easil(. The
!isin* !ate o" vene!eal
xxx "otnote! sta!t xxx
.1 5lain Leto&!m( and -!an\ois Oi'e!t, SantF, envi!onnement, consommations mFdicales !n
*odile et son estimation O partir des donnFes de mortality apport principal 2+aris=
CEE,E 2Centre de echerche sur le )ien8]t!e), I&ne 197/). 0oma!es mo!talit( !ates in
di""e!ent !e*ions o" -!anceR the( a!e &n!elated to medical densit(, hi*hl( !elated to the "at
content o" the sa&ces t(ical o" each !e*ion, and some%hat less to alcohol cons&mtion.
., The model st&d( on this matte! at !esent seems to 'e 5. L. 0och!ane, E, ectiwness and
E""icienc(: 3andon 3&ions on %ealth Services, N&""ield 1!ovincial #ositals T!&st, 197,. <ee
also ,ritish *edical fowaal, 9>:J, J=@; 5. 2&e!ido, Efficiency of *edical Care (Ne% No!+:
Inte!national 1&'lications, 196.).
xxx "otnote! sl&tt xxx
((,,))
disease is d&e to ne% mo!es, not to ine""ect&al medicine. The !eaea!ance o" mala!ia is d&e
to the develoment o" esticide8!esistant mosA&itoes and not to an( lac+ o" ne% antimala!ial
d!&*s... Imm&ni=ation has almost %ied o&t a!al(tic oliom(elitis, a disease o" develoed
co&nt!ies, and vaccines have ce!tainl( cont!i'&ted to the decline o" %hooin* co&*h and
measles,M th&s seemin* to con"i!m the o&la! 'elie" in Gmedical !o*!ess.G .5 )&t "o! most
othe! in"ections, medicine can sho% no coma!a'le !es&lts. 7!&* t!eatment has heled to
!ed&ce mo!talit( "!om t&'e!c&losis, tetan&s, dihthe!ia, and sca!let "eve!, '&t in the total
decline o" mo!talit( o! mo!'idit( "!om these diseases, chemothe!a( la(ed a mino! and
ossi'l( insi*ni"icant !ole..6 Mala!ia, leishmaniasis, and sleein* sic+ness indeed !eceded "o!
a time &nde! the onsla&*ht o" chemical attac+, '&t a!e no% on the !ise a*ain..7
xxx "otnote! sta!t xxx
.. IacA&es M. Ma(, GIn"l&ence o" Envi!onmental T!ans"o!mation in Oan*in* the Ma o"
7isease,G in M. Ta*hi -a!va! and Iohn 1. Milton, eds., The Careless Technology (Oa!den
0it(, N.N.: Nat&!al #isto!( 1!ess, 197,), . 198./. Ma( %a!ns that mosA&ito !esistance to
insecticides on the one hand and a!asite !esistance to chemothe!ae&tic a*ents on the othe!
ma( have c!eated an &nans%e!a'le challen*e to h&man adatation.
./ #en!( I. 1a!ish, A %istory of h&manisation (Edin'&!*h: Livin*stone, 1965). 0ons&lt
histo!ical int!od&ction "o! lite!at&!e. The e""ectiveness o" !evention in !elation to an( seci"ic
disease m&st 'e distin*&ished "!om its cont!i'&tion to the vol&me o" disease: I. #. 5lston, 5
.ew Loo+ at )nfectious 7isease (London: 1itman, 1967), sho%s ho% in"ections a!e !elaced
'( ne% ones, %itho&t !ed&ction in ove!8all vol&me. @eith Mellan'(, 1esticides and +ollution
(Ne% No!+: 0ollins, 1967), in an easil( &nde!standa'le %a( demonst!ates ho% the
en*inee!in* mechanisms desi*ned to !ed&ce one in"ection "oste! othe!s.
.5 3ei'lica de 0&'a, Ministe!io de la <al&d 1^'lica, Cuba= B!*ani=aci_n de los servicios y
nivel de salud (#avana, 197/), int!od&ction '( -idel 0ast!o. 5n im!essive demonst!ation o"
the shi"t in mo!talit( and mo!'idit( atte!ns ove! one decade, d&!in* %hich ma:o! in"ections
on the %hole island %e!e si*ni"icantl( a""ected '( a &'lic8health camai*n. N*&(en @hac
?ien, G,5 5nnTes d6activitTs mTdico8sanitai!es,G Etudes vietnamiennes (#anoi), no. ,5, 197>.
.6 O. B. <o"ol&%e, G1!omotive Medicine: 5 )oost to the Econom( o" 7eveloin*
0o&nt!ies,G Tropical and Oeo*!ahical 5'dici v ,, (I&ne 197>): ,5>8/. 7&!in* the .> (ea!s
'et%een 19.5 and 196;, &"ost c&!ative meas&!es &sed "o! a!asitic diseases and in"ections o"
the s+in and !esi!ato!( o!*ans and "o! dia!!hea have le"t Gthe atte!n o" mo!'idit( on the
%hole &nchan*ed.G
.7 In -a!va! and Milton, eds., The Careless Technology, seve!al a&tho!s ma+e this
xxx "otnote! "o!tsette! neste side xxx
((,.))
The e""ectiveness o" medical inte!vention in com'attin* nonin"ectio&s diseases is even mo!e
A&estiona'le. In some sit&ations and for some conditions, e""ective !o*!ess has indeed 'een
demonst!ated: the a!tial !evention o" ca!ies th!o&*h "l&o!idation o" %ate! is ossi'le, tho&*h
at a cost not "&ll( &nde!stood.G 3elacement the!a( lessens the di!ect imact o" dia'etes,
tho&*h onl( in the sho!t !&n.G Th!o&*h int!aveno&s "eedin*, 'lood t!ans"&sions, and s&!*ical
techniA&es, mo!e o" those %ho *et to the hosital s&!vive t!a&ma, '&t s&!vival !ates "o! the
most common t(es o" cance!8those %hich ma+e & 9> e!cent o" the cases8have !emained
vi!t&all( &nchan*ed ove! the last t%ent(8"ive (ea!s. This "act has consistentl( 'een clo&ded '(
anno&ncements "!om the 5me!ican 0ance! <ociet( !eminiscent o" Oene!al $estmo!eland6s
!oclamations "!om ?ietnam. Bn the othe! hand, the dia*nostic val&e o" the 1aanicolao&
va*inal smea! test has 'een !oved: i" the tests a!e *iven four times a (ea!, ea!l( inte!vention
"o! ce!vical cance! demonst!a'l( inc!eases the "ive8(ea! s&!vival !ate. <ome s+in8cance!
t!eatment is hi*hl( e""ective. )&t the!e is little evidence o" e""ective t!eatment o" most othe!
cance!s./> The "ive8(ea! s&!vival !ate in '!east8can8
xxx "otnote! "o!tsette! "!a "o!!i*e side xxx
oint seci"icall( "o! mala!ia, )anc!o"tian "ila!iasis (#annon), schistasomiasis (van de!
<chalie), and *enito8&!ina!( in"ections (-a!!a!).
.; )!&ce Mitchel, (luoridation ,ibliography, 0o&ncil o" 1lannin* Li'!a!ians Exchan*e
)i'lio*!ah( no. ,6;, ($ate!loo, Bnt., Ma!ch 197,). 0ove!s the de'ate and eseciall( the
social scientist6s e!cetion o" eole6s 'ehavio! !e*a!din* "l&o!idation in 0anada.
.9 0. L. Meine!t et al., G5 <t&d( o" the E""ects o" #(o*l(cemic 5*ents on ?asc&la!
0omlications in 1atients %ith 5d&lt8Bnset 7ia'etes. #. Mo!talit( 3es&lts, 197>,G Diabetes
9>, s&l. & (197>): 7;98;.>. O. L. @natte!&d et al., GE""ects o" #(o*l(cemic 5*ents on
?asc&la! 0omlications in 1atients %ith 5d&lt8Bnset 7ia'etes,G 3ournal of the American
*edical Association ,17 (1971): 7778;/. 0och!ane, Ef festiveness and E""icienc(, comments
on the last t%o. The( s&**est that *ivin* tol'&tamide and hen"o!min is de"initel(
disadvanta*eo&s in the t!eatment o" mat&!e dia'etics and that the!e is no advanta*e in *ivin*
ins&lin !athe! than a diet.
/> #. Bese!, Erebsbe#ampfinng= %offnung and alitRt 2Stuttgart= Thieme, 197/). This is so
"a!, to m( +no%led*e, the most &se"&l int!od&ction "o! the *ene!al
xxx "otnote! "o!tsette! E neste side xxx
((,/))
ce! cases is 5> e!cent, !e*a!dless o" the "!eA&enc( o" medical chec+8&s and !e*a!dless o" the
t!eatment &sed./1 No! is the!e evidence that the !ate di""e!s "!om that amon* &nt!eated
%omen. 5ltho&*h !acticin* docto!s and the &'licists o" the medical esta'lishment st!ess the
imo!tance o" ea!l( detection and t!eatment o" this and seve!al othe! t(es o" cance!,
eidemiolo*ists have 'e*&n to do&'t that ea!l( inte!vention can alte! the !ate o" s&!vival/,
<&!*e!( and chemothe!a( "o! !a!e con*enital and !he&matic hea!t disease have inc!eased the
chances "o! an active li"e "o! some o" those %ho s&""e! "!om de*ene!ative conditions./. The
medical t!eatment o" common ca!diovasc&la! diseaseG and the intensive t!eatment o" hea!t
xxx "otnote! "o!tsette! "!a "o!!i*e side xxx
h(sician o! la(man to a c!itical eval&ation o" %o!ld lite!at&!e on the e""ectiveness o" cance!
t!eatment. <ee also N. E. Mc@innon, GThe E""ects o" 0ont!ol 1!o*!ams on 0ance! Mo!talit(,G
0anadian *edical 5ssociation Io&!nal ;, (196>): 1.>;81,. @. T. Evans, G)!ant 0ance!
<(mosi&m: 1oints in the 1!actical Mana*ement o" )!east 0ance!. 5!e 1h(sical Methods o"
7ia*nosis o" ?al&e4G )!itish Io&!nal of Surgery 56 (1969): 7;/86.
/1 Ed%in -. Le%ison, G5n 5!aisal o" Lon*8Te!m 3es&lts in <&!*ical, T!eatment o" )!east
0ance!.G "oamed of the 5me!ican *edical 5ssociation 1;6 (196.): 9758;. GThe most
im!essive "eat&!e o" the s&!*ical t!eatment o" '!east cance! is the st!i+in* simila!it( and
s&!!isin* &ni"o!mit( o" lon*8te!m end !es&lts desite %idel( di""e!in* the!ae&tic techniA&es
as !eo!ted "!om this co&nt!( and a'!oad.G The same can 'e said toda(.
/, 3o'e!t <&the!land, Cancer; The Significance of Delay 2-ondon= ,utterworth, 9>?BA, pp;
9>?4&B&; Also %edley At#ins et al;, DTreatment of Early ,reast Cancer= A eport after Ten
<ears of Clinical Trial,D ,ritish *edical 5ournal, 9>:&, &=J&04>M also p; J9:; D; +; ,yar and
6eterans Administration Cooperative !rological esearch $roup, DSurvival of +atients with
)ncidentally (ound *icroscopic Cancer of the +rostate= esults of Clinical Trial of
Conservative Treatment,D 3ournal of !rology 9BC 2December 9>:&A= >BC490; andom
comparison of four treatments 2placebo, estrogen, placebo and orchiectomy, and estrogen
and orchiectomyA reveals no significant differences among them, nor in comparison with
radical prostatectomy; (or a broad survey of analogous research on cancer in various sites,
see note JB above;
/. 5nn O. @&tne!, G0&!!ent <tat&s o" <te!oid The!a( in 3he&matic -eve!,G 5me!ican
#a!tIonnsal 7> (5&*&st 1965): 1/789. 3he&matic -eve! $o!+in* 1a!t( o" the Medical
3esea!ch 0o&ncil o" O!eat )!itain and <&'committee o" 1!incial Investi*ato!s o" the
5me!ican 0o&ncil on 3he&matic -eve! and 0on*enital #ea!t 7isease, 5me!ican #ea!t
5ssociation, GT!eatment o" 5c&te 3he&matic -eve! in 0hild!en: 5 0ooe!ative 0linical T!ial
o" 50T#, 0o!tisone and 5si!in,G ,ritish Medical "o!mal, 1955, 1:55587/.
// 5l'e!t N. )!est, GT!eatment o" 0o!ona!( Bccl&sive 7isease: 0!itical 3evie%,G 7iseases of
the Chat J@ 23anuary 9>?JA= JB4J@; *alcolm ); -indsay and
xxx "otnote! "o!tsette! E neste side xxx
((,5))
disease,U ho%eve!, a!e e""ective onl( %hen !athe! excetional ci!c&mstances com'ine that a!e
o&tside the h(sician6s cont!ol. The d!&* t!eatment o" hi*h 'lood !ess&!e is e""ective and
%a!!ants the !is+ o" side8e""ects in the "e% in %hom it is a mali*nant conditionR it !e!esents a
conside!a'le !is+ o" se!io&s ha!m, "a! o&t%ei*hin* an( !oven 'ene"it, "o! the 1> to ,> million
5me!icans on %hom !ash a!te!(8l&m'e!s a!e t!(in* to "oist it./6
-octor.Inflicted In0uries
9n"o!t&natel(, "&tile '&t othe!%ise ha!mless medical ca!e is the least imo!tant o" the
dama*es a !oli"e!atin* medical ente!!ise in"licts on contemo!a!( societ(. The ain,
d(s"&nction, disa'ilit(, and an*&ish !es&ltin* "!om technical medical inte!vention no% !ival
the mo!'idit( d&e to t!a""ic and ind&st!ial accidents and even %a!8!elated activities, and ma+e
the imact o" medicine one o" the most !aidl( s!eadin* eidemics o" o&! time. 5mon*
m&!de!o&s instit&tional to!ts, onl( mode!n maln&t!ition in:&!es mo!e eole than iat!o*enic
disease in its va!io&s mani"estations./7 In the most na!!o% sense, iat!o*enic disease incl&des
onl( illnesses that %o&ld not have come
xxx "otnote! "o!tsette! "!a "o!!i*e side xxx
3alh E. <te, G3e8eval&ation o" The!a( o" 5c&te M(oca!dial In"a!ction,G 5%ait` %art
:o&!nal 67 (5!il 196/): 55986/. #a!ve( 7. 0ain et al., G0&!!ent The!a( o" 0a!diovasc&la!
7isease,G $eriatrics 1; (I&l( 196.): 5>781;.
/5 #. O. Mathe! et al., G5c&te M(oca!dial In"a!ction: #ome and #osital T!eatment,G ,ritish
*edical 3ournal, 1971, .:../8;.
/6 0om'ined <ta"" 0linic, G3ecent 5dvances in #(e!tension,G 5me!ican 5ournal of
*edicine .9 (Bcto'e! 1965): 6./8;.
/7 -o! some o" the standa!d text'oo+s see 3o'e!t #. Mose!, The 7isease of Medical
+rogress= A Stdy of latrogenic Disease, 0rd ed. (<!in*"ield, Ill.: Thomas, 1969). 7avid M.
<ain, The Complications of *odem *edical +ractices (Ne% No!+: O!&ne V <t!atton, 196.).
#. 1. @Ymme!le and N. Ooossens, @lini+ &nd Therapie der Ne'en%i!+&n*en (<t&tt*a!t:
Thieme, 197. a1st ed., 196>b). 3. #eint=, der .ebenwir#ungen durch Art8neimittel=
Diagnosti#, Elini#, +athogemese, Therapie (<t&tt*a!t: Thieme, 1966). O&( 7&chesna(, -e
3isA&e thFrapeutique (1a!is: 7oin, 195/). 1. -. 765!c( and I. 1. O!i""in, latrogenic Disease
(Ne% No!+: Bx"o!d 9niv. 1l&s, 197,).
xxx "otnote! sl&tt xxx
((,6))
a'o&t i" so&nd and !o"essionall( !ecommended t!eatment had not 'een alied. /; $ithin
this de"inition, a atient co&ld s&e his the!aist i" the latte!, in the co&!se o" his mana*ement,
"ailed to al( a !ecommended t!eatment that, in the h(sician6s oinion, %o&ld have !is+ed
ma+in* him sic+. In a mo!e *ene!al and mo!e %idel( acceted sense, clinical iat!o*enic
disease com!ises all clinical conditions "o! %hich !emedies, h(sicians, o! hositals a!e the
atho*ens, o! Gsic+enin*G a*ents. I %ill call this letho!a o" the!ae&tic side8e""ects clinical
iat!o*enesis. The( a!e as old as medicine itsel",/9 and have al%a(s 'een a s&':ect o" medical
st&dies.5>
Medicines have al%a(s 'een otentiall( oisono&s, '&t thei! &n%anted side8e""ects have
inc!eased %ith thei! o%e! 51 and %ides!ead &se.5, Eve!( t%ent(8"o&! to thi!t(8
xxx "otnote! sta!t xxx
/; -o! the evol&tion o" :&!is!&dence !elated to this +ind o" to!n see M. N. Qald, GThe <ocial
0ont!ol o" Oene!al #ositals,G in ). <. Oeo!*oo&los, ed., 'rganisation esearch on %ealth
)nstitutions (5nn 5!'o!: 9niv. o" Michi*an, Instit&te "o! <ocial 3esea!ch, 197,). <ee also
5n*ela #olde!, *edical *alpractice -aw (Ne% No!+: $ile(, 197/).
/9 <&ch side8e""ects %e!e st&died '( the 5!a's. 5l83ani (5.7. ;6589,5), the medical chie" o"
the hosital o" )a*hdad, %as conce!ned %ith the medical st&d( o" iat!o*enesis, acco!din* to
5l8Nadim in the (ihrist, cha. 7, sec. .. 5t the time o" 5l8Nadim (5.7. 9.5), th!ee 'oo+s and
one lette! o" 5l83ani on the s&':ect %e!e still availa'le: The *ista#es in the +urpose of
+hysiciansM 'n +urging (ever 1atients ,efore the Time )s ipeM The eason "hy the
)gnorant +hysicians, the Common +eople, and the $omen in Cities Are *ore Successfull
Than *en of Science in Treating Certain Diseases and the E/cuses "hich 1h(sicians *a#e
for ThisM and the lette!: G$h( a 0leve! 1h(sician 7oes Not #ave the 1o%e! to #eal 5ll
7iseases, "o! That Is Not $ithin the 3ealm o" the 1ossi'le.G
5> <ee also E!%in #. 5c+e!+necht, GQ&! Oeschichte de! iat!o*enen @!an+heiten,G Oesne/&s
,7 (197>): 5786.. #e distin*&ishes th!ee %aves, o! e!iods, since 175> %hen the st&d( o"
iat!o*enesis %as conside!ed imo!tant '( the medical esta'lishment. E!in #. 5c+e!+necht,
GQ&! Oeschichte de! iat!o*enen E!+!an+&n*en des Ne!vens(stems,G Therapeutische !mschau
S evue thFrapeutique &:, no; ? 29>:BA= 0J@4?; A short survey of medical awareness of the
side4effects of drugs on the central nervous system, starting with Avicenna 2>CB49B0:A on
mercury;
51 L. Me(le!, Side Elects of Drugs ()altimo!e: $illiams V $il+ins, 197,). Adverse
eactions Titles, a monthl( 'i'lio*!ah( o" titles "!om a!oximatel( .,/>> 'iomedical
:o&!nals &'lished th!o&*ho&t the %o!ldR &'lished in 5mste!dam since 1966. Allergy
)nformation ,ulletin, 5lle!*( In"o!mation 5ssociation, $eston, Bnta!io.
5, 1. E. <a!t%ell, GIat!o*enic 7isease: 5n Eidemiolo*ical 1e!sective,G Intonational :o&!nal
of %ealth Services J 2winter 9>:JA= C>4>0;
xxx "otnote! sl&tt xxx
((,7))
six ho&!s, "!om 5> to ;> e!cent o" ad&lts in the 9nited <tates and the 9nited @in*dom
s%allo% a medicall( !esc!i'ed chemical. <ome ta+e the %!on* d!&*R othe!s *et an old o! a
contaminated 'atch, and othe!s a co&nte!"eitR5. othe!s ta+e seve!al d!&*s in dan*e!o&s
com'inationsR5/ and still othe!s !eceive in:ections %ith im!oe!l( ste!ili=ed s(!in*es 55
<ome d!&*s a!e addictive, othe!s m&tilatin*, and othe!s m&ta*enic, altho&*h e!has onl( in
com'ination $ith "ood colo!in* o! insecticides. In some atients, anti'iotics alte! the no!mal
'acte!ial "lo!a and ind&ce a s&e!in"ection, e!mittin* mo!e !esistant o!*anisms to !oli"e!ate
and invade the host. Bthe! d!&*s cont!i'&te to the '!eedin* o" d!&*8!esistant st!ains o"
'acte!ia.56 <&'tle +inds o" oisonin* th&s have s!ead even "aste! than the 'e%ilde!in*
va!iet( and &'iA&it( o" nost!&ms.57 9nnecessa!( s&!*e!( is a standa!d !oced&!e.5;
Disabling nondiseases
/// fotnoter start ///
5. 1ha!mace&tical <ociet( o" O!eat )!itain, )ndenbfuation of Drugs and +oisons (London: the
<ociet(, 1965). 3eo!ts on d!&* ad&lte!ation and anal(sis. Ma!*a!et @!ei*, ,lac# *ar#et
*edicine (En*le%ood 0li""s, NI.: 1!entice8#all, 1967), !eo!ts that an inc!easin* e!centa*e
of a!ticles sold '( le*itimate !o"essional ha!macies a!e ine!t co&nte!"eit d!&*s
indistin*&isha'le in ac+a*in* and !esentation "!om the t!adema!+ed !od&ct.
5/ Mo!ton Mint=, ,y 1!esc!ition 'nly, ,nd ed. ()oston: )eacon 1!ess, 1967). (-o! a "&lle!
desc!ition o" this 'oo+, see 'elo%, note 9;, . 67.) <olomon Oa!', !ndesirable Drug
Inte!actions, 9>:J4:@, !ev. ed. (Ne% No!+: <!in*e!, 1975). Incl&des in"o!mation on
inactivation, incomati'ilit(, otentiation, and lasma 'indin*, as %ell as on inte!"e!ence %ith
elimination, di*estion, and test !oced&!es.
55 ). Bit= and #. #o!n, G?e!hYt&n* iat!o*ene! In"e+tionen 'ei <ch&t=im"&n*en,G
Deutsches $eswsdheitsweseu ,7L,/ (197,): 11.186. Bn in"ections associated %ith
imm&ni=ation !oced&!es.
56 #a!!( N. )eat( and 3o'e!t O. 1ete!edo!", GIat!o*enic -acto!s in In"ectio&s 7isease,G
5nnals of )nternal *edicine 65 (Bcto'e! 1966): 6/1856.
57 Eve!( (ea! a million eole8that is, . to 5 e!cent of all hosital admissions8a!e admitted
!ima!il( 'eca&se o" a ne*ative !eaction to d!&*s. Nicholas $ade, G7!&* 3e*&lation: -75
3elies to 0ha!*es '( Economists and Ind&st!(,G <cience 179 (197.): 77587.
5; E&*ene ?a(da, G5 0oma!ison o" <&!*ical 3ates do 0anada and in En*land and $ales,G
.ew England 3ournal of *edicine ,;9 (197.): 1,,/89, sho%s that s&!*ical !ates in 0anada in
196; %e!e 1.; times *!eate! "o! men and 1.6 times *!eate! "o! %omen than in En*land.
7isc!etiona!( oe!ations s&ch as tonsillectom( and adenoidectom(, hemo!!oidectom(, and
in*&inal he!nio!!ha8
xxx "otnote! sl&tt xxx
((,;))
!es&lt "!om the medical t!eatment o" nonexistent diseases and a!e on the inc!ease:59 the
n&m'e! o" child!en disa'led in Massach&setts th!o&*h the t!eatment o" ca!diac non8disease
exceeds the n&m'e! o" child!en &nde! e""ective t!eatment "o! !eal ca!diac disease. W
7octo!8in"licted ain and in"i!mit( have al%a(s 'een a a!t o" medical !actice.s6 1!o"essional
callo&sness, ne*li8
xxx "otnote! "o!tsette! "!a "o!!i*e side xxx
h( %e!e t%o o! mo!e times hi*he!. 0holec(stectom( !ates %e!e mo!e than "ive times *!eate!.
The main dete!minants ma( 'e di""e!ences in a(ment o" health se!vices and availa'le
hosital 'eds and s&!*eons. 0ha!les E. Le%is, G?a!iations in the Incidence o" <&!*e!(,G .ew
England fowl of *edicine &C9 (1969): CCB4J, "inds th!ee8 to "o&!"old va!iations in !e*ional
!ates "o! six common s&!*ical !oced&!es in the 9.<.5. The n&m'e! o" s&!*eons availa'le %as
"o&nd to 'e the si*ni"icant !edicto! in the incidence o" s&!*e!(. <ee also Iames 0. 7o(le,
G9nnecessa!( #(ste!ectomies: <t&d( o" ?,&JC Be!ations in Thi!t(8"ive #ositals 7&!in*
19/;,G 3ournal of the American *edical Association 151 (195.): .6>85. Iames 0. 7o(le,
G9nnecessa!( Bva!iectomies: <t&d( )ased on the 3emoval o" 7>/ No!mal Bva!ies "!om 5/6
1atients,G 3ournal of the American *edical Association 1/; (195,): 11>5811. Thomas #.
$elle!, G1ediat!ic 1e!cetions: The 1ediat!ician and Iat!ic In"ectio&s 7isease,G 1ediat!ics 51
(5!il 197.): 59586>,.
59 0li"ton Meado!, GThe 5!t and <cience o" Nondisease,G .ew England 3ournal of *edicine
,7, 29>?@A= >&4@; -o! the h(sician acc&stomed to dealin* onl( %ith atholo*ic entities,
te!ms s&ch as Gnondisease entit(G o! GnondiseaseG a!e "o!ei*n and di""ic&lt to com!ehend.
This ae! !esents, %ith ton*&e in chee+, a classi"ication o" nondisease and the imo!tant
the!ae&tic !inciles 'ased on this concet. Iat!o*enic disease !o'a'l( a!ises as o"ten "!om
t!eatment o" nondisease as "!om t!eatment o" disease.
6> 5'!aham ). )e!*man and <tanle( I. <tamm, GThe Mo!'idit( o" 0a!diac Nondisease in
<chool 0hild!en,G .ew England 5ournal of *edicine &:? 29>?:A= 1>>;81.. Oives one
a!tic&la! examle "!om the Glim'o %he!e eole eithe! e!ceive themselves o! a!e e!ceived
'( othe!s to have a nonexistent disease. The ill e""ects accoman(in* some nondiseases a!e as
ext!eme as those accoman(in* thei! co&nte!a!t diseases . . . the amo&nt o" disa'ilit( "!om
ca!diac nondisease in child!en is estimated to 'e *!eate! than that d&e to act&al hea!t disease.G
<ee also I. 5nd!iola, G5 Note on 1ossi'le Iat!o*enesis o" <&icide,G +sychiatry .6 (197.):
&9049C;
61 0linical iat!o*enesis has a lon* histo!(. 1lini&s <ec&nd&s, .aturalis %istoria &>;9>= DTo
protect us against doctors there is no law against ignorance, no e/ample of capital
punishment; Doctors learn at our ris#, they e/periment and #ill with sovereign impunity, in
fact the doctor is the only one who may #ill; They go further and ma#e the patient
responsible= they blame him who has succumbed;D )n fact, oman law already contained
some provisions against medically inflicted torts, Ddamnum in:&!ia dat&m e! medic&m.G
I&!is!&dence in 3ome made the docto! le*all( acco&nta'le not onl( "o! i*no!ance and
!ec+lessness '&t "o! '&m'lin*. 5 docto! %ho oe!ated on a slave '&t did not !oe!l( "ollo%
& his convalescence had to a( the !ice o" the slave and the
xxx "otnote! "o!tsette! E neste side xxx
((,9))
*ence, and shee! incometence a!e a*e8old "o!ms o" mal!actice 6, $ith the t!ans"o!mation
o" the docto! "!om an a!tisan exe!cisin* a s+ill on e!sonall( +no%n individ&als into a
technician al(in* scienti"ic !&les to classes o" atients, mal!actice acA&i!ed an anon(mo&s,
almost !esecta'le stat&s.65 $hat had "o!me!l( 'een conside!ed an a'&se o" con"idence and a
mo!al "a&lt can no% 'e !ationali=ed into the occasional '!ea+do%n o" eA&iment ,and
oe!ato!s. In a comlex technolo*ical hosital, ne*li*ence 'ecomes G!andom h&man e!!o!G o!
Gs(stem '!ea+8do%n,G callo&sness 'ecomes Gscienti"ic detachment,G and incometence
'ecomes Ga lac+ o" seciali=ed eA&iment.G The dee!sonali=ation o" dia*nosis and the!a(
has chan*ed mal!actice "!om an ethical into a technical !o'lem 6/
xxx "otnote! "o!tsette! "!a "o!!i*e side xxx
loos o" the maste!6s income d&!in* his !ot!acted sic+ness. 0iti=ens %e!e not cove!ed '( these
stat&tes, '&t co&ld aven*e mal!actice on thei! o%n initiative.
6, MontesA&ie&, De l1esp,it dis lois, b#; &>, chap; 9J, b (1a!is: 1lTiade, 1951). The 3oman
la%s o!dained that h(sicians sho&ld 'e &nished "o! ne*lect o! lac+ o" s+ill (the 0o!nelian
la%s, De Sicariis, inst. iv. tit. ., de le*e 5A&ila 7). I" the h(sician %as a e!son o" an(
"o!t&ne o! !an+, he %as onl( condemned to deo!tation, '&t i" he %as o" lo% condition he %as
&t to death. In o&! instit&tions it is othe!%ise. The 3oman la%s %e!e not made &nde! the
same ci!c&mstances as o&!s: in 3ome eve!( i*no!ant !etende! meddled %ith h(sic, '&t o&!
h(sicians a!e o'li*ed to *o th!o&*h a !e*&la! co&!se o" st&d( and to ta+e de*!ees, "o! %hich
!eason the( a!e s&osed to &nde!stand thei! !o"ession. In this assa*e the 17th8cent&!(
hilosohe! demonst!ates an enti!el( mode!n otimism a'o&t medical ed&cation.
6. -o! Oe!man inte!nists, the time the atient can send "ace8to8"ace %ith his docto! has no%
'een !ed&ced to 1.7 min&tes e! visit. #ein!ich E!dmann, #ein=8OYnthe! Bve!!ath, and
$ol"*an* and Th&!e 9x+&ll, GB!*anisations!o'leme de! c!=tlichen @!an+enve!so!*&n*:
7a!*estellt am )eisiel eine! medi=inischen 9nive!sitcts+lini+,G Deutsches Ar8teblatt4
Tntliche *itteilungen 71 29>:JA=
./,186. In *ene!al !actice, this time %as (in 196.) a'o&t . min&tes. <ee T. Oe(e!,
6erschwUrung (#ilchen'ach: Medi=inolitische! ?e!la*, 1971), . .>.
6/ -o! the '!oade! iss&e o" *enetic !athe! than individ&al dama*e, see Iohn $. Oo""inan and
5!th&! 3. Tamlin, GEidemiolo*ical <t&dies o" 0a!cino*enesis '( Ioni=in* 3adiation,G in
+roceedings of the Si/th ,er#eley Symposium on *athanatical Statistics and +robability,
!niv; of California, 3uly 9>:B, pp; &0@4::; The presumption is all too common that where
uncertainty e/ists about the magnitude of carcinogenic effects, it is appropriate to continue
the e/posure of humans to the ris#; The authors show that it is neither appropriate nor good
public4health practice to demand human epidemiological evidence before stopping e/posure;
The argument against ioni8ing radiation from nuclear
xxx "otnote! "o!tsette! E neste sdie xxx
((.>))
In 1971, 'et%een 1,,>>> and 15,>>> mal!actice s&its %e!e lod*ed in 9nited <tates co&!ts.
Less than hal" o" all mal!actice claims %e!e settled in less than ei*hteen months, and mo!e
than 1> e!cent o" s&ch claims !emain &nsettled "o! ove! six (ea!s. )et%een sixteen and
t%ent( e!cent o" eve!( dolla! aid in mal!actice ins&!ance %ent to comensate the victimR
the !est %as aid to la%(e!s and medical exe!ts.65 In s&ch cases, docto!s a!e v&lne!a'le onl(
to the cha!*e o" havin* acted a*ainst the medical code, o" the incometent e!"o!mance o"
!esc!i'ed t!eat8ment, o! o" de!eliction o&t o" *!eed o! la=iness. The !o'lem, ho%eve!, is that
most o" the dama*e in"licted '( the mode!n docto! does not "all into an( o" these cate*o!ies .
66 It occ&!s in the o!dina!( !actice o" %ell8t!ained men and %omen %ho have lea!ned to 'o%
to !evailin* !o"essional :&d*ment and !oced&!e, even tho&*h the( +no% (o! co&ld and
sho&ld +no%) %hat dama*e the( do.
The 9nited <tates 7ea!tment o" #ealth, Ed&cation, and $el"a!e calc&lates that 7 e!cent o"
all atients s&""e! comensa'le in:&!ies %hile hositali=ed, tho&*h "e% o" them do an(thin*
a'o&t it. Mo!eove!, the "!eA&enc( o" !eo!ted accidents in hositals is hi*he! than in all
ind&st!ies '&t mines and hi*h8!ise const!&ction. 5ccidents a!e the ma:o! ca&se o" death in
5me!ican child!en. In
xxx "otnote! "o!tsette! "!a "o!!i*e side xxx
*ene!ation o" elect!ical ene!*( can 'e alied to all medical t!eatment in %hich the!e is
&nce!taint( a'o&t *enetic imact. The cometence o" h(sicians to esta'lish levels o"
tole!ance "o! enti!e o&lations m&st 'e A&estioned on theo!etical *!o&nds.
65 -o! data "&!the! 'i'lio*!ah( see 9.<. #o&se o" 3e!esentatives, 0ommittee on Inte!state
and -o!ei*n 0omme!ce, 5n 'seraiaa of *edical *alpractice, 9/th 0on*., 1st <eas., Ma!ch
17, 1975.
66 The malt!eatment o" atients has 'ecome an acceted m&tineR see 0ha!les )&tte!%o!th,
GIat!o*enic Maln&t!ition,G .etritios Today, Ma!ch85!il 197/. Bne o" the la!*est oc+ets o"
&n!eco*ni=ed maln&t!ition in 5me!ica and 0anada exists, not in !&!al sl&ms o! &!'an *hettos,
'&t in the !ivate !ooms and %a!ds df 'i*8cit( hositals. I. Ma(e!, GIat!o*enic Maln&t!ition,G
.ew England 3ournal of *edicine &CJ (1971): 9&9C;
xxx "otnote! sl&tt xxx
((.1))
!oo!tion to the time sent the!e, these accidents seem to occ&! mo!e o"ten in hositals than
in an( othe! +ind o" lace. Bne in "i"t( child!en admitted to a hosital s&""e!s an accident
%hich !eA&i!es seci"ic t!eatment.67 9nive!sit( hositals a!e !elativel( mo!e atho*enic, o!,
in 'l&nt lan*&a*e, mo!e sic+enin*. It has also 'een esta'lished that one o&t o" eve!( "ive
atients admitted to a t(ical !esea!ch hosital acA&i!es an iat!o*enic disease, sometimes
t!ivial, &s&all( !eA&i!in* secial t!eatment, and in one case in thi!t( leadin* to death. #al" o"
these eisodes !es&lt "!om comlications o" d!&* the!a(R ama=in*l(, one in ten comes "!om
dia*nostic !oced&!es.6; 7esite *ood intentions and claims to &'lic se!vice, a milita!(
o""ice! %ith a simila! !eco!d o" e!"o!mance %o&ld 'e !elieved o" his command, and a
!esta&!ant o! am&sement cente! %o&ld 'e closed '( the olice. No %onde! that the health
ind&st!( t!ies to shi"t the 'lame "o! the dama*e ca&sed onto the victim, and that the doe8sheet
o" a m&ltinational ha!mace&tical conce!n tells its !eade!s that Giat!o*enic disease is almost
al%a(s o" ne&!otic o!i*in.G 69
-efenseless Patients
The &ndesi!a'le side8e""ects o" a!oved, mista+en, callo&s, o! cont!aindicated technical
contacts %ith the medical s(stem !e!esent :&st the "i!st level o" atho*enic medicine. <&ch
clinical iatrogenesis incl&des not onl( the dama*e that docto!s in"lict %ith the intent o" c&!in*
o! o" exloitin* the atient, '&t also those othe! to!ts that !es&lt "!om the docto!6s attemt to
!otect himsel" a*ainst the
xxx "otnote! sta!t xxx
67 Oeo!*e #. Lo%!e(, GThe 1!o'lem o" #osital 5ccidents to 0hild!en,G +ediatrics .,
(7ecem'e! 196.): 1>6/8;.
6; I. T. McLam' and 3. 3. #&ntle(, GThe #a=a!ds o" #ositali=ation,G <o&the!n *edical
:o&!nal 6> (Ma( 1967): /6987,.
69 La maladie iat!o*Xne est !esA&e to&:o&!s d 'ase nTv!otiA&eG: L. Is!ael, GLa Maladie
iat!o*Xne,G in 7oc&menta <ando=, n.d.
xxx "otnote! sl&tt xxx
((.,))
ossi'ilit( o" a s&it "o! mal!actice. <&ch attemts to avoid liti*ation and !osec&tion ma(
no% do mo!e dama*e than an( othe! iat!o*enic stim&l&s.
Bn a second level,7> medical !actice sonso!s sic+ness '( !ein"o!cin* a mo!'id societ( that
enco&!a*es eole to 'ecome cons&me!s o" c&!ative, !eventive, ind&st!ial, and
envi!onmental medicine. Bn the one hand de"ectives s&!vive in inc!easin* n&m'e!s and a!e "it
onl( "o! li"e &nde! instit&tional ca!e, %hile on the othe! hand, medicall( ce!ti"ied s(mtoms
exemt eole "!om ind&st!ial %o!+ and the!e'( !emove them "!om the scene o" olitical
st!&**le to !eshae the societ( that has made them sic+. <econd8level iat!o*enesis "inds its
ex!ession in va!io&s s(mtoms o" social ove!medicali=ation that amo&nt to %hat I shall call
the ex!o!iation o" health. This second8level imact o" medicine I desi*nate as social
iatrogenesis, and I shall disc&ss it in 1a!t II.
Bn a thi!d level, the so8called health !o"essions have an even deee!, c&lt&!all( health8
den(in* e""ect inso"a! as the( dest!o( the otential o" eole to deal %ith thei! h&man
%ea+ness, v&lne!a'ilit(, and &niA&eness in a e!sonal and a&tonomo&s %a(. The atient in the
*!i o" contemo!a!( medicine is '&t one instance o" man+ind in the *!i o" its e!nicio&s
techniA&es.71 This cultural iatrogen4
xxx "otnote! sta!t xxx
7> The distinction o" seve!al levels o" iat!o*enesis %as made '( 3alh 5&d(, GMan8made
Maladies and Medicine,G California *edicine, Novem'e! 197>, . /;85.. #e !eco*ni=es that
iat!o*enic GdiseasesG a!e onl( one t(e o" man8made malad(. 5cco!din* to thei! etiolo*(,
the( "all into seve!al cate*o!ies: those !es&ltin* "!om dia*nosis and t!eatment, those !elatin* to
social and s(cholo*ical attit&des and sit&ations, and those !es&ltin* "!om man8made
!o*!ams "o! the cont!ol and e!adication o" disease. )esides iat!o*enic clinical entities, he
!eco*ni=es othe! maladies that have a medical etiolo*(.
71 7as <chic+sal des @!an+en ve!+Z!e!t als <(m'ol das <chic+sal de! Menschheit im
<tadi&m eine! technischen $eltent%ic+l&n*G: $ol"*an* Iaco', Der #ran#e *ensch in der
technischen "elt, )P; )nternationaler (ortbildungs#urs fGr pra#tische und wissenschaftliche
+harma8ie der ,undesapothe#er#ammer in *eran 2(ran#furt am *ain= "erbe4 und
6ertriebsgesellschaft Deutscher Apothe#er, 9>:9A;
xxx "otnote! sl&tt xxx
((..))
esis, %hich I shall disc&ss in 1a!t III, is the &ltimate 'ac+lash o" h(*ienic !o*!ess and
consists in the a!al(sis o" health( !esonses to s&""e!in*, imai!ment, and death. It occ&!s
%hen eole accet health mana*ement de8si*ned on the en*inee!in* model, %hen the(
consi!e in an attemt to !od&ce, as i" it %e!e a commodit(, somethin* called G'ette! health.G
This inevita'l( !es&lts in the mana*ed maintenance o" li"e on hi*h levels o" s&'lethal illness.
This &ltimate evil o" medical G!o*!essG m&st 'e clea!l( distin*&ished "!om 'oth clinical and
social iat!o*enesis.
I hoe to sho% that on each o" its th!ee levels iat!o*enesis has 'ecome medicall( i!!eve!si'le:
a "eat&!e '&ilt !i*ht into the medical endeavo!. The &n%anted h(siolo*ical, social, and
s(cholo*ical '(8!od&cts o" dia*nostic and the!ae&tic !o*!ess have 'ecome !esistant to
medical !emedies. Ne% devices, a!oaches, and o!*ani=ational a!!an*ements, %hich a!e
conceived as !emedies "o! clinical and social iat!o*enesis, themselves tend to 'ecome
atho*ens cont!i'&tin* to the ne% eidemic. Technical and mana*e!ial meas&!es ta+en on an(
level to avoid dama*in* the atient '( his t!eatment tend to en*ende! a sel"8!ein"o!cin*
iat!o*enic loo analo*o&s to the escalatin* dest!&ction *ene!ated '( the oll&tin* !oced&!es
&sed as antioll&tion devices.7,
I %ill desi*nate this sel"8!ein"o!cin* loo o" ne*ative instit&tional "eed'ac+ '( its classical
O!ee+ eA&ivalent and call it medical nemesis; The O!ee+s sa% *ods in the "o!ces o" nat&!e.
-o! them, nemesis !e!esented divine ven*eance
xxx "otnote!sta!t xxx
7,Iames ). 2&inn, GNext )i* Ind&st!(: Envi!onmental Im!ovement,G %arvard bra eisu, J>
(<etem'e!8Bcto'e! 1971): 1,>8.>. #e 'elieves that envi!onmental im!ovement is 'ecomin*
a d(namic and !o"ita'le se!ies o" ma!+ets "o! ind&st!( that a( "o! themselves and in the end
%ill !e!esent an imo!tant addition to income and ON1. Imlicitl( the same a!*&ment is
'ein* made "o! the health8ca!e "ield '( the !oonents o" no8"a&lt mal!actice ins&!ance.
xxx "otnote sta!t xxx
((./))
visited &on mo!tals %ho in"!in*e on those !e!o*atives the *ods envio&sl( *&a!d "o!
themselves. Nemesis %as the inevita'le &nishment "o! attemts to 'e a he!o !athe! than a
h&man 'ein*. Li+e most a'st!act O!ee+ no&ns, Nemesis too+ the shae o" a divinit(. <he
!e!esented nat&!e6s !esonse to hubris= to the individ&al6s !es&mtion in see+in* to acA&i!e
the att!i'&tes o" a *od. B&! contemo!a!( h(*ienic h&'!is has led to the ne% s(nd!ome o"
medical nemesis.7.
)( &sin* the O!ee+ te!m I %ant to emhasi=e that the co!!esondin* henomenon does not "it
%ithin the exlanato!( a!adi*m no% o""e!ed '( '&!ea&c!ats, the!aists, and ideolo*&es "o!
the sno%'allin* diseconomies and dis&tilities that, lac+in* all int&ition, the( have en*inee!ed
and that the( tend to call the Gco&nte!int&itive 'ehavio! o" la!*e s(stems.G )( invo+in* m(ths
and ancest!al *ods I sho&ld ma+e it clea! that m( "!ame%o!+ "o! anal(sis o" the c&!!ent
'!ea+do%n o" medicine is "o!ei*n to the ind&st!iall( dete!mined lo*ic and ethos. I 'elieve that
the reversal of nemesis can come onl( "!om %ithin man and not "!om (et anothe! mana*ed
(hete!onomo&s) so&!ce deendin* once a*ain on !es&mtio&s exe!tise and s&'seA&ent
m(sti"ication.
Medical nemesis is !esistant to medical !emedies. It can 'e !eve!sed onl( th!o&*h a !ecove!(
o" the %ill to sel"8ca!e amon* the lait(, and th!o&*h.. the le*al, olitical, and instit&tional
!eco*nition o" the !i*ht to ca!e, %hich imoses limits &on the !o"essional monool( o"
h(sicians. M( "inal chate! !ooses *&idelines "o! stemmin* medical nemesis and !ovides
c!ite!ia '( %hich the medical ente!!ise can 'e +et %ithin health( 'o&nds. I do not s&**est
an( seci"ic "o!ms o" health ca!e o!
xxx "otnote! sta!t xxx
7. The te!m %as &sed '( #ono!T 7a&mie! (1;1>879). <ee !e!od&ction o" his d!a%in*
GNTmTsis mTdicaleG in $e!ne! )loc+, Der Amt und der Tod in ,ildren aas sechs
(ahrhunderten (<t&tt*a!t: En+e, 1966).
xxx "otnote! sl&tt xxx
((.5))
sic+8ca!e, and I do not advocate an( ne% medical hilosoh( an( mo!e than I !ecommend
!emedies "o! medical techniA&e, doct!ine, o! o!*ani=ation. #o%eve!, I do !oose an
alte!native a!oach to the &se o" medical o!*ani=ation and technolo*( to*ethe! %ith the
allied '&!ea&c!acies and ill&sions.
((.6))
P)%, II.Social Iatrogenesis
((.7))
((.;))
1. ,he &edicali2ation of 3ife
Political ,ransmission of Iatrogenic -isease
9ntil !ecentl( medicine attemted to enhance %hat occ&!s in nat&!e. It "oste!ed the tendenc(
o" %o&nds to heal, o" 'lood to clot, and o" 'acte!ia to 'e ove!come '( nat&!al imm&nit(. 1
No% medicine t!ies to en*inee! the d!eams o" !eason., B!al cont!acetives, "o! instance, a!e
!esc!i'ed Gto !event a no!mal occ&!!ence in health( e!sons.G . The!aies ind&ce the
o!*anism to inte!act %ith molec&les o! %ith machines in %a(s "o! %hich the!e is no !ecedent
in evol&tion. O!a"ts involve the o&t!i*ht o'lite!ation o" *eneticall( !o*!ammed
imm&nolo*ical de"enses./ The !elationshi 'et%een the inte!est o" the atient and the s&ccess
o" each secialist %ho mani&lates one o" his GconditionsG can th&s no lon*e! 'e ass&medR it
m&st no%
xxx "otnote! sta!t xxx
1 I&dith 1. <%a=e( and 3enTe -ox, GThe 0linical Mo!ato!i&m: 5 0ase <t&d( o" Mit!al ?alve
<&!*e!(,G in 1a&l 5. -!e&nd, ed., E/perimentatio& %ith #&man Sub5ects (Ne% No!+:
)!a=ille!, 197>), . .15857.
, -!ancisco Oo(a, in Los Caprichos, the se!ies o" etchin*s o" 17;6, sho%s a man aslee at his
des+ %ith his head on his c!ossed a!ms, %hile monste!s s&!!o&nd him. The insc!ition on the
des+ !eads, GEl s&eeo de la !a=_n !od&ce monst!&os.G 3enT 7&'os &ses this ict&!e as
"!ontisiece o" his 'oo+ The *irage of %ealth 2see above, note 0, p; 90A; )t encapsulates his
thesis, on which ) try to elaborate in the present boo#;
. Mo!ton Mint=, The +illV 5n Alarming eport ()oston: )eacon 1!ess, 197>). Model "o! a
st&d( of medicine '( a ne%sae! !eo!te! %ho +no%s ho% to com'ine st&dies in medicine
%ith in"o!mation that is si*ni"icant '&t has 'een ove!loo+ed, !e!essed, o! veiled in medical
lite!at&!e.
/ -!ancis 7. Moo!e, GThe The!ae&tic Innovation: Ethical )o&nda!ies in the Initial 0linical
T!ials o" Ne% 7!&*s and <&!*ical 1!oced&!es,G in -!e&nd, ed., E/perimentation with %uman
Sub5ects, pp; 0@C4:C;
xxx "otnote! sl&tt xxx
((.9))
'e !oved, and the net cont!i'&tion o" medicine to societ(6s '&!den o" disease m&st 'e
assessed "!om %itho&t the !o"ession5 )&t an( cha!*e a*ainst medicine "o! the clinical
dama*e it ca&ses constit&tes onl( the "i!st ste in the indictment o" atho*enic medicine.6 The
t!ail 'eaten in the ha!vest is onl( a !eminde! o" the *!eate! dama*e done '( the 'a!on to the
villa*e that his h&nt ove!!&ns.
Social Iatrogenesis
Medicine &nde!mines health not onl( th!o&*h di!ect a**!ession a*ainst individ&als '&t also
th!o&*h the imact o" its social o!*ani=ation on the total milie&. $hen medical dama*e to
individ&al health is !od&ced '( a socioolitical mode o" t!ansmission, I %ill sea+ o" Gsocial
iat!o*enesis,G a te!m desi*natin* all imai!ments to health that a!e d&e !ecisel( to those
socio8economic t!ans"o!mations %hich have 'een made att!active, ossi'le, o! necessa!( '(
the instit&tional shae health ca!e has ta+en.
xxx "otnote! sta!t xxx
5 Bne examle o" the need "o! s&ch o&tside cont!ol . ove! !o"essional !o*!ess mi*ht 'e
&se"&l. 1ete! 3. )!e**in, GThe 3et&!n o" Lo'otom( and 1s(chos&!*e!(,G 0on*!essional
ecord 11; (-e'!&a!( ,/, 197,): 5567877, !esents a t!&l( shoc+in* !evie% o" the vast
lite!at&!e on the c&!!ent !es&!*ence o" lo'otom( in the 9.<. and a!o&nd the %o!ld. The "i!st
%ave %as aimed mostl( (f) at "emale state hosital atients, and claimed 5>,>>> e!sons in
the 9.<. alone 'e"o!e 196/. Ne% methods a!e availa'le to dest!o( a!ts o" the '!ain '(
&lt!asonic %aves, elect!ic coa*&lation, and imlantation o" !adi&m seeds. The techniA&e is
!omoted "o! the sedation o" the elde!l(, to !ende! thei! instit&tionali=ation less exensiveR "o!
the cont!ol o" h(e!active child!enR and to !ed&ce e!otic "antasies and the tendenc( to *am'le.
6 Each societ( has its cha!acte!istic Gnosolo*(,G o! classi"ication o" diseases. )oth the extent
o" conditions classi"ied as disease and the n&m'e! and +inds o" diseases listed chan*e %ith
histo!(. The official o! medical nosolo*( !eco*ni=ed in a societ( can 'e to a ve!( hi*h de*!ee
o&t o" *ea! %ith the e!cetion o" the disease sha!ed '( one o! seve!al o" the societ(6s classes.
<ee Michel -o&ca&lt, The ,irth of the Clinic, t!ans. 5. M. <he!idan <mith (Ne% No!+:
1antheon, 197.). In o&! societ( nosolo*( is almost totall( medicali=edR ill8health that is not
la'eled '( the h(sician is %!itten o"" eithe! as malin*e!in* o! as ill&sion. 5s lon* as
iat!o*enic disease is t!eated as one small cate*o!( %ithin the esta'lished nosolo*(, its
cont!i'&tion to the total vol&me o" !eco*ni=ed diseases %ill not 'e a!eciated.
xxx "otnote! sl&tt xxx
((/>))
<ocial iat!o*enesis desi*nates a cate*o!( o" etiolo*( that encomasses man( "o!ms. It o'tains
%hen medical '&!ea&c!ac( c!eates ill8health '( inc!easin* st!ess, '( m&lti8l(in* disa'lin*
deendence, '( *ene!atin* ne% ain"&l needs, '( lo%e!in* the levels o" tole!ance "o!
discom"o!t o! ain, '( !ed&cin* the lee%a( that eole a!e %ont to concede to an individ&al
%hen he s&""e!s, and '( a'olishin* even the !i*ht to sel"8ca!e. <ocial iat!o*enesis is at %o!+
%hen health ca!e is t&!ned into a standa!di=ed item, a staleR %hen all s&""e!in* is
Ghositali=edG and homes 'ecome inhosita'le to 'i!th, sic+ness, and deathR %hen the
lan*&a*e in %hich eole co&ld exe!ience thei! 'odies is t&!ned into '&!ea&c!atic
*o''lede*oo+R o! %hen s&""e!in*, mo&!nin*, and healin* o&tside the atient !ole a!e la'eled a
"o!m o" deviance.
&edical &onopoly
Li+e its clinical co&nte!a!t, social inat!o*enesis can escalate "!om an adventitio&s "eat&!e into
an inhe!ent cha!acte!istic o" the medical s(stem. $hen the intensit(7 o" 'iomedical
inte!vention c!osses a c!itical th!eshold, clinical iat!o*enesis t&!ns "!om e!!o!, accident, o!
"a&lt into an inc&!a'le e!ve!sion o" medical !actice. In the same %a(, %hen !o"essional
a&tonom( de*ene!ates into a !adical monool(; and eole a!e !ende!ed imotent to coe
%ith thei! milie&, social iat!o*enesis 'ecomes the main !od&ct o" the medical o!*ani=ation.
xxx "otnote! sta!t xxx
7 I &se the te!m Gintensit(G to desi*nate an inc!ease that can 'e ma!+ed '( n&m'e!s '&t not
meas&!ed di!ectl(. 1a!al(=in* "ea!, is '( no means s&e!io! to a lesse! "ea! that d!ives to
"li*ht. -e!nand 3enoit!e, Elements de critique des sciences et ds counologie, course published
by the Instit&t <&T!ie&! de 1hilosohie, Lo&vain, 19/7, . 1,98.>.
; -o! a mo!e s(stematic anal(sis o" the te!m G!adical monool(G as alied to !o"essional
instit&tions, see Ivan Illich, ToofsforConvivialit 6London: 0alde! V )o(a!s, 197.), cha. .,
sec. ,, . 5187.
xxx "otnote! sl&tt xxx
((/1))
5 !adical monool( *oes deee! than that o" an( one co!o!ation o! an( one *ove!nment. It
can ta+e man( "o!ms. $hen cities a!e '&ilt a!o&nd vehicles, the( deval&e h&man "eetR %hen
schools !e8emt lea!nin*, the( deval&e the a&todidactR %hen hositals d!a"t all those %ho a!e
in c!itical condition, the( imose on societ( a ne% "o!m o" d(in*. B!dina!( monoolies co!ne!
the ma!+etR9 !adical monoolies disa'le eole "!om doin* o! ma+in* thin*s on thei! o%n.1>
The comme!cial monool( !est!icts the "lo% o" commoditiesR the mo!e insidio&s social
monool( a!al(=es the o&t&t o" nonma!+eta'le &se8val&es. 11 3adical monoolies imin*e
still "&!the! on "!eedom and indeendence. The( imose a societ(8%ide s&'stit&tion o"
commodities "o! &se8val&es '( !eshain* the milie& and '( Ga!o!iatin*G those o" its
*ene!al cha!acte!istics %hich have ena'led eole so "a! to coe on thei! o%n. Intensive
ed&cation t&!ns a&todidacts into &nemlo(a'les, intensive a*!ic&lt&!e dest!o(s the s&'sistence
"a!me!, and the delo(ment o" olice &nde!mines the comm&nit(6s sel"8cont!ol. The mali*nant
s!ead o" medicine has coma!a'le !es&lts: it t&!ns m&t&al ca!e and sel"8medication into
misdemeano!s o! "elonies. I&st as clinical iat!o*enesis 'ecomes medicall( inc&!a'le %hen it
!eaches a c!itical intensit( and then can 'e !eve!sed onl( '( a decline o" the ente!!ise, so can
social iat!o*enesis 'e !eve!sed onl( '( olitical action that !et!enches !o"essional
dominance.
xxx "otnote! sta!t xxx
9 5n examle: 9ntil a'o&t 1969, enicillin O ta'lets %e!e availa'le in Mexican ha!macies
&nde! thei! *ene!ic name at a ve!( lo% !ice. The( have since disaea!ed "!om the ma!+et.
The (armacopea *e/icans does not list any oral penicillin $ even in trademar#
preparations; 'nly considerably more e/pensive preparations are available;
1> Iohn )la+e, ed., Safeguarding the +ublic= %istorical Aspects of *edical Drug 0ost!&l,
1ae!s "!om a 0on"e!ence <onso!ed '( the National Li'!a!( o" Medicine ()altimo!e: :ohns
#o+ins, 197>). Bn the !ocess '( %hich the medical !o"ession develoed its sel"8ima*e o"
'enevolent ca!eta+e!, see L. Edelstein, The %ippocratic 'ath ()altimo!e: Iohns #o+ins,
19/.).
1 1 -o! the classic distinction 'et%een exchan*e8val&e and &se8val&e cons&lt @a!l Ma!x,
Capita-2Chicago= @e!!, 191,), vol. 1, cha. 1, eseciall( sec. /.
xxx "otnote! sl&tt xxx
((/,))
5 !adical monool( "eeds on itsel". lat!o*enic medicine !ein"o!ces a mo!'id societ( in %hich
social cont!ol o" the o&lation '( the medical s(stem t&!ns into a !incial economic
activit(. It se!ves to le*itimi=e social a!!an*ements into %hich man( eole do not "it. It
la'els the handicaed as &n"it and '!eeds eve! ne% cate*o!ies o" atients. 1eole %ho a!e
an*e!ed, sic+ened, and imai!ed '( thei! ind&st!ial la'o! and leis&!e can escae onl( into a
li"e &nde! medical s&e!vision and a!e the!e'( sed&ced o! disA&ali"ied "!om olitical st!&**le
"o! a healthie! %o!ld.1,
<ocial iat!o*enesis is not (et acceted as a common etiolo*( o" disease. I" it %e!e !eco*ni=ed
that dia*nosis o"ten se!ves as a means o" t&!nin* olitical comlaints a*ainst the st!ess o"
*!o%th into demands "o! mo!e the!aies that a!e :&st mo!e o" its costl( and st!ess"&l o&t&ts,
the ind&st!ial s(stem %o&ld lose one o" its ma:o! de"enses. 1. 5t the same time, a%a!eness o"
the de*!ee to %hich iat!o*enic ill8health is oliticall( comm&nicated %o&ld sha+e the
"o&ndations o" medical o%e! m&ch mo!e !o"o&ndl( than an( catalo*&e o" medicine6s
technical "a&lts.1/
xxx "otnote! sta!t xxx
1, Michel )osA&et, G2&and la mTdecine !end malade: La Te!!i'le 5cc&sation d6&n *!o&e
d6exe!ts,G -e .ouvel 'bservateur, no. 519 (197/), . ;/811;, and no. 5,> (197/), . 9>8
1.>. This a!ticle sho%s ho% social iat!o*enesis is "&ndamentall( the !es&lt o" the ali'i
"&nction la(ed '( the !o"essional monool( o" the sic+8!ole.
1. 1a&l .3amse(, (abricated Man: The Ethics of $enetic Control 2.ew #aven,
0onn.: Nale 9niv. 1!ess, 197>), 5!*&es that the!e a!e thin*s %e can do %hich o&*ht not to 'e
done. To excl&de these thin*s is a necessa!( condition "o! sa"e*&a!din* man "!om total
a'asement '( technical cont!ol. 3amse( !eaches this concl&sion a'o&t seci"ic +inds o"
medical techniA&es. I ma+e the same a!*&ment, '&t a'o&t the *lo'al intensit( o" the medical
endeavo!.
1/ 1. M. )!&netti, G#ealth in Ecolo*ical 1e!sective,G Ada 1/ iat!ica <cand navica /9, "asc. /
(197.): .9.8/>/. )!&netti a!*&es that the concent!ation o" o%e! and the deendence on
ext!ameta'olic ene!*( can ma+e the vital milie& &ninha'ita'le "o! 'ein*s %hose inte*!ation
deends on the exe!cise o" thei! a&tonom(. Medicine is &sed to !ationali=e this t!ans"e!.
xxx "otnote! sl&tt xxx
((/.))
4alue free Cure(
The iss&e o" social iat!o*enesis is o"ten con"&sed %ith the dia*nostic a&tho!it( o" the heale!.
To de"&se the iss&e and to !otect thei! !e&tation, some h(sicians insist on the o'vio&s:
namel(, that medicine cannot 'e !acticed %itho&t the iat!o*enic c!eation o" disease.
Medicine al8%a(s c!eates illness as a social state.15 The !eco*ni=ed heale! t!ansmits to
individ&als the social ossi'ilities "o! actin* sic+.16 Each c&lt&!e has its o%n cha!acte!istic
e!cetion o" disease17 and th&s its &niA&e h(*ienic mas+.1; 7isease ta+es its "eat&!es "!om
the h(sician %ho casts the acto!s into one o" the availa'le !oles.19 To ma+e eole
le*itimatel( sic+ is as imlicit in the h(sician6s o%e! as the oisono&s otential o" the
!emed( that %o!+s.,W The medicine man commands oisons and
xxx "otnote! sta!t xxx
15 3enTe -ox, GIllness,G in Inte!national Encyclopedia of the <ocial Sciences (196;), 7: 9>86.
5n excellent int!od&ction to the evol&tion o" this concet.
16 Talcott 1a!sons, The Social System 2.ew <or#= (ree +ress, 9>@9A, pp; J&C if;, contains the
classic formulation of the sic#4role; *iriam Siegler and %umphrey Bsmond, *odels of
*adness, *odels of *edicine (Ne% No!+: Macmillan, "o!thcomin*) coma!e seve!al models
"o! disa'lin* deviance and lead, "o! olitical !easons, "o! the !elative exansion o" the
1a!sonian sic+ !ole on the *!o&nds that it alone c!eates a claim to the!a(. -o! the cont!a!(
lea see Niels 0h!istie6s still &ntitled "o!thcomin* 'oo+ on the co&nte!!od&ctivit( o" the!a(.
(-o! man&sc!it, %!ite to Niels 0h!istie, -ac&lt( o" La% and I&!is!&dence, 9nive!sit( o"
Bslo.)
17 -o!!est E. 0lements, G1!imitive 0oncets o" 7isease,G !niversity o" 0ali"o!nia
1&'lications in American Archaeology and Ethnology .,, no. , (19.,): 1;58,5,. 0ommon
etiolo*ies "all into "o&! main cate*o!ies: (1) so!ce!(, (,) '!each o" ta'oo, (.) int!&sion o"
"o!ei*n o':ect, (/) loss o" so&l.
1; Eliot -!eidson, G7isa'ilit( as 7eviance,G in M. ). <&ssman, ed., Sociology and
ehabilitation ($ashin*ton: 5me!ican <ociolo*ical 5ssociation, 1966), . 71899.
1!o"essional dia*nosis tends me!el( to *ive validit( to la( e!cetions o" the val&e att!i'&ted
to ce!tain individ&als.
19 #a!old Oa!"in+el, G0onditions o" <&ccess"&l 7e*!adation 0e!emonies,G 5me!ican 3ournal
of Sociology 61 (Ma!ch 1956): /,>8//. In o&! societ( &'lic de*!adation ce!emonies o&tside
the co&!ts a!e !athe! !a!e. )&t medicine even toda( &ts &'lic eval&ation on cha!acte!istics
conside!ed as essential as sel"8cont!ol o! sex&alit(.
,> Lo&is Le%in, The !ntoward Elects of Drugs, t!ans. $. T. 5lexand!e (7et!oit: 7avis,
1;;.). Not%ithstandin* its ea!l( date, this !emains a "ascinatin* 'oo+ to !ead, "&ll o" histo!ical
"ootnotes. It lists victims o" medicine "!om Ne!o6s *&a!d catain (<anish "l() to Btto II
(aloes), and 5vicenna (ee! enema).
xxx "otnote! sl&tt xxx
((//))
cha!ms. The O!ee+s6 onl( %o!d "o! GdrugG44pharma#on4 did not distin*&ish 'et%een the
o%e! to c&!e and the o%e! to +ill.,1
Medicine is a mo!al ente!!ise and the!e"o!e inevita'l( *ives content to *ood and evil. In
eve!( societ(, medicine, li+e la% and !eli*ion, de"ines %hat is no!mal, !oe!, o! desi!a'le.
Medicine has the a&tho!it( to la'el one man6s comlaint a le*itimate illness, to decla!e a
second man sic+ tho&*h he himsel" does not comlain, and to !e"&se a thi!d social !eco*nition
o" his ain, his disa'ilit(, and even his death.,, It is medicine %hich stams some ain as
Gme!el( s&':ective,G ,. some imai!ment as malin*e!in*,,/ and some deaths8tho&*h not
othe!s8as s&icide.,5 The
xxx "otnote! sta!t xxx
,1 Bn the do&'le meanin* o" this te!m "!om a!chaic texts to the #ioc!atic co!&s, see
$alte! 5!telt, Studien 8ur $eschichte der ,egri3 G#eilmittelG ta&t GOi"tg: 9!=eit8#ome!8
0o!&s #ioc!alician (7a!mstadt: $issenscha"tliche )&ch*eeelL8cha"t, 196;). Iohn 7.
Oimlette, *alay +oisons and 0ha!m Cures (@&ala L&m&!: Bx"o!d 9niv. 1!ess, 1971)R Iohn
7. Oimlette and #. $. Thomson, 5 Dictionary of *alayan *edicine (@&ala L&m&!:
Bx"o!d 9niv. 1!ess, 1971): 'oth vol&mes "o!m a "ascinatin* int!od&ction to the same
am'i*&it( in an enti!el( di""e!ent %o!ld.
,, I&dith Lo!'e!, G7eviance as 1e!"o!mance: The 0ase o" Illness,G in Eliot -!eidson and
I&dith Lo!'e!, eds., *edical *en and Thei! "or# (0hica*o: 5ldine, 197,), . /1/8,..
7isc&sses the attemts o" the deviant e!son to conve( the im!ession %hich he hoes %ill
lead to the imosition o" a ce!tain la'el !athe! than anothe!.
,. Thomas <. <=as=, GThe 1s(cholo*( o" 1e!sistent 1ain: 5 1o!t!ait o" l6#omme
7o&lo&!e&x,G in 5. <o&lai!ac, I. 0ahn, and I. 0ha!entie!, eds. +ain, 1!oceedin*s o" the
Inte!national <(mosi&m B!*ani=ed '( the La'o!ato!( o" 1s(choh(siolo*(, -ac&lt( o"
<ciences, 1a!is, 5!il 1181., 1967 (Ne% No!+: 5cademic 1!ess, 196;), . 9.811..
,/ Ma!+ O. -ield, G<t!&ct&!ed <t!ain in the 3ole o" the <oviet 1h(sician,G American 3ournal
of Sociology, 5; (195.): /9.85>,. 7esc!i'es a sit&ation in %hich the *ove!nment !ationed sic+
asses, %hich %e!e in *!eat demand '( ove!8st!ained %o!+e!s. 1h(sicians %e!e "o!ced to
!ead:&st the de"inition o" sic+ness to 'alance the inte!est o" the %o!+e!s a*ainst the demands
o" the !od&ction !ocess. Thomas <. <=as=, GMalin*e!in*: 7ia*nosis o! <ocial
0ondemnation4G in -!eidson, and Lo!'e!, eds., *edical *en and Their "or#, . .5.86;.
,5 Ed%in <. <hneidman, GB!ientations To%a!ds 7eath: 5 ?ital 5sect o" the <t&d( o" Lives,G
in 3o'e!t $. $hite, ed., The Study of -ives= Essays on +ersonality in %onor of A; *urray
(Ne% No!+: 5the!ton, 196.). -o! the classi"ication o" death '( intention and le*itimac( and
"&!the! lite!at&!e on the s&':ect, see O!e*o!( Qil'oo!*, G<&icide 5mon* 0ivili=ed and
1!imitive 3aces,G American 3ournal of 1s(chiat!( 9, (Ma( 19.6): 1./7869.
xxx "otnote! sl&tt xxx
((/5))
:&d*e dete!mines %hat is le*al and %ho is *&ilt(.,6 The !iest decla!es %hat is hol( and %ho
has '!o+en a ta'oo. The h(sician decides %hat is a s(mtom and %ho is sic+. #e is a mo!al
ent!e!ene&!,,7 cha!*ed %ith inA&isito!ial o%e!s to discove! ce!tain %!on*s to 'e !i*hted.,;
Medicine, li+e all c!&sades, c!eates a ne% *!o& o" o&tside!s each time it ma+es a ne%
dia*nosis stic+.,9 Mo!alit( is as imlicit in sic+ness as it is in c!ime o! in sin.
In !imitive societies it is o'vio&s that in the exe!cise o" medical s+ill, the !eco*nition o"
mo!al o%e! is imlied. No'od( %o&ld s&mmon the medicine man &nless he conceded to him
the s+ill o" disce!nin* evil si!its "!om *ood ones. In a hi*he! civili=ation this o%e! exands.
#e!e medicine is exe!cised '( "&ll8time secialists %ho cont!ol la!*e o&lations '( means o"
'&!ea&c!atic instit&tions..> These secialists "o!m !o"essions %hich exe!cise a &niA&e +ind
o" cont!ol ove! thei! o%n %o!+..1 9nli+e &nions, these !o"essions o%e thei! a&tonom( to a
*!ant o" con"idence !athe! than to victo!( in a st!&**le. 9nli+e *&ilds, %hich dete!mine onl(
%ho shall %o!+ and ho%, the( dete!mine also %hat %o!+ shall 'e done. In the 9nited <tates
the medical !o"ession o%es this s&!eme
xxx "otnote! sta!t xxx
,6 1ha!macists, "o! instance, %ill not 'e condemned "o! oisonin* thei! clients. <ee Ea!l 3.
2&inne(, GBcc&ational <t!&ct&!e and 0!iminal )ehavio!: 1!esc!ition ?iolation '( 3etail
1ha!macists,G Social +roblems 11 (196.): 1798;5.
,7 #o%a!d <. )ec+e!, 'utsiders= <t&dies in the Sociology of Deviance (Ne% No!+:
-!ee 1!ess, 196.). 0la!i"ies the connection 'et%een the the!ae&tic o!ientation o" an
occ&ation o! !o"ession and Gent!e!ene&!shi.G
,; Ioseh 3. O&s"ield, G<ocial <t!&ct&!e and Mo!al 3e"o!m: 5 <t&d( o" the $oman6s
0h!istian Teme!ance 9nion,G American 3ournal of Sociology 61 (Novem'e! 1955): ,,18.,.
Mo!al c!&sade!s a!e al%a(s o'sessed %ith im!ovin* those %hom the( set o&t to 'ene"it.
,9 -!an+ Tannen'a&m, Crime and the Community (Ne% No!+: 0ol&m'ia 9niv. 1!ess, 19.;).
.> $il'e!t Moo!e and Oe!ald $. 3osen'l&m, The +rufessions= oles and ules (Ne% No!+:
3&ssell <a*e, 197>). <ee eseciall( cha. . o" this com!ehensive *&ide to the lite!at&!e, GThe
1!o"essionali=ation o" Bcc&ations.G
.1 $illiam I. Ooode, GEnc!oachment, 0ha!latanism, and the Eme!*in* 1!o"essions:
1s(cholo*(, Medicine, and <ociolo*(,G American Sociological eview ,5 (7ecem'e! 196>):
9>,81/.
xxx "otnote! sl&tt xxx
((/6))
a&tho!it( to a !e"o!m o" the medical schools :&st 'e"o!e $o!ld $a! I. The medical !o"ession
is a mani"estation in one a!tic&la! secto! o" the cont!ol ove! the st!&ct&!e o" class o%e!
%hich the &nive!sit(8t!ained elites have acA&i!ed. Bnl( docto!s no% G+no%G %hat constit&tes
sic+ness, %ho is sic+, and %hat shall 'e done to the sic+ and to those %hom the( conside! at a
special ris#; 1a!adoxicall(, $este!n medicine, %hich has insisted on +eein* its o%e! aa!t
"!om la% and !eli*ion, has no% exanded it 'e(ond !ecedent. In some ind&st!ial societies
social la'elin* has 'een medicali=ed to the oint %he!e all deviance has to have a medical
la'el. The eclise o" the exlicit mo!al comonent in medical dia*nosis has th&s invested
5esc&laian a&tho!it(., %ith totalita!ian o%e!.
The divo!ce 'et%een medicine and mo!alit( has 'een de"ended on the *!o&nd that medical
cate*o!ies, &nli+e those o" la% and !eli*ion, !est on scienti"ic "o&ndation exemt "!om mo!al
eval&ation... Medical ethics have 'een sec!eted into a seciali=ed dea!tment that '!in*s
theo!( into line %ith act&al !actice../ The co&!ts and the la%, %hen the( a!e not &sed to
en"o!ce the 5esc&laian monool(, a!e t&!ned into doo!men o" the hosital %ho select "!om
amon* the clients those %ho can meet the docto!s6 c!ite!ia..5 #ositals t&!n into mon&ments
o"
xxx "otnote! sta!t xxx
., <ee Mi!iam <ie*le! and #&mh!e( Bsmond, G5esc&laian 5&tho!it(,G %astings Caster
<t&dies 1, no. , (197.): /185,.
.. Eliot -!eidson, +rofession of *edicine= A Study of the Sociology of Applied Enowledge
(Ne% No!+: 7odd, Mead, 1971), . ,>; i".
./ I&ne Oood"ield, G3e"lections on the #ioc!atic Baths,G %astings Caster <t&dies 1, no. ,
(197.): 7989,.
.5 The la% has had little exe!ience %ith the !o'lem o" selectin* one individ&al to live and
the!e'( doomin* othe!s to die. <eamen have 'een convicted o" mansla&*hte! "o! havin*
heled to th!o% 1/ o" /1 assen*e!s o&t o" a lea+in* li"e'oat into the sea (9.< vs; %olmes,
1;/,). <o "a! the silence o" the 9.<. :&dicia!(, com'ined %ith the silence o" the le*islat&!e,
seems to iml( a !e"e!ence for leavin* decisions involvin* selection for s&!vival to !ocesses
not s&':ect to le*al anal(sis. )&t inc!easin* demands a!e made to c!eate a !&le o" la% to
!otect individ&als see+in* so8called li"e8!olon*in* t!eatment a*ainst the !e:&dices and
a!'it!a!iness o" !o"essional men. <ee 'elo%, note ,>6, . 1>,.
xxx "otnote! sl&tt xxx
((/7))
na!cissistic scientism, conc!ete mani"estations o" those !o"essional !e:&dices %hich %e!e
"ashiona'le on the da( thei! co!ne!stone %as laid and %hich %e!e o"ten o&tdated %hen the(
came into &se. The technical ente!!ise o" the h(sician claims val&e8"!ee o%e!. It is o'vio&s
that in this +ind o" context it is eas( to sh&n the iss&e o" social iat!o*enesis %ith %hich I am
conce!ned. 1oliticall( mediated medical dama*e is th&s seen as inhe!ent in medicine6s
mandate, and its c!itics a!e vie%ed as sohists t!(in* to :&sti"( la( int!&sion into the medical
'aili%ic+. 1!ecisel( "o! this !eason, a la( !evie% o" social iat!o*enesis is &!*ent. The asse!tion
o" val&e8"!ee c&!e and ca!e is o'vio&sl( mali*nant nonsense, and the ta'oos that have shielded
i!!esonsi'le medicine a!e 'e*innin* to %ea+en.
The Medicali=ation o" the )&d*et
The most hand( meas&!e o" the medicali=ation o" li"e is the sha!e ta+en o&t o" a t(ical (ea!l(
income to 'e sent &nde! docto!6s o!de!s. In 5me!ica 'e"o!e 195>, this %as less than a month6s
income, '&t '( the mid8seventies, the eA&ivalent o" 'et%een "ive and seven %ee+s o" the
t(ical %o!+e!6s ea!nin*s %e!e sent on the &!chase o" medical se!vices. The 9nited <tates
no% sends a'o&t M95 'illion a (ea! "o! health ca!e, a'o&t ;./ e!cent o" the *!oss national
!od&ct in 1975, & "!om /.5 e!cent in 196,..6 7&!in* the ast t%ent( (ea!s, %hile the !ice
index in the 9nited <tates has !isen '( a'o&t 7/ e!cent, the cost o" medical ca!e has escalated
'( ..> e!cent. )et%een 195> and 1971 &'lic exendit&!e "o! health ins&!ance in8c!eased
ten"old, !ivate ins&!ance 'ene"its inc!eased ei*ht"old,.7 and di!ect o&t8o"8oc+et a(ments
a'o&t th!ee
xxx "otnote sta!t xxx
.6 <e(mo&! E. #a!!is, The Economics o" 5me!ican *edicine (Ne% No!+: Macmillan, 196/).
5 detailed s&!ve( o" the cost o" se!vices, d!&*s, va!io&s levels o" mano%e!, and hositalsR o"
histo!ical val&e "o! the e!iod 'et%een 19/6 and 1961, d&!in* %hich health8ca!e costs !ose '(
.;>f,
.7 3o'e!t $. #ethe!in*ton, 0a!l E. #o+ins, and Milton I. 3oeme!, %ealth )nsurance 1lans:
+romise and +erformance (Ne% No!+: $ile( 1975). The 9.<. is
xxx "otnote "o!tsette! E neste side xxx
((/;))
"old..; In ove!8all exendit&!es othe! co&nt!ies s&ch as -!ance.9 and Oe!man(/> +et a'!east
o" the 9nited <tates.
In all ind&st!ial nationsD5tlantic, <candinavian, o! East E&!oeanDthe *!o%th !ate o" the
health secto! has advanced "aste! than that o" the ON1 /1 Even disco&ntin* in"lation, "ede!al
health o&tla(s inc!eased '( mo!e than /> e!cent 'et%een 1969 and 197/./, The
medicali=ation o" the national '&d*et, mo!eove!, is not a !ivile*e o" the !ich: in 0olom'ia, a
oo! co&nt!( that noto!io&sl( "avo!s
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
dominated '( a *alax( o" a&tonomo&s and o"ten cometin* health lans that a!e sometimes
comme!cial, sometimes !ovide!8sonso!ed, and sometimes o!*ani=ed alon* the lines o"
*!o& !actice. -o! most citi=ens all this is s&lemented '( some cove!a*e th!o&*h national
health ins&!ance. This eval&ation o" cliente !eactions to di""e!ent choices sho%s ho% little
the( !eall( di""e!.
.; Ma!tin <. -eldstein, The 3isin* 0ost of %ospital Care 2"ashington, D;C;= )nformation
esources, 9>:9A; %ospital care has outstripped by far the rise in physicians1 fees; The over4
all cost of medical care has gone up faster than the average cost of all goods and services in
the consumer price inde/; +rescription and drug costs have risen the least; 'ver4the4counter
drug prices have actually fallen, but the drop is more than made up for by prescription costs;
.9 03E7B0 (0ent!e de !eche!ches et de doc&mentation s&! la consommation), Evol&tion de
la structure des soins mFdicau/, 9>@>49>:& (1a!is, 197.).
/> G@!an+heits+osten: 67ie 'om'e tic+t6R 7as %estde&tsche Oes&ndheits%esen,G I. G7e!
@am" &m die @assen8Millia!denGR ,. G7ie 1halanx de! niede!*elassenen 5nte,G Der Spiegel,
no. 19 (1975), . 5/866R no. ,> (1975), . 1,68/,.
/1 5n excellent *ene!al int!od&ction to the cost exlosion in health ca!e is 3. Max%ell,
%ealth 0a!e: The +roving DilemmaM .eeds vs; esources in "estern Europe, the !;S;, and
the !;S;S;; 2.ew <or#= *cEinsey & Co;, 9>:J; )an Douglas4"ilson and $ordon
*c-achlan, eds;, %ealth Service +ro5ects= An )nternational Survey, 2,oston= -ittle, ,rown,
9>:0A; This international comparison shows Dthe e/treme heterogeneity in organi8ation and
ideologyD of different systems; Everywhere Dthe rationali8ation is motivated, not by politics of
the left or the right, but by the sheer necessity to secure more effective use of scarce and
e/pensive resources;D .o country can indefinitely sustain unchec#ed increases in funds
allocated for the treatment of illness;
/, Lo&ise 3&ssell et al., (ederal %ealth Spending, 9>?>4:J 2"ashington, D;C;= Center for
%ealth +olicy Studies, .ational +lanning Association, 9>:JA; (or comparison chec# ,; Able
Smith, An )nternational Study of %ealth E/penditure and )ts elevance foi %ealth +lanning,
+ublic %ealth +aper no; 0& 2$eneva4"orld %ealth 'rgani8ation, 9>?:A; ,ased on a
questionnaire to ministries, this supersedes the author1s earlier +aying for %ealth Services
and provides data for the study of trends; %erbert E; Elarman, The Economics of %ealth
2.ew <or#= Columbia !niv; +ress, 9>?@A, gives a qualitative analysis of demand, supply, and
organi8ation in the !;S;, with ample bibliographical guidance;
xxx "otnote sl&tt xxx
((/9))
its !ich, the !oo!tion, as in En*land, is mo!e than 1> e!cent./.
<ome o" this has en!iched docto!s, %ho &ntil the -!ench 3evol&tion ea!ned thei! livin* as
a!tisans. 5 "e% al%a(s lived %ell, '&t mo!e died oo!. The !ove!' G-e% la%(e!s die %ell,
"e% h(sicians live %ellG had its eA&ivalent in most E&!oean lan*&a*es. No% h(sicians
have come to the to, and in caitalist societies this to is hi*h indeed. Net it %o&ld 'e
inacc&!ate to 'lame the in"lation in medicine on the *!eed o" the medical !o"ession. M&ch
mo!e o" the inc!ease has *one to a host o" %ell8titled medical ae!8sh&""le!s whom 9nited
<tates &nive!sities 'e*an to *!ad&ate in the "i"ties: to those %ith maste!s6 de*!ees in n&!sin*
s&e!vision o! %ith docto!ates in hosital administ!ation, and to all the lo%e! !an+s on %hich
the ne% '&!ea&c!ats "eed. The cost o" administe!in* 8the atient, his "iles, and the chec+s he
%!ites and !eceives can ta+e a A&a!te! o&t o" each dolla! on his 'ill.// Mo!e *oes to the
'an+e!sR in some cases the so8called Gle*itimateG administ!ative costs in the medical health
ins&!ance '&siness have !isen to 7> e!cent o" the a(ment made to comme!cial ca!!ie!s.
Even mo!e si*ni"icant is the ne% !e:&dice in "avo! o" hi*h8cost hosital ca!e. <ince 195> the
cost o" +eein* a atient "o! one da( in a comm&nit( hosital in the 9nited <tates has !isen '(
5>> e!cent./5 The 'ill "o! atient ca!e in the ma:o! &nive!sit( hositals has !isen even "aste!,
xxx "otnote sta!t xxx
/. Iohn )!(ant, %ealth and the Developing "orld (Ithaca, N.N.: 0o!nell 9niv. 1!ess, 1969).
5 ict&!e o" health ca!e in co&nt!ies !eceivin* inte!national aid.
// -o! doc&mentation assem'led '( !o"essional administ!ato!s, see )!&ce )al+ et al.,
esource *aterials on the <ocio8sconomic and ,usiness Aspects of *edicine (0hica*o:
0ente! "o! #ealth <e!vices 3 V 7., 5me!ican Medical 5ssociation, 1971). -o! o!ientation on
c&!!ent, mostl( 9.<., mate!ials on medical economics !an*in* "!om !esea!ch !eo!ts to a!ticles
in Tune ma*a=ine, see 5me!ican Medical 5ssociation, *edical Socioeconomic esearch
Sources, 1, iss&es e! (ea! since 197>.
/5 -eldstein, 3isin* Cost of %ospital 0a!t.
xxx "otnote sl&tt xxx
((5>))
t!ilin* in ei*ht (ea!s. 5dminist!ative costs have exloded, m&ltil(in* since 196/ '( a "acto!
o" sevenR la'o!ato!( costs have !isen '( a "acto! o" "ive, medical sala!ies onl( '( a "acto! o" ,.
/6 The const!&ction o" hositals no% costs in excess o" M;5,>>> e! 'ed, o" %hich t%o8thi!ds
'&(s mechanical eA&iment that is made o'solete %ithin less than ten (ea!s./7 These !ates a!e
almost t%ice those o" the cost inc!eases and o" the o'solescence !evalent in mode!n %eaons
s(stems. 0osts ove!!&ns in !o*!ams o" the #ealth, Ed&cation, and $el"a!e 7ea!tment
exceed those in the 1enta*on. )et%een 196; and 197> Medicaid costs inc!eased th!ee times
"aste! than the n&m'e! o" eole se!ved. In the last "o&! (ea!s hosital ins&!ance 'ene"its have
almost do&'led in cost, and h(sicians6 "ees have inc!eased almost t%ice as "ast as had 'een
lanned./; The!e is no !ecedent "o! a simila! s&stained exansion in an( othe! ma:o! secto!
in the civilian econom(. It is the!e"o!e i!onic that d&!in* this &niA&e 'oom in health ca!e the
9nited <tates esta'lished anothe! G"i!st.G <ho!tl( a"te! the 'oom sta!ted, the li"e exectanc(
"o! ad&lt 5me!ican males 'e*an to decline and is no% exected to decline even "&!the!. The
death !ate "o! 5me!ican males a*ed "o!t(8"ive to "i"t(8"o&! is coma!ativel( hi*h. B" eve!(
1>> males in the 9nited <tates %ho t&!n "o!t(8"ive onl( 9> %ill see thei! "i"t(8"i"th 'i!thda(,
%hile in <%eden 95 %ill s&!vive the decade /9 )&t <%eden, Oe!man(, )el*i&m,
xxx "otnote sta!t xxx
/6 Iohn #. @no%les, GThe #osital,G Scientific American ,,9 (<etem'e! 197.): 1,;8.7.
0ontains cha!ts and *!ahs on the evol&tion o" hosital exendit&!es.
/7 Ma!tin <. -eldstein, G#osital 0ost In"lation: <t&d( o" Non!o"it 1!ice 7(namics,G
American Economic eview 61 (7ecem'e! 1971): ;5.876. -o! a comlementa!( !ediction o"
a "&!the! inc!ease in caital8intensive medicine see 7ale L. #iestand, G3esea!ch into
Mano%e! "o! #ealth <e!vices,G Mil'an+ *emorial (und Wuarterly // (Bcto'e! 1966): 1/68
;1.
/; 3o'e!t 3&shme!, *edical Engineering= +ro5ections for %ealth Care Delivery (Ne% No!+:
5cademic 1!ess, 197,), . 115.
/9 ?icto! 3. -&chs, "ho Shall -ive7 %ealth, Economics and Social Choice (Ne% No!+: )asic
)oo+s, 197/), . 15.
xxx "otnote sl&tt xxx
((51))
0anada, -!ance, and <%it=e!land a!e no% catchin* & %ith the 9nited <tates: 'oth thei! a*e8
seci"ic death !ates "o! ad&lt males and thei! *lo'al medical costs a!e shootin* &. 5>
The henomenal !ise in cost o" health se!vices in the 9nited <tates has 'een exlained in
di""e!ent %a(s: some 'lame i!!ational lannin*,51 othe!s the hi*he! cost o" the ne% *immic+s
that eole %ant in hositals.5, The most common inte!!etation at !esent !elates to the
*!o%in* incidence o" !ea(ment o" se!vices. #ositals !e*iste! %ell ins&!ed atients, and
!athe! than !ovidin* old !od&cts mo!e e""icientl( and cheal(, a!e economicall( motivated
to move to%a!ds ne% and inc!easin*l( exensive %a(s o" doin* thin*s. 0han*in* !od&cts
!athe! than hi*he! la'o! costs, 'ad administ!ation, o! lac+ o" technolo*ical !o*!ess a!e
'lamed "o! the !ise.5. In this e!sective the chan*e in !od&cts seems d&e !ecisel( to the
inc!eased ins&!ance cove!a*e %hich enco&!a*es hositals to !ovide !od&cts mo!e exensive
than the c&stome! act&all( %ants, needs, o! %o&ld have 'een %illin* to a( "o! di!ectl(. #is
o&t8o"8oc+et costs aea! inc!easin*l( modest, even tho&*h the se!vices o""e!ed '( the
hosital a!e mo!e costl(. Ins&!ance "o! hi*h8cost sic+8ca!e is th&s a sel"8!ein"o!cin* !ocess
%hich invests the !ovide!s o" ca!e %ith the cont!ol o" inc!easin* !eso&!ces. 5/ 5s an antidote,
xxx "otnote sta!t xxx
5> $. #. -o!'es, GLon*evit( and Medical 0osts,G .ew England 5ournal of *ecliicina &::
(1967): 718;. Lon*evit( is meas&!ed as Gave!a*e !emainin* li"etimeG (53L). It has !emained
nea!l( constant "o! 19/781965, '&t the 9.<. !ate coma!ed %ith othe! ind&st!iali=ed co&nt!ies
has "allen sha!l( for men and sli*htl( for %omen. GThe!e is no lon*e! an( si*ni"icant
!elationshi ain .> co&nt!ies st&diedb 'et%een the mone( sent on health and the lon*evit( o"
the o&lation.G <ee also 1. Lon*one, GMo!talitT et mo!'iditT,G 1o&lation et <ociTti, no. /.
(Ian&a!( 197,).
51 ?icto! 0ohen, GMo!e #ositals To -ill: 5'&ses O!o%,G Technology eview, Bcto'e!8
Novem'e! 197., . 1/816.
5, 3o'e!t -. 3&shme!, *edical En*inee!in*: ("5ections for %ealth Care Delivery (Ne%
No!+: 5cademic 1!ess, 197,), ex!esses the hoe that the "o!thcomin* inc!ease in "ede!al
"&ndin* %ill c!eate a ne% ma!+et "o! sa!e a!ts, "!om '!east8enhance!s to a!ti"icial hea!ts.
5. -eldstein, ising Cost of %ospital Care;
@J $illiam 5. Olase!, +aying the 7octo!: Systems o" es ssneration and 7heir E5ects
()altimo!e: Iohns #o+ins, 197>). 0ons&lt this c!oss8national coma!ative
xxx "otnote sl&tt xxx
((5,))
some c!itics !ecommend enli*htened cost conscio&sness on the a!t o" cons&me!sR55 othe!s,
not t!&stin* the sel"8cont!ol o" la(men, !ecommend mechanisms to hei*hten the cost
conscio&sness o" !od&ce!s 56 1h(sicians, the( a!*&e, %o&ld !esc!i'e mo!e !esonsi'l( and
less %antonl( i" the( %e!e aid (as a!e *ene!al !actitione!s in )!itain) on a GcaitationG 'asis
that !ovided a "ixed amo&nt "o! the maintenance o" thei! clients !athe! than a "ee "o! se!vice.
)&t li+e all othe! s&ch !emedies, caitation enla!*es the iat!o*enic "ascination %ith the health
supply; 1eole "o!*o thei! o%n lives to *et as m&ch t!eatment as the( can.
In En*land the National #ealth <e!vice has t!ied, al'eit &ns&ccess"&ll(, to ens&!e that cost
in"lation %ill 'e less la*&ed '( consic&o&s "lim"lam.57 The National #ealth <e!vice 5ct o"
19/6 esta'lished access to health8ca!e !eso&!ces "o! all those in need as a h&man !i*ht. The
need %as ass&med to 'e "inite and A&anti"ia'le, the 'allot 'ox the 'est lace to decide the total
'&d*et "o! health, and docto!s the onl( ones a'le to dete!mine the !eso&!ces that %o&ld satis"(
the need o" each atient. )&t need as assessed '( medical !actitione!s has !oved to 'e :&st
as extensive in En*land as an(%he!e else. The "&ndamental hoe "o! the s&ccess o" the
En*lish health8ca!e s(stem la( in the 'elie" in the a'ilit( o" the En*lish to !ation supply;
xxx "otnote sta!t xxx
anal(sis "o! the imact o" di""e!ent methods o" a(ment on the costliness o" the h(sician.
55 Iohn and <(lvia Ie%+es, 6alue for *oney in *edicine (Bx"o!d: )lac+%ell, 196.), . .>8
7, a!*&e: GIt ma( 'e that, as electo!ates 'ecome mo!e sohisticate tiGthe( %ill !eco*ni=e the(
have in "act to a( "o! "!ee se!vicesGR also that !elativel( chea !evention th!o&*h mo!e
health( eve!(da( ha'its is mo!e e""ective than &!chase o" !eai!s.
56 -&chs, in "ho Shall -ive7, chap; 0, a!*&es "o! instit&tional licensin* as a s&'stit&te "o! the
licensin* o" individ&als. 9nde! s&ch a s(stem, medical8ca!e instit&tions %o&ld 'e licensed '(
the state and %o&ld then 'e "!ee to hi!e and &se e!sonnel as each sa% "it. This s(stem %o&ld
delo( !eso&!ces mo!e e""icientl( and !ovide mo!e &%a!d :o' mo'ilit(. )&t the h(sician6s
cont!ol ove! ca!e !od&ced and delive!ed '( othe!s %o&ld 'e %ea+ened.
57 -o! a 'i'lio*!ah( on sociali=ed medicine in )!itain, cons&lt -!eidson, +rofession of
*edicine, . 0J, n. 9.
xxx "otnote sl&tt xxx
((5.))
9ntil a'o&t 197, the( did so, in the oinion o" an a&tho! %ho s&!ve(ed )!itish health
economics, G'( means in thei! %a( almost as !&thlessD'&t *ene!all( held to 'e mo!e
acceta'leDthan the a'ilit( to a(.G 5; 9ntil that time health ca!e %as +et 'elo% 6 e!cent
o" ON1, 1> e!cent o" &'lic sendin*. 1!ivate !actice had sh!&n+ "!om hal" o" all ca!e to /
e!cent. 7i!ect cha!*es to atients %e!e +et at a henomenall( lo% 5 e!cent o" the cost. )&t
this ste!n commitment to eA&alit( !evented onl( those asto&ndin* misallocations "o!
!esti*io&s *ad*et!( %hich !ovided an eas( sta!tin* oint "o! &'lic c!iticism in the 9nited
<tates. <ince 197, the #ealth <e!vice in )!itain has &nde!*one a t!a&matic chan*e, "o!
comlex economic and olitical !easons. The initial s&ccess o" the #ealth <e!vice and the
!esent &niA&e disa!!a( in the s(stem ma+e !edictions "o! the "&t&!e imossi'le.
7emedicali=ation o" health ca!e is as essential the!e as else%he!e. Net c&!io&sl(, En*land is
also one o" the "e% ind&st!iali=ed co&nt!ies %he!e the li"e exectanc( o" ad&lt males has not
(et declined, tho&*h the ch!onic diseases o" this *!o& have al!ead( sho%n an inc!ease simila!
to that o'se!ved a decade ea!lie! ac!oss the 5tlantic.
In"o!mation on costs in the <oviet 9nion is mo!e di""ic&lt to come '(. The n&m'e! o"
h(sicians and hosital da(s e! caita seems to have do&'led 'et%een 196> and 197,, and
costs to have inc!eased '( a'o&t ,6> e!cent.59 The main claim to s&e!io!it( o" <oviet
medicine is still 'ased on G!oh(laxis '&ilt into the social s(stem itsel",G %itho&t this
a""ectin* the !elative vol&me o" disease o! ca!e in coma!ison %ith othe! ind&st!ial co&nt!ies
o" simila! develoment.6> )&t the theo!( that
xxx "otnote sta!t xxx
5; Michael #. 0ooe!, ationing %ealth Care (London: #alsted 1!ess, 1975). 5 so'e!,
c!itical, and livel( attemt at an ove!8all economic !evie% o" the nat&!e and !o'lems o" the
"i!st ,6 (ea!s o" the )!itish National #ealth <e!vice.
59 N. Lisitsin, %ealth +rotection in the !SS 2*oscow= +rogress +ublithers, 9>:&A;
6> Ma!+ O. -ield, Soviet Sociali8ed *edicine= An )ntroduction 2.ew <or#= (ree +ress, 9>?:A;
A standard introduction 2now 9& years out of dateA to the Soviet
xxx "otnote "o!tsette! neste side xxx
((5/))
the!ae&tics %o&ld %ithe! a%a( %ith the state 'ecame and has !emained he!es( since 19.,.61
7istinct olitical s(stems o!*ani=e atholo*ies into di""e!ent diseases and th&s c!eate distinct
cate*o!ies o" demand, s&l(, and &nmet needs 6, )&t no matte! ho% disease is e!ceived,
the cost o" t!eatment !ises at coma!a'le !ates. The 3&ssians, "o! instance, limit '( dec!ee
mental disease !eA&i!in* hositali=ation: the( allo% onl( 1> e!cent o" all hosital 'eds "o!
s&ch cases.6. )&t at a *iven ON1 all ind&st!ial nations *ene!ate the same +ind o" deendence
on the h(sician, and do so i!!esective o" thei! ideolo*( and the nosolo*( these 'elie"s
en*ende!.6/ (B" co&!se, caitalism has !oved that it can do so at a m&ch hi*he! social
cost.65) Eve!(%he!e in the mid8seventies the main const!aint on !o"essional activit( is the
necessit( to !ed&ce costs.
The !oo!tion o" national %ealth %hich is channeled to docto!s and exended &nde! thei!
cont!ol va!ies "!om one nation to anothe! and "alls some%he!e 'et%een one8tenth and one8
t%entieth o" all availa'le "&nds. )&t this sho&ld lead no'od( to 'elieve that health
exendit&!es on the t(ical citi=en in oo! co&nt!ies a!e an(%he!e !oo!tionate to the
co&nt!ies6 e! caita ave!a*e income.
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
medical system; +p; ix8xii !ovide a c!itical o!ientation to Oe!man, En*lish, and -!ench
lite!at&!e, and cha. 5, !e"e!ences to the !et&!n "!om social to c&!ative !io!ities.
61 <ee 'elo%, note 6/.
6, Iohn -!e(, *edicine in Three Societies 2*T+, 5(les'&!(, En*land, 197/).
6. Ma!+ O. -ield, G<oviet and 5me!ican 5!oaches to Mental Illness: 5 0oma!ative
1e!sective,G eview of Soviet *edical Sciences 9 29>?JA= 940?;
6/ Ioachim Is!ael, G#&manisie!&n* ode! )ii!o+!atisie!&n* de! Medi=in4G Nevi Oese tscha" t
,1 (197/): .978/>/. 1!ovides an invento!( o" 15 st!on* tendencies to%a!ds the
'&!ea&c!ati=ation o" li"e, %hich t*+es seci"icall( health8!elated "o!ms in medicine and
menaces eole eA&all( in the -ede!al 3e&'lic o" Oe!man( and in the 9.<.<.3.
65 Bdin $. 5nde!son, %ealth 0a!e: 0an There ,e EA&is., Thee !nited States, Sweden, and
England (Ne% No!+: $ile(, 197,). 5ll th!ee s(stems *!o% to%a!ds the same +ind o"
'&!ea&c!ac(, at coma!a'le costs, '&t eA&it( in access is m&ch lo%e! in the 9<5.
xxx "otnote sl&tt xxx
((55))
Most eole *et a'sol&tel( nothin*. Excetin* onl( the mone( allocated "o! t!eatment o"
%ate! s&lies, 9> e!cent o" all "&nds ea!ma!+ed "o! health in develoin* co&nt!ies is sent
not "o! sanitation '&t "o! t!eatment o" the sic+. -!om 7> e!cent to ;> e!cent o" the enti!e
public health '&d*et *oes to the c&!e and ca!e o" individ&als as oosed to &'lic health
se!vices.66 Most o" this mone( is sent everywhere on the same +inds o" thin*s.
5ll co&nt!ies %ant hositals, and man( %ant them to have the most exotic mode!n eA&iment.
The oo!e! the co&nt!(, the hi*he! the !eal cost o" each item on thei! invento!ies. Mode!n
hosital 'eds, inc&'ato!s, la'o!ato!ies, !esi!ato!s, and oe!atin* !ooms cost even mo!e in
5"!ica than thei! co&nte!a!ts in Oe!man( o! -!ance %he!e the( a!e man&"act&!ed: the( also
'!ea+ do%n mo!e easil( in the t!oics, a!e mo!e di""ic&lt to se!vice, and a!e mo!e o"ten than
not o&t o" &se. 5s to cost, the same is t!&e. o" the h(sicians %ho a!e made to meas&!e "o!
these *ad*ets. The ed&cation o" an oen8hea!t s&!*eon !e!esents a coma!a'le caital
investment, %hethe! he comes "!om the Mexican school s(stem o! is the co&sin o" a )!a=ilian
catain sent on a *ove!nment schola!shi to st&d( in #am'&!*.67 The 9nited <tates mi*ht 'e
too oo!
xxx "otnote sta!t xxx
66 Inte!national )an+ "o! 3econst!&ction and 7eveloment, %ealth Sector +olio, +aper,
"ashington, D;C;, *arch 9>:@;
67 It m&st not 'e ove!loo+ed that medical schools in oo! co&nt!ies constitltte one o" the most
e""ective means "o! the net t!ans"e! o" mone( to the !ich co&nt!ies. B.B=la+ and 7. 0a&to,
GThe Mi*!ation o" Medical 1e!sonnel "!om Latin 5me!ica to the 9.<.: To%a!ds an 5lte!native
Inte!!etation,G ae! !esented at the 1an85me!ican 0on"e!ence on #ealth and Mano%e!
1lannin*, Btta%a, 0anada, <etem'e! 1>81/, 197.. The a&tho!s estimate that the ann&al net
loss "o! the %hole o" Latin 5me!ica d&e to the "lo% o" h(sicians to the 9<. is M,>> million, a
"i*&!e eA&al to the total medical aid *iven '( the 9.<. to Latin 5me!ica d&!in* the "i!st
develoment decade, i.e., the e!iod that sta!ted %ith the G5lliance "o! 1!o*!ess.G #ossain 5.
3ona*h(, @athleen 0ahill, and Timoth( 7. )a+e!, G1h(sician Mi*!ation to the 9nited <tates:
Bne 0o&nt!(6s T!ans"&sion Is 5nothe! 0o&nt!(6s #emo!!ha*e,GIe%nmal o" the American
*edical Association ,,7 (197/): 5.;8/,, !ovides in"o!mation on o&tmi*!ation o" I!anian
st&dents '( the &nive!sit( "!om %hich the( *!ad&ated. Bsca! Oish, ed;, Doctor Mi*!ation and
xxx "otnote "o!tsette! neste side xxx
((56))
to !ovide !enal dial(sis at M15,>>> e! (ea! to all those citi=ens %ho %o&ld claim to need it,
'&t Ohana is too oo! to !ovide the eole eA&ita'l( %ith h(sicians "o! !ima!( ca!e.6;
<ociall( c!itical maxim&m cost o" items that can 'e eA&ita'l( sha!ed va!ies "!om one lace to
anothe!. )&t %heneve! tax "&nds a!e &sed to "inance t!eatment a'ove the c!itical cost, the
s(stem o" medical ca!e acts inevita'l( as a device "o! the net t!ans"e! o" o%e! "!om the
ma:o!it( %ho a( the taxes to the "e% %ho a!e selected 'eca&se o" thei! mone(, schoolin*, o!
"amil( ties, o! 'eca&se o" thei! secial inte!est to the exe!imentin* s&!*eon.
It is clea!l( a "o!m o" exloitation %hen "o&!8"i"ths o" the !eal cost o" private clinics in oo!
Latin 5me!ican co&nt!ies is aid "o! '( the taxes collected "o! medical ed&cation, &'lic
am'&lances, and medical eA&iment.69 In this case the concent!ation o" &'lic !eso&!ces on a
"e% is o'vio&sl( &n:&st 'eca&se the a'ilit( to a( o&t o" oc+et a "!action o" the total cost o"
t!eatment is a condition "o! *ettin* the !est &nde!%!itten. )&t the exloitation is no less in
laces
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
"orld %ealth, Bccasional 1ae!s on <ocial 5dminist!ation no. /., <ocial 5dminist!ation
3esea!ch T!&st (London: )ell, 1971). <tehen <. Mic+, GThe -o!ei*n Medical O!ad&ate,G
<cienti"ic 5me!ican ,., (-e'!&a!( 1975): 1/8,,. The!e a!e 5;,>>> imo!ted h(sicians no%
!acticin* in the 9.<.R "&ll( licensed !actitione!s have A&ad!&led. In the Middle 5tlantic,
No!th 0ent!al, and Ne% En*land !e*ions, the( o&tn&m'e! native h(sicians. India, the
1hiliines, Ital(6, and 0anada each aid "o! the "&ll ed&cation o" mo!e than .,>>> o" theseR
5!*entina, <o&th @o!ea, and Thailand, amon* othe!s, "o! mo!e than 1,>>> each. N.).: The
t!ainin* o" a 1e!&vian h(sician costs a'o&t six tho&sand times as m&ch as the ed&cation o" a
t(ical 1e!&vian easant.
6; In Ohana, the 0ent!al #osital a'so!'ed 1/9 o" the ,9; h(sicians availa'le to the official
health se!vices, (et onl( a'o&t 1f o" the atients had 'een o""iciall( !e"e!!ed '( medical
e!sonnel o&tside the hosital. M. I. <ha!ston, G9neven Oeo*!ahical 7ist!i'&tion o"
Medical 0a!e, a Ohanaian 0ase <t&d(,GIo&!nal of Development Studies ; (Ian&a!( 197,):
,>58,,.
69 -o! a &se"&l s&!ve( o" social science !esea!ch on health in Latin 5me!ica, see 5!th&!
3&'el, GThe 3ole o" <ocial <cience 3esea!ch in 3ecent #ealth 1!o*!ams in Latin 5me!ica,G
-atin American esearch eview & 29>??A= 0:4@?; 7iete! Qcchoc+, G#ealth 1lannin* in Latin
5me!ica: 3evie% and Eval&ation,G -atin American esearch eview @ 29>:BA= 0@4@?;
xxx "otnote sl&tt xxx
((57))
%he!e the &'lic, th!o&*h a national health se!vice, assi*ns to h(sicians the sole o%e! to
decide %ho GneedsG thei! +ind o" t!eatment, and then lavishes &'lic s&o!t on those on
%hom the( exe!iment o! !actice. The &'lic acA&iescence in the docto!6s monool( on
identi"(in* needs onl( '!oadens the 'ase "!om %hich docto!s can sell thei! se!vices.7>
Indi!ectl(, consic&o&s the!aies se!ve as o%e!"&l devices to convince eole that the(
sho&ld a( mo!e taxes to *et them to all those %hom docto!s have decla!ed in need. Bnce
1!esident -!ei o" 0hile had sta!ted on one alace "o! medical sectato!8so!ts, his s&ccesso!,
<alvado! 5llende, %as "o!ced to !omise th!ee mo!e. The !esti*e o" a &n( national team in
the medical Bl(mics is &sed to intensi"( a nation%ide addiction to the!ae&tic !elation8shis
that a!e atho*enic on a level m&ch deee! than me!e medical vandalism. Mo!e health
dama*e is ca&sed '( eole6s 'elie" that the( cannot coe %ith thei! illness &nless the( call on
the docto! than docto!s co&ld eve! ca&se '( "oistin* thei! minist!ations on eole.
Bnl( in 0hinaDat least, at "i!st si*htDdoes the t!end seem to !&n in the oosite di!ection:
!ima!( ca!e is *iven '( non!o"essional health technicians assisted '( health a!entices
%ho leave thei! !e*&la! :o's in the "acto!( %hen the( a!e called on to assist a mem'e! o" thei!
'!i*ade.71 N&t!ition, envi!onmental h(*iene, and 'i!th
xxx "otnote sta!t xxx
7> ?icto! 3. -&chs, GThe 0ont!i'&tion o" #ealth <e!vices to the 5me!ican Econom(,G
*ilban# *emorial (und WuartaH JJ (Bcto'e! 1966): 6581>.. -&chs d!ives this oint home.
71 -o! o!ientation see Iosh&a #o!n, Away %ith 5ll +eser 5n En*lish Surgeon is +eople1s
0hino, 195/81969 (Ne% No!+: Monthl( 3evie% 1!ess, 1971). ?icto! $. and 3&th <idel,
GMedicine in 0hina: Individ&al and <ociet(,G %astings 0ente! Studies &, no. . (197/): ,..8.6.
?icto! <idel, GThe )a!e"oot 7octo!s o" the 1eole6s 3e&'lic o" 0hina,G .ew England
"o&nnal of Medicine ,;6 (197,): 1,9,81.>>. 5. I. <mith, GMedicine in 0hinaG (5 a!ticles),
,ritish *edical 5ournal, 197/, ,:.6787>, and the "ollo%in* "o&! iss&es. 0a!l 7:en&si, GThe
0hinese 5chievement in -e!tilit( 0ont!ol,G ,ulletin o5the Atomic <cientists, I&ne 197/, .
178,/. 1a&l T. @. 9n, GMedicine in 0hina,G Center *agasine 2Santa ,arbara, Calif;A, *ay4
3une,
xxx "otnote "o!tsette! neste side xxx
((5;))
cont!ol have im!oved 'e(ond coma!ison. The achievements in the 0hinese health secto!
d&!in* the late sixties have !oved, e!has de"initivel(, a lon*8de'ated oint: that almost all
demonst!a'l( e""ective technical health devices can 'e ta+en ove! %ithin months and &sed
cometentl( '( millions o" o!dina!( eole. 7esite s&ch s&ccesses, an o!thodox commitment
to $este!n d!eams o" !eason in Ma!xist shae ma( no% dest!o( %hat olitical vi!t&e,
com'ined %ith t!aditional !a*matism, has achieved. The 'ias to%a!ds technolo*ical !o*!ess
and cent!ali=ation is !e"lected al!ead( in the !o"essional !eaches o" medical ca!e. 0hina
ossesses not onl( a a!amedical s(stem '&t also medical e!sonnel %hose ed&cational
standa!ds a!e +no%n to 'e o" the hi*hest o!de! '( thei! co&nte!a!ts a!o&nd the %o!ld, and
%hich di""e! onl( ma!*inall( "!om those o" othe! co&nt!ies. Most investment d&!in* the last
"o&! (ea!s seems to have *one to%a!ds the "&!the! develoment o" this ext!emel( %ell
A&ali"ied and hi*hl( o!thodox medical !o"ession, %hich is *ettin* inc!easin* a&tho!it( to
shae the ove!8all health *oals o" the nation. G)a!e"oot medicineG is losin* its ma+eshi"t,
semi8indeendent, *!ass!oots cha!acte! and is 'ein* inte*!ated into a &nita!( health8ca!e
technoc!ac(. 9nive!sit(8t!ained e!sonnel inst!&ct, s&e!vise, and comlement the locall(
elected heale!. This ideolo*icall( "&eled develoment o" !o"essional medicine in 0hina %ill
have to 'e conscio&sl( limited in the ve!( nea! "&t&!e i" it is to !emain a 'alancin*
comlement !athe! than an o'stacle to hi*h8level sel"8ca!e.7, $itho&t coma!a'le
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
197/. M. #. Lian* et al., G0hinese #ealth 0a!e: 7ete!minants o" the <(stem,G American
Io&!nal of +ublic %ealth 6. (-e'!&a!( 197.): 1>,81>. #o!n6s is still the 'est "i!st8e!son
!eo!t. <idel6s and <mith6s a!e !eo!ts "!om t!avelin* collea*&es to the !o"ession. 7:e!assi
*ives val&a'le insi*hts into the stat&s o" cont!acetion. Lin calls attention to the ne%
challen*es c!eated '( the !ecent !evalence o" de*ene!ative disease. <ee also 3alh 0.
0!oi=ie!, Traditional *edicine in *odern China= Science, .ationalism, and the Tension of
Cultural CArange 2Cambridge= %arvard !niv; +ress, 9>?CA;
7, 7avid Lamton, %ealth, Conflict, and the Chinese +olitical System, Michi*an 1ae!s in
0hinese <t&dies no. 1; (5nn 5!'o!: 9niv. o" Michi*an, 0ente! "o!
xxx "otnote "o!tsette! E neste side xxx
((59))
statistics, statements on 0hinese medical econom( !emain va*&e. )&t the!e is no !eason to
'elieve that cost inc!eases in ha!mace&tical, hosital, and !o"essional medicine in 0hina a!e
less than in othe! co&nt!ies. -o! the time 'ein*, ho%eve!, it can 'e a!*&ed that in 0hina
mode!n medicine in !&!al dist!icts %as so sca!ce that !ecent inc!ements cont!i'&ted
si*ni"icantl( to health levels and to inc!eased eA&it( in access to ca!e.7.
In all co&nt!ies the medicali=ation o" the '&d*et is !elated to %ell8!eco*ni=ed exloitation
%ithin the class st!&ct&!e. No do&'t, the dominance o" caitalist oli*a!chies in the 9nited
<tates,7/ the s&e!cilio&sness o" the ne% manda!ins in <%eden,75 the se!vilit( and
ethnocent!ism o" Mosco% !o"essionals,76 and the lo''( o" the 5me!ican Medical and
1ha!mace&tical 5ssociations,77 as %ell as the
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
0hinese <t&dies, 197/). <ince 1971 cometin* inte!est *!o&s, each t!(in* to maximi=e
!eali=ation o" its val&es, have heled to !e8esta'lish the !e8196; '&!ea&c!atic model in
medicine.
7. Inst!&ments "o! the "&!the! st&d( o" contemo!a!( 0hinese health ca!e: Ioseh 2&inn,
*edicine and +ublic %ealth in the +eople6s epublic of China, 9.<. 7ea!tment o" #ealth,
Ed&cation, and $el"a!e no. NI# 7.867. -o*a!t( Inte!national 0ente!, A ,ibliography of
0hinese Sources on *edicine and +ublic %ealth in the +eople1s epublic of China= 9>?B4
9>:B, 7ea!tment o" #ealth, Ed&cation, and $el"a!e &'lication no. NI# 7.8/.9. American
3ournal of 0hinese *edicine, 1.B. )ox 555, Oa!den 0it(, N.N. 115.>.
7/ ?icente Nava!!o, GThe 9nde!develoment o" #ealth o! the #ealth o" 9nde!develoment:
5n 5nal(sis o" the 7ist!i'&tion o" #&man #ealth 3e8so&!ces in Latin 5me!ica,G
)nternational 3ournal of %ealth Services J, no; 9 29>:JA= @4&:; Scarcity of health care is
consistent with the general scarcity of industrial outputs that favors an urban,
entrepreneurial lumpen4bourgeoisie dependent on its foreign counterparts; This paper is
based on a presentation at the +an4American Conference on %ealth and *anpower +lanning
in 'ttawa, Canada, September 9B49J, 9>:0; A modified version appears in the spring 9>:J
issue of +olitics and Society;
75 ). <hen+in, G1olitics and Medical 0a!e in <%eden: The <even 0!o%ns 3e"o!m,G .ew
England 3ournal of *edicine &CC (197.): 555859. -o! 'ac+*!o&nd cons&lt 3onald #&nt"o!d,
The .ew Totalitarians (Ne% No!+: <tein is 7a(, 197,).
76 3o( 5. and Qho!es Medvedev, A 2&estion of *adness 2.ew <or#= Enopf, 9>:&A,
complain that the nature of society is such that at least two professions, medicine and law,
are not part of the state system; The totalitarian centrali8ation of medical services, while it
has introduced the progressive principle of free health care for all, has also made it possible
to use medicine as a means of government control and political regulation;
77 7avid 3. #(de et al., GThe 5me!ican Medical 5ssociation: 1o%e!, 1&!ose, and 1olitics in
B!*ani=ed Medicine,G <ale La% Io&!nal 6. (Ma( 195/):
((6>))
ne% !ise o" &nion o%e! in the health secto!,7; a!e all "o!mida'le o'stacles to a dist!i'&tion o"
!eso&!ces in the inte!ests o" the sic+ !athe! than o" thei! sel"8aointed ca!eta+e!s. )&t the
"&ndamental !eason %h( these costl( '&!ea&c!acies a!e health8den(in* lies not in thei!
inst!&mental '&t in thei! s(m'olic "&nction: the( all st!ess delive!( o" !eai! and maintenance
se!vices "o! the h&man comonent o" the me*amachine,79 and c!iticism that !ooses 'ette!
and mo!e eA&ita'le delive!( onl( !ein8"o!ces the social commitment to +ee eole at %o!+ in
sic+enin* :o's. The %a! 'et%een the !oonents o" &nlimited national health ins&!ance and
those %ho stand & "o! national health maintenance, as %ell as the %a! 'et%een those
de"endin* and those attac+in* all !ivate !actice, shi"ts &'lic attention "!om the dama*e
done '( docto!s %ho !otect a dest!&ctive social o!de! to the "act that docto!s do less than
exected in de"ense o" a cons&me! societ(.
)e(ond a ce!tain enc!oachment on the '&d*et, mone( that exands medical cont!ol ove!
sace, sched&les, ed&cation, diet, o! the desi*n o" machines and *oods %ill inevita'l( &nleash
a Gni*htma!e "o!*ed "!om *ood intentions.G Mone( ma( al%a(s th!eaten health. Too m&ch
mone( co!!&ts it. )e(ond a ce!tain oint, %hat can
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
9.;81>,,. #(de is an ea!l(, dated, '&t still val&a'le c!itic. 3icha!d #a!!is, 5 Sacred Trust
()altimo!e: 1en*&in, 1969). 5 histo!( o" the 5me!ican Medical 5ssociation6s cleve! and
costl( 'attle a*ainst &'lic health le*islation in the sixties. Elton 3a(ac+, +rofessional +ower
and American *edicines The Economics of the American *edical Association (0leveland:
$o!ld 1&'., 1967), desc!i'es 'lac+mail and consi!ac( '( the 5me!ican Medical 5ssociation
lo''( to maintain ti*ht cont!ol ove! licensin* and the settin* o" standa!ds "o! eve!( !od&ct
that h(sicians e!ceive as health8!elated. This cont!ol !emoves all limits "!om thei! o%e!.
7; Bn the !easons that "o!eshado% the &nioni=ation o" docto!s, see <. @elman, GTo%a!ds a
1olitical Econom( o" Medical 0a!e,G InA&i!( ;, no. . (1971): .>8;R also note 76, . 6>.
79 Le%is M&m"o!d, The +entagon of +ower, vol; &, The *yth of the *achine 2.ew <or#=
%arcourt ,race, 9>:BA, elaborates on the concept of society as megamachine;
xxx "otnote sl&tt xxx
((61))
!od&ce mone( o! %hat mone( can '&( !est!icts the !an*e o" sel"8chosen Gli"e.G Not onl(
!od&ction '&t also cons&mtion st!esses the sca!cit( o" time, sace, and choice;> The!e"o!e
the !esti*e o" medical stales m&st sa the c&ltivation o" health, %hich, %ithin a *iven
envi!onment, to a la!*e extent deends on innate and in'!ed mettle.;1 The mo!e time, toil,
and sac!i"ice sent '( a o&lation in !od&cin* medicine as a commodit(, the la!*e! %ill 'e
the '(8!od&ct, namel(, the "allac( that societ( has a s&l( o" health loc+ed a%a( %hich can
'e mined and ma!+eted.;, The ne*ative "&nction o" mone( is that o" an indicato! o" the
deval&ation o" *oods and . se!vices that cannot 'e 'o&*ht.;. The hi*he! the !ice ta* at %hich
%ell8'ein* is commandee!ed, the *!eate! %ill 'e the olitical !esti*e o" an ex!o!iation o"
e!sonal health.
xxx "otnote sta!t xxx
;> )e(ond a ce!tain oint o" intensit(, cons&mtion !od&ces a sca!cit( o" time: <ta""an ).
Linde!, %arried -eisure Class (Ne% No!+: 0ol&m'ia 9niv. 1!ess, 197>)R accele!ation
!od&ces a en&!( o" sace: Iean 3o'e!t, GEssai s&! l6accTlT!ation des dons,G -1Arc (5ix8en8
1!ovence), "all 1975R and lannin* dest!o(s the ossi'ilities "o! choice: #e!'e!t Ma!c&se,
Eros and Civili8ation ()oston: )eacon 1!ess, 1955).
;1 3enT 7&'os, Man and %is Envi!onment: ,iomedical Enowledge and <ocial 5ction, 1an8
5me!ican #ealth B!*ani=ation, <cienti"ic 1&'lication no. 1.1 ($ashin*8ton, 7.0., Ma!ch
1966). GThe +ind o" health that men desi!e most is . . . the condition 'est s&ited to !each *oals
that each individ&al "o!m&lates "o! himsel".G <ee also #ein= von -oe!ste!, *olecular
Ethology= An )mmodest +roposal (Ne% No!+: 1len&m 1!ess, 197>), "o! a demonst!ation "!om
theo!etical 'iolo*( that nont!ivial Gli"eG can 'e extin*&ished '( ove!!o*!ammin*.
;, ?icto! -&chs, G<ome Economic 5sects o" Mo!talit( in 7eveloed 0o&nt!ies,G ae!
!esented at the 0on"e!ence on the Econom( o" #ealth and Medical 0a!e, To+(o, 197.,
mimeo*!ahed. -&chs ass&mes that Gli"e is !ima!il( !od&ced '( nonma!+et activities, and
that the "emale tends to seciali=e in s&ch activities.G The attemt to !elace !athe! than to
comlement these Gnonma!+et activitiesG %ith commodities is lite!all( unhealthy; <ee 5lan
)e!*, The .utrition (actor; )ts ole in .ational Development ($ashin*ton, 7.0.: )!oo+in*s
Instit&tion, 197.), a. 0, . ,,9, on the sic+enin* e""ects o" the s&'stit&tion o" va!io&s
"o!m&las "o! '!east mil+.
;. The medicali=ation o" the '&d*et is a meas&!e o" the !o"essional dissei=in o" health and
o"6 the acA&iescence o" eole in thei! o%n disendo%ment '( the!ae&tic ca!eta+e!s.
Disseisin= Gthe %!on*"&l &ttin* o&t o" him "!om that %hich is act&all( sei=ed as a "!eeholdG:
1. O. Bs'o!n, Concise -aw Dictionary (London: <%eet V Max%ell, 196/).
xxx "otnote sl&tt xxx
((6,))
,he Pharmaceutical In$asion
7octo!s a!e not needed to medicali8e a societ(6s d!&*s.;/ Even %itho&t too man( hositals
and medical schools a c&lt&!e can 'ecome the !e( o" a ha!mace&tical invasion. Each c&lt&!e
has its oisons, its !emedies, its lace'os, and its !it&al settin*s "o! thei! administ!ation.;5
Most o" these a!e destined "o! the health( !athe! than "o! the sic+.;6 1o%e!"&l medical d!&*s
easil( dest!o( the histo!icall( !ooted atte!n that "its each c&lt&!e to its oisonsR the( &s&all(
ca&se mo!e dama*e than !o"it to health, and &ltimatel( esta'lish a ne% attit&de in %hich the
'od( is e!ceived as a machine !&n '( mechanical and mani&latin* s%itches ;7
xxx "otnote sta!t xxx
;/ -o! a "i!st o!ientation: 5l"!ed M. 5:ami, I!., Drugs= An Annotated ,ibliogrerhy and O&ide
to the -iterature ()oston: #all, 197.). 5:ami selects and annotates mo!e than 5>> !e"e!ences
on s(choha!macolo*( "o! an inte!discilina!( co&!se on the 9.<. GsceneG o" the late sixties.
9<. National 0lea!in* #o&se "o! Mental #ealth, ,ibliography of Drug Dependence and
Abuse 19,;81966 (0hev( 0hase, Md., 1969). Indisensa'le "o! histo!ical !esea!ch. 5lice L
)!&nn, %ow to (ind 'ut in 1ha!mac( 5 $uide to Sources of +harmaceutical )nformation;
(Bx"o!d: 1e!*amon 1!ess, 1969). 5 simle !e"e!ence *&ide. 3. #. )l&m et al., Society and
Drugs, , vols. ()e!+ele(, 0ali".: Iame(8)ass, 197>). 5 o!ta'le li'!a!( on societ( and d!&*s.
;5 O. E. ?aillant, GThe Nat&!al #isto!( o" Na!cotic 7!&* 5ddiction,G in Seminars in
+vchiatry & (Novem'e! 197>): /;689;. 7!&*s deend 'oth "o! thei! desi!a'ilit( and thei!
e""ect on the milie& in %hich the( a!e ta+en. The choice o" the d!&* is a "&nction o" the
c&lt&!e, '&t the a'&se o" the d!&* is a "&nction o" the man. The !it&ali=ation o" d!&*8ta+in*
c!eates its s&'c&lt&!e: th&s the histo!( o" d!&* addiction as that o" societ( m&st 'e !e%!itten
eve!( "e% (ea!s. <am&el 1!a*e!, ed., The *edicated Society (Ne% No!+: Macmillan, 196;),
!ovides doc&ments sho%in* the +ind o" d!&* c&lt&!e that !evailed in the 9.<. lon* 'e"o!e
L<7.
The extent to %hich addicts a!e "o!ced into a *hetto o" thei! o%n deends &on the comm&nit(
that !e:ects them. -o! instance, 1&e!to 3icahs in Ne% No!+ do not !e:ect thei! addicts in the
%a( middle8class 5me!icans do: I. 1. -it=at!ic+, G1&e!to 3ican 5ddicts and Nonaddicts: 5
0oma!ison,G &n&'lished !eo!t, Instit&te "o! <ocial 3esea!ch, -o!dham 9nive!sit(, 1975.
;6 #ans $is%e, Eulbngesuhich a der @och+&nst EochbGcher and 3osette a&s =%ei
3ahrtausenden (M&nich: Moos, 197>). Most societies cannot distin*&ish clea!l( 'et%een thei!
ha!macoeia and thei! diet. This s&!ve( o" coo+'oo+s sho%s that man( %e!e %!itten '(
h(sicians, %ith a "!eA&ent insistence that the 'est medicine comes "!om the +itchen and not
"!om the ha!mac(. Most contain G!eciesG "o! the ca!e o" the sic+.
;7 -o! the !esent in"o!mation availa'le on d!&* action, see Lo&is <. Ooodman and 5l"!ed
Oilman, The +harmacological ,asis of Therapeutics, Jth ed; 2.ew <or#=
xxx "otnote "o!tsette! neste side xxx
((6.))
In the 19/>s "e% o" the !esc!itions %!itten in #o&ston o! Mad!id co&ld have 'een "illed in
Mexico, excet in the 8ona rosa o" Mexico 0it(, %he!e inte!national ha!macies "lo&!ish
alon*side 'o&tiA&es and hotels. Toda( Mexican villa*e d!&*sto!es o""e! th!ee times as man(
items as d!&*sto!es in the 9nited <tates. In Thailand ;; and )!a=il, man( items that a!e
else%he!e o&tdated, o! ille*al s&!l&s and d&ds, a!e d&med into ha!macies '( man&"act&!e!s
%ho sail &nde! man( "la*s o" convenience. In the ast decade, %hile a "e% !ich co&nt!ies
'e*an to cont!ol the dama*e, %aste, and exloitation ca&sed '( the licit d!&*8&shin* o" thei!
docto!s, h(sicians in Mexico, ?ene=&ela, and even 1a!is had mo!e di""ic&lt( than eve! 'e"o!e
in *ettin* information on the side8e""ects o" the d!&*s the( !esc!i'ed.;9 Bnl( ten (ea!s a*o,
%hen d!&*s %e!e !elativel( sca!ce in Mexico, eole %e!e oo!, and most sic+ e!sons %e!e
attended '( *!andmothe! o! the he!'alist, ha!mace&ticals came ac+a*ed %ith a desc!itive
lea"let. Toda( d!&*s a!e mo!e lenti"&l, mo!e o%e!"&l, and mo!e dan*e!o&sR the( a!e sold '(
television and !adioR eole %ho have attended school "eel ashamed o" thei! lin*e!in*
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
Macmillan, 197>). Bn !esc!i'in* atte!ns, see @a!en 7&nnell and 5nn 0a!t%!i*ht, *edicine
Ta#ers, +rescribers and %oarders (London: 3o&tled*e, 197,). $ho ta+es %hich so!t o"
medicines "o! %hat t(es o" conditions and s(mtoms4 #o% do docto!s enco&!a*e o!
disco&!a*e this atte!n4 $hat +inds o" medicines a!e +et in the home and "o! ho% lon*4
7etailed in"o!mation a'o&t En*land. 5lso see Iohn 1. Mo!*an and Michael $eint!a&', G5
0o&!se on the <ocial -&nctions o" 1!esc!ition 7!&*s: <emina! <(lla'&s and )i'lio*!ah(,G
Annals of )nternal *edicine :: (5&*&st 197,): ,17D,,R 1a&l <tolle( and Lo&is Lasa*na,
G1!esc!i'in* 1atte!ns o" 1h(sicians,G 3ournal of Chronic 7iseases ,, (7ecem'e! 1969): .958
/>5.
;; ,usiness in ThailandR secial iss&e on the ha!mace&tical ind&st!(, 5&*&st 197/.
;9 The 5me!ican h(sician can easil( *ain access to this in"o!mation "!om s&ch so&!ces as
*edical -ater on Drugs and Therapeutics, Medical Li'!a!( 5ssociation, 919 N. Michi*an
5ven&e, 0hica*o, Ill. This is an &n'iased so&!ce o" d!&* in"o!mation mailed "o!tni*htl(.
Nothin* coma!a'le is availa'le in -!ench, Oe!man, o! <anish. 5lso see 3icha!d )&!ac+,
The .ew %andboo# of +rescription Drugs; 'fficial .ames, +rices, and Sources for +atient
and Doctor, !ev. ed. (Ne% No!+: 1antheon, 197>). (<ee 'elo%, note 99, . 67, "o! desc!ition
o" this 'oo+.)
xxx "otnote sl&tt xxx
((6/))
t!&st in the 5=tec c&!e!R and the lea"let has 'een !elaced '( one standa!d note %hich sa(s Gon
!esc!ition.G The "iction %hich is meant to exo!cise the d!&* '( medicali=in* it in "act onl(
con"o&nds the '&(e!. The %a!nin* to cons&lt a docto! ma+es the '&(e! 'elieve he is
incometent to 'e%a!e. In most co&nt!ies o" the %o!ld, docto!s a!e siml( not %ell eno&*h
s!ead o&t to !esc!i'e do&'le8ed*ed medicine each time it is indicated, and most o" the time
the( themselves a!e not !ea!ed, o! a!e too i*no!ant, to !esc!i'e %ith d&e !&dence. 5s a
conseA&ence the h(sician6s "&nction, eseciall( in oo! co&nt!ies, has 'ecome t!ivial: he has
'een t&!ned into a !o&tine !esc!ition machine that is constantl( !idic&led, and most eole
no% ta+e the same d!&*s, :&st as haha=a!dl(, '&t %itho&t his a!oval 9>
0hlo!amhenicol is a *ood examle o" the %a( !eliance on !esc!ition can 'e &seless "o! the
!otection o" atients and can even !omote a'&se. 7&!in* the 196>s this d!&* %as ac+a*ed
as 0hlo!om(cetin '( 1a!+e, 7avis and '!o&*ht in a'o&t one8thi!d o" the coman(6s ove!8all
!o"its. )( then it had 'een +no%n "o! seve!al (ea!s that eole %ho ta+e this d!&* stand a
ce!tain chance o" d(in* o" alastic anemia, an inc&!a'le disease o" the 'lood. T(hoid is
almost the onl( disease that, %ith se!io&s A&ali"ications, does :&sti"( the ta+in* o" this
s&'stance. Th!o&*h the late "i"ties and ea!l( sixties, 1a!+e, 7avis, not%ithstandin* st!on*
clinical cont!aindications, sent la!*e s&ms to !omote thei! %inne!. 7octo!s in the 9nited
<tates !esc!i'ed chlo!amhenicol to almost "o&! million eole e! (ea! to t!eat them "o!
acne, so!e th!oat, the common cold, and even s&ch t!i"les as in"ected han*nail. <ince t(hoid
is !a!e in the 9nited <tates, no mo!e than
xxx "otnote sta!t xxx
9> 5!t&!o 5ldama, GEsta'lecimiento de &n la'o!ato!io "a!macT&tico na8clonal,G %igiene=V
'rgan of sial de la Sociedad *e/ican ds %igiene 99 23anuary4(ebruary 9>@>A; This sounded
the alarm;
xxx "otnote sl&tt xxx
((65))
one in />> o" those *iven the d!&* GneededG the t!eatment. 9nli+e thalidomide, %hich
dis"i*&!es, chlo!amhenicol +ills: it &ts its victims o&t o" si*ht, and h&nd!eds o" them in the
9nited <tates died &ndia*nosed 91
<el"8cont!ol '( the !o"ession on s&ch matte!s has neve! %o!+ed,9, and medical memo!ies
have !oved a!tic&la!l( sho!t 9. The 'est one can sa( is that in #olland o! No!%a( o!
7enma!+, sel"8!e*&lation has at ce!tain moments 'een less ine""ective than in Oe!man( o!
-!ance9/ o! Ital(,95 and
xxx "otnote sta!t xxx
91 The in"o!mation on 0lo!om(cetin is ta+en "!om 9.<. <enate, <elect 0ommittee on <mall
)&siness, <&'committee on Monool(, 0ometitive 1mllsn& in flee Drug Ind&st!(, 9>th
0on*!ess, 1st and ,nd <essions, 196786;, t. ,, . 565.
9, Bn the mechanisms that t&!n sel"8!e*&lation into license "o! e!"o!mance o" the maxim&m
&'licall( tole!ated a'&se, see Eliot -!eidson and )&"o!d 3hea, G1!ocess o" 0ont!ol in a
0oman( o" EA&als,G Social +roblems > (196.): 11981.1. The( sho% that, tho&*h m&ch
a'&se *oes &no'se!ved, even i" o'se!ved it is not comm&nicated to collea*&es, and even i"
comm&nicated it is t!eated '( Gtal+in* to the o""ende!G and !emains &ncont!olled. <el"8
!e*&lation !inciall( !otects the !o"ession '( eliminatin* the incometent '&tche! and the
'!a=en mo!al lee!. $illiam I. Ooode, GThe 1!otection o" the Inet,G 5me!ican Sociological
3evie% ., (-e'!&a!( 1967): 5819. Ooode desc!i'es ho% sel"8!e*&lation consists to a la!*e
de*!ee in the !otection o" the inet %ithin the *!o& and the !otection o" the *!o&6s sel"8
inte!est "!om the excesses o" the inet. Mode!ni=ation consists in the mo!e e""icient &tili=ation
o" the inet in the sel"8inte!est o" the *!o&. Eliot -!eidson and )&"o!d 3hea, G@no%led*e and
I&d*ment in 1!o"essional Eval&ations,G Administrative Science Wuarterly 1> (I&ne 1965):
1>78,/.
9. Memo!( is no *&ide to %hich d!&*s have 'een !esc!i'ed o! cons&med in the ast. 5
sea!ch in the national !e*ist!( o" !esc!itions in En*land and $ales sho%s that ; o&t o" 1>
%omen %ho had 'o!ne a de"ective child a"te! ta+in* thalidomide on !esc!ition denied that
the( had ta+en the d!&*, and that thei! h(sicians denied havin* o!de!ed it. <ee 5. L. <ei!s,
GThalidomide and 0on*enital 5'no!malities,G Lancet, 196,, 1:.>..
9/ #en!i 1!adal, $uide des mii+ammts #s plus courant= 2+aris= <e&il, 197/). In Novem'e!
197. m( -!ench &'lishe!, <e&il, '!o&*ht o&t a ae!'ac+ o!i*inal o" this 'oo+ '( a h(sician
%ith man( (ea!s6 exe!ience as a toxicolo*ist. It is a list o" the 1>> 'est8sellin*
ha!mace&ticals, incl&din* !esc!ition d!&*s, exlainin* %hat each one is, %hat it is
indicated "o!, ho% it tends to 'e &sed o! !esc!i'ed, and %ith %hat conseA&ences. Bn
&'lication da( 57 d!&* "i!ms sta!ted sea!ate le*al actions to have the 'oo+ %ithd!a%n and
s&ed "o! !eim'&!sement "o! !o'a'le dama*es.
95 5. del -ave!o and O. Loiaoono, (arman1, salute s pmfitti in halia 2*ilan= (eltrinelli,
9>:JA, describe the dependence and servility of the )talian physician in his relations with the
drug industry, and the e/ploitative integration of the )talian drug fans among t!ansnational
comanies. -&ll o" doc&mentation and detail.
xxx "otnote sl&tt xxx
((66))
that 5me!ican docto!s have a a!tic&la! "acilit( "o! admittin* ast mista+es and :&min* on
ne% 'and%a*ons.96 In the 9nited <tates in the "i"ties, cont!ol ove! d!&*s '( !e*&lato!(
a*encies %as at a lo% e'' and sel"8cont!ol %as nominal.97 Then, d&!in* the sixties, conce!ned
ne%sae!men,9; medical men,99 and oliticians1>> la&nched a camai*n that exosed the
s&'se!vience o" h(sicians and *ove!nment o""icials to ha!mace&tical "i!ms and de8sc!i'ed
some o" the !evalent atte!ns o" %hite8colla! c!imes in medicine.1>1 $ithin t%o months
a"te! the
xxx "otnote sta!t xxx
96 Iames #. No&n*, *edical *essiahs= A Social %istory of %ealth Wuac#ery in Twentieth4
Century America (1!inceton, N. I.: 1!inceton 9niv. 1!ess, 1967). #isto!ical 'ac+*!o&nd "o!
the cavalie! con"idence o" 9.<. o!*ani=ed medicine 'ased on its !otection o" the &'lic
a*ainst "!ee8lance heale!s and sel"8medication. -o! the ea!lie! histo!( see Iames #. No&n*,
The Toadstool *illionaires= A Social %istory of +atent *edicines in America ,efore (ederal
egulation (1!inceton, N .I.: 1!inceton 9niv. 1!ess, 1961).
97 3o'e!t <. Mc0lee!(, 'ne -ifeX'ne +hysician= An )nquiry into the *edical +rofession1s
+erformance in Self4egulation, A 3eo!t to the 0ente! "o! the <t&d( o" 3esonsive La%
($ashin*ton, 7.0.: 1&'lic 5""ai!s 1!ess, 1971). This !eo!t to a st&d( *!o& initiated '(
3alh Nade! concl&des that the!e is a total lac+ o" inte!nal A&alit( cont!ol %ithin the medical
!o"ession.
9; Mo!ton Mint=, ,y +rescription 'nly= A eport on the oles of the !nited States (ood and
Drug Administration, the American *edical Association, +harmaceutical *anufacturers,
and 'thers in Connection with the )rrational and *assive !se of +rescription Drugs That
*ay ,e "orthless, )n5urious, or Even -ethal, &nd ed; 2,oston= ,eacon +ress, 9>?:A;
'riginally published as The Therapeutic .ightmare 2,oston= %oughton *ifflin, 9>?@A, this
masterpiece of investigative 5ournalism by a staff reporter of the "ashington +ost has done
more than any other boo# to change the focus of the !;S; discussion of medicine; (or ten
years a benevolent minority had worried about the damage done by capitalist medicine to the
poor; .ow the pill4swallowing ma5ority became aware of what it was doing to them;
99 3icha!d )&!ac+, M.7., The .ew %andboo# of +rescription Drugs= 'fficial .ames, +rices
and Sources for +atient and Doctor (Ne% No!+: 1antheon, 197>). 1&'lished at a time %hen
:&dicial evidence "o! the &nd&e 'ias o" !e*&lato!( commissions, consi!ac( "o! the
dissemination o" misleadin* in"o!mation on oisono&s d!&*s, and the venalit( o" not a "e%
!o"esso!s o" medicine %as still di""ic&lt to o'tain this 'oo+ !ovides in"o!mation and
eval&ation o" the e""icienc(, &se"&lness, side8e""ects, and alication o" the ,>> most
!esc!i'ed d!&*s, comments on thei! !ices in coma!ison %ith *ene!ic eA&ivalents ("o! %hich
s&lie!s a!e listed %ith add!esses), and adds sic( anecdotes on man( o" the t!adema!+ed
nost!&ms.
1>> Iames L Oodda!d, GThe 7!&* Esta'lishment,G Esquire, Ma!ch 1969. 5 !eada'le and %ell8
!esea!ched !eo!t.
1>1 Ed%in <&the!land, "hite4Collar Crime 2.ew <or#= %olt, 9>?9A, uses this term to
designate a wide variety of serious offenses involving recogni8ed social
xxx "otnote "o!tsette! E neste side xxx
((67))
exos&!e at a con*!essional hea!in*, the &se o" chlo!amhenicol in the 9nited <tates
d%indled. 1a!+e, 7avis %as "o!ced to inse!t st!ict %a!nin*s o" ha=a!ds and ca&tiona!(
statements a'o&t the &se o" this d!&* into eve!( ac+a*e. )&t these %a!nin*s did not extend to
exo!ts.1>, The d!&* contin&ed to 'e &sed indisc!iminatel( in Mexico, not onl( in sel"8
medication '&t on !esc!ition, the!e'( '!eedin* a d!&*8!esistant st!ain o" t(hoid 'acilli
%hich is no% s!eadin* "!om 0ent!al 5me!ica to the !est o" the %o!ld.
Bne docto! in Latin 5me!ica, %ho %as also a statesman did t!( to stem the ha!mace&tical
invasion !athe! than :&st enlist h(sicians to ma+e it loo+ mo!e !esecta'le. 7&!in* his sho!t
ten&!e as !esident o" 0hile, 7!. <alvado! 5llende1>. A&ite s&ccess"&ll( mo'ili=ed the oo! to
identi"( thei! o%n health needs and m&ch less s&ccess"&ll( comelled the medical !o"ession
to se!ve 'asic !athe! than !o"ita'le needs. #e !oosed to 'an d!&*s &nless the(
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
ha!m that eithe! a!e not !osec&ted o! a!e con"ined to civil co&!ts. The medical va!iet( has
eidemic conseA&ences and mi*ht 'e called G%hite8coat c!ime.G
1>, #e!'e!t <ch!eie! and La%!ence )e!*e!, GBn Medical Ime!ialism: 5 Lette!,G -ancet,
197/, 1:1161: G9nde! !ess&!e "!om the 9< -ood and 7!&* 5dminist!ation, 1a!+e87avis
inse!ted st!ict %a!nin*s o" ha=a!ds and ca&tiona!( statements a'o&t indications "o! the &se o"
the d!&* in the 9<5. The %a!nin* did not extend to the same d!&* a'!oad.G 5lso see Iohn -.
#elle!*e!s, G0hlo!amhenicol in Iaan: Let It )leed,G ,ulletin of Concerned Asia Scholars @
(I&l( 197.): .78/5. The exansion o" "ede!al cont!ols ove! the exo!t o" drugs %o&ld onl(
a!tiall( !emed( this "o!m o" ime!ialism. -ede!al a&tho!it(, %hich no% does cove! the M6
'illion ha!mace&tical d!&* ind&st!(, does not (et extend ove! the M. 'illion medical device
ind&st!(. It cannot, "o! examle, sto the 5. #. 3o'ins coman( "!om s&l(in* "o!ei*n
comanies %ith a model o" a cont!acetive shield %hich has 'een %ithd!a%n "!om the 9.<.
ma!+et 'eca&se o" its hi*h in"ection !ateR see %astings Center Studies @, no; . (1975): ,.
1>. Bn medicine in 0hile &nde! 5llende cons&lt #o%a!d $ait=+in and #ila!( Modell,
GMedicine, <ocialism, and Totalita!ianism: Lesson "!om 0hile,G .ew England 3ournal of
*edicine ,91 (197/): 17187R ?icente Nava!!o, G$hat 7oes 0hile Mean4 5n 5nal(sis o"
Events in the #ealth <ecto! )e"o!e, 7&!in*, and 5"te! 5llende6s 5dminist!ation,G *ilban#
*emorial (und Wuarterly 5, (s!in* 197/): 9.81.>. This a!ticle is 'ased on a ae! !esented
at the Inte!national #ealth <emina! at #a!va!d 9nive!sit(, -e'!&a!( 197/. -o! an e(e%itness
!eo!t, see 9!s&la )e!na&e! and Elisa'eth -!eita*, -odo! popular in Chile am ,eispiel
$esundheit= Do#umente aus Elendsvierteln 2SteinS.uremberg= -aetereS)mba, 9>:JA;
xxx "otnote sl&tt xxx
((6;))
had 'een t!ied on a(in* clients in No!th 5me!ica o! E&!oe "o! as lon* as the atent
!otection %o&ld !&n. #e !evived a !o*!am aimed at !ed&cin* the national ha!macoeia to a
"e% do=en items, mo!e o! less the same as those ca!!ied '( the 0hinese 'a!e"oot docto! in his
'lac+ %ic+e! 'ox. Nota'l(, %ithin one %ee+ a"te! the 0hilean milita!( :&nta too+ o%e! on
<etem'e! 11, 197., man( o" the most o&tso+en !oonents o" a 0hilean medicine 'ased on
comm&nit( action !athe! than on d!&* imo!ts and d!&* cons&mtion had 'een m&!de!ed.1>/
The ove!cons&mtion o" medical d!&*s is, o" co&!se, not !est!icted to a!eas %he!e docto!s a!e
sca!ce o! eole a!e oo!. In the 9nited <tates, the vol&me o" the d!&* '&siness has *!o%n '(
a "acto! o" 1>> d&!in* the c&!!ent cent&!(: 1>5 ,>,>>> tons o" asi!in a!e cons&med e! (ea!,
almost ,,5 ta'lets e! e!son.1>6 In En*land, eve!( tenth ni*ht o" slee is ind&ced '( a
h(notic d!&* and 19 e!cent o" %omen and 9 e!cent o" men ta+e a !esc!i'ed t!anA&ili=e!
d&!in* an( one (ea!.1>7 In the 9nited <tates, cent!alne!vo&s8s(stem a*ents a!e the "astest8
*!o%in* secto! o" the ha!mace&tical ma!+et, no% ma+in* & .1 e!cent o" total sales.1>;
7eendence on !esc!i'ed t!anA&ili=e!s has
xxx "otnote sta!t xxx
1>/ 5l'e!t Ionsen et al., G7octo!s in 1olitics: 5 Lesson "!om 0hile,G .ew England 3ournal of
*edicine ,91 (197/): /718,. 7esc!i'es the a!tic&la! violence %ith %hich h(sicians %e!e
e!sec&ted '( the :&nta.
1>5 Iohn M. -i!estone, Trends in +rescription Drug +rices ($ashin*ton, 7.0.: Ente!!ise
Instit&te "o! 1&'lic 1olic( 3esea!ch, 197>). 7!&* exendit&!es acco&nt "o! onl( a'o&t 1>f o"
health exendit&!es. The mode!ate !ise in the cost o" each !esc!ition d&!in* the last (ea!s is
d&e mainl( to an inc!ease in the si=e o" the ave!a*e !esc!ition.
1>6 Ed%a!d M. )!eche! and 0ons&me! 3eo!ts Edito!s, -icit and )llicit Drugs The
Consumers 9nion eport on .arcotics, <tim&lants, Depressants, Inhalants, %allucino*ens
and *ari5uana )ncluding Caffeine, .icotine and Alcohol ()oston: Little, )!o%n, 197.).
1>7 7. M. 7&nlo, GThe 9se and 5'&se o" 1s(chot!oic 7!&*s,G in +roceedings of the oyal
Society of *edicine 6. (197>): 1,79. O. L. @le!man, G<ocial ?al&es and the 0ons&mtion o"
1s(chot!oic Medicine,G in +roceedings of the (irst "orld Congress on Envi!onmental
*edicine and ,iology (#aa!lem: No!th8#olland, 197/). -o! a a!tic&la!l( e!nicio&s "o!m o"
medicall( !esc!i'ed d!&* addiction see 7o!oth( Nel+in, *ethadone *aintenance= A
Technological (i/ (Ne% No!+: )!a=ille!, 197.).
1>; Iames L. Oodda!d, GThe Medical )&siness,G <cienti"ic American ,,9 (<etem'e! 197.):
16186. 0ontains *!ahs and cha!ts sho%in* 9.<. sales o"
xxx "otnote "o!tsette! E neste side xxx
((69))
!isen '( ,9> e!cent since 196,, a e!iod d&!in* %hich the e! caita cons&mtion o" liA&o!
!ose '( onl( ,. e!cent and the estimated cons&mtion o" ille*al oiates '( a'o&t 5>
e!cent.1>9 5 si*ni"icant A&antit( o" G&e!sG and Gdo%ne!sG is o'tained in all co&nt!ies '(
ci!c&mventin* the docto!. 11> Medicali=ed addiction 111 in 1975 has o&t8*!o%n all sel"8
chosen o! mo!e "estive "o!ms o" c!eatin* %ell8'ein*.11,
It has 'ecome "ashiona'le to 'lame m&ltinational ha!mace&tical "i!ms "o! the inc!ease in
medicall( !e8
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
!esc!ition and non!esc!ition d!&*s '( cate*o!(, 196,871R '!ea+do%n '( sales dolla!
estimated in 196; "o! 17 leadin* ha!mace&tical ho&sesR int!od&ction o" ne% d!&*s,
com'inations, and dosa*e "o!ms, 195;.87,. 5lso identi"ia ; classes o" !esc!ition d!&*s.
$ithin the cate*o!( Gne!vo&s s(stem d!&*sG alone, sales a**!e*ate mo!e than M1 'illion e!
(ea!. This coma!es %ith th!ee othe! cate*o!ies each a**!e*atin* a'o&t M5>> million, and the
!est, each less than M.5> million. -o! a '!ea+do%n '( a*e, sex, and t(e o" 76, million
medicines %o!th M,.5 million !esc!i'ed to nonhositali=ed atients in the co&!se o" one (ea!
in the 9.<., see ). <. #. #a!!is and I. ). #allan, GThe N&m'e! and 0ost o" 1!esc!i'ed
Medicines: <elected 7iseases,G )nquiry : (197>): .;85>.
1>9 Dreg !se in America. +roblem in +erspective, <econd 3eo!t o" the National
0ommission on Ma!ih&ana and 7!&* 5'&se, 197,, 197., 197/, / vols. ($ashin*ton, 7.0.:
Oove!nment 1!intin* B""iceR stoc+ no. 5,668>>>.). National 0ommission "o! the <t&d( o"
N&!sin* and N&!sin* Ed&cation, An Abstract for Action (Ne% No!+: McO!a%8#ill, 197>).
11> Mitchell )aite! et al., G0!oss8national <t&d( o" the Extent o" 5nti85nxiet(L<edative 7!&*
9se,G .ew England 3ournal of *edicine &>B 29>:JA= :?>4:J;
111 Michael )alint, Treatment or Diagnosis= A Study of epeat +rescriptions in $eneral
+ractice, Mind and Medicine Mono*!ahs (1hiladelhia: Liincott, 197>). 1!esc!ition
!ovides l&ste! and seemin* !ationalit( to the 'elie" that !o*!ess consists in '&(in* one6s %a(
o&t o" eve!(thin*, incl&din* !ealit( itsel". )alint oints o&t that in t%o8thi!ds o" cases in %hich
d!&*s %e!e !eeatedl( !esc!i'ed %itho&t an( technical :&sti"ication, the h(sician himsel"
too+ the initiative to o""e! the d!&*. #a!!( 7o%lin*, G#o% 7o 1!acticin* 1h(sicians 9se Ne%
7!&*s4G 3ournal of the American *edical Association 1;5 (196.): ,..8.6. B&t o" "ea! o"
Gdoin* nothin*G the !actitione! is led to !esc!i'e mo!e than is indicated '( inst!&ctions on
the ac+a*e. Bn the atte!n acco!din* to %hich !esc!ition a'&ses s!ead, see Lei*hton E.
0l&"" et al., G<t&dies in the Eidemiolo*( o" 5dve!se 7!&* 3eactions,G 3ournal of the
American *edical Association 1;; (196/): 9768;..
11, 1hilie de -elice, +oisons sac!Ts: )vresses divinesM Essai sur quelques formes infnieures
de la mystique (1a!is: 5l'in, 19.6R !e!inted 197>). The t!aditional, &s&all( !eli*io&s settin*
and *oal "o! d!&* cons&mtion a!e cont!asted %ith !esent8da( laici=ed &se o" mind8alte!in*
s&'stances.
xxx "otnote sl&tt xxx
((7>))
sc!i'ed d!&* a'&seR thei! !o"its a!e hi*h and thei! cont!ol ove! the ma!+et is &niA&e. -o!
"i"teen (ea!s, d!&* ind&st!( !o"its (as a e!centa*e o" sales and coman( net %o!th) have
o&t!an+ed those o" all othe! man&"act&!in* ind&st!ies listed on the <toc+ Exchan*e. 7!&*
!ices a!e cont!olled and mani&lated: the same 'ottle that sells "o! t%o dolla!s in 0hica*o o!
Oeneva %he!e it is !od&ced, '&t %he!e it "aces cometition, sells "o! t%elve dolla!s in a oo!
co&nt!( %he!e it does not.11. The ma!+&, mo!eove!, is henomenal: "o!t( dolla!s6 %o!th o"
dia=eam, once stamed into ills and ac+a*ed as ?ali&m, sells "o! 9JB times as m&ch, and
"o! 7> times mo!e than heno'a!'ital, %hich, in the oinion o" most ha!macolo*ists, has the
same indications, e""ects, and dan*e!s.11/ 5s commodities, !esc!ition d!&*s 'ehave
di""e!entl( "!om most othe! items: the( a!e !od&cts that the &ltimate cons&me! !a!el( selects
"o! him8sel". 115 The !od&ce!6s sales e""o!ts a!e di!ected at the Ginst!&mental cons&me!,G the
docto! %ho !esc!i'es '&t does not a( "o! the !od&ct. To !omote ?ali&m,
xxx "otnote sta!t xxx
11. 0ha!les Levinson, 6alium rum ,eispiel= Die multinationalen Eon8erne der
pharma8eutischen )ndustrie 2%amburg= owohlt, 9>:JA; The prices charged in )ndia by
$la/o, +fi8er, %oechst, C),A4$eigy, and %offmann4-aoche are on the average 0@:Y
higher than those listed in the "estern countries where these firms have their home offices;
11/ The data a!e ta+en "!om )&!ac+, Ne% #and'oo+ of +rescription Drugs;
115 In most co&nt!ies, most in"o!mation on d!&*s "o! the h(sician comes "!om ind&st!(8
sonso!ed man&als s&ch as +hysicians1 Des# eference to +harmaceutical Specialities and
,iologicals, &'lished since 19/6 '( Medical Economics, 3&the!"o!d, N .I. This ann&al
&'lication, +no%n as 173, is s&o!ted '( the ha!mace&tical ind&st!(. The d!&*
desc!itions a!e %!itten '( the comanies themselves, %hich a( M115 e! col&mn8inch "o!
the saceR see Iohn 1e++anen, The American Connection= +rofiteering and +olitic#ing in the
DEthicalD Drug )ndustry (0hica*o: -ollett, 197.), . 1>6. The -!ench 6idal contains
desc!itions %hich s&!ess the %a!nin*s that a!e o'li*ato!( in the lea"let that comes %ith the
d!&*. In cont!ast to these, the 9.<. has t%o semio""icial ha!macolo*ical comendia, the
+harmacopeia of the !nited States of America 2!S+A and the .ational (ormulary 2.(A; The
!S+ has consistently given consideration to therapeutic worth and to/icity; These compendia
are not %!itten "o! the *&idance o" h(sicians, '&t to !ovide d!&* man&"act&!e!s %ith
technical standa!ds that !ea!ations m&st meet to 'e ma!+eted le*all( in inte!state comme!ce
in the 9.<.
xxx "otnote sl&tt xxx
((71))
#o""mann8La3oche sent M,>> million in ten (ea!s and commissioned some t%o h&nd!ed
docto!s a (ea! to !od&ce scienti"ic a!ticles a'o&t its !oe!ties.116 In 197., the enti!e d!&*
ind&st!( sent an ave!a*e o" M/,5>> on each !acticin* h(sician "o! adve!tisin* and
!omotion, a'o&t the eA&ivalent o" the cost o" a (ea! in medical schoolR in the same (ea!, the
ind&st!( cont!i'&ted less than . e!cent to the '&d*et o" 5me!ican medical schools.117
<&!!isin*l(, ho%eve!, the e! caita &se o" medicall( !esc!i'ed d!&*s a!o&nd the %o!ld
seems to have little to do %ith comme!cial !omotionR it co!!elates mostl( %ith the n&m'e! o"
docto!s, even in socialist co&nt!ies %he!e the ed&cation o" h(sicians is not in"l&enced '(
d!&* ind&st!( &'licit( and %he!e co!o!ate d!&*8&shin* is limited.11; Bve!8all d!&*
cons&mtion in ind&st!ial societies is not "&ndamentall( a""ected '( the !oo!tion o" items
sold '( !esc!ition, ove! the co&nte!, o! ille*all(, and it is not a""ected '( %hethe! the
&!chase is aid "o! o&t o" oc+et, th!o&*h !eaid ins&!ance, o! th!o&*h %el"a!e "&nds.119 In
all co&nt!ies, docto!s %o!+ inc!easin*l(
xxx "otnote sta!t xxx
116 -o! an idea o" the n&m'e! o" h(sicians at the se!vice o" a sin*le man&"act&!e! in the
decision to !omote :&st one !od&ct cons&lt -ibrinn= "orldwide ,ibliography, &'lished
(ea!l( since 1959 '( 3oche La'o!ato!ies. The "i!st "o&! (ea!s contain ;., ent!ies. <ee also
Science 1;> (197.): 1>.;, "o! a !eo!t o" a st&d( cond&cted '( the -ede!al 7!&*
5dminist!ation on the ethics o" h(sicians %ho cond&ct "ield !esea!ch %ith ne% d!&*s. Bne8
"i"th o" those investi*ated had invented the data the( sent to the d!&* comanies, and oc+eted
the "ees.
117 <eli* O!een'e!*, The Wuality of *erry= A eport on the Critical Condition of %ospital
and *edical Care in America (Ne% No!+: 5thene&m, 1971). Bne (ea! o" d!&* adve!tisin*
costs mo!e than it %o&ld cost to send eve!( docto! in the 9.<. to medical school "o! a (ea!.
11; #. -!ie'el, G5!=neimittelve!'!a&chs8<t&dien,G in #. I. 7en*le! and $.
$i!th, eds., <emina! f Ir Elinische +harma#ologie auf Schloss eisenberg bei *arburgS
Donau, vom &@;4&>; '#tober, 9>:9, !berreicht von der *edi8inisch4+harma8eutischen
Studiengesellschaft E;6;, (ran#furt am *ain, pp; &&C4JB; Short, valuable statement on the
lac# of useful measurements, which ma#es such a broad statement the best that can be
responsibly offered; The author is a director of the Drug Efficacy and Safety Division of the
"orld %ealth 'rgani8ation;
119 $o!ld #ealth B!*ani=ation, 3e*ional B""ice "o! E&!oe, 0ons%Mtion o" Drugs= eport
on a Symposium, 'slo, .ovember 04:, 1969. Limited edition, availa'le
xxx "otnote "o!tsette! E neste side xxx
22:&AA
%ith t%o *!o&s o" addicts: those "o! %hom the( !esc!i'e d!&*s, and those %ho s&""e! "!om
thei! conseA&ences. The !iche! the comm&nit(, the la!*e! the e!centa*e o" atients %ho
'elon* to 'oth.1,>
To 'lame the d!&* ind&st!( "o! !esc!i'ed8d!&* addiction is the!e"o!e as i!!elevant as 'lamin*
the Ma"ia1,1 "o! the &se o" illicit d!&*s. The c&!!ent atte!n o" ove!cons&mtion o" d!&*sD'e
the( e""ective !emed( o! anod(neR !esc!ition item o! a!t o" eve!(da( dietR "!ee, "o! sale, o!
stolen88can 'e exlained onl( as the !es&lt o" a 'elie" that so "a! has develoed in eve!(
c&lt&!e %he!e the ma!+et "o! cons&me! *oods has !eached a c!itical vol&me. This atte!n is
consistent %ith the ideolo*( o" an( societ( o!iented to%a!ds oen8ended en!ichment,
!e*a!dless %hethe! its ind&st!ial !od&ct is meant "o! dist!i'&tion '( the !es&mtion o"
lanne!s o! '( the "o!ces o" the ma!+et. In s&ch a societ(, eole come to 'elieve that in
health ca!e, as in all othe! "ields o" endeavo!, technolo*( can 'e &sed to chan*e the h&man
condition acco!din* to almost an( desi*n. 1enicillin and 77T, conseA&entl(, a!e vie%ed as
the ho!s d6oe&v!es !ecedin* an e!a o" "!ee l&nches. The sic+ness !es&ltin* "!om each
s&ccessive co&!se o" mi!acle "oods is dealt %ith '( se!vin* still anothe! co&!se o" d!&*s. Th&s
ove!cons&mtion !e"lects a sociall( sanctioned, senti8mental han+e!in* "o! (este!da(6s
!o*!ess.
xxx "otnote "o!tsete! "!a "o!!i*e side xxx
onl( to e!sons %ith o""icial !o"essional standin* th!o&*h the $#B !e*ional o""ice in
0oenha*en. This st&d( is the "i!st o" its +ind. It coma!es ,, co&nt!ies, notin* si*ni"icant
di""e!ences in d!&*8cons&mtion atte!ns '&t eno!mo&s di""ic&lties in esta'lishin* !ecise
coma!isons. The!ae&tic cate*o!ies, cost eval&ations, and meas&!ements "o! ha!macolo*ical
&nits di""e!. -!om the in"o!mation it is le*itimate to ded&ce that total cons&mtion o"
medicine is la!*el( indeendent o" cost o! o" the +ind o" !actice that is !evalent, i.e., !ivate
o! sociali=ed. The cons&mtion in a *iven co&nt!( o" those d!&*s that !eA&i!e a !esc!ition is
ositivel( !elated to the densit( o" !esc!i'in* h(sicians.
1,> 5l"!ed M. -!eedman, G7!&*s and <ociet(: 5n Ecolo*ical 5!oach,G Coneprthsasivs
1s(chiat!( 1. (<etem'e!8Bcto'e! 197,): /118,>.
1,1 Alvin *oscow, *srthants of %eroin (Ne% No!+: 7ial 1!ess, 196;). This can se!ve as an
int!od&ction to one '!anch o" &nde!%o!ld '&siness.
xxx "otnote sl&tt xxx
((7.))
The a*e o" ne% d!&*s 'e*an %ith asi!in in 1;99. )e"o!e that time, the docto! himsel" %as
%itho&t dis&te the most imo!tant the!ae&tic a*ent.l,, )esides oi&m, the onl( s&'stances
o" %ide alication %hich %o&ld have assed tests "o! sa"et( and e""ectiveness %e!e smallox
vaccine, A&inine "o! mala!ia, and iecac "o! d(sente!(. 5"te! 1;99 the "lood o" ne% d!&*s
contin&ed to !ise "o! hal" a cent&!(. -e% o" these t&!ned o&t to 'e sa"e!, mo!e e""ective, and
cheae! than %ell8+no%n and lon*8tested the!ae&tic stand'(s, %hose n&m'e!s *!e% at a
m&ch slo%e! !ate. In 196,, %hen the 9nited <tates -ood and 7!&* 5dminist!ation 'e*an to
examine the /,.>> !esc!ition d!&*s that had aea!ed since $o!ld $a! II, onl( , o&t o" 5
%e!e "o&nd e""ective. Man( o" the ne% d!&*s %e!e dan*e!o&s, and amon* those that met -75
standa!ds, "e% %e!e demonst!a'l( 'ette! than those the( %e!e meant to !elace.1,. -e%e!
than 9; e!cent o" these chemical s&'stances constit&te val&a'le cont!i'&tions to the
ha!macoeia &sed in !ima!( ca!e. The( incl&de some ne% +inds o" !emedies s&ch as
anti'iotics, '&t also old !emedies %hich, in the co&!se o" the d!&* a*e, came to 'e &nde!stood
%ell eno&*h to 'e &sed e""ectivel(: di*italis, !ese!ine, and 'elladonna a!e examles.
Binions va!( a'o&t the act&al n&m'e! o" &se"&l d!&*s: some exe!ienced clinicians 'elieve
that less than t%o do=en 'asic d!&*s a!e all that %ill eve! 'e desi!a'le "o! 99 e!cent o"
xxx "otnote sta!t xxx
1,, -o! the histo!( o" the conscio&s &se o" the lace'o e""ect, see 5!th&! @. <hai!o, G5
0ont!i'&tion to a #isto!( o" the 1lace'o E""ect,G ,ehavioral <cience < (5!il 196>): 1>98.5R
Oe!ha!d @ienle, Ar8neinrittelsicheJheit und $esellschafV Eine #ritische !ntersuchung
2Stuttgart= Schattauer, 9>:JA; The ability of the placebo to provo#e symptoms of a specific
#ind, even when given in a double4blind situation, is discussed by Eienle in chap; :; A mine of
international literature on drug safety;
1,. <ee the statements '( #en!( <immons, di!ecto! o" the -ood and 7!&* 5dminist!ation6s
)&!ea& o" 7!&*s, in Nicholas $ade, G7!&* 3e*&lation: -ood and 7!&* 5dminist!ation
3elies to 0ha!*es '( Economists and Ind&st!(,G Science 179 (197.): 77587.
xxx "otnote sl&tt xxx
((7/))
the total o&lationR othe!s, that & to "o&! do=en items a!e otimal "o! 9; e!cent.
The a*e o" *!eat discove!ies in ha!macolo*( lies 'ehind &s. 5cco!din* to the !esent di!ecto!
o" -75, the d!&* a*e 'e*an to decline in 1956. Oen&inel( ne% d!&*s have aea!ed in
dec!easin* n&m'e!s, and man( %hich temo!a!il( *litte!ed in Oe!man(, En*land, o! -!ance,
%he!e standa!ds a!e less st!in*ent than in the 9nited <tates, <%eden, and 0anada, %e!e soon
"o!*otten o! a!e !emem'e!ed %ith em'a!!assment.1,/ The!e is not m&ch te!!ito!( le"t to
exlo!e. Novelties a!e eithe! Gac+a*e dealsGD"ixed8dose com'inationsDo! medical
GmetoosD 1,5 that a!e !esc!i'ed '( h(sicians 'eca&se the( have 'een %ell !omoted.1,6
The seventeen8(ea! !otection that the atent la% *ives to si*ni"icant ne%come!s has !&n o&t
"o! most. No% an(one can ma+e them, so lon* as he does not &se the o!i*inal '!and names,
%hich a!e inde"initel( !otected '( t!adema!+ la%s. 0onside!a'le !esea!ch has so "a! !od&ced
no !eason to s&sect that d!&*s ma!+eted &nde! thei! *ene!ic names in the 9nited <tates a!e
less e""ective than thei! '!and8named co&nte!8a!ts, %hich cost "!om . to 15 times mo!e.1,7
xxx "otnote sta!t xxx
9&J )bid
1,5 -&chs, "ho Shall -ive7
1,6 $illiam M. $a!dell, G)!itish 9sa*e and 5me!ican 5%a!eness o" <ome Ne% The!ae&tic
7!&*s,G Clinical +harmacology and Therapeutics 1/ (Novem'e!87ecem'e! 197.): 1>,,8./.
<t&dies ne% d!&*s %hich 'ecame availa'le in En*land and %e!e %idel( disc&ssed in the
lite!at&!e to %hich 9.<. docto!s s&'sc!i'e. 8 $a!dell "inds that the 5me!ican secialist is not
a%a!e o" the existence o" these d!&*s &nless the( a!e ma!+eted in the 9.<. and that he is
the!e"o!e s&':ect to enli*htment '( detail men.
1,7 Medi=inisch81ha!ma=e&tischen <t&dien*esellscha"t E.?., ,ioverfGgbar#eit von
Ar8neistoffen, <ch!i"ten!eihe de! Medi=inisch81ha!ma=e&tischen <t&dien*esellscha"t E.?.,
vol. 6 (-!an+"&!t: 9mscha&, 197/). Ioint &'lic8!elations camai*ns cond&cted '( othe!%ise
cometin* "i!ms dese!ve secial attention. 5t !esent, the( "oc&s on extollin* the s&e!io!it(
o" t!adema!+ed !od&cts ove! *ene!ic eA&ivalentsDe.*., o" )a(e! 5si!in ove! the *ene!ic
d!&* asi!inDon the *!o&nds o" G'io8availa'ilit(,G a hi*he! and mo!e cont!olled 'iolo*ical
availa'ilit( o" the d!&* once it is inco!o!ated into the o!*anism. -o! an( &n!e:&diced
xxx "otnote "o!tsette! E neste side xxx
((75))
The "allac( that societ( is ca&*ht "o!eve! in the d!&* a*e is one o" the do*mas %ith %hich
medical olic(8ma+in* has 'een enc&m'e!ed: it "its ind&st!iali=ed man.1,; #e has lea!ned to
t!( to purchase %hateve! he "ancies. #e *ets no%he!e %itho&t t!anso!tation o! ed&cationR his
envi!on8ment has made it imossi'le "o! him to %al+, to lea!n, and to "eel in cont!ol o" his
'od(. To ta+e a d!&*, no matte! %hich and "o! %hat !easonDis a last chance to asse!t cont!ol
ove! himsel", to inte!"e!e on his o%n %ith his 'od( !athe! than let othe!s inte!"e!e. The
ha!mace&tical invasion leads him to medication, '( himsel" o! '( othe!s, that !ed&ces his
a'ilit( to coe %ith a 'od( "o! %hich he can still ca!e.
-iagnostic Imperialism
In a medicali=ed societ( the in"l&ence o" h(sicians extends not onl( to the &!se and the
medicine chest '&t also to the cate*o!ies to %hich eole a!e assi*ned. Medical '&!ea&c!ats
s&'divide eole into those %ho ma( d!ive a ca!, those %ho ma( sta( a%a( "!om %o!+, those
xxx "otnote "o!tsette!" !a "o!!i*e side xxx
mind, ten (ea!s6 !esea!ch has !oved that %ith the one excetion o" a *ene!ic !ea!ation o"
chlo!amhenicol (see )&!ac+, A .ew %andboo# of +rescription Drugs, . ;5), *ene!ic d!&*s
a!e in no %a( in"e!io! to those !od&ced &nde! t!ade names. This concl&sion has 'een
inco!o!ated into 9.<. "ede!al olic(8ma+in*. Neve!theless, "o! the last 5 (ea!s the d!&*
comanies have sonso!ed seve!al h&nd!ed G!esea!ch ae!sG e! (ea! on di""e!ences in G'io8
availa'ilit(,G sendin* on the a&tho! o" each ae! an ave!a*e o" M6,>>> in hono!a!ia,
exenses, and costs o" attendin* !o"essional con"e!ences. Man( o" these a&tho!s a!e
dea!tment heads o" ma:o! &nive!sities. The concl&sions o" most ae!s sho% no medicall(
si*ni"icant di""e!ence. )&t the total imact o" this hantom !esea!ch is the m(sti"ication o" the
!esc!i'in* *ene!al !actione!, %ho %ill o"ten !ecommend the d!&* adve!tised "o! its hi*h
G'io8availa'ilit(,G i!!esective o" its cost.
1,; I. 1. 7&&( and 5. Leto&!m(, 7itenninants et coats socia&x de l6innovation en matiKre de
santF, !eo!t '( the B07E, 197/. The a&tho!s s&o!t this thesis. The !e"inement o" those
c!ite!ia '( %hich a secialist meas&!es the e""ectiveness o" his seciali=ed inte!vention, a"te! a
ce!tain th!eshold, %ill ens&!e the aea!ance o" *ene!icall( !edicta'le &n%anted side8e""ects.
I", in thei! t&!n, the seci"ic dia*nosis and t!eatment o" these side8e""ects %e!e attemted, this
"&!the! medical inte!vention %o&ld onl( !ein"o!ce iat!o*enesis.
xxx "otnote sl&tt xxx
((76))
%ho m&st 'e loc+ed &, those %ho ma( 'ecome soldie!s, those %ho ma( c!oss 'o!de!s, coo+,
o! !actice !ostit&tion,1,9 those %ho ma( not !&n "o! the vice8!esidenc( o" the 9nited
<tates, those %ho a!e dead,1.> those %ho a!e cometent to commit a c!ime, and those %ho
a!e lia'le to commit one. Bn Novem'e! 5, 1766, the Em!ess Ma!ia The!esa iss&ed an edict
!eA&estin* the co&!t h(sician to ce!ti"( "itness to &nde!*o to!t&!e so as to ens&!e health(, i.e.
Gacc&!ate,G testimon(R it %as one o" the "i!st la%s to esta'lish mandato!( medical ce!ti"ication.
Eve! since, "illin* o&t "o!ms and si*nin* statements has ta+en & inc!easin*l( mo!e medical
time.1.1 Each +ind o" ce!ti"icate !ovides the holde! %ith a secial stat&s 'ased on medical
!athe! than civic oinion.1., 9sed o&tside the the!ae&tic !ocess, this medicali=ed stat&s
does t%o o'vio&s thin*s: (1) it exemts the holde! "!om %o!+, !ison, milita!( se!vice, o! the
ma!!ia*e 'ond, and (,) it *ives othe!s the !i*ht to enc!oach &on the holde!6s "!eedom '(
&ttin* him into an instit&tion o! den(in* him %o!+. In addition, the !oli"e!ation o" medical
ce!ti"ications can invest school, emlo(ment, and olitics %ith oo!t&nities "o! ne%
the!ae&tic "&nctions. In a societ( in %hich most eole a!e ce!ti"ied as . deviants, the milie&
"o! s&ch deviant
xxx "otnote sta!t xxx
1,9 Bn the ce!ti"ication o" !ostit&tes, see $illiam $. <an*e!, The %istory of +rostitution
2.ew <or#= American *edical +ress, 9C@CA;
1.> -o! histo!( o" medical death certifisates, see !;S; National B""ice o" ?ital <tatistics, (irst
Things and -ast= The Story of ,irt) seed Death Certificates, !;S; 1&'lic #ealth <e!vice
1&'lication no. 7,/ ($ashin*ton, 7.0., 196>).
1.1 B""ice o" #ealth Economics, B" <ic+, Ian&a!( 1971, . 17. It is estimated that 'et%een 15
and .>f o" all visits to the docto! have no othe! &!ose than o'tainin* a ce!ti"icate. In 5;f
o" the cases, the "inal da( o" incaacit( noted on ce!ti"icates :&sti"(in* sic+ leave is <at&!da(.
1., The enc!oachment o" exe!tise on the !&le a*ainst hea!sa( is o" co&!se not limited to
medicine. It is a common "eat&!e o" sec&la!i=ation and o" the !ise o" the !o"essions. Inside
and o&tside the co&!t!oom, it %hittles a%a( con"idence in %hat the common man sees acid
hea!s, and th&s &nde!mines 'oth the :&dicial and the olitical !ocess. Bn the a&tho!6s vie% o"
!o"essional ex!o!iation o" lan*&a*e, science, and le*al !oced&!es, see Ivan Illich, Tools
for 0onvivialit( (London : 0alde! V )o(a!s, 197.), . ;5899.
xxx "otnote sl&tt xxx
((77))
ma:o!ities %ill come to !esem'le a hosital. To send one6s li"e in a hosital is o'vio&sl( 'ad
"o! health.
Bnce a societ( is so o!*ani=ed that medicine can t!ans"o!m eole into atients 'eca&se the(
a!e &n'o!n, ne%'o!n, menoa&sal, o! at some othe! Ga*e o" !is+,G the o&lation inevita'l(
loses some o" its a&tonom( to its heale!s. The !it&ali=ation o" sta*es in li"e is nothin* ne%R1..
%hat is ne% is thei! intense medicali=ation. The so!ce!e! o! medicine manDas oosed to the
malevolent %itchDd!amati=ed the !o*!ess o" an 5=ande t!i'esman "!om one sta*e o" his
health to the next.1./ The exe!ience ma( have 'een ain"&l,1.5 '&t the !it&al %as sho!t and
it se!ved societ( in hi*hli*htin* its o%n !e*ene!ative o%e!s.l.6 Li"elon* medicals&e!vision
is somethin* else. It t&!ns li"e into a se!ies o" e!iods o" !is+, each callin* "o! t&tela*e o" a
secial +ind. -!om the c!i' to the o""ice and "!om the 0l&' Medite!!anTe to the te!minal %a!d,
each a*e8coho!t is conditioned '( a milie& that de"ines health "o! those %hom it se*!e*ates.
#(*ienic '&!ea&c!ac( stos the a!ent in "!ont o" the school and the mino! in "!ont o" the
co&!t, and ta+es the old o&t o" the home. )( 'ecomin* a seciali=ed lace, school, %o!+, o!
home is made &n"it "o! most eole.
xxx "otnote! sta!t xxx
1.. -!an= )oll, G7ie Le'ensalte!: Ein )eit!a* =&! anti+en Etholo*ie &nd =&! Oeschichte de!
Qahlen,G .eue fahrbiicher fur das #lassische Altertu m, $eschichte und deutsche -iteratur 9?,
no; 09 29>90A= C>49J@;
1./ <ee E. E. Evans81!itcha!d, "itchcraft, 'racles, and *agic Among the A8ands (Ne%
No!+: Bx"o!d 9niv. 1!ess, 19.7), "o! the distinction o" the so!ce!e! "!om the %itch. This
distinction is !e"ined and alied to $este!n c&lt&!e '( Ie""!e( ). ussell, "itchcraft in the
*iddle Ages (Ithaca, N.N.: 0o!nell 9niv. 1!ess, 197,). The demonolo*ical element that
t!ans"o!ms the so!ce!ess into a he!etic is &s&all( *!a"ted on at the level o" the co&!ts.
1.5 ?icto! $. T&!ne!, G)et%ixt and )et%een: The Liminal 1e!iod in ites de +assage,D in
5me!ican Ethnolo*ical <ociet(, Symposium on .ew 4Approaches to the Study of eligion=
+roceedings, 196/ (<eattle: 9niv. o" $ashin*ton 1!ess, 1965), . /8,>. )( medicali=ation o"
li"e, %hat aea!ed to 'e GliminalG in ast societies has 'een made the eve!(da( sit&ation o"
administe!ed man.
1.6 5!nold van Oenne, The ites of +assage (London: 3o&tled*e, 9>?B (-!ench o!i*inal,
19>9b). The !ecent c!itiA&e o" the a&tho! '( LTv(8<t!a&ss has not called into A&estion his 'asic
idea that e!iods o" initiation a""i!m and s(m'oli=e the contin&in* health8maintainin* "&nction
o" c&lt&!e.
xxx "otnote! sl&tt xxx
((7;))
The hosital, the mode!n cathed!al, lo!ds it ove! this hie!atic envi!onment o" health devotees.
-!om <toc+holm to $ichita the to%e!s o" the medical cente! im!ess on the landscae the
!omise o" a consic&o&s "inal em'!ace. -o! !ich and oo!, li"e is t&!ned into a il*!ima*e
th!o&*h chec+8&s and clinics 'ac+ to the %a!d %he!e it sta!ted.6.7 Li"e is th&s !ed&ced to a
Gsan,G to a statistical henomenon %hich, for 'ette! o! for %o!se, m&st 'e instit&tionall(
lanned and shaed. This li"e8san is '!o&*ht into existence %ith the !enatal chec+8&, %hen
the docto! decides i" and ho% the "et&s shall 'e 'o!n, and it %ill end %ith a ma!+ on a cha!t
o!de!in* !es&scitation s&sended. )et%een delive!( and te!mination this '&ndle o" 'iomedical
ca!e "its 'est into a cit( that is '&ilt li+e a mechanical %om'. 5t each sta*e o" thei! lives
eole a!e a*e8seci"icall( disa'led. The old a!e the most o'vio&s examle: the( a!e victims
o" t!eatments meted o&t "o! an inc&!a'le condition.1.;
Most o" man6s ailments consist o" illnesses that a!e ac&te and 'eni*nDeithe! sel"8limitin* o!
s&':ect to cont!ol th!o&*h a "e% do=en !o&tine inte!ventions. 1.9-o! a %ide
xxx "otnote! sta!t xxx
1.7 -o! lite!at&!e on the s&'tle enet!ation o" the hosital into the inte!stices o" the modem
cit( cons&lt Oe!ald -. 1(le. GThe Oeo*!ah( o" #ealth 0a!e,G in Iohn Melton #&nte!, The
$eography of %ealth and Disease, <t&dies in Oeo*!ah( no. 6 (0hael #ill, N.0.: 9niv. o"
No!th 0a!olina 1!ess, 197/), a satial anal(sis at the se!vice o" health lanne!s. -o! a 'oo+8
len*th t!eatment o" the a!chitectonic imact o" hositals on o&! societ(, see 3osl(n Lindheim,
The %ospitalisation of Space (London : Ma!ion )o(a!s, 1977). Lindheim demonst!ates ho%
the !eo!*ani=ation o" satial atte!ns at the se!vice o" h(sicians has imove!ished the
nonmedical, health8s&o!tin*, and healin* asects o" the social and h(sical envi!onment "o!
modem man.
1.; -o! o!ientation on the social science lite!at&!e on the old and a*in*, see Iames E. )i!!en,
Nonina Talmon and Ea!l -. 0heit, G5*in*: 1. 1s(cholo*ical 5sectsR ,. <ocial 5sectsR ..
Economic 5sects,G )nternational Encyclopedia of the Social Sciences (196;), 1:1768,>,. -o!
o!ientation on Oe!man lite!at&!e, see ?ol+ma! )oehla&, ed., "ege 8ur Erforschwsg des
Ahern=, $e*e de! -o!sch&n*, vol. 1;9 (7a!mstadt: $issenscha"liche )&ch*esellscha"t,
197.), an antholo*(. Bn -!ench contemo!a!( a*in*, Michel 1hili'e!t, -1Lchelle des Zges
(1a!is: <e&il, 196;).
1.9 Iohn #. 7in*le, GThe Ills o" Man,G Scientific 5me!ican ,,9 (<etem'e! 197.): 778;,.
The st&d( that comes to this Gconcl&sionG is '!oadl( 'ased. It
xxx "otnote! "o!tsette! E neste side xxx
((79))
!an*e o" conditions, those %ho a!e t!eated least !o'a'l( ma+e the 'est !o*!ess. G-o! the
sic+,G #ioc!ates said, Gthe least is 'est.G Mo!e o"ten than not, the 'est a lea!ned and
conscientio&s h(sician can do is convince his atient that he can live %ith his imai!ment,
!eass&!e him o" an event&al !ecove!( o! o" the availa'ilit( o" mo!hine at the time %hen he
%ill need it, do "o! him %hat *!andmothe! co&ld have done, and othe!%ise de"e! to nat&!e.1/>
The ne% t!ic+s that have "!eA&ent alication a!e so simle that the last *ene!ation o"
*!andmothe!s %o&ld have lea!ned them lon* a*o had the( not 'een '!o%'eaten into
incometenc( '( medical m(sti"ication. )o(8sco&t t!ainin*, *ood8<ama!itan la%s, and the
d&t( to ca!!( "i!st8aid eA&iment in each ca! %o&ld !event mo!e hi*h%a( deaths than an(
"leet o" helicote!8am'&lances. Those othe! inte!ventions %hich a!e a!t o" !ima!( ca!e and
%hich, tho&*h the( !eA&i!e the %o!+ o" secialists, have 'een !oved e""ective on a o&lation
'asis can 'e emlo(ed mo!e e""ectivel( i" m( nei*h'o! o! I "eel !esonsi'le "o! !eco*ni=in*
%hen the( a!e needed and al(in* "i!st t!eatment. -o! ac&te sic+ness, t!eatment so comlex
that it !eA&i!es a secialist is o"ten ine""ective and m&ch mo!e o"ten inaccessi'le o! siml( too
late. 5"te! t%ent( (ea!s o" sociali=ed medicine in En*land and $ales, docto!s *et to co!ona!(
cases on an ave!a*e o" "o&! ho&!s a"te! the 'e*innin* o" s(mtoms, and '( this time 5>
e!cent o" atients a!e dead.1/1 The "act that mode!n medicine has 'ecome ve!( e""ective in
the t!eatment o"
xxx "otnote! "o!tsette! "!a "o!!i*e side xxx
distin*&ishes "o&! e!sectives on GailmentG: (1) eole, (,) h(sicians, (.) atients, (/)
comile!s o" vital statistics. -!om all "o&! oints o" vie% this concl&sion seems to hold.
1/> Max Ne&'&!*e!, The Doctrine of the %ealing +ower of .ature Throughout the Course of
Time, t!ans. L. I. )o(d (Ne% No!+: !ivatel( !inted, 19.,). -o! mo!e !ecent !e"e!encees,
Ioseh <ch&mache!, Anti#e *edi8in= Die nat&!hilosohischen $rundlagen der *edi8in in
der griechischen Anti#e ()e!lin: O!&(te!, 196.).
1/1 I. -. 1a!t!id*e and I. <. Oeddes, G5 Mo'ile IntensiveP0a!e 9nit in the Mana*ement o"
M(oca!dial In"a!ction,G -ancet, 1967, ,:,71.
xxx "otnote! sl&tt xxx
((;>))
seci"ic s(mtoms does not mean that it has 'ecome mo!e 'ene"icial "o! the health o" the
atient.
$ith some A&ali"ications, the seve!e limits o" e""ective medical t!eatment al( not onl( to
conditions that have lon* 'een !eco*ni=ed as sic+nessD!he&matism, aendicitis, hea!t
"ail&!e, de*ene!ative disease, and man( in"ectio&s diseasesD'&t even mo!e d!asticall( to
those that have onl( !ecentl( *ene!ated demands "o! medical ca!e. Bld a*e, "o! examle,
%hich has 'een va!io&sl( conside!ed a do&'t"&l !ivile*e o! a iti"&l endin* '&t neve! a
disease,1/, has !ecentl( 'een &t &nde! docto!6s o!de!s. The demand "o! old8a*e ca!e has
inc!eased, not :&st 'eca&se the!e a!e mo!e old eole %ho s&!vive, '&t also 'eca&se the!e a!e
mo!e eole %ho state thei! claim that thei! old a*e sho&ld 'e c&!ed.
The maxim&m li"e8san has not chan*ed, '&t the ave!a*e li"e8san has. Li"e exectanc( at
'i!th has in8c!eased eno!mo&sl(. Man( mo!e child!en s&!vive, no matte! ho% sic+l( and in
need o" a secial envi!onment and secial ca!e. The li"e exectanc( o" (o&n* ad&lts is still
inc!easin* in some oo!e! co&nt!ies. )&t in !ich co&nt!ies the li"e exectanc( o" those 'et%een
"i"teen and "o!t(8"ive has tended to sta'ili=e 'eca&se accidents1/. and the ne% diseases o"
civili=ation +ill as man( as "o!me!l( s&cc&m'ed to ne&monia and othe! in"ections. 3elativel(
mo!e old eole a!e a!o&nd, and the( a!e inc!easin*l( !one to 'e ill, o&t o" lace, and
helless. No matte! ho%
xxx "otnote! sta!t xxx
1/, <imone de )ea&voi!, The Coming of Age= The Study of the Aging +rocess, t!ans. 1at!ic+
B6)!ian (Ne% No!+: 1&tnam, 197,). 5 mon&mental t!eatment o" old a*e th!o&*ho&t histo!( in
the e!sective o" contemo!a!( a*in*. <ee also Iean 5me!(, 'ber das Alter= evolte and
esignation 2Stuttgart= Elette, 9>?CA, an e/ceptionally sensitive contemporary
phenomenology of aging;
1/. "orld %ealth Statistics eport &:, September 9>:J; An international comparison of &:
industriali8ed countries shows that for the age group 9@4JJ years old, accidents were the
leading cause of death in 9>:9 2e/cept for England and "alesA; )n half of these countries they
accounted for more than 0B[? of all deaths;
xxx "otnote! sl&tt xxx
((;1))
m&ch medicine the( ta+e, no matte! %hat ca!e is *iven them, a li"e exectanc( o" sixt(8"ive
(ea!s has !emained &nchan*ed ove! the ast cent&!(. Medicine :&st cannot do m&ch "o! the
illness associated %ith a*in*, and even less a'o&t the !ocess and exe!ience o" a*in* itsel".
1// It cannot c&!e ca!diovasc&la! disease, most cance!s, a!th!itis, advanced ci!!hosis, not even
the common cold. It is "o!t&nate that some o" the ain the a*ed s&""e! can 'e lessened.
9n"o!t&natel(, tho&*h, most t!eatment o" the old !eA&i!in* !o"essional inte!vention not onl(
tends to hei*hten thei! ain '&t, i" s&ccess"&l, also to !ot!act it.1/5
Bld a*e has 'een medicali=ed at !ecisel( the histo!ical moment %hen it has 'ecome a mo!e
common occ&!!ence "o! demo*!ahic !easonsR ,; e!cent o" the 5me!ican medical '&d*et is
sent on the 1> e!cent o" the o&lation %ho a!e ove! sixt(8"ive. This mino!it( is o&t*!o%in*
the !emainde! o" the o&lation at an ann&al !ate o" . e!cent, %hile the e! caita cost o"
thei! ca!e is !isin* 5 to 7 e!cent "aste! than the ove!8all e! caita cost. 5s mo!e o" the elde!l(
acA&i!e !i*hts to !o"essional ca!e, oo!t&nities "o! indeendent a*in* decline. Mo!e have to
see+ !e"&*e in instit&tions. <im&ltaneo&sl(, as mo!e o" the elde!l( a!e initiated into t!eatment
"o! the co!!ection o" inco!!i*i'le imai!ment o! "o! the c&!e o" inc&!a'le disease, the n&m'e!
o" &nmet claims "o! old8a*e se!vices sno%'alls.9J? I" the e(esi*ht o" an old %oman "ails, he!
xxx "otnote! sta!t xxx
1// 7avid I&tman, GThe #&n*e! o" Bld Men,G Trans4Action, Novem'e! 1,, 1971, . 55866.
1/5 5. N. Exton8<mith, GTe!minal Illness in the 5*ed,G -ancet, 1961, ,:.>58;. *ost pain and
s&""e!in* a!e associated %ith !ocesses that lead indi!ectl( to death. 5ltho&*h the &se o"
anti'iotics ma( ave!t o! dela( comlications such as '!onchone&monia, %hich %o&ld
othe!%ise 'e "atal, this o"ten adds little time and m&ch ain to a li"e.
1/6 3ic+ 0a!lson, in T ht End of Afedicine (Ne% No!+: $ile( Inte!science, 1975), develos
this %hole oint ve!( %ell. <ee also #. #a!msen, G7ie so=ialtnedixinische )ede&t&n* de!
E!hZh&n* de! Le'ense!%a!t&n* &nd de! Q&nahme des 5nteils de! )e:ah!ten 'is 19;>,G
+l#5si#aliswhe Mtdisin &nd ehabilitative 9, no. 5 (196;): 1198,1.
xxx "otnote! sl&tt xxx
((;,))
li*ht %ill not 'e !eco*ni=ed &nless she ente!s the G'lindness esta'lishmentGDone o" the ei*ht
h&nd!ed8odd 9nited <tates a*encies %hich !od&ce se!vices "o! the 'lind, !e"e!a'l( "o! the
(o&n* and those %ho can 'e !eha'ilitated "o! %o!+.9J: <ince she is neithe! (o&n* no! o"
%o!+in* a*e, she %ill !eceive onl( a *!&d*in* %elcomeR at the same time, she %ill have
di""ic&lt( "ittin* into the old8a*e esta'lishment. <he %ill th&s 'e ma!*inall( medicali=ed '(
t%o sets o" instit&tions, the one desi*ned to sociali=e he! amon* the 'lind, the othe! to
medicali=e he! dec!eit&de.
5s mo!e old eole 'ecome deendent on !o"essional se!vices, mo!e eole a!e &shed into
seciali=ed instit&tions "o! the old, %hile the home nei*h'o!hood 'ecomes inc!easin*l(
inhosita'le to those %ho han* on.9JC These instit&tions seem to 'e the contemo!a!(
st!ate*( "o! the disosal o" the old, %ho have 'een instit&tionali=ed in mo!e "!an+ and
a!*&a'l( less hideo&s "o!ms '( most othe! societies.1/9 The mo!talit( !ate d&!in* the "i!st
(ea! a"te! instit&tionali=ation is si*ni"icantl( hi*he! than the !ate "o! those %ho sta( in thei!
acc&stomed s&!!o&ndin*s.15> <ea!ation "!om home cont!i'&tes to the aea!ance and
mo!talit( o" man( a se!io&s disease.151 <ome old eole
xxx "otnote! sta!t xxx
1/7 3o'e!t 5. <cott, The *a#ing of ,lind *en 2.ew <or#= ussell Sage, 9>?>A; ,eing
accepted among the blind and behaving li#e a blind person are to a great e/tent independent
of the degree of optical impairment; (or most of the Dblind,D it is above all the result of their
successful client relationship to an agency concerned with Dblindness;D
1/; 3osl(n Lindheim, GEnvi!onments "o! the Elde!l(: -&t&!e8B!iented 7esi*n "o! Livin*4G
-e'!&a!( ,>, 197/, mimeo*!ahed. 7esc!i'es the %a( the old exe!ience sace.
1/9 Bn the social elimination o" the old the main so&!ce !emains Iohn @ot(, Die ,ehandlung
der Alten und Eran#en bei den .aturei l#em (<t&tt*a!t: #i!sch"eld, 19./). I have not seen
-!it= 1a&dle!, Die 5llen8 und Eran#entUtung als Sitte bei den indo*emtanisehen 6Ul#ern
(#eidel'e!*, 19.6). 0omlete !e"e!ence to the lite!at&!e in $ill8Eich 1e&c+e!t, ed.,
G5ltentZt&n*,G in %andwUrterbuch der Sage (OZttin*en: ?andenhoec+ V 3&!echt, 1961).
15> 5. Io!es and #. O. 1&chta, G7e! 1ensionie!&n*stod: 9nte!s&ch&n*en an #am'&!*e!
)eamten,G *edi8inische Elini# 5/, no. ,5 (1959): 115;86/.
151 7avid )a+an, Disease, 1ain and <ac!i"ice Toward a +sychology of <&""e!in* ()oston:
)eacon 1!ess, 1971). These diseases incl&de asthma, cance!, con*estive
xxx "otnote! "o!tsette! E neste side xxx6
((;.))
see+ instit&tionali=ation %ith the intention o" sho!tenin* thei! lives.15, 7eendence is al%a(s
ain"&l, and mo!e so "o! the old. 1!ivile*e o! ove!t( in ea!lie! li"e !eaches a climax in mode!n
old a*e. Bnl( the ve!( !ich and the ve!( indeendent can choose to avoid that medicali=ation
o" the end to %hich the oo! m&st s&'mit and %hich 'ecomes inc!easin*l( intense and
&nive!sal as the societ( the( live in 'ecomes !iche!.15. The t!ans"o!mation o" old a*e into a
condition callin* "o! !o"essional se!vices has cast the elde!l( in the !ole o" a mino!it( %ho
%ill "eel ain"&ll( de!ived at an( !elative level o" tax8s&o!ted !ivile*e. -!om %ea+ old
eole %ho a!e sometimes mise!a'le and 'itte!l( disaointed '( ne*lect, the( a!e t&!ned into
ce!ti"ied mem'e!s o" the saddest o" cons&me! *!o&s, that o" the a*ed !o*!ammed neve! to
*et eno&*h.15/ $hat medical la'elin* has done to the end o" li"e, it has eA&all( done to its
'e*innin*. I&st as the docto!6s o%e! %as "i!st a""i!med ove! old a*e and event&all(
enc!oached on ea!l( !eti!ement and climacte!ic, so his a&tho!it( ove! the
xxx "otnote! "o!tsette! "!a "o!!i*e side xxx
hea!t "ail&!e, dia'etes mellit&s, disseminated l&&s, "&nctional &te!ine 'leedin*, 3a(na&d6s
disease, !he&matoid a!th!itis, th(!otoxicosis, t&'e!c&losis and &lce!ative colitis. <ee i'id. "o!
lite!at&!e on each.
15, Elisa'eth Ma!+son, G5 #idin* 1lace To 7ie,G Trans4Action, Novem'e! 1,, 197,, . /;8
5/. 5 athetic and sensitive !eo!t. <ee also I&tman, GThe #&n*e! o" Bld Men.G The old have
al%a(s o'li*ed '( d(in* on !eA&est: 7avid Leste!, G?oodoo 7eath: <ome Ne% Tho&*hts on
an Bld 1henomenon,G American Anthropologist :J 23une 9>:&A= 0C?4>BM "alter ,; Cannon,
D6oodoo Death,D American Anthropologist JJ 2April43une 9>J&A= 9?>4C9; There were always
ways of driving them to suicide= 3; $isse, Selbstmord und Todesfurcht bei den .atwvil#ern
(Q&then: Thieme, 19..).
15. 1ete! To%nsend, The -ast efuges A Survey of esidential )nstitutions and %omes for the
Aged in England and "ales (London: 3o&tled*e, 196,). 0omlements !evio&s %o!+ done
'( the a&tho!. Eval&ates !esidential accommodations as !ovided &nde! the )!itish National
5ssistance 5ct o" 19/; and oints to the lac+ o" eA&it( in t!eatment. 5nne8Ma!ie O&illema!d,
-a etraite, une mort socials; Sociologie des conduites en situation de retraite 2+aris=
*outon, 9>:&A; A socio4economic study which shows that class discrimination is strongly
accentuated in (rench retirement;
15/ 5. Ea!dle( and I. $a+e"ield, "hat +atients Thin# About the 0h!istie %ospital, 9nive!sit(
#osital o" <o&th Mancheste!, 197/. -!om (ea! to (ea! the demands made '( eole at a
ce!tain a*e a'ove 7> 'ecome mo!e seci"ic and costl(.
xxx "otnote! sl&tt xxx
((;/))
delive!( !oom, %hich dates "!om the mid8nineteenth cent&!(, s!ead to the n&!se!(, the
+inde!*a!ten, and the class!oom and medicali=ed in"anc(, childhood, and &'e!t(. )&t %hile it
has 'ecome acceta'le to advocate limits to the escalation o" costl( ca!e "o! the old, limits to
so8called medical investments in childhood a!e still a s&':ect that seems ta'oo. Ind&st!ial
a!ents, "o!ced to !oc!eate mano%e! "o! a %o!ld into %hich no'od( "its %ho has not 'een
c!&shed and molded '( sixteen (ea!s o" "o!mal ed&cation, "eel imotent to ca!e e!sonall( "o!
thei! o""s!in* and, in desai!, sho%e! them %ith medicine. 155 1!oosals to !ed&ce medical
o&t&ts in the 9nited <tates "!om thei! !esent level o" a'o&t M1>> 'illion to thei! 195> level
o" M1> 'illion, o! to close medical schools in 0olom'ia, neve! t&!n into cont!ove!sial iss&es
'eca&se those %ho ma+e them a!e soon disc!edited as hea!tless !oonents o" in"anticide o! o"
mass exte!mination o" the oo!. The en*inee!in* a!oach to the ma+in* o" economicall(
!od&ctive ad&lts has made death in childhood a scandal, imai!ment th!o&*h ea!l( disease a
&'lic em'a!!assment, &n!eai!ed con*enital mal"o!mation an in8tole!a'le si*ht, and the
ossi'ilit( o" e&*enic 'i!th cont!ol a !e"e!!ed theme "o! inte!national con*!esses in the
seventies.
5s "o! in"ant mo!talit(, it has indeed 'een !ed&ced. Li"e exectanc( in the develoed
co&nt!ies has inc!eased "!om thi!t(8"ive (ea!s in the ei*hteenth cent&!( to sevent( (ea!s toda(.
This is d&e mainl( to the !ed&ction o" in"ant mo!talit( in these co&nt!iesR "o! examle, in
En*land and $ales the n&m'e! o" in"ant deaths e! 1,>>> live 'i!ths declined "!om 15/ in
1;/> to ,, in 196>. )&t it %o&ld 'e
xxx "otnote! sta!t xxx
155 The G'a'(G is a !athe! !ecentl( develoed social cate*o!(: the "i!st sta*e in the
develoment o" man8the8cons&me!. Bn the !ocess '( %hich the s&c+lin* %as slo%l( t&!ned
into a 'a'( and the assistance that medicine !ovided in this !ocess, see L&c )oltana+i,
G1!ime ed&cation et mo!ale de classe,G Cahiers du Centre de sociologie europFenne (The
#a*&eL1a!is: Mo&ton, 1969).
xxx "otnote! sl&tt xxx
((;5))
enti!el( inco!!ect to att!i'&te mo!e than one o" those lives GsavedG to a c&!ative inte!vention
that !es&oses an(8thin* li+e a docto!6s t!ainin*, and it %o&ld 'e a del&sion to att!i'&te the
in"ant mo!talit( !ate o" oo! co&nt!ies, %hich in some cases is ten times that o" the 9nited
<tates, to a lac+ o" docto!s. -ood, antisesis, civil en*inee!in*, and a'ove all, a ne%
%ides!ead disval&e laced on the death o" a child,156 no matte! ho% %ea+ o! mal"o!med, a!e
m&ch mo!e si*ni"icant "acto!s and !e!esent chan*es that a!e onl( !emotel( !elated to medical
inte!vention. $hile in *!oss in"ant mo!talit( the 9nited <tates !an+s seventeenth amon*
nations, in"ant mo!talit( amon* the. oo! is m&ch hi*he! than amon* hi*he!8income *!o&s.
In Ne% No!+ 0it(, in"ant mo!talit( amon* the 'lac+ o&lation is mo!e than t%ice as hi*h as
"o! the o&lation in *ene!al, and !o'a'l( hi*he! than in man( &nde!develoed a!eas s&ch as
Thailand and Iamaica.157 The insistence that mo!e docto!s a!e needed to !event in"ants "!om
d(in* can th&s 'e &nde!stood as a %a( o" avoidin* income eA&ali=ation %hile at the same
time c!eatin* mo!e :o's "o! !o"essionals. It %o&ld 'e eA&all( !ec+less to claim that those
chan*es in the *ene!al envi!onment that do have a ca&sal !elation8shi to the !esence o"
docto!s !e!esent a ositive 'alance "o! health. 5ltho&*h h(sicians did ionee! antisesis,
imm&ni=ation, and dieta!( s&lements, the( %e!e also involved in the s%itch to the 'ottle
that t!ans"o!med the t!aditional s&c+lin* into a mode!n 'a'( and !ovided ind&st!( %ith
%o!+in* mothe!s %ho a!e clients "o! a "acto!(8made "o!m&la.
xxx "otnote! sta!t xxx
156 The c&lt&!e o" childhood as that cha!acte!istic "o! an a*e *!o& distinct "!om the ad&lt and
the in"ant is o" social o!i*in, li+e that o" the G'a'(.G <ee 1hilie 5!ies, Centuries of
Childhood A Social %istory of (amily -ife 2.ew <or#= Enopf, 9>?&A, especially on the
profound change the attitude towards the death of a child underwent between the 9:th and
the 9>th centuries;
157 Iohn )!(ant, M.7., %ealth and the Developing "orld 2)thaca, .;<;= Cornell !niv; +ress,
9>?>A;
xxx "otnote! sl&tt xxx
((;6))
The dama*e this s%itch does to nat&!al imm&nit( mechanisms "oste!ed '( h&man mil+ and
the h(sical and emotional st!ess ca&sed '( 'ottle "eedin* a!e coma!a'le to i" not *!eate!
than the 'ene"its that a o&lation can de!ive "!om seci"ic imm&ni=ations.15; Even mo!e
se!io&s is the cont!i'&tion the 'ottle ma+es to the menace o" %o!ld%ide !otein sta!vation. -o!
instance, in 196>, 96 e!cent o" 0hilean mothe!s '!east8"ed thei! in"ants & to and 'e(ond the
"i!st 'i!thda(. Then, "o! a decade, 0hilean %omen &nde!%ent intense olitical indoct!ination
'( 'oth !i*ht8%in* 0h!istian 7emoc!ats and a va!iet( o" le"t8%in* a!ties. )( 197> onl( 6
e!cent '!east8"ed 'e(ond the "i!st (ea! and ;> e!cent had %eaned thei! in"ants 'e"o!e the
second "&ll month. 5s a !es&lt, ;/ e!cent o" otential h&man '!east mil+ no% !emains
&n!od&ced. The mil+ o" an additional .,,>>> co%s %o&ld have to 'e added to 0hile6s
ove!*!a=ed ast&!es to comensateDas "a! as ossi'leD"o! this loss.159 5s the 'ottle
'ecame a stat&s s(m'ol, ne% illnesses aea!ed amon* child!en %ho had 'een denied the
'!east, and since mothe!s lac+ t!aditional +no%8ho% to deal %ith 'a'ies %ho do not 'ehave
li+e s&c+lin*s, 'a'ies 'ecame ne% cons&me!s o" medical attention and o" its !is+s.16> The
s&m total o" h(sical imai!8
xxx "otnote! sta!t xxx
15; 5'o&t the !elativel( m&ch hi*he! !esistance to mala!ia, in"ections, and de"icienc(
diseases o" '!east8"ed 'a'ies, see GMil+ and Mala!ia,G ,ritish *edical 3ournal, 9>@&, &=9JB@,
and 195., &=9&9B; B. Mellande! and ). ?ahlA&iest, G)!east -eedin* and 5!ti"icial -eedin*,G
Acta +aediatrica &, s&l. (195;): 1>1. -o! a s&!ve( o" lite!at&!e, the edito!ial G)!east
-eedin* and 1olio <&sceti'ilit(,G .utrition eview, *ay 9>?@, pp; 90940; Leona!do I. Mata
and 3icha!d $(att, G#ost 3esistance to In"ection,G American 3ournal of Clinical .utrition &J
2August 9>:9A= >:?4C?;
159 -o! mo!e data on the imact o" the 'ottle on %o!ld n&t!ition, see 5lan )e!*, The
.utrition (actor;; )ts ole in .ational Development ($ashin*ton, 7.0.: )!oo+in*s
Instit&tion, 9>:0A; A child n&!sed th!o&*h the "i!st t%o (ea!s o" its li"e !eceives the n&t!itional
eA&ivalent o" /61 A&a!ts o" co%6s mil+, %hich costs the eA&ivalent o" the ave!a*e (ea!l(
income o" an Indian.
16> The atte!n o" %o!ld%ide mode!n maln&t!ition is !e"lected in the t%o "o!ms that in"ant
maln&t!ition ta+es. The s%itch "!om the '!east to the 'ottle int!od&ces 0hilean 'a'ies to a li"e
o" endemic &nde!no&!ishmentR the same
xxx "otnote! "o!tsette! neste side xxx
((;7))
ment d&e :&st to this s&'stit&tion o" ma!+eted 'a'( "ood "o! mothe!6s mil+ is di""ic&lt to
'alance a*ainst the 'ene"its de!ived "!om c&!ative medical inte!vention in childhood sic+ness
and "!om s&!*ical co!!ection o" 'i!th de"ects !an*in* "!om ha!eli to hea!t de"ects.
It can, o" co&!se, 'e a!*&ed that the medical classi"ication o" a*e *!o&s acco!din* to thei!
dia*nosed need "o! health commodities does not *ene!ate ill8health '&t onl( !e"lects the
health8den(in* '!ea+do%n o" the "amil( as a cocoon, o" the nei*h'o!hood as a net%o!+ o" *i"t
!elation8shis, and o" the envi!onment as the shelte! o" a local s&'sistence comm&nit(. No
do&'t, it is t!&e that a medicali=ed social e!cetion !e"lects a !ealit( that is dete!mined '( the
o!*ani=ation o" caital8intensive !od&ction, and that it is the co!!esondin* social atte!n o"
n&clea! "amilies, %el"a!e a*encies, and oll&ted nat&!e that de*!ades home, nei*h'o!hood,
and milie&. )&t medicine does not siml( mi!!o! !ealit(R it !ein"o!ces and !e!od&ces the
!ocess that &nde!mines the social cocoons %ithin %hich man has evolved. Medical
classi"ication :&sti"ies the ime!ialism o" standa!d stales li+e 'a'( "ood ove! mothe!6s mil+
and o" old8a*e homes ove! a co!ne! at home. )( t&!nin* the ne%'o!n into a hositali=ed
atient &ntil he o! she is ce!ti"ied as health(, and '( de"inin* *!andmothe!6s comlaint as a
need "o! t!eatment !athe! than "o! atient !esect, the medical ente!!ise c!eates not onl(
'iolo*icall( "o!m&lated le*itimac( "o! man8the8cons&me! '&t also ne% !ess&!es "o! an
escalation o" the me*amachine.161 Oenetic selection o" those %ho "it into that machine is the
lo*ical next ste o" medicosocial cont!ol.
xxx "otnote! sta!t xxx
s%itch initiates )!itish 'a'ies into a li"e o" sic+enin*, addictive ove!alimentation: see 3. @.
Bates, GIn"ant -eedin* 1!actices,G )!itish *sdicol Io&!nal, 197., ,:76,.8/.
161 Bn li"e as a constant t!ainin* "o! s&!vival in the me*amachine, see Le%is *umford, The
+earagoa of +ower T he *yth of the *achins, 6olume & 2.ew <or#= %arcourt ,race, 9>:BA;
xxx "otnote! sl&tt xxx
((;;))
Pre$enti$e Stigma
5s c&!ative t!eatment "oc&ses inc!easin*l( on conditions in %hich it is ine""ect&al, exensive,
and ain"&l, medicine has 'e*&n to ma!+et !evention. The concet o" mo!'idit( has 'een
enla!*ed to cove! !o*nosticated !is+s. 5lon* %ith sic+8ca!e, health ca!e has 'ecome a
commodit(, somethin* one a(s "o! !athe! than somethin* one does. The hi*he! the sala!( the
coman( a(s, the hi*he! the !an+ o" an aparatchi#, the more will be spent to #eep the
valuable cog well oiled; *aintenance costs for highly capitali8ed manpower are the new
measure of status for those on the upper rungs; +eople #eep up with the 3oneses by emulating
their Dchec#4ups,D an English word which has entered (rench, Serbian, Spanish, *alay, and
%ungarian dictionaries; +eople are turned into patients with4out being sic#; The
medicali8ation of prevention thus becomes another ma5or symptom of social iatrogenesis; )t
tends to transform personal responsibility for my future into my management by some agency;
9s&all( the dan*e! o" !o&tine dia*nosis is even less "ea!ed than the dan*e! o" !o&tine
t!eatment, tho&*h social, h(sical, and s(cholo*ical to!ts in"licted '( medical classi"ication
a!e no less %ell doc&mented. 7ia*noses made '( the h(sician and his hele!s can de"ine
eithe! temo!a!( o! e!manent !oles "o! the atient. In eithe! case, the( add to a 'ioh(sical
condition a social state c!eated '( !es&ma'l( a&tho!itative eval&ation.16, $hen a
vete!ina!ian dia*noses a co%6s disteme!, it doesn6t &s&all( a""ect the atient6s 'ehavio!. $hen
a docto! dia*noses a h&man 'ein*, it does.16. In those instances
xxx "otnote! sta!t xxx
16, Thomas I. <cha"", ,eing *entally )ll= A Sociological Theory (0hica*o: 5ldine, 1966).
Tho&*h he deals !ima!il( %ith s(chiat!ic iss&es, <che"" does st!ess the anal(tic di""e!ence
'et%een mental illness that is a!t o" the social s(stem and the co!!esondin* 'ehavio!.
16. -!eidson, +rofession of *edicine, p; &&0;
xxx "otnote! sl&tt xxx
((;9))
%he!e the h(sician functions as heale! he con"e!s on the e!son !eco*ni=ed as sic+ ce!tain
!i*hts, d&ties, and exc&ses %hich have a conditional and temo!a!( le*itimac( and %hich
lase %hen the atient is healedR most sic+ness leaves no taint o" deviance o! diso!de!l(
cond&ct on the atient6s !e&tation. No one is inte!ested in ex8alle!*ies o! ex8aendectom(
atients, :&st as no one %ill 'e !emem'e!ed as an ex8t!a""ic o""ende!. In othe! instances,
ho%eve!, the h(sician acts !ima!il( as an act&a!(, and his dia*nosis can de"ame the atient,
and sometimes his child!en, "o! li"e. )( attachin* i!!eve!si'le de*!adation to a e!son6s
identit(, it '!ands him "o!eve! %ith a e!manent sti*ma.16/ The o':ective condition ma( have
lon* since disaea!ed, '&t the iat!o*enic la'el stic+s. Li+e ex8convicts, "o!me! mental
atients, eole a"te! thei! "i!st hea!t attac+, "o!me! alcoholics, ca!!ie!s o" the sic+le8cell t!ait,
and (&ntil !ecentl() ex8t&'e!c&lotics a!e t!ans"o!med into o&tside!s "o! the !est o" thei! lives.
1!o"essional s&sicion alone is eno&*h to le*itimi=e the sti*ma even i" the s&sected condition
neve! existed. The medical la'el ma( !otect the atient "!om &nishment onl( to s&'mit him
to inte!mina'le inst!&ction, t!eatment, and disc!imination, %hich a!e in"licted on him "o! his
!o"essionall( !es&med 'ene"it. 165
In the ast, medicine la'eled eole in t%o %a(s: those "o! %hom c&!es co&ld 'e attemted,
and those %ho %e!e 'e(ond !eai!, s&ch as lee!s, c!iles, oddities, and the
xxx "otnote! sta!t xxx
16/ E!vin* 0o""inan, <ti*ma: .otes on the *anagement of Spoiled )dentity (En*le8%ood
0li""s, NI.: <ect!&m 196.). <ee also 3icha!d <ennett, GT%o on the 5isle,G .ew <or# eview
of ,oo#s, Novem'e! 1, 197., %ho &nde!lines that "o! 0o""man the cent!al tas+ is a desc!ition
o" the conscio&sness ind&ced '( livin* in a mode!n cit(. 0ontemo!a!( li"e inevita'l(
sti*mati=esR on the mechanisms see #. 1. 7!eit=el, Die gesellschafflidhen -eiden and des
-eiden an der $esellschaft 6orstudien su einer +athologic des ollenverha#ens 2Stuttgart=
En#e, 9>:&A;
165 $ilhelm 5&'e!t and <heldon Messin*e!, GThe 0!iminal and the <ic+,G )nquiry 9 (195;):
1.786>. 7isc&sses the di""e!ent "o!ms social cont!ol can ta+e, deendin* on the secial %a( in
%hich sti*ma imin*es on mo!al identit(.
xxx "otnote! sl&tt xxx
((9>))
d(in*. Eithe! way, dia*nosis co&ld lead to sti*ma. Medicali=ed !evention no% c!eates a thi!d
%a(. It t&!ns the h(sician into an o""iciall( licensed ma*ician %hose !ohecies c!ile even
those %ho a!e le"t &nha!med '( his '!e%s.166 7ia*nosis ma( excl&de a h&man 'ein* %ith
'ad *enes "!om 'ein* 'o!n, anothe! "!om !omotion, and a thi!d "!om olitical li"e. The mass
h&nt "o! health !is+s 'e*ins %ith d!a*nets desi*ned to a!ehend those needin* secial
!otection: !enatal medical visitsR %ell8child8ca!e clinics "o! in"antsR school and cam chec+8
&s and !eaid medical schemes.167 3ecentl( *enetic and 'lood !ess&!e Gco&nselin*G
se!vices %e!e added. The 9nited <tates !o&dl( led the %o!ld in o!*ani=in* disease8h&nts and,
late!, in A&estionin* thei! &tilit(.16;
In the ast decade, a&tomated m&ltihasic health8testin* 'ecame oe!ational and %as
%elcomed as the oo! man6s escalato! into the %o!ld o" Ma(o and Massach&setts Oene!al.
This assem'l(8line !oced&!e o" comlex chemical and medical examinations can 'e
e!"o!med '( a!a!o"essional technicians at a s&!!isin*l( lo% cost. It &!o!ts to o""e!
&nco&nted millions mo!e sohisticated detection o" hidden the!ae&tic needs than %as
availa'le in the sixties even "o! the most Gval&a'leG hie!a!chs in #o&ston o! Mosco%. 5t the
o&tset o" this testin*, the lac+
xxx "otnote! sta!t xxx
166 -!ed 7avis, +assage Through Crisis= +olio 6ictims and Their (amilies (Indianaolis:
)o''s8Me!!ill, 196.). 7avis !elates t!ansito!iness not onl( to se!io&sness '&t also to social
class. The oo! %ill 'e dia*nosed as Ge!manentl( imai!edG much soone! than the !ich.
167 0. M. $(lie, G1a!ticiation in a M&ltile <c!eenin* 0linic %ith -ive8Nea! -ollo%8&,G
+ublic %ealth eports 76 (I&l( 1961): 59686>,. 3eo!t indicates disaointin* !es&lts.
16; O. <. <ie*el, GThe 9selessness o" 1e!iodic Examination,G Archives of Environmental
%ealth 1. (<etem'e! 1966): ,9,85. G1e!iodic health examination o" ad&lts, as o!i*inall(
conceived and c&!!entl( !acticed, !emains, a"te! 5> (ea!s o" vi*o!o&s 5me!ican !omotion, a
scienti"icall( &n!oven medical !oced&!e. $e do not have concl&sive evidence that a
o&lation !eceivin* such care lives lon*e!, 'ette!, healthie!, o! haie! 'eca&se o" it, no! do
%e have evidence to the cont!a!(.G
xxx "otnote! sl&tt xxx
((91))
o" cont!olled st&dies allo%ed the salesmen o" mass8!od&ced !evention to "oste!
&ns&'stantiated exectations. (Mo!e !ecentl(, cont!olled coma!ative st&dies o" o&lation
*!o&s 'ene"ittin* "!om maintenance se!vice and ea!l( dia*nosis have 'ecome availa'leR t%o
do=en s&ch st&dies indicate that these dia*nostic !oced&!esDeven %hen "ollo%ed '( hi*h8
level medical t!eatmentsDhave no ositive imact on li"e exectanc(. 169) I!onicall(, the
se!io&s as(mtomatic diso!de!s %hich this +ind o" sc!eenin* alone can discove! amon* ad&lts
a!e "!eA&entl( inc&!a'le illnesses in %hich ea!l( t!eatment onl( a**!avates the atient6s
h(sical condition. In an( case, it t!ans"o!ms eole %ho "eel health( into atients anxio&s "o!
thei! ve!dict.
In the detection o" sic+ness medicine does t%o thin*s: it Gdiscove!sG ne% diso!de!s, and it
asc!i'es these diso!de!s to conc!ete individ&als. To discove! a ne% cate*o!( o" disease is the
!ide o" the medical scientist. 17> To asc!i'e the atholo*( to some Tom, 7ic+, o! #a!!( is
the "i!st tas+ o" the h(sician actin* as mem'e! o" a cons&ltin* !o"ession.171 T!ained to Gdo
somethin*G and ex!ess his conce!n, he "eels active, &se"&l, and e""ective %hen he can
dia*nose disease. 17, Theo!eticall(, at the "i!st enco&nte! the h(sician does not !es&me that
his atient is a""ected
xxx "otnote! sta!t xxx
169 1a&l 7. 0lote, G5&tomated M&ltihasic #ealth Testin*: 5n Eval&ation,G indeendent
st&d( %ith Iohn Mc@ni*ht, No!th%este!n 9nive!sit(, 197.R !e!od&ced in 5ntolo*ia 5;
(0&e!navaca: 0I7B0, 197/). 3evie%s the availa'le lite!at&!e.
17> I. <ch%a!t= and O. L. )a&m, GThe #isto!( o" #istolasmosis,G .ew England 3ournal of
*edicine &@? 29>@:A= &@04C; Describes the costly discovery of an incurable DdiseaseD that
neither #ills nor impairs and seems to be endemic wherever people come in contact with
chic#ens, cattle, cats, or dogs;
171 -!eidson, +rofession of *edicine, . 7. ""., ma+es the distinction I he!e al(. 5s a
schola!l( !o"essional, the medical scientist need contend onl( %ith his collea*&es and thei!
accetance of his GinventionG o" a ne% disease. 5s a cons&ltin* !o"essional, the !acticin*
h(sician deends on an ed&cated &'lic that accets his excl&sive !i*ht to dia*nose.
17, 1a!sons, The Social System, . /66 "". The a&tho! ma+es this oint commentin* on
1a!eto.
xxx "otnote! sl&tt xxx
((9,))
'( a disease, th!o&*h a "o!m o" "ail8sa"e !incile he &s&all( acts as i" im&tin* a disease to
the atient %e!e 'ette! than dis!e*a!din* one. The medical8decision !&le &shes him to see+
sa"et( '( dia*nosin* illness !athe! than health.17. The classic demonst!ation o" this 'ias came
in an exe!iment cond&cted in 19./.17/ In a s&!ve( o" 1,>>> eleven8(ea!8old child!en "!om
the &'lic schools o" Ne% No!+, 61 e!cent %e!e "o&nd to have had thei! tonsils !emoved.
GThe !emainin* .9 e!cent %e!e s&':ected to examination '( a *!o& o" h(sicians, %ho
selected /5 e!cent o" these "o! tonsillectom( and !e:ected the !est. The !e:ected child!en %e!e
!e8examined '( anothe! *!o& o" h(sicians, %ho !ecommended tonsillectom( "o! /6 e!cent
o" those !emainin* a"te! the "i!st examination. $hen the !e:ected child!en %e!e examined a
thi!d time, a simila! e!centa*e %as selected "o! tonsillectom( so that a"te! th!ee examinations
onl( sixt(8"ive child!en !emained %ho had not 'een !ecommended "o! tonsillectom(. These
s&':ects %e!e not "&!the! examined 'eca&se the s&l( o" examinin* h(sicians !an o&t.G 175
This test %as cond&cted at a "!ee clinic, %he!e "inancial conside!ations co&ld not exlain the
'ias.
7ia*nostic 'ias in "avo! o" sic+ness com'ines %ith "!eA&ent dia*nostic e!!o!. Medicine not
onl( im&tes A&estiona'le cate*o!ies %ith inA&isito!ial enth&siasmR it does so at a !ate o"
misca!!ia*e that no co&!t s(stem co&ld tole!ate. In one instance, a&tosies sho%ed that mo!e
than hal" the atients %ho died in a )!itish &nive!sit( clinic %ith a dia*nosis o" seci"ic hea!t
"ail&!e had in "act died o" somethin* else. In anothe! instance, the same se!ies o"
xxx "otnote! sta!t xxx
17. Thomas I. <che"", G7ecision 3&les, T(es o" E!!o!, and Thei! 0onseA&ences in Medical
7ia*nosis,G ,ehavioral Science C (196.): 9781>7.
17/ 5me!ican 0hild #ealth 5ssociation, +hysical Defects= The +athway to affection (Ne%
No!+, 19./), cha. ;, . ;>896.
175 #a!!( )a+%in, G1se&dodoxia 1ediat!ica,G .ew England 3ournal of *edicine &0& 29>J@A=
?>94>:;
xxx "otnote! sl&tt xxx
((9.))
chest [8!a(s sho%n to the same team o" secialists on di""e!ent occasions led them to chan*e
thei! mind on ,> e!cent o" all cases. 9 to th!ee times as man( atients %ill tell 7!. <mith
that the( co&*h, !od&ce s&t&m, o! s&""e! "!om stomach c!ams as %ill tell 7!. Iones. 9 to
one8A&a!te! o" simle hosital tests sho% se!io&sl( dive!8*ent !es&lts %hen done "!om the
same samle in t%o di""e!ent la's.176 No! do machines seem to 'e an( mo!e in"alli'le. In a
cometition 'et%een dia*nostic machines and h&man dia*nosticians in ;. cases
!ecommended "o! elvic s&!*e!(, atholo*( sho%ed that 'oth man and machine %e!e co!!ect
in ,, instancesR in .7 instances the com&te! co!!ectl( !e:ected the docto!6s dia*nosisR in 11
instances the docto!s !oved the com&te! %!on*R and in 1> cases 'oth %e!e in e!!o!.177
In addition to dia*nostic 'ias and e!!o!, the!e is %anton a**!ession.17; 5 ca!diac
cathete!i=ation, &sed to dete!mine i" a atient is s&""e!in* "!om ca!diom(oath(Dadmittedl(,
this is not done !o&tinel(Dcosts M.5> and +ills one atient
xxx "otnote! sta!t xxx
176 -o! !e"e!ences and "&!the! 'i'lio*!ah( see L. #. Oa!land, G<t&dies on the 5cc&!ac( o"
7ia*nostic 1!oced&!es,G 5me!ican 3ournal of oentgenology, 3adi&m Therapy, and .uclear
*edicine C& (I&l( 1959): &@40C; <ee also 5. L. 0och!ane and L. #. Oa!land, GB'se!ve! E!!o!
in the Inte!!etation o" 0hest -ilms: 5n Inte!national 0oma!ison,G -ancet &?0 29>@&A= @B@;4
>; <&**ests that 5me!ican dia*nosticians mi*ht have a st!on*e! enchant "o! ositive "indin*s
than thei! )!itish co&nte!a!ts. 5. L. 0och!ane, 1. I. 0haman, and 1. 7. Bldham, GB'se!ve!s6
E!!o!s in Ta+in* Medical #isto!ies,G -ancet &?B 29>@9A= 9BB:4>;
177 Bsie! 1ete!son, E!nest M. )a!samian, and M&!!a( Eden, G5 <t&d( o" 7ia*nostic
1e!"o!mance: 5 1!elimina!( 3eo!t,G 3ournal of *edical Education /1 (5&*&st 1966): :>:4
CB0;
17; Ma&!ice 1a%o!th, %uman O&inea 1i*s: E/perimentation on *an ()oston: )eacon
1!ess, 9>?CA; In 9>?: 7!. 1a%o!th &'lished a !eo!t on exe!imental dia*nostic
!oced&!es that involved hi*h !is+s o" e!manent dama*e o! death, %hich had !ecentl( 'een
desc!i'ed in the most !esecta'le medical :o&!nals and %e!e o"ten e!"o!med on nonatients,
in"ants, !e*nant %omen, mental de"ectives, and the old. #e has 'een attac+ed "o! !ende!in* a
disse!vice to his !o"ession, "o! &nde!minin* the t!&st la( eole have in docto!s, and "o!
&'lishin* in a ae!'ac+ %hat co&ld Gethicall(G 'e told onl( in lite!at&!e %!itten "o! docto!s.
1e!has most s&!!isin* in these !eo!ts is the !elentless !eetition o" identical hi*h8!is+
!oced&!es "o! the sole &!ose o" ea!nin* academic !omotions.
xxx "otnote! sl&tt xxx
((9/))
in "i"t(. Net the!e is no evidence that a differential dia*nosis 'ased on its !es&lts extends eithe!
the li"e exectanc( o! the com"o!t o" the atient. 179 Most tests a!e less m&!de!o&s and m&ch
mo!e commonl( e!"o!med, '&t man( still involve +no%n !is+s to the individ&al o! his
o""s!in* %hich a!e hi*h eno&*h to o'sc&!e the val&e o" %hateve! in"o!mation the( can
!ovide. Man( !o&tine &ses o" [8!a(s and "l&o!oscoe on the (o&n*, the in:ection o! in*estion
o" !ea*ents and t!ace!s, and the &se o" 3italin to dia*nose h(e!activit( in child!en a!e
examles.1;> 5t8tendance in &'lic schools %he!e teache!s a!e vested %ith dele*ated medical
o%e!s constit&tes a ma:o! health !is+ "o! child!en.1;1 Even simle and othe!%ise 'eni*n
examinations t&!n into !is+s %hen m&ltilied. $hen a test is associated %ith seve!al othe!s, it
has conside!a'l( *!eate! o%e! to ha!m than %hen it is cond&cted '( itsel". B"ten tests
!ovide *&idance in the choice o" the!a(. 9n"o!t&natel(, as the tests t&!n mo!e comlex and
a!e m&ltilied, thei! !es&lts "!eA&entl( !ovide *&idance onl( in selectin* the "o!m o"
inte!vention %hich the atient ma( s&!vive,
xxx "otnote! sta!t xxx
179 G<&ch a !oced&!e is as in"o!mative as !eco!din* a atient6s 'lood !ess&!e once in a
li"etime, o! examinin* his &!ine once eve!( ,> (ea!s. This !actice is !idic&lo&s, a's&!d and
&nnecessa!( . . . and o" a'sol&tel( no val&e in dia*nosis o! t!eatment.G Ma&!ice 1a%o!th,
G7an*e!o&s #ead That Ma( 3&le the #ea!t,G +erspective, . 6787>.
1;> Minimal '!ain dama*e in child!en is as o"ten as not a c!eation o" 3italinR it is a dia*nosis
dete!mined '( the t!eatment. <ee 3o*e! 7. -!eeman, G3evie% o" Medicine in <ecial
Ed&cation: Medical8)ehavio!al 1se&do!elationshis,GIoa! nal of Special Education 5 (%inte!8
s!in* 1971): 9.899.
1;1 5lexande! 3. L&cas and Mo!!is $eiss, GMeth(lhenidate #all&cinosis,G Io&!nal of the
American *edical 5ssociation ,17 (1971): 1>798;1. 3italin is &sed "o! the cont!ol o" minimal
'!ain d(s"&nction in schoolchild!en. The a&tho! A&estions the ethics o" &sin* a o%e!"&l a*ent
%ith se!io&s side8e""ects, some %ell de"ined and othe!s s&sected, "o! mass the!a( o" a
condition that is ill8de"ined. <ee also )a!'a!a -ish, GThe Bne80hild8Bne87!&* M(th o"
<tim&lants in #(e!+inesis,G 5!chives of $eneral +ychiatry ,5 (<etem'e! 1971): 19.8,>..
0onside!a'le e!manent dama*e has !o'a'l( 'een done to h(e!active child!en t!eated %ith
amhetamines "o! a condition ossi'l( d&e to 'iochemical st!ess "!om lead oisonin*: 7.
)!(ce8<mith and #. 5. $ald!on, GLead, )ehavio!, and 0!iminalit(,G Ecologist J, no. 1>
(1975).
xxx "otnote! sl&tt xxx
((95))
and not necessa!il( that %hich %ill hel him. $o!st o" all, %hen eole have lived th!o&*h
comlex ositive la'o!ato!( dia*nosis, &nha!med o! not, the( have inc&!!ed a hi*h !is+ o"
'ein* s&'mitted to the!a( that is odio&s, ain"&l, c!ilin*, and exensive. No %onde! that
h(sicians tend to dela( lon*e! than la(men 'e"o!e *oin* to see thei! o%n docto! and that the(
a!e in %o!se shae %hen the( *et the!e. 1;,
3o&tine e!"o!mance o" ea!l( dia*nostic tests on la!*e o&lations *&a!antees the medical
scientist a '!oad 'ase "!om %hich to select the cases that 'est "it existin* t!eatment "acilities o!
a!e most &se"&l in the attainment o" !esea!ch *oals, %hethe! o! not the the!aies c&!e,
!eha'ilitate, o! soothe. In the !ocess, eole a!e st!en*thened in thei! 'elie" that the( a!e
machines %hose d&!a'ilit( deends on visits to the maintenance sho, and a!e th&s not onl(
o'li*ed '&t also !ess&!ed to "oot the 'ill "o! the ma!+et !esea!ch and the sales activities o" the
medical esta'lishment.
7ia*nosis al%a(s intensi"ies st!ess, de"ines incaacit(, imoses inactivit(, and "oc&ses
a!ehension on non!ecove!(, on &nce!taint(, and on one6s deendence &on "&t&!e medical
"indin*s, all o" %hich amo&nts to a loss o" a&tonom( "o! sel"8de"inition. It also isolates a
e!son in a secial !ole, sea!ates him "!om the no!mal and health(, and !eA&i!es s&'mission
to the a&tho!it( o" seciali=ed e!sonnel. Bnce a societ( o!*ani=es "o! a !eventive disease8
h&nt, it *ives eidemic !oo!tions to dia*nosis. This &ltimate t!i&mh o" the!ae&tic c&lt&!e
1;. t&!ns the indeendence o" the ave!a*e health( e!son into an intole!a'le "o!m o"
deviance.
xxx "otnote! sta!t xxx
1;, )a!'a!a )lac+%ell, The -iterature of Delay is See#ing *edical Care for Chronic
)llnesses, %ealth Education *onograph no; 9? 2San (rancisco= Society for +ublic %ealth
Education, 9>?0A;
1;. 1hili ieff, Triumph of the Therapeutic !ses of (aith after (reud 2.ew <or#= %arper
Torchboo#, 9>?CA, argues that the hospital has succeeded the church and the parliament as
the archetypical institution of "estern culture;
xxx "otnote! sl&tt xxx
((96))
In the lon* !&n the main activit( o" s&ch an inne!8di!ected s(stems societ( leads to the
hantom !od&ction o" li"e exectanc( as a commodit(. )( eA&atin* statistical man %ith
'iolo*icall( &niA&e men, an insatia'le demand "o! "inite !eso&!ces is c!eated. The individ&al is
s&'o!dinated to the *!eate! GneedsG o" the %hole, !eventive !oced&!es 'ecome com&lso!(,
1;/ and the !i*ht o" the atient to %ithhold consent to his o%n t!eatment vanishes as the
docto! a!*&es that he m&st s&'mit to dia*nosis, since societ( cannot a""o!d the '&!den o"
c&!ative !oced&!es that %o&ld 'e even mo!e exensive. 1;5
,erminal Ceremonies
The!a( !eaches its ao*ee in the death8dance a!o&nd the te!minal atient.1;6 5t a cost o"
'et%een M5>> and M,,>>> e! da(,1;7 cele'!ants in %hite and 'l&e envelo %hat !emains o"
the atient in antisetic smells.16; The
xxx "otnote! sta!t xxx
1;/ Li+e olicemen in &!s&it o" c!ime !evention, docto!s a!e no% *iven the 'ene"it o" the
do&'t i" the( ha!m the atient. $illiam 5. $estle(, G?iolence and the 1olice,G American
3ournal of Sociology 59 (I&l( 195.): ./8/1, "o&nd that one8thi!d o" all eole in a small
ind&st!ial cit(, as+ed, G$hen do (o& thin+ a oliceman is :&sti"ied in !o&*hin* & a man4G
said the( 'elieved it %as le*itimate to &se violence :&st to coe!ce !esect "o! the olice.
1;5 Ioseh 0ooe!, G5 Non81h(sician Loo+s at Medical 9toia,G 3ournal of the American
*edical Association 197 (1966): 69789.
1;6 B!ville )!im et al., eds., The Dying +atient (Ne% No!+: 3&ssell <a*e, 196>). 5n
antholo*( %ith a 'i'lio*!ah( "o! each cont!i'&tion. -i!st deals %ith the sect!&m o" technical
anal(sis and decision8ma+in* in %hich health !o"essionals en*a*e %hen the( a!e "aced %ith
the tas+ o" dete!minin* the ci!c&mstances G&nde! %hich an individ&al6s death sho&ld occ&!.G
1!ovides a se!ies o" !ecommendations a'o&t %hat mi*ht 'e done to ma+e this en*inee!in*
!ocess Gsome%hat less *!aceless and less distaste"&l "o! the atient, his "amil( and, most o"
all, the attendin* e!sonnel.G
1;7 Tho&*h the cost o" intensive te!minal ca!e has easil( do&'led :&st in the last / (ea!s, it is
still &se"&l to cons&lt 3o'e!t I. Olase!, GInnovation and #e!oic 5cts in 1!olon*in* Li"e,G in
)!im et al., 7lie Dying +atient, cha. 6, . 1>,8,;.
1;; 3icha!d 5. @alish, G7eath and 7(in*: 5 )!ie"l( 5nnotated )i'lio*!ah(,G in )!im et al.,
The Dying +atient, . .,78;>. 5n annotated 'i'lio*!ahic s&!ve( o" En*lish8lan*&a*e
lite!at&!e on d(in*, limited mainl( to items %hich deal %ith contemo!a!( !o"essional
activit(, decision8ma+in*, and technolo*(
xxx "otnote! "o!tsette! neste side xxx
((97))
mo!e exotic the incense and the (!e, the mo!e death moc+s the !iest.1;9 The !eli*io&s &se
o" medical techniA&e has come to !evail ove! its technical &!ose, and the line sea!atin*
the h(sician "!om the mo!tician has 'een 'l&!!ed.19> )eds a!e "illed %ith 'odies neithe! dead
no! alive. 191 The con:&!in* docto! e!ceives himsel" as a mana*e! o" c!isis. 19, In an
insidio&s %a( he !ovides each
xxx "otnote! "!a "o!!i*e side xxx
in the hosital. This is an ext!act "!om a m&ch la!*e! list '( the same a&tho!. -o!
comlementin* items see 5&stin #. @&tsche!, I!., and 5&stin #. @&tsche!, 5 ,ibliogry Jy of
)oo+s an 7eath, )e!aventatt, -oss and Critf 9>@04?C (Ne% No!+: #ealth <ciences 1&'lishin*
0o!., 1969).
1;9 Inc!ease in medical exendit&!es can add no mo!e to the ave!a*e li"e exectanc( o" enti!e
o&lations in !ich co&nt!ies, "!om the 9.<. to 0hina. It can add si*ni"icantl( onl( to the li"e8
san o" the ve!( (o&n* in most o" the oo!e! co&nt!ies. This has 'een dealt %ith in the "i!st
chate!. The a'ilit( o" medicine to a""ect the s&!vival !ates o" small *!o&s o" eole selected
'( medical dia*nosis is somethin* else. 5nti'iotics have eno!mo&sl( inc!eased the chances o"
s&!vivin* ne&moniaR o!al !eh(d!ation, the !o'a'ilit( o" s&!vivin* d(sente!( o! chole!a.
<&ch e""ective inte!ventions a!e ove!%helmin*l( o" the chea and simle +ind. Thei!
administ!ation &nde! the cont!ol o" a !o"essional h(sician ma( have 'ecome a c&lt&!al m&st
"o! 5me!icans, '&t it is not (et so for Mexicans. 5 thi!d iss&e is the a'ilit( o" medical
t!eatment. to inc!ease the chances "o! s&!vival amon* an even smalle! !oo!tion o" eole:
those a""ected '( ac&te conditions that can 'e c&!ed than+s to seed( and comlex hosital
ca!e, and those a""ected '( de*ene!ative conditions in %hich comlex technolo*( can o'tain
!emissions. -o! this *!o& the !&le alies: the mo!e exensive the t!eatment, the less its val&e
in te!ms o" added li"e exectanc(. 5 "o&!th *!o& a!e the te!minall( ill: mone( tends to
!olon* d(in* onl( '( sta!tin* it ea!lie!.
19> -o! the lan*&a*e %ith %hich 5me!icans !e"e!!ed to the co!se :&st 'e"o!e h(sicians
int!&ded into the mo!tician6s '&siness, see Iessica Mit"o!d, The 5me!ican "ay of Death (Ne%
No!+: <imon V <ch&ste!, 196.).
191 9nde! ne% names the G=om'ieG has 'ecome an imo!tant s&':ect in medioole*al
dis&tations, to :&d*e "!om the in"lation o" lite!at&!e on con"lictin* claims o" death and life
ove! the 'od(. Instit&te o" <ociet(, Ethics, and the -ife <ciences, 3esea!ch O!o& on Ethical,
<ocial, and Le*al Iss&es in Oenetic 0o&nselin* and Oenetic En*inee!in*, GEthical and <ocial
Iss&es in <c!eenin* "o! Oenetic 7isease,G .ov England 3ournal of Medicine ,;6 (197,):
11,98.,. 5 *ood s&mma!( o" c&!!ent oinions on the c!ite!ia "o! dete!minin* that death has
occ&!!ed. The a&tho!s ca!e"&ll( sea!ate this iss&e "!om an( attemt to de"ine death.
5lexand!e 0a!on and Leon 3. @ass, G5 <tat&to!( 7e"inition o" the <tanda!ds "o!
7ete!minin* #&man 7eath: 5n 5!aisal and a 1!oosal,G 9nive!sit( of 1enns(lvania -aw
eview 1,1 (Novem'e! 197,): ;7811;. 5n int!od&ction to the le*al asects o" the h(sician6s
int!&sion into the *!avedi**e!6s domain.
19, This s!ead o" le*itimac( for the instit&tional mana*ement o" c!isis has eno!mo&s
olitical otential 'eca&se it !ea!es "o! i!!eve!si'le c!isis *ove!n8
xxx "otnote! "o!tsette! E neste side xxx
((9;))
citi=en at the last ho&! %ith an enco&nte! %ith societ(6s deadenin* d!eam o" in"inite o%e!.19.
Li+e an( c!isis mana*e! o" 'an+, state, o! co&ch, he lans sel"8de"eatin* st!ate*ies and
commandee!s !eso&!ces %hich, in thei! &selessness and "&tilit(, seem all the mo!e *!otesA&e.
5t the last moment, he !omises to each atient that claim on a'sol&te !io!it( "o! %hich most
eole !e*a!d themselves as too &nimo!tant.
The !it&ali=ation o" c!isis, a *ene!al t!ait o" a mo!'id societ(, does th!ee thin*s "o! the medical
functionary; It !ovides him %ith a license that &s&all( onl( the milita!( can claim. 9nde! the
st!ess o" c!isis, the !o"essional %ho is 'elieved to 'e in command can easil( !es&me
imm&nit( "!om the o!dina!( !&les o" :&stice and decenc(. #e %ho is assi*ned cont!ol ove!
death ceases to 'e an o!dina!( h&man. 5s %ith the di!ecto! o" a t!ia*e, his +illin* is cove!ed
'( olic(.19/ Mo!e imo!tant, his enti!e e!"o!mance ta+es lace in the a&!a o" c!isis.195
)eca&se the( "o!m
xxx "otnote! "o!tsette! "!a "o!!i*e side xxx
ment. I&st as $e'e! co&ld a!*&e that 1&!itan %ealth %as an &nintended conseA&ence o" the
anxiet( a!o&sed '( the doct!ine o" !edestination, so a mo!alist histo!ian o" Ta%ne(6s "i'e!
mi*ht a!*&e that !eadiness "o! techno"ascism is the &nintended conseA&ence o" a societ( that
voted "o! te!minal ca!e to 'e aid "o! '( national ins&!ance.
19. )( G!it&ali=ationG c!isis is t!ans"o!med "!om an &!*ent occasion "o! e!sonal inte*!ation
(E!i+son) into a st!ess sit&ation (3o'inson, "o! some disc&ssion) in %hich a '&!ea&c!atic
aa!at&s is "o!ced into action in &!s&it o" a *oal "o! %hich, '( its ve!( nat&!e, it cannot 'e
o!*ani=ed. 9nde! s&ch ci!c&mstances, the instit&tion6s ma+e8'elieve "&nctions %ill ta+e the
&e! hand. This m&st haen %hen medicine &!s&es a Gd(in* olic(.G The con"&sion is
enhanced '( the &se o" a %o!d s&ch as Gd(in*G o! Gdecision,G %hich desi*nates action that
s!in*s "!om intimac( in a context devoid o" it. E!i+ E!i+son, G1s(choanal(sis and Bn*oin*
#isto!(: 1!o'lems o" Identit(, #at!ed, and Nonviolence,G 5me!ican Io&!nal of + ichiatry 1,,
(<etem'e! 1965): ,/185.. Iames 3o'inson, The Concept of Crisis in Decision4*a#ing,
<(mosi <t&dies <e!ies no. 11 ($ashin*ton, 7.0.: National Instit&te o" <ocial and )ehavio!al
<cience, 196,).
19/ Leona!d Le%in, Triage (Ne% No!+: 7ial 1!ess, 197,), !aises the iss&e o" societ(
committed to d(in* olic( in a novel %hich, &n"o!t&natel(, does not coma!e %ith his
!evio&s eport "!om I!on Mo&ntain.
195 ?alentina )o!!emans and Ivan Illich, G7(in* 1olic(,G man&sc!it !e8a!ed "o!
Encyclopedia of ,io4Ethics, Eennedy )nstitute, "ashington, D;C;, to be published in 9>:?;
The authors have agreed to contribute the entry under the
xxx "otnote! "o!tsette! E neste side xxx
((99))
a cha!med 'o!de!land not A&ite o" this %o!ld, the time8san and the comm&nit( sace claimed
'( the medical ente!!ise a!e as sac!ed as thei! !eli*io&s and milita!( co&nte!a!ts. Not onl(
does the medicali=ation o" te!minal ca!e !it&ali=e maca'!e d!eams and enla!*e !o"essional
license "o! o'scene endeavo!s: the escalation o" te!minal t!eatments !emoves "!om the
h(sician all need to !ove the technical e""ectiveness o" those !eso&!ces he commands.196
The!e a!e no limits to his o%e! to demand mo!e and eve! mo!e. -inall(, the atient6s death
laces the h(sician 'e(ond otential cont!ol and c!iticism. In the last *lance o" the atient
and in the li"e8lon* e!sective o" the Gmo!it&!iG the!e is no hoe, '&t onl( the h(sician6s last
exectation.197 The o!ientation o" an( instit&tion to%a!ds Gc!isisG :&sti"ies eno!mo&s o!dina!(
ine""ectiveness.19;
#osital death is no% endemic.199 In the last t%ent(8"ive (ea!s the e!centa*e o" 5me!icans
%ho die in a hosital has *!o%n '( a thi!d.,>> The e!centa*e o" hosital deaths
xxx "otnote! "o!tsette! "!a "o!!i*e side xxx
title !oosed '( the edito!s o" the enc(cloedia !ecisel( to hi*hli*ht the "act that the
com'ination o" the int!ansitive ve!' Gto dieG and the '&!ea&c!atic te!m Golic(G constit&tes the
s&!eme attac+ on lan*&a*e and !eason.
196 #e %ho s&ccess"&ll( claims o%e! in an eme!*enc( s&sends and can dest!o( !ational
eval&ation. The insistence o" the h(sician on his excl&sive caacit( to eval&ate and solve
individ&al c!ises moves him s(m'olicall( into the nei*h'o!hood o" the $hite #o&se.
197 -o! the a&tho!6s vie% on the distinction 'et%een hoe and exectation as t%o oosed
"&t&!e8o!iented attit&des, see Ivan Illich, GThe 7a%n o" Eithimethean Man,G ae! !ea!ed
"o! a s(mosi&m in hono! o" E!ich -!omm. Exectation is an otimistic o! essimistic
!eliance on instit&tionali=ed technical meansR hoe, a t!&stin* !eadiness to 'e s&!!ised '(
anothe! e!son.
19; G0!isisG th&s 'ecomes the !ed he!!in* &sed '( the exec&tive to hei*hten his o%e! in
inve!se !oo!tion to the se!vices he !ende!s. It also 'ecomes, in eve! ne% com'inations
(ene!*( c!isis, a&tho!it( c!isis, East8$est c!isis), an inexha&sti'le s&':ect "o! %ell8"inanced
!esea!ch '( scientists aid to *ive to Gc!isisG the schola!l( content that :&sti"ies the *!anto!.
<ee 3en=o Tomatis, La ticerca illimitata (Milan: -elt!inelli, 1975).
199 The te!m Ghosital deathG is &sed he!e to desi*nate all deaths that haen in a hosital,
and not onl( that 1>f o" the total %hich a!e Gassociated %ith a dia*nostic o! the!ae&tic
!oced&!e %hich is conside!ed a cont!i'&tin*, !eciitatin* o! !ima!( ca&se o" o'it&s.G Elih&
<chimmel, GThe #a=a!ds o" #ositali=ation,G Annals of )nternal *edicine ?B 23anuary 9>?JA=
9BB49?;
,>> Mon!oe Le!ne!, G$hen, $h(, and $he!e 1eole 7ie,G in )!im et al., The Dying +atient,
. 58,9. Oives '!ea+do%ns o" this evol&tion 'et%een 1955 and 1967 '( ca&se o" death,
colo!, and !e*ion o" the 9.<.
xxx "otnote! sl&tt xxx
((1>>))
in othe! co&nt!ies has *!o%n even "aste!. 7eath %itho&t medical !esence 'ecomes
s(non(mo&s %ith !omantic i*headedness, !ivile*e, o! disaste!. The cost o" a citi=en6s last
da(s has inc!eased '( an estimated 1,,>> e!cent, m&ch "aste! than that o" ove!8all health
ca!e. <im&ltaneo&sl(, at least in the 9nited <tates, "&ne!al costs have sta'ili=edR thei! *!o%th
!ate has come in line %ith the !ise o" the *ene!al cons&me!8!ice index. The most ela'o!ate
hase o" the te!minal ce!emonies no% s&!!o&nds the d(in* atient and has 'een sea!ated,
&nde! medical cont!ol, "!om the !emoval exeA&ies and the '&!ial o" %hat !emains. In a s%itch
o" lavish exendit&!e "!om tom' to %a!d, !e"lectin* the ho!!o! o" d(in* %itho&t medical
assistance,,>1 the ins&!ed a( "o! a!ticiation in thei! o%n "&ne!al !ites.,>,
-ea! o" &nmedicated death %as "i!st "elt '( ei*hteenth8cent&!( elites %ho !e"&sed !eli*io&s
assistance and !e:ected 'elie" in the a"te!li"e.,>. 5 ne% %ave o" this "ea! has no% s%et !ich
and oo!, and has com'ined %ith e*alita!ian athos to c!eate a ne% cate*o!( o" *oods: those
%hich a!e Gte!minall(G sca!ce, 'eca&se the( a!e commandee!ed '( the h(sician in hi*h8cost
death cham'e!s. To dist!i'&te
xxx "otnote! sta!t xxx
,>1 E!%in #. 5c+e!+necht, G7eath in the #isto!( o" Medicine,G ,ulletin of the %istory of
*edicine J& 29>?CA= 9>4&0; -o! the elites o" the Enli*htenment, death 'ecame di""e!ent and
"a! mo!e "!i*htenin* than it had 'een "o! ea!lie! *ene!ations. 5a!ent death 'ecame a +ind o"
sec&la!i=ed hell and a ma:o! medical conce!n. GLive testsG '( t!&met8'lo%in* (1!o"esso!
#&"eland) and elect!ic shoc+ (0!e%e) %e!e int!od&ced. )ichat6s echerches physiologiques
sur la vie et la mort 29CBBA ended the anti8aa!ent8death movement in medicine as s&ddenl(
as Lancisi6s %o!+ had sta!ted it in 9:B:;
,>, 5ll societies seem to have distin*&ished sta*es '( %hich the livin* ass into the *!ave. I
%ill deal %ith these in chate! >, and sho% ho% the !ene%ed conce!n %ith the taxonom( o"
deca( is consistent %ith othe! contemo!a!( !e*!essions to !imitive "ascinations.
,>. Ma!*ot 5&*ene!, G<cheintod ale medi=inisches 1!o'lem im 1;. Iah!h&nde!t,G
*itteilungen sin $eschichte der *edi8in and der .aturwissenschaflen, nos; ?4: 29>?:A; The
seculari8ed fear of hell on the part of the enlightened rich focused on the honor of being
buried alive; )t also led to the creation of philanthropic foundations dedicated to the succor of
the drowning or the burning;
xxx "otnote! sl&tt xxx
((1>1))
these *oods, a ne% '!anch o" le*al ,>/ and ethical lite!at&!e has a!isen to deal %ith the
A&estion ho% to excl&de some, select othe!s, and :&sti"( choices o" li"e8!olon*in* techniA&es
and %a(s o" ma+in* death mo!e com"o!ta'le and acceta'le. ,>5 Ta+en as a %hole, this
lite!at&!e tells a !ema!+a'le sto!( a'o&t the mind o" the contemo!a!( :&!ist and hilosohe!.
Most o" the a&tho!s do not even as+ %hethe! the techniA&es that s&stain thei! sec&lations
have in "act !oved to 'e li"e8!olon*in*. Nahvel(, the( *o alon* %ith the del&sion that
ongoing !it&als that a!e costl( m&st 'e &se"&l. In this %a( la% and ethics 'olste! 'elie" in the
val&e o" olicies that !e*&late oliticall( innoc&o&s medical eA&alit( at the oint o" death.
The mode!n. "ea! o" &nh(*ienic death ma+es li"e aea! li+e a !ace to%a!ds a te!minal
sc!am'le and has '!o+en e!sonal sel"8con"idence in a &niA&e %a(. ,>6 It has "oste!ed the
'elie" that man toda( has lost the a&tonom( to !eco*ni=e %hen his time has come and to ta+e
his death into his o%n hands.,>7 The docto!6s !e"&sal to !eco*ni=e the oint at %hich he has
ceased to 'e &se"&l as a heale! ,>; and
xxx "otnote! sta!t xxx
,>/ G<ca!ce Medical 3eso&!ces,G edito!ial, Cohvnb" -aw eview 69 (5!il 1969): 69>8,. 5
!evie% a!ticle 'ased on inte!vie%s %ith seve!al do=en 9.<. exe!ts. 7esc!i'es and eval&ates
the c&!!ent olicies o" excl&sion and selection "!om a le*al oint o" vie%. 9nc!iticall( accets
the !o'a'le e""ectiveness o" the techniA&es s&osed to 'e in ext!eme demand.
,>5 <hannon <ollito and 3o'e!t M. ?eatch, ,ibliography of Society, Ethics and the -ife
<ciences, a #astin*s 0ente! 1&'lication (#astin*s8on8#&dson, N.N., 197/). I. 3. El+inton,
GThe Lite!at&!e o" Ethical 1!o'lems in Medicine,G ts. 1, ,, ., 5nnals of Inte!nal Medicine :0
(<etem'e! 197>): /958;R (Bcto'e! 197>): 66,86R (Novem'e! 197>): ;6.87>. These a!e
m&t&all( comlementa!( int!od&ctions to the ethical lite!at&!e.
,>6 #e!mann -ei"el, G1h(sicians 0onside! 7eath,G in 1!oceedin*s o" the 5me!ican
+sychological Association Convention ($ashin*ton, 7.0.: the 5ssociation, 1967), . ,>18,.
1h(sicians seem si*ni"icantl( mo!e a"!aid o" death than eithe! the h(sicall( sic+ o! the
no!mal health( individ&al. The a!*&ment co&ld lead to the thesis that h(sicians a!e no%
ca!!ie!s o" in"ectio&s "!i*ht.
,>7 E&thanasia: An Annotated ,ibliography, Euthanasia Educational (und, &@B "est @:th
Street, .ew <or#, .;<; 9BB9>;
,>; The !i*ht to heal as an int!ansitive activit( that m&st 'e exe!cised '( the atient can ente!
into con"lict %ith the asse!tion o" the h(sician6s !i*ht to heal, a t!ansitive activit(. -o! the
o!i*ins o" a medical !i*ht to heal, %hich %o&ld
xxx "otnote! "o!tsette! E neste side xxx
((1>,))
to %ithd!a% %hen death sho%s on his atient6s "ace ,>9 has made him into an a*ent o"
evasion o! o&t!i*ht dissim&lation.,1> The atient6s &n%illin*ness to die on his o%n ma+es
him atheticall( deendent. #e has no% lost his "aith in his a'ilit( to die, the te!minal shae
that health can ta+e, and has made the !i*ht to 'e !o"essionall( +illed into a ma:o! iss&e.,11
xxx "otnote! "o!tsette! "!a "o!!i*e side xxx
co!!esond to a !o"essional d&t(, see L&d%i* Edelstein, GThe 1!o"essional 6Ethic o" the
O!ee+ 1h(sician,G ,ulletin of the %istory of *edicine 0B 2September\'ctober 9>@?A= 0>94
J9>; "alter eich raises the contemporary issue about the substance in the physician4patient
contract when the disease turns from curable to terminal and therefore a Dhealer contractD
comes to an end; "alter eich, DThe +hysician1s 1Duty1 to +reserve -ife,D %astings Center
eport @ 2April 9>:@A= 9J;49@;
,>9 The !eco*nition o" the "acia hippoeratica, the si*ns o" a!oachin* death that indicated to
the h(sician the oint at %hich c&!ative e""o!ts had to 'e a'andoned, %as a!t o" medical
c&!!ic&la &ntil the end o" the 19th cent&!(. Bn this s&':ect, see chate! ;.
,1> -!ed 7avis, G9nce!taint( in Medical 1!o*nosis, 0linical and -&nctional,G American
Io&!nal of Sociology 66 (I&l( 196>): /187. 7avis examines the docto!6s 'ehavio! %hen an
&n"avo!a'le !o*nosis o" imai!ment o! death 'ecomes ce!tain, and "inds %ides!ead
c&ltivation o" &nce!taint( '( dissim&lation o! evasion. 7issim&lation "eeds 7!. <lo o! 7!.
@noc+, %ho proffers clinicall( &ns&'stantiated dia*noses to c&!!( "avo!a'le oinion '(
sellin* &n%a!!anted lace'os. Evasion, o! the "ail&!e to comm&nicate a clinicall(
s&'stantiated !o*nosis, +ees the atient and his "amil( in the da!+, lets them "ind o&t Gin a
nat&!al so!t o" %a(,G allo%s the docto! to avoid loss o" his timeDand scenes, and e!mits the
docto! to &!s&e t!eatments the atient %o&ld have !e:ected had he +no%n they cannot c&!e.
9nce!taint( is o"ten c&ltivated as a consi!ac( 'et%een docto! and atient to avoid accetance
o" the i!!eve!si'le, a cate*o!( %hich does not "it thei! ethos.
,11 <issela )o+ et al., GThe 7ilemmas o" E&thanasia,G ,ioscience ,. (5&*&st 197.): /6187;.
It is o"ten ove!loo+ed that e&thanasia, o! the medical te!mination o" h&man li"e, co&ld not
have 'een an imo!tant iss&e 'e"o!e te!minal ca!e %as medicali=ed. 5to!esent, most le*al and
ethical lite!at&!e dealin* %ith the le*itimac( and the mo!al stat&s o" s&ch !o"essional
cont!i'&tions to the accele!ation o" death is o" ve!( limited val&e, 'eca&se it does not call in
A&estion the le*al and ethical stat&s o" medicali=ation, %hich c!eated the iss&e in the "i!st
lace. #. L. #a!t, -aw, -iberty and *ordi y 2Stanford, 0ali".: <tan"o!d 9niv. 1!ess, 196.). )(
a!*&in* that the la% o&*ht to ta+e a ne&t!al osition, #a!t *oes e!has "&!thest in this
disc&ssion. Bn one side the t!avest( o" ethic ta+es the "o!m o" "o!ced sale o" medical !od&cts
at lite!all( an( cat. -!eeman states that Gthe death o" an &noe!ated atient is an &nacceta'le
means o" alleviatin* sufferingsD not onl( "o! the atient '&t also "o! his "amil(: Iohn M.
-!eeman, G$hose <&""e!in*4G and 3o'e!t E. 0oo+e, GIs The!e a 3i*ht To 7ie 8
xxx "otnote! "o!tsette! E neste side xxx
((1>.))
<eve!al &nexamined exectations a!e inte!%oven in the c&lt&!al o!ientation to%a!ds death in
the %a!ds. 1eole thin+ that hositali=ation %ill !ed&ce thei! ain o! that the( %ill !o'a'l(
live lon*e! in the hosital. Neithe! is li+el( to 'e t!&e. B" those admitted %ith a "atal condition
to the ave!a*e )!itish clinic, 1> e!cent died on the da( o" a!!ival, .> e!cent %ithin a %ee+,
75 e!cent %ithin a month, and 97 e!cent %ithin th!ee months.,1, In homes "o! te!minal
ca!e, 56 e!cent %e!e dead %ithin a %ee+ o" admission. In te!minal cance!, the!e is no
di""e!ence in li"e exectanc( 'et%een those %ho end in the home and those %ho die in the
hosital. Bnl( a A&a!te! o" te!minal cance! atients need secial n&!sin* at home, and then
onl( d&!in* thei! last %ee+s. -o! mo!e than hal", s&""e!in* %ill 'e limited to "eelin* "ee'le and
&ncom"o!ta'le, and %hat ain the!e is can &s&all( 'e !elieved.,1. )&t '( sta(in* at home the(
avoid the exile, loneliness, and indi*nities %hich, in all '&t excetional hositals, a%ait
them.,1/ 1oo! 'lac+s seem to +no% this and &set the hosital !o&tine '( ta+in* thei! d(in*
home. Biates a!e not availa'le on demand. 1atients %ho have seve!e ains ove! months o!
(ea!s, %hich na!cotics co&ld ma+e tole!a'le, a!e as li+el( to 'e !e"&sed medication in the
hosital as at home, lest the( "o!m a ha'it in thei! inc&!a'le '&t not di!ectl( "atal
condition.,15 -inall(, eole 'elieve that hositali=ation
xxx "otnote! "o!tsette! "!a "o!!i*e side xxx
2&ic+l(4G "a&nal of +ediatrics ;> (Ma( 197,): 9>/8;. Bn the othe! hand, even the so+esmen
in "avo! o" te!minal sel"8medication %ith ain8+ille!s !oceed on the ass&mtion that in this as
in an( othe! cons&mtion o" d!&*s, the atient m&st '&( %hat anothe! selects "o! him.
,1, Iohn #inton, Dying ()altimo!e: 1en*&in )oo+s, 197/).
,1. Instit&te o" Medicine o" 0hica*o, Terminal Care for Cancer +atients (0hica*o: 0ent!al
<e!vice "o! the 0h!onicall( Ill, 195>).
,1/ 7avid <&dno%, +assing 'n= The Social 'rgani8ation of Dying (En*le%ood 0li""i, NI.:
1!entice8#all, 1967). 7esc!i'ed in its int!od&ction as Gsal&ta!( !eadin* "o! the la(man %hose
contact %ith the te!minal hase o" h&man li"e is limited to occasional enco&nte!s,G this 'oo+
sho&ld c&!e one o" an( desi!e "o! !o"essional assistance.
,15 Exton8<mith, GTe!minal Illness in the 5*ed.G
xxx "otnote! sl&tt xxx
((1>/))
inc!eases thei! chances o" s&!vivin* a c!isis. $ith some clea!8c&t excetions, on this oint too,
mo!e o"ten than not, the( a!e %!on*. Mo!e eole die no% 'eca&se c!isis inte!vention is
hosital8cente!ed than can 'e saved th!o&*h the s&e!io! techniA&es the hosital can !ovide.
In the oo! co&nt!ies man( mo!e child!en have died o" chole!a o! dia!!hea d&!in* the last ten
(ea!s 'eca&se the( %e!e not !eh(d!ated on time %ith a simle sol&tion "o!ced do%n thei!
th!oats: ca!e %as cente!ed on sohisticated int!aveno&s !eh(d!ation at a distant hosital.,16 In
!ich co&nt!ies the deaths ca&sed '( the &se o" evac&ation eA&iment a!e 'e*innin* to 'alance
the n&m'e! o" lives th&s saved. #osital G%o!shiG is &n!elated to the hosital6s e!"o!mance.
Li+e an( othe! *!o%th ind&st!(, the health s(stem di!ects its !od&cts %he!e demand seems
&nlimited: into de"ense a*ainst death. 5n inc!easin* e!centa*e o" ne%l( acA&i!ed tax "&nds is
allocated to%a!ds li"e8extension technolo*( "o! te!minal atients. 0omlex '&!ea&c!acies
sanctimonio&sl( select "o! dial(sis maintenance one in six o! one in th!ee o" those 5me!icans
%ho a!e th!eatened '( +idne( "ail&!e. The atient8elect is conditioned to desi!e the sca!ce
!ivile*e o" d(in* in exA&isite to!t&!e.,17 5s a docto! o'se!ves in an acco&nt o" the t!eatment
o" his o%n illness, m&ch time and e""o!t m&st *o into !eventin* s&icide d&!in* the "i!st and
sometimes the second (ea! that the a!ti"icial +idne( ma( add to li"e.,1; In a societ( %he!e
xxx "otnote! sta!t xxx
,16 -o! a s&mma!( o" seve!al st&dies, see Inte!national )an+ "o! 3econst!&ction and
7eveloment, %ealth Sector +olicy +aper ($ashin*ton, 7.0., Ma!ch 1975), . ./.
,17 GIm!ovements in a!ti"icial +idne(s a!e needed, as 'o!ne o&t '( the "act that &!emic
atients o"ten a!e s&':ectivel( %o!se "o! a e!iod a"te! dial(sis even tho&*h thei! 'lood
chemist!( is aa!entl( nea! no!mal. 1ossi'le exlanations a!e the non!emoval o" an &n+no%
6&!emic "acto!6 o! mo!e li+el( the &n%anted !emoval o" a needed "acto! "!om the 'lood, o!
e!has some s&'tle in:&!( to the 'lood '( the +idne( machine.G 3&shme!, *edical
Engineering, . .1/.
,1; 0. #. 0alland, GIat!o*enic 1!o'lems in End8<ta*e 3enal -ail&!e,G .ew
xxx "otnote! "o!tsette! neste side xxx
((1>5))
the ma:o!it( die &nde! the cont!ol o" &'lic a&tho!it(, the solemnities "o!me!l( s&!!o&ndin*
le*ali=ed homicide o! exec&tion ado!n the te!minal %a!d. The s&mt&o&s t!eat8ment o" the
comatose ta+es the lace o" the doomed man6s '!ea+"ast in othe! c&lt&!es.,19
1&'lic "ascination %ith hi*h8technolo*( ca!e and death can 'e &nde!stood as a dee8seated
need "o! the en*inee!in* o" mi!acles. Intensive ca!e is '&t the c&lmination o" a &'lic %o!shi
o!*ani=ed a!o&nd a medical !iesthood st!&**lin* a*ainst death.,,> The %illin*ness o" the
&'lic to "inance these activities ex!esses a desi!e "o! the nontechnical "&nctions o" medicine.
0a!diac intensive8ca!e &nits, "o! examle, have hi*h visi'ilit( and no !oven statistical *ain
"o! the ca!e o" the sic+. The( !eA&i!e th!ee times the eA&iment and "ive times the sta"" needed
"o! no!mal atient ca!eR 1, e!cent o" all *!ad&ate hosital n&!ses in the 9nited <tates %o!+ in
this he!oic medicine. This *a&d( ente!!ise is s&o!ted, li+e a lit&!*( o" old, '( the exto!tion
o" taxes, '( the solicitation o" *i"ts, and '( the !oc&!ement o" victims. La!*e8scale !andom
samles have 'een &sed to coma!e the mo!talit( and !ecove!( !ates o"
xxx "otnote! "o!tsette! "!a "o!!i*e side xxx
England 3ournal of *edicine ,;7 (197,): ../8;. 5n a&to'io*!ahical acco&nt o" a medical
docto! in s&ch te!minal t!eatment.
,19 #ans von #enti*, 6om !rsprwg der %as#ersmahl8eit (TY'in*en: Moh!, 195;). The
medicali=ation o" death has eno!mo&sl( inc!eased the e!centa*e o" eole %hose death
haens &nde! '&!ea&c!atic cont!ol. In his enc(cloedic st&d( o" the '!ea+"ast o""e!ed a
condemned man '( his exec&tione!, #enti* concl&des that the!e exists a dee8"elt need to
lavish "avo!s on e!sons %ho die in a &'licl( dete!mined %a(. 9s&all( this "avo! ta+es the
"o!m o" a s&mt&o&s meal. Even d&!in* $o!ld $a! I soldie!s still exchan*ed ci*a!ettes, and
the sA&ad commande! o""e!ed a last ci*a!ette. Te!minal t!eatment in %a!, !ison, and hosital
has no% 'een dee!sonali=ed. Intensive ca!e "o! the d(in* can also 'e seen as a "&ne!al *i"t
"o! the &n'&!ied.
,,> <tehen 1. <t!ic+land, +olitics, Science and Dread Disease A Short %istory of the !nited
States *edical esearch +olicy, 0ommon%ealth -&nd <e!ies (0am'!id*e: #a!va!d 9niv.
1!ess, 197,). <t!ic+land desc!i'es ho% the 9.<. *ove!nment medical !esea!ch olic( *ot
&nde! %a( %ith the 19,7 !oosal '( a senato! to ost a M5 million !e%a!d "o! the e!son %ho
colla!ed the %o!st +ille!, namel( cance!. Oives the histo!( o" the 'oom in cance! !esea!ch. The
9.<. *ove!nment no% sends mo!e than M5>> million e! (ea! on it.
xxx "otnote! sl&tt xxx
((1>6))
atients se!ved '( these &nits %ith those o" atients *iven home t!eatment. <o "a! the( have
demonst!ated no advanta*e. The atients %ho have s&""e!ed ca!diac in"a!ction themselves
tend to ex!ess a !e"e!ence "o! home ca!eR the( a!e "!i*htened '( the hosital, and in a c!isis
%o&ld !athe! 'e close to eole the( +no%. 0a!e"&l statistical "indin*s have con"i!med thei!
int&ition: the hi*he! mo!talit( o" those 'ene"itted '( mechanical ca!e in the hosital is &s&all(
asc!i'ed to "!i*ht.,,1
Black &agic
Technical inte!vention in the h(sical and 'iochemical ma+e8& o" the atient o! o" his
envi!onment is not, and neve! has 'een, the sole "&nction o" medical instit&tions.,,, The
!emoval o" atho*ens and the alication o" !emedies (e""ective o! not) a!e '( no means the
sole %a( o" mediatin* 'et%een man and his disease. Even in those ci!c&mstances in %hich the
h(sician is technicall( eA&ied to la( the technical !ole to %hich he asi!es, he inevita'l(
also "&l"ills !eli*io&s, ma*ical, ethical, and olitical "&nctions. In each o" these "&nctions the
contemo!a!( h(sician is mo!e atho*en than heale! o! :&st anod(ne.
Ma*ic o! healin* th!o&*h ce!emonies is clea!l( one o" the imo!tant t!aditional "&nctions o"
medicine. ,,. In
xxx "otnote! sta!t xxx
,,1 #. O. Mathe! et al., G5c&te M(oca!dial In"a!ction: #ome and #osital Treatment,D
,rutish *edicoS 3ournal, 9>:9, 0=00J4C;
,,, Iohn 1o%les has made this a!*&mentR see GBn the Limitations o" Mode!n Medicine,G in
Science, *edicine and *an 2-ondon= +ergamon, 9>:0A, 9=940B; An increasingly large
proportion of the contemporary disease burden is man4madeM engineering intervention in
sic#ness is not ma#ing much progress as a strategy; The continued insistence on this, strategy
can be e/plained only if it serves nontechnical purposes; Diminishing returns within medicine
are a specific instance of a wider crisis in industrial man1s relationship to his environment;
,,. M. )a!tels, Die *edi8in der .aturvUl#er (Lei=i*: O!ie'en, 1;9.). 5 classic on the
ma*ical element in the medicine o" !imitive eoles.
xxx "otnote! sl&tt xxx
((1>7))
ma*ic the heale! mani&lates the settin* and the sta*e. In a some%hat ime!sonal %a( he
esta'lishes an ad hoc !elationshi 'et%een himsel" and a *!o& o" individ&als. Ma*ic %o!+s i"
and %hen the intent o" atient and ma*ician coincides,,,/ tho&*h it too+ scienti"ic medicine
conside!a'le time to !eco*ni=e its o%n !actitione!s as a!t8time ma*icians. To distin*&ish the
docto!6s !o"essional exe!cise o" %hite ma*ic "!om his "&nction as en*inee! (and to sa!e him
the cha!*e o" 'ein* a A&ac+), the te!m Glace'oG %as c!eated. $heneve! a s&*a! ill %o!+s
'eca&se it is *iven '( the docto!, the s&*a! ill acts as a lace'o. 5 lace'o (Latin "o! GI %ill
leaseG) leases not onl( the atient '&t the administe!in* h(sician as %ell. ,,5
In hi*h c&lt&!es, !eli*io&s medicine is somethin* A&ite distinct "!om ma*ic.,,6 The ma:o!
!eli*ions !ein"o!ce !esi*nation to mis"o!t&ne and o""e! a !ationale, a st(le, and a comm&nit(
settin* in %hich s&""e!in* can 'ecome a di*ni"ied e!"o!mance. The oo!t&nities o""e!ed '(
the accetance o" s&""e!in* can 'e di""e!entl( exlained in each o" the *!eat t!aditions: as
+a!ma acc&m&lated th!o&*h ast inca!nationsR as an invitation to Islam, the s&!!ende! to OodR
o! as an oo!t&nit( "o! close! association %ith the <avio! on the 0!oss. #i*h !eli*ion
stim&lates e!sonal !esonsi'ilit( "o! healin*, sends ministe!s "o! sometimes omo&s and
sometimes e""ective consolation,
xxx "otnote! sta!t xxx
,,/ $illiam I. Ooode, G3eli*ion and Ma*ic,G in Ooode, ed., eligion Among the 1!imitives
(Ne% No!+: -!ee 1!ess, 1951), . 5>8/.
,,5 Bn the histo!( o" medical st&dies o" the lace'o e""ect and the evol&tion o" the te!m, see
5!th&! @. <hai!o, G5 0ont!i'&tion to a #isto!( o" the 1lace'o E""ect,G ,ehavioral Science @
(5!il 196>): 1>98.5.
,,6 The distinction 'et%een the ma*ical elimination, !eli*io&s inte!!etation, o! ethical
sociali=ation o" s&""e!in* and its technical mani&lation and le*al cont!ol dese!ves m&ch mo!e
detailed anal(sis. I int!od&ce these distinctions onl( to cla!i"( that (1) medical techniA&e does
have nontechnical e""ects (,) some o" %hich cannot 'e conside!ed economic o! social
exte!nalities (.) 'eca&se the( seci"icall( in"l&ence health levels. (/) These health8!elated
latent "&nctions do have a comlex, m&ltila(e!ed st!&ct&!e and (5) mo!e o"ten than not soil
health.
xxx "otnote! sl&tt xxx
((1>;))
!ovides saints as models, and &s&all( !ovides a "!ame8%o!+ "o! the !actice o" "ol+
medicine. In o&! +ind o" sec&la! societ( !eli*io&s o!*ani=ations a!e le"t %ith onl( a small a!t
o" thei! "o!me! !it&al healin* !oles. Bne devo&t 0atholic mi*ht de!ive intimate st!en*th "!om
e!sonal !a(e!, some ma!*inal *!o&s o" !ecent a!!ivals in no 1aolo mi*ht !o&tinel( heal
thei! &lce!s in 5"!o8Latin dance c&lts, and Indians in the valle( o" the Oan*es still see+ health
in the sin*in* o" the ?edas. )&t s&ch thin*s have onl( a !emote a!allel in societies 'e(ond a
ce!tain e! caita ON1. In these ind&st!iali=ed societies sec&la! instit&tions !&n the ma:o!
m(th8ma+in* ce!emonies.,,7
The sea!ate c&lts o" ed&cation, t!anso!tation, and mass comm&nication !omote, &nde!
di""e!ent names, the same social m(th %hich ?oe*lin ,,; desc!i'es as contemo!a!( *nosis.
0ommon to a *nostic %o!ld8vie% and its c&lt a!e six cha!acte!istics: (1) it is !acticed '(
mem'e!s o" a movement %ho a!e dissatis"ied %ith the %o!ld as it is 'eca&se the( see it as
int!insicall( oo!l( o!*ani=ed. Its adhe!ents a!e (,) convinced that salvation "!om this %o!ld is
ossi'le (.) at least "o! the elect and (/) can 'e '!o&*ht a'o&t %ithin the !esent *ene!ation.
Onostics "&!the! 'elieve that this salvation deends (5) on technical actions %hich a!e
!ese!ved (6) to initiates %ho monooli=e the secial "o!m&la "o! it. 5ll these !eli*io&s 'elie"s
&nde!lie the social o!*ani=ation o" technolo*ical medicine, %hich in t&!n !it&ali=es and
cele'!ates the nineteenth8cent&!( ideal o" !o*!ess.
xxx "otnote sta!t xxx
,,7 )( m(ths I he!e mean set 'ehavio! atte!ns %hich have the a'ilit( to *ene!ate amon* the
a!ticiants a 'lindness to o! tole!ance "o! the dive!*ence 'et%een the !ationali=ation
!ein"o!ced '( the cele'!ation o" the !it&al and the social conseA&ences !od&ced '( this same
cele'!ation, %hich a!e in di!ect cont!adiction to the m(th. -o! an anal(sis see Max Ol&c+man,
'rder and ebellion in Tribal Africa 2.ew <or#= (ree +ress, 9>?0A;
,,; E!ic ?oe*lin, Science, +olitics and Onosticism, t!ans. $illiam -it=at!ic+ (0hica*o:
3e*ne!(, 196;).
xxx "otnote sl&tt xxx
((1>9))
5mon* the imo!tant nontechnical "&nctions o" medicine, a thi!d one is ethical !athe! than
ma*ical, sec&la! !athe! than !eli*io&s. It does not deend on a consi!ac( into %hich the
so!ce!e! ente!s %ith his adet, no! on m(ths to %hich the !iest *ives "o!m, '&t on the shae
%hich medical c&lt&!e *ives to inte!e!sonal !elations. Medicine can 'e so o!*ani=ed that it
motivates the comm&nit( to deal in a mo!e o! less e!sonal "ashion %ith the "!ail, the dec!eit,
the tende!, the c!iled, the de!essed, and the manic. )( "oste!in* a ce!tain t(e o" social
cha!acte!, a societ(6s medicine co&ld e""ectivel( lessen the s&""e!in* o" the diseased '(
assi*nin* an active !ole to all mem'e!s o" the comm&nit( in the comassionate tole!ance "o!
and the sel"less assistance o" the %ea+.,,9 Medicine co&ld !e*&late societ(6s *i"t
!elationshis.,.> 0&lt&!es %he!e comassion "o! the &n"o!t&nate, hositalit( "o! the c!iled,
lee%a( "o! the t!o&'led, and !esect "o! the old have 'een develoed can, to a la!*e extent,
inte*!ate the ma:o!it( o" thei! mem'e!s into eve!(da( li"e.
#eale!s can 'e !iests o" the *ods, la%*ive!s, ma*icians, medi&ms, 'a!'e!8ha!macists, o!
scienti"ic advise!s.,.1 No common name %ith even the a!oximate semantic !an*e cove!ed
'( o&! Gdocto!G existed in E&!oe 'e"o!e the "o&!teenth cent&!(.,., In O!eece the !eai!man,
&sed mostl( "o! slaves, %as !esected ea!l(, tho&*h he %as not
xxx "otnote sta!t xxx
,,9 The social o!de!in* o" comassion, n&!t&!e, and cele'!ation has 'een the most e""ective
asect o" !imitive medicineR see E!%in #. 5c+e!+nec+t, GNat&!al 7iseases and 3ational
T!eatment in 1!imitive Medicine,G ,ulletin of the %istory of *edicine 19 (Ma( 19/6): /678
97.
,.> 3icha!d M. Tit!n&ss, The C' elationship 2.ew <or#= +antheon, 9>:9A, compares the
mar#et for human blood under !;S; commercial and ,ritish sociali8ed medical systems,
shows the immense superiority of ,ritish blood transfusions, and argues that the greater
effectiveness of the ,ritish approach is due to the lower level of commerciali8ation;
,.1 Bnl( in 0ha&ce!6s time did a common name "o! all heale!s aea!: ?e!n L. )&llo&*h,
GMedical <t&d( at Medieval Bx"o!d,G Speculum .6 (1961): 6>>81,.
,., GThe Te!m J7octo!,6 G 3ournal of the %istory of *edicine and Allied Sciences 1; (196.):
,;/87.
xxx "otnote sl&tt xxx
((11>))
on a level %ith the healin* hilosohe! o! even %ith the *(mnast "o! the "!ee.,.. 3e&'lican
3ome conside!ed the seciali=ed c&!e!s a dis!e&ta'le lot. La%s on %ate! s&l(, d!aina*e,
*a!'a*e !emoval, and milita!( t!ainin*, com'ined %ith the state c&lt o" healin* *ods, %e!e
conside!ed s&""icientR *!andmothe!6s '!e% and the a!m( sanita!ian %e!e not di*ni"ied '(
secial attention. 9ntil I&li&s 0aesa! *ave citi=enshi to the "i!st *!o& o" 5scleiads in /6
).0., this !ivile*e %as !e"&sed to O!ee+ h(sicians and healin* !iests. ,./ The 5!a's
hono!ed the h(sicianR,.5 the Ie%s le"t health ca!e to the A&alit( o" the *hetto o!, %ith a 'ad
conscience, '!o&*ht in the 5!a' h(sician.,.6 Medicine6s seve!al "&nctions com'ined in
di""e!ent %a(s in di""e!ent !oles. The "i!st occ&ation to monooli=e health ca!e is that o" the
h(sician o" the late t%entieth cent&!(.
1a!adoxicall(, the mo!e attention is "oc&sed on the technical maste!( o" disease, the la!*e!
'ecomes the s(m'olic and nontechnical "&nction e!"o!med '( medical technolo*(. The less
!oo" the!e is that mo!e mone( inc!eases s&!vival !ates in a *iven '!anch o" \ance! t!eatment,
the mo!e mone( %ill *o to the medical divisions delo(ed in that secial theate! o" oe!ations.
Bnl( *oals
xxx "otnote sta!t xxx
,.. Lo&is 0ohn8#a"t, The +ublic +hysician of Ancient O!eece (No!thamton, Mass.: <mith
0olle*e, 1956).
,./ 5dal'e!to 1a==ini, Storia della medicima, & vols; 2*ilan= SocietO editrice libraria, 9>J:A;
,.5 -o! 5!a' medicine in *ene!al, cons&lt L&cien Lecle!c, %istoire de le aine arabe= E/posF
complet des t!ad&ctions da grec= -es Sciences on B!ient, leur t!% neissias d l1'ccident par les
t!ad&ctions Sstings, , vols. (1;76R !e!int ed., Ne% No!+: -!an+lin, 1971)R Man"!ed 9llmann,
Die *edi8in im )slam (Leiden: )!ill, 197>), an exha&stive *&ide. )&t see also the :&d*ment o"
I'n @hald&n, 4lis *ugaddimah= Am Int!od&ction to %istory, t!ans. -!an= 3osenthal,
)ollin*en <e!ies [LIII, . vols. (1!inceton, NI.: 1!inceton 9niv. 1!ess, 1967). -o! a c!itical
!evie% o" 5!a'ic cont!i'&tions to the $este!n ima*e o" the docto!, see #ein!ich <chie!*es,
GIdeolo*ie &nd #isto!io*!ahie des 5!a'ism&s,G Sudhoffs Archiv, s&l. 9, 1961.
,.6 Iaco' Ma!c&s, 0omm&nal Sic#4Care in the Oe!man $hetto (0incinnati: #e'!e% 9nion
0olle*e 1!ess, 19/7). This 'oo+ !ovides !easons "o! 'ad conscience "o! !el(in* on o&tside!s.
xxx "otnote sl&tt xxx
((111))
&n!elated to t!eatment, s&ch as :o's "o! the secialists, eA&al access '( the oo!, s(m'olic
consolation "o! atients, o! exe!imentation on h&mans, can exlain the exansion o" l&n*8
cance! s&!*e!ies d&!in* the last t%ent(8"ive (ea!s. Not onl( %hite coats, mas+s, antisetics,
and am'&lance si!ens '&t enti!e '!anches o" medicine contin&e to 'e "inanced 'eca&se the(
have 'een invested %ith nontechnical, &s&all( s(m'olic o%e!.
$ill(8nill( the mode!n docto! is th&s "o!ced into s(m'olic, nontechnical !oles. Nontechnical
"&nctions !evail in the !emoval o" adenoids: mo!e than 9> e!cent o" all tonsillectomies
e!"o!med in the 9nited <tates a!e technicall( &nnecessa!(, (et ,> to .> e!cent o" all
child!en still &nde!*o the oe!ation. Bne in a tho&sand dies di!ectl( as a conseA&ence o" the
oe!ation and 16 in a tho&sand s&""e! "!om se!io&s comlications. 5ll lose val&8a'le imm&nit(
mechanisms. 5ll a!e s&':ected to emotional a**!ession: the( a!e inca!ce!ated in a hosital,
sea!ated "!om thei! a!ents, and int!od&ced to the &n:&sti"ied and mo!e o"ten than not
omo&s c!&elt( o" the medical, esta'lishment.,.7 The child lea!ns to 'e exosed to
technicians %ho, in his !esence, &se a "o!ei*n lan*&a*e in %hich the( ma+e :&d*ments a'o&t
his 'od(R he lea!ns that his 'od( ma( 'e invaded '( st!an*e!s "o! !easons the( alone +no%R
and he is made to "eel !o&d to live in a co&nt!( %he!e social sec&!it( a(s "o! s&ch a medical
initiation into the !ealit( o" li"e.,.;
1h(sical a!ticiation in a !it&al is not a necessa!(
xxx "otnote sta!t xxx
,.7 <. 7. Liton, GBn 1s(cholo*( o" 0hildhood Tonsillectom(,G in 3. <. Made! et al., eds.,
+sychoanalytic <t&d( of the Child (Ne% No!+: Inte!national 9nivs. 1!ess, 196,), 17:.6.8/17R
!e!inted in 5ntholo*ia 5; (0&e!navaca: 0I7B0, 197/).
,.; I&li&s 5. 3oth, G3it&al and Ma*ic in the 0ont!ol o" 0onta*ion,G 5me!iaas Sociological
eview ,, (I&ne 1957): .1>81/. 7esc!i'es ho% docto!s come to 'elieve in ma*ic. )elie" in
the dan*e! o" conta*ion "!om t&'e!c&losis atients leads to !it&ali=ed !oced&!es and i!!ational
!actices. -o! instance, the !&les comellin* atients to %ea! !otective mas+s a!e st!ictl(
en"o!ced %hen the( *o to [8!a( se!vices '&t not %hen the( *o to movies o! socials.
xxx "otnote sl&tt xxx
((11,))
condition "o! initiation into the m(th %hich the !it&al is o!*ani=ed to *ene!ate. Medical
sectato! so!ts cast o%e!"&l sells. I haened to 'e in 3io de Ianei!o and in Lima %hen 7!.
0h!istiaan )a!na!d %as to&!in* the!e. In 'oth cities he %as a'le to "ill the ma:o! "oot'all
stadi&m t%ice in one da( %ith c!o%ds %ho h(ste!icall( acclaimed his maca'!e a'ilit( to
!elace h&man hea!ts. Medical8mi!acle t!eatments o" this +ind have %o!ld%ide imact. Thei!
alienatin* e""ect !eaches eole %ho have no access to a nei*h'o!hood clinic, m&ch less to a
hosital. It !ovides them %ith an a'st!act ass&!ance that salvation th!o&*h science is ossi'le.
The exe!ience in the stadi&m at 3io !ea!ed me "o! the evidence I %as sho%n sho!tl(
a"te!%a!ds %hich !oved that the )!a=ilian olice have so "a! 'een the "i!st to &se li"e8
extendin* eA&iment in the to!t&!e o" !isone!s. <&ch ext!eme a'&se o" medical techniA&es
seems *!otesA&el( cohe!ent %ith the dominant ideolo*( o" medicine.
The &nintended nontechnical in"l&ence that medical techniA&e exe!cises on societ(6s health
can, o" co&!se, 'e ositive.,.9 5n &nnecessa!( shot o" enicillin can ma*icall( !esto!e
con"idence and aetite.,/> 5 cont!aindicated oe!ation can solve a ma!!ia*e !o'lem and
!ed&ce s(mtoms o" disease in 'oth a!tne!s.,/1 Not onl( the docto!6s s&*a! ills '&t even his
oisons can 'e o%e!"&l lace'os. )&t this is not the !evailin* !es&lt o" the
xxx "otnote sta!t xxx
,.9 5!th&! @. <hai!o, G-acto!s 0ont!i'&tin* to the 1lace'o E""ect: Thei! Imlications "o!
1s(chothe!a(,G 5me!ican 3ournal of +sychotherapy 1;, s&l. 1 (Ma!ch 196/): 7.8;M.
,/> Btto Li!on, -ogi# and *ages in der *edirin (M&nich: Lehmann, 1969), . 19;8,1;.
Li!oes a!*&es, and doc&ments his 'elie", that most e""ective healin* deends on the
h(sician6s choice o" the method that most s&its his e!sonalit(. -o! 'i'lio*!ah(, see .
1968,1;.
,/1 #en!( @. )eeche!, G<&!*e!( as 1lace'o: 5 2&antitative <t&d( o" )ias,G 3ournal of the
American *edical Association 176 (1961): 11>,87. It has 'een lon* +no%n that s&!*e!( can
have lace'o e""ects on the atient. I a!*&e he!e that simila! e""ects can 'e sociooliticall(
t!ansmitted '( hi*hl( visi'le inte!ventions.
xxx "otnote sl&tt xxx
((11.))
nontechnical side8e""ects o" medical technolo*(. It can 'e a!*&ed that in !ecisel( those
na!!o% a!eas in %hich hi*h8cost medicine has 'ecome mo!e seci"icall( e""ective, its
s(m'olic side8e""ects have 'ecome ove!%helmin*l( health8den(in*:,/, the t!aditional %hite
medical ma*ic that s&o!ted the atient6s o%n efforts to heal has t&!ned 'lac+.,/.
To a la!*e extent, social iat!o*enesis can 'e exlained as a ne*ative lace'o, as a nocebo
e""ect.,// Bve!%helmin*l( the nontechnical side8e""ects o" 'iomedical inte!ventions do
o%e!"&l dama*e to health. The intensit( o" the 'lac+8ma*ic in"l&ence o" a medical !oced&!e
does not deend on its 'ein* technicall( e""ective. The e""ect o" the noce'o, li+e that o" the
lace'o, is la!*el( indeendent o" %hat the h(sician does.
Medical !oced&!es t&!n into blac# magic %hen, instead o" mo'ili=in* his sel"8healin*
o%e!s, the( t!ans"o!m the sic+ man into a lim and m(sti"ied vo(e&! o" his o%n t!eatment.
Medical !oced&!es t&!n into sic# religion %hen the( a!e e!"o!med as !it&als that "oc&s the
enti!e exectation o" the sic+ on science and its "&nctiona!ies instead o" enco&!a*in* them to
see+ a oetic inte!!etation o" thei! !edicament o! "ind an admi!a'le examle in some e!son
Dlon* dead o! next doo!D%ho lea!ned to s&""e!.
xxx "otnote sta!t xxx
,/, Oe!ha!d @ienle, Arsneimittelsicheriteit wnd $esellschef Eire #ritIclis 9nte!s&ch&n*
(<t&tt*a!t: <chatta&e!, 197/), ma+es this oint '&t deals onl( %ith the ha!macolo*(8!elated
secto! o" medical technolo*(.
,/. #en!( @. )eeche!, GNonseci"ic -o!ces <&!!o&ndin* 7isease and the T!eatment o"
7isease,G Io&!nal of the 5me!ican *edical 5ssociation 179 (196,): /.78/>. G5n( "ea! can
+ill, '&t "ea!"&l dia*nosis can almost *&a!antee death "!om dia*nosis.G $alte! ). 0annon,
G?oodoo 7eath,G 5me!ican 5nth!oolo*ist // (5!il8I&ne 19/,): 1698;1. ?ictims o" #aitian
ma*ic have omino&s and e!sistent "ea!s, %hich ca&se intense action o" the s(matico8ad!enal
s(stem and a s&dden "all o" 'lood !ess&!e !es&ltin* in death.
,// 3. 0. 1o**e, G6The Toxic 1lace'o,G *edical Times 91 (5&*&st 196.): 77;8;1. <. %ol",
GE""ects o" <&**estion and 0onditionin* on the 5ction o" 0hemical 5*ents in #&man
<&':ects: The 1ha!macolo*( o" 1lace'os,GIaeanal of 0linical heat gation ,9 (Ian&a!( 195>):
1>>89. O. #e!sha"t, GL6E""et noce'o,G Encillale 5; (Novem'e!87ecem'e! 1969): /;685>..
xxx "otnote sl&tt xxx
((11/))
Medical !oced&!es m&ltil( disease '( moral degradation %hen the( isolate the sic+ in a
!o"essional envi!onment !athe! than !ovidin* societ( %ith the motives and discilines that
inc!ease social tole!ance "o! the t!o&'led. Ma*ical havoc, !eli*io&s in:&!(, and mo!al
de*!adation *ene!ated &nde! the !etext o" a 'iomedical &!s&it a!e all c!&cial mechanisms
cont!i'&tin* to social iat!o*enesis. The( a!e amal*amated '( the medicali=ation o" death.
$hen docto!s "i!st set & sho o&tside the temles in O!eece, India, and 0hina, the( ceased to
'e medicine men. $hen the( claimed !ational o%e! ove! sic+ness, societ( lost the sense o"
the comlex e!sona*e and his inte*!ated healin* %hich the so!ce!e!8shaman o! c&!e! had
!ovided.,/5 The *!eat t!aditions o" medical healin* had le"t the mi!acle c&!e to !iests and
+in*s. The caste that had an GinG %ith the *ods co&ld call "o! thei! inte!vention. To the hand
that %ielded the s%o!d %as att!i'&ted the o%e! to s&'d&e not onl( the enem( '&t also the
si!it. 9 to the ei*hteenth cent&!(, the +in* o" En*land laid his hands eve!( (ea! &on those
a""licted %ith "acial t&'e!c&losis %hom h(sicians +ne% the( %e!e &na'le to c&!e.,/6
Eiletics, %hose ills !esisted even #is Ma:est(6s to&ch, too+ !e"&*e in the healin* st!en*th
that "lo%ed "!om the hands o" the exec&tione!.,/7
$ith the !ise o" medical civili=ation and healin* *&ilds, the h(sicians distin*&ished
themselves "!om the A&ac+s
xxx "otnote sta!t xxx
,/5 E!%in 5c+e!+necht, G1!o'lems of 1!imitive Medicine,G in $illiam 5. Lessa and Evon Q.
?o*t, eader in Comparative eligion (Ne% No!+: #a!e! V 3o%, 1965), cha. ;, . .9/8
/>,. 5c+e!+necht o""e!s an imo!tant co!!ective to the 1a!sonian !e:&dice that all societies
inco!o!ate a seci"ic +ind of o%e! in the heale!. #e sho%s that medicine man and mode!n
h(sician a!e anta*onists !athe! than collea*&es: 'oth ta+e ca!e o" disease, '&t in all othe!
%a(s the( a!e di""e!ent.
,/6 Ma!c )loch, The oyal Touc# Sacred *onarchy and Scrofula in England and (rance,
trans; 3; E; Anderson 2*ontreal= *c$ill4Wueens !niv; +ress, 9>:0A;
,/7 $e!ne! 7anc+e!t, !nehrlich; -ade Die verfemten ,erufe ()e!n: -!anc+e, 196.). 7eals
%ith the healin* o%e!s t!aditionall( att!i'&ted to o&tcastes and ma!*ina' s&ch as
exec&tione!s, *!avedi**e!s, !ostit&tes, and mille!s.
xxx "otnote sl&tt xxx
((115))
and the !iests 'eca&se the( +ne% the limits o" thei! a!t. Toda( the medical esta'lishment is
a'o&t to !eclaim the !i*ht to e!"o!m mi!acles. Medicine claims the atient even %hen the
etiolo*( is &nce!tain, the !o*nosis &n"avo!a'le, and the the!a( o" an exe!imental nat&!e.
9nde! these ci!c&mstances the attemt at a Gmedical mi!acleG can 'e a hed*e a*ainst "ail&!e,
since mi!acles ma( onl( 'e hoed "o! and cannot, '( de"inition, 'e exected. The !adical
monool( ove! health ca!e that the contemo!a!( h(sician claims no% "o!ces him to
!eass&me !iestl( and !o(al "&nctions that his ancesto!s *ave & %hen the( 'ecame
seciali=ed as technical heale!s.
The medicali=ation o" the mi!acle !ovides "&!the! insi*ht into the social "&nction o" te!minal
ca!e. The atient is st!aed do%n and cont!olled li+e a saceman and then disla(ed on
television. These he!oic e!"o!mances se!ve as a !ain8dance "o! millions, a lit&!*( in %hich
!ealistic hoes "o! a&tonomo&s li"e a!e t!ansm&ted into the del&sion that docto!s %ill delive!
health "!om o&te! sace.
Patient &a0orities
$heneve! medicine6s dia*nostic o%e! m&ltilies the sic+ in excessive n&m'e!s, medical
!o"essionals t&!n ove! the s&!l&s to the mana*ement o" nonmedical t!ades and occ&ations.
)( d&min*, the medical lo!ds divest them8selves o" the n&isance o" lo%8!esti*e ca!e and
invest olicemen, teache!s, o! e!sonnel o""ice!s %ith a de!ivative medical "ie"dom. Medicine
!etains &nchec+ed a&tonom( in de"inin* %hat constit&tes sic+ness, '&t d!os on othe!s the
tas+ o" "e!!etin* o&t the sic+ and !ovidin* "o! thei! t!eatment. Bnl( medicine +no%s %hat
constit&tes addiction, tho&*h olicemen a!e s&osed to +no% ho% it sho&ld 'e cont!olled.
Bnl( medicine can de"ine '!ain dama*e, '&t it allo%s teache!s to sti*mati=e and mana*e
((116))
the health(8loo+in* c!iles. $hen the need "o! a !et!enchment o" medical *oals is disc&ssed
in medical lite!at&!e, it no% &s&all( ta+es the shae o" lanned atient8d&min*. $h( sho&ld
not the ne%'o!n and the d(in*, the ethnocent!ic, the sex&all( inadeA&ate, and the ne&!otic,
l&s an( n&m'e! o" othe! &ninte!estin* and time8cons&min* victims o" dia*nostic "e!vo!, 'e
&shed 'e(ond the "!ontie!s o" medicine and 'e t!ans"o!med into clients o" nonmedical
the!ae&tic &!ve(o!s: social %o!+8e!s, television !o*!amme!s, s(cholo*ists, e!sonnel
o""ice!s, and sex co&nselo!s4 ,/; This m&ltilication o" ena'lin* :o's that hold !e"lected
medical !esti*e has c!eated an enti!el( ne% settin* "o! the !ole o" the sic+.
5n( societ(, to 'e sta'le, needs ce!ti"ied deviance. 1eole %ho loo+ st!an*e o! %ho 'ehave
oddl( a!e s&'ve!sive &ntil thei! common t!aits have 'een "o!mall( named and thei! sta!tlin*
'ehavio! slotted into a !eco*ni=ed i*eonhole. )( 'ein* assi*ned a name and a !ole, ee!ie,
&settin* "!ea+s a!e tamed, 'ecomin* !edicta'le excetions %ho can 'e ame!ed, avoided,
!e!essed, o! exelled. In most societies the!e a!e some eole %ho assi*n !oles to the
&ncommon onesR acco!din* to the !evalent social !esc!ition, the( a!e &s&all( those %ho
hold secial +no%led*e a'o&t the nat&!e o" deviance:,/9 the( decide %hethe! the deviant is
ossessed '( a *host, !idden '( a *od, in"ected '( oison, 'ein* &nished "o! his sin, o! the
victim o" ven*eance %!o&*ht '( a %itch. The a*ent %ho does this la'elin* does not
necessa!il( have to 'e coma!a'le to medical a&tho!it(: he ma( hold :&!idi8
xxx "otnote sta!t xxx
,/; 7ominiA&e $olton, -e .avel 'rdre se/uel 2+aris= Seuil, 9>:JA, describes the outcome of
the (rench se/ual revolution= a new Dse/ocracyD made up of physicians, militants, educators,
and pharmacists has seculari8ed and schooled (rench se/uality and Dby sub5ecting body
awareness to orthopedic management has reproduced the welfare receiver even in this
intimate domain;D
,/9 #en!( E. <i*e!ist, 0ivili=ation and 7isease (0hica*o: 9niv. o" 0hica*o 1!ess, 197>).
xxx "otnote sl&tt xxx
((117))
cal, !eli*io&s, o! milita!( o%e!. )( namin* the si!it that &nde!lies deviance, a&tho!it( laces
the deviant &nde! the cont!ol o" lan*&a*e and c&stom and t&!ns him "!om a th!eat into a
s&o!t o" the social s(stem. Etiolo*( is sociall( sel"8"&l"illin*: i" the sac!ed disease is
'elieved to 'e ca&sed '( divine ossession, then the *od sea+s in the eiletic "it.,5>
Each civili=ation de"ines its o%n diseases.,51 $hat is sic+ness in one mi*ht 'e ch!omosomal
a'no!malit(, c!ime, holiness, o! sin in anothe!. Each c&lt&!e c!eates its !esonse to disease.
-o! the same s(mtom o" com&lsive stealin* one mi*ht 'e exec&ted, t!eated to death, exiled,
hositali=ed, o! *iven alms o! tax mone(. #e!e thieves a!e "o!ced to %ea! secial clothesR
the!e, to do enanceR else%he!e, to lose a "in*e!, o! a*ain, to 'e conditioned '( ma*ic o! '(
elect!ic shoc+. To ost&late "o! eve!( societ( a seci"icall( Gsic+G +ind o" deviance %ith even
minimal common cha!acte!istics,5, is a ha=a!do&s &nde!ta+in*. The contemo!a!(
assi*nation o" sic+8!oles is o" a &niA&e +ind. It develoed not m&ch mo!e than a *ene!ation
'e"o!e #ende!son and 1a!sons anal(=ed it.,5. It de"ines
xxx "otnote sta!t xxx
,5> -o! comlementa!( !e"e!ences, !e"e! to notes 1581;, . // a'ove.
,51 T. -. T!oels8L&nd, $esundheit and Eran#heit in der Anschauung alter ]eiten (Lei=i*,
19>1), is an ea!l( st&d( o" the shi"tin* "!ontie!s o" sic+ness in di""e!ent c&lt&!es. $althe!
3iese, The Conception of Disease= )ts %istory, )ts 6ersions and )ts .ature (Ne% No!+:
1hilosohical Li'!a!(, 195.), attemts a hilosohical eistemolo*(. -o! o!ientation on the
evol&tion o" !ecent disc&ssion see 7avid Mechanic, Medical Sociology= A Selective 6iew
(Ne% No!+: -!ee 1!ess, 196;), eseciall( . .. i".
,5, 5s :&st one examle o" a societ( %itho&t the 5esc&laian !ole, see 0ha!les B. -!a+e,
GThe 7ia*nosis o" 7isease 5mon* the <&'an&n o" Mindanao,G American Anthropologist 6.
(1961): 11.8.,. In the she!e o" ma+in* decisions a'o&t disease, di""e!ences in individ&al
s+ill and +no%led*e !eceive !eco*nition, '&t the!e is no "o!mal stat&s o" dia*nostician o! even,
'( <&'an&n concetion, o" c&!e!.
,5. La%!ence I. #ende!son, G1h(sician and 1atient as a <ocial <(stem,G .ew England
3ournal of *edicine &9& (19.5): ;198,., %as e!has the "i!st to s&**est that the h(sician
exone!ates the sic+ "!om mo!al acco&nta'ilit( "o! thei! illness. -o! the classical "o!m&lation o"
the mode!n, almost mo!alit(8"!ee sic+8!ole, see Talcott 1a!sons, GIllness and the 3ole o" the
1h(sicianG (o!i*. 19/;), in 0l(de
xxx "otnote "o!tsette! neste side xxx
((11;))
deviance as the secial le*itimate 'ehavio! o" o""iciall( selected cons&me!s %ithin an
ind&st!ial milie&.,5/ Even i" the!e %e!e somethin* to sa( "o! the thesis that in all societies
some eole a!e, so to sea+, temo!a!il( &t o&t o" se!vice and ame!ed %hile 'ein*
!eai!ed, the context %ithin %hich this exemtion oe!ates else%he!e cannot 'e coma!ed to
that o" the %el"a!e state. $hen he assigns sic+8stat&s to a client, the contemo!a!( h(sician
mi*ht indeed 'e actin* in some %a(s simila! to the so!ce!e! o! the elde!R '&t in 'elon*in* also
to a scienti"ic !o"ession that invents the cate*o!ies it assi*ns %hen cons&ltin*, the mode!n
h(sician is totall( &nli+e the heale!. Medicine men en*a*ed in the occ&ation o" c&!in* and
exe!cised the a!t o" distin*&ishin* evil si!its "!om each othe!. The( %e!e not !o"essionals
and had no o%e! to invent ne% devils. Ena'lin* !o"essions in thei! ann&al assem'lies c!eate
the sic+8!oles the( assi*n.
The !oles availa'le "o! an individ&al have al%a(s 'een o" t%o +inds: those %hich a!e
standa!di=ed '( c&lt&!al t!adition and those %hich a!e the !es&lt o" '&!ea&c!atic o!*ani=ation.
Innovation at all times meant a !elative inc!ease o" the latte!, !ationall( c!eated !oles. No
do&'t, en*inee!ed !oles co&ld 'e !ecove!ed '( c&lt&!al t!adition. No do&'t a neat distinction
'et%een the t%o +inds o" !oles is di""ic&lt to ma+e. )&t on the %hole, the sic+8!ole tended
&ntil !ecentl( to 'e o" the t!aditional +ind.,55 In the last
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
@l&c+hohn and #en!( M&!!a(, eds., 1e!sonalit( in .ature, <ociet( and 0&lt&!e, !ev. ed. (Ne%
No!+: @no", 195.).
,5/ 7avid 3o'inson, The +rocess of ,ecoming )ll (London: 3o&tled*e, 1971), discove!s a
"&ndamental %ea+ness in most st&dies done so "a! on the sic+8!ole: the( a!e 'ased on eole
%ho "inall( did 'ecome atients, and deal %ith the e!son %ho "eels ill '&t does not see the
docto! as some'od( %ho dela(s. #e !e:ects the notion that illness sta!ts %ith the !esentation
o" s(mtoms to a !o"essional. Most eole a!e not atients most o" the time the( "eel ill.
3o'inson st&dies emi!icall( the sic+ 'ehavio! o" nonatients.
,55 The distinction 'et%een the int!a&itive healing '( the atient and the t ansitine healing
!ovided "o! him m&st 'e "&!the! !e"ined. The latte!, a se!vice to the atient, can 'e !ovided
in t%o !o"o&ndl( distinct %a(s. It can 'e the
xxx "otnote "o!tsette! E neste side xxx
((119))
cent&!(, ho%eve!, %hat -o&ca&lt has called the ne% clinical vision has chan*ed the
!oo!tions. The h(sician has inc!easin*l( a'andoned his !ole as mo!alist and ass&med that
o" enli*htened scienti"ic ent!e!ene&!. To exone!ate the sic+ "!om acco&nta'ilit( "o! thei!
illness has 'ecome a !edominant tas+, and ne% scienti"ic cate*o!ies o" disease have 'een
shaed "o! the &!ose. Medical school and clinic !ovide the docto! %ith the atmoshe!e in
%hich disease, in his e(es, ma( 'ecome a tas+ "o! 'iolo*ical o! social techniA&eR his atients
still ca!!( thei! !eli*io&s and cosmic inte!!etations into the %a!d, m&ch as the la(men once
ca!!ied thei! sec&la! conce!ns into ch&!ch "o! <&nda( se!vice.,56 )&t the sic+8!ole desc!i'ed
'( 1a!sons "its mode!n societ( onl( as lon* as docto!s act as i" t!eatment %e!e &s&all(
e""ective and %hile the *ene!al &'lic is %illin* to sha!e thei! !os( vie%.,57 The mid8
nineteenth8cent&!( sic+8!ole has 'ecome inadeA&ate "o! de8sc!i'in* %hat haens in a medical
s(stem that claims a&tho!it( ove! eole %ho a!e not (et ill, eole %ho cannot !easona'l(
exect to *et %ell, and those "o! %hom docto!s have no mo!e e""ective t!eatment than that
%hich
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
o&t&t o" an instit&tion and its "&nctiona!ies exec&tin* olicies, o! it can 'e the !es&lt o"
e!sonal, sontaneo&s inte!action %ithin a c&lt&!al settin*. The distinction has 'een ela'o!ated
'( IacA&es Ell&l, The Technological Society (Ne% No!+: 3andom #o&se, 196/). Ell&l6s
concet o" Ginstit&tionali=ed val&esG has 'een s&':ected to the anal(sis o" a s(mosi&m:
Eatalagete a)e 3econcilejb: 3ournal of the Committee of <o&the!n Churchmen , (%inte!8
s!in* 197>): 1865. The henomenolo*( o" personal care has 'een develoed '( Milton
Ma(e!o"", Bn 0anin* (Ne% No!+: #a!e! V 3o%, 1971).
,56 3ene -ox, E/periment +erilossr +hysicians and +atients (acing the 9ni'so&m (Olencoe,
Ill.: -!ee 1!ess, 1959), st&dies te!minal atients %ho have consented to 'e &sed as s&':ects "o!
medical exe!iment. Not%ithstandin* the !evailin* lo*ical and !ational exlanations "o! thei!
sic+ness, they too *!ale %ith it in !eli*io&s, cosmic, and eseciall( mo!al te!ms.
,57 <ic+ness 'ecomes associated %ith hi*h livin* standa!ds and hi*h exectations. In the "i!st
six months o" 197>, 5 million %o!+in* da(s %e!e lost in )!itain o%in* to ind&st!ial dis&tes.
This has 'een exceeded in onl( , (ea!s since the *ene!al st!i+e in 19,6. In coma!ison, ove!
.>> million %o!+in* da(s %e!e lost through a'sence d&e to ce!ti"ied sic+ness. B""ice o"
#ealth Economics, 'f Sic# (London, 1971).
xxx "otnote sl&tt xxx
((1,>))
co&ld 'e o""e!ed '( thei! &ncles o! a&nts. Exe!t selection o" a "e% "o! instit&tional ame!in*
%as a %a( to &se medicine "o! the &!ose o" sta'ili=in* an ind&st!ial societ(:,5; it entailed
the easil( !e*&lated entitlement o" the a'no!mal to a'no!mal levels o" &'lic "&nds. @et
%ithin limits, d&!in* the ea!l( t%entieth cent&!( the ame!in* o" deviants Gst!en*thenedG the
cohesion o" ind&st!ial societ(. )&t a"te! a c!itical oint social cont!ol exe!cised th!o&*h the
dia*nosis o" &nlimited needs dest!o(ed its o%n 'ase.,59 9ntil !oved health(, the citi=en is
no% !es&med to 'e sic+.,6> In a t!i&mhantl( the!ae&tic societ(, eve!('od( can ma+e
himsel" into a the!aist and someone else into his client.
The !ole o" the docto! has no% 'ecome 'l&!!ed.,61 The
xxx "otnote sta!t xxx
,5; 0la!ence @a!ie!, GTestin* "o! B!de! and 0ont!ol in the 0o!o!ate Li'e!al <tate,G
Educational Them y && (s!in* 197,), sho%s the !ole the 0a!ne*ie -o&ndation la(ed in
develoin* ed&cational testin* mate!ials that can 'e &sed "o! social cont!ol in sit&ations %he!e
the a'ilit( o" schools to e!"o!m this tas+ has '!o+en do%n. 5cco!din* to @a!ie!, tests *iven
o&tside the schools a!e a mo!e o%e!"&l device "o! disc!imination than tests *iven %ithin a
eda*o*ical sit&ation. In the same %a(, it can 'e a!*&ed that medical testin* 'ecomes an
inc!easin*l( o%e!"&l means "o! classi"ication and disc!imination, as the n&m'e! o" test
!es&lts acc&m&late "o! %hich no si*ni"icant t!eatment is "easi'le. Bnce the atient !ole
'ecomes &nive!sal, medical la'elin* t&!ns into a tool "o! total social cont!ol.
,59 <ie*le! and Bsmond, G5esc&laian 5&tho!it(.G 5cco!din* to the a&tho!s, 5esc&laian
a&tho!it( %as8 "i!st mentioned in T. T. 1ate!son, GNotes on 5esc&laian 5&tho!it(,G
&n&'lished man&sc!it, 1957. It com!ises th!ee !oles: saiential a&tho!it( to advise, inst!&ct,
and di!ectR mo!al a&tho!it(, %hich ma+es medical actions the !i*ht thin* and not :&st
somethin* *oodR and cha!ismatic a&tho!it(, '( %hich the docto! can aeal to some s&!eme
o%e! and %hich o"ten o&t!an+s the atient6s conscience and the raison d1Ftat; 1eda*o*&es,
s(cholo*ists, movement leade!s, and nonconventional heale!s tend inc!easin*l( to aeal to
this th!ee8tie!ed a&tho!it( in the name o" thei! ec&lia! techniA&e, th&s :oinin* the !an+s o" the
scienti"ic docto!s and cont!i'&tin* to a cance!o&s exansion o" the 5esc&laian !ole.
,6> -!anco )asa*lia, -a maggioran8a deviante= -1ideologia del controllo socials totale,
N&ovo 1olitecnico no. /. (T&!in: Eina&di, 1971). <ince the sixties a citi=en %itho&t a
medicall( !eco*ni=ed stat&s has come to constit&te an excetion. 5 "&ndamental condition o"
contemo!a!( olitical cont!ol is the conditionin* o" eole to 'elieve the( need s&ch a stat&s
"o! the sa+e not onl( o" thei! o%n '&t o" othe! eole6s health.
,61 Nils 0h!istie, GLa% and Medicine: The 0ase 5*ainst 3ole )l&!!in*,G -aw and Society
eview @ (-e'!&a!( 1971): .57866. 5 case st&d( '( a c!iminolo*ist o"
xxx "otnote "o!tsette! E neste side xxx
((1,1))
health !o"essions have come to com'ine clinical se!vice, &'lic8health en*inee!in*, and
scienti"ic medicine. The docto! deals %ith clients %ho a!e sim&ltaneo&sl( cast in seve!al !oles
d&!in* eve!( contact the( have %ith the health esta'lishment. The( a!e t&!ned into atients
%hom medicine tests and !eai!s, into administe!ed citi=ens %hose health( 'ehavio! a medical
'&!ea&c!ac( *&ides, and into *&inea i*s on %hom medical science constantl( exe!iments.
The 5esc&laian o%e! o" con"e!!in* the sic+8!ole has 'een dissolved '( the !etensions o"
delive!in* totalita!ian health ca!e. #ealth has ceased to 'e a native endo%ment each h&man
'ein* is !es&med to ossess &ntil !oven ill, and has 'ecome an eve!8!ecedin* *oal to %hich
one is entitled '( vi!t&e o" social :&stice.
The eme!*ence o" a con*lome!ate health !o"ession has !ende!ed the atient !ole in"initel(
elastic. The docto!6s ce!ti"ication o" the sic+ has 'een !elaced '( the '&!ea&c!atic
!es&mtion o" the health mana*e!8 %ho a!!an*es eole acco!din* to de*!ees and cate*o!ies
o" the!ae&tic need, and medical a&tho!it( no% extends to s&e!vised health ca!e, ea!l(
detection, !eventive the!aies, and inc!easin*l(, t!eatment o" the inc&!a'le. 1!evio&sl( mod8
em medicine cont!olled onl( a limited ma!+etR no% this ma!+et has lost all 'o&nda!ies. 9nsic+
eole have come to deend on !o"essional ca!e "o! the sa+e o" thei! "&t&!e health. The !es&lt
is a mo!'id societ( that demands &nive!sal medicali=ation and a medical esta'lishment that
ce!ti"ies &nive!sal mo!'idit(.
In a mo!'id societ(,6, the 'elie" !evails that de"ined
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
the con"lict 'et%een t%o monoolistic !o"essional emi!es. Medicine conve!*es %ith
ed&cation and la% en"o!cement. The medicali=ation o" all dia*nosis denies the deviant the
!i*ht to his o%n val&es: he %ho accets the atient !ole imlies '( this s&'mission that, once
!esto!ed to health (%hich is :&st a different +ind o" atient !ole in o&! societ(), he %ill
con"o!m. The medicali=ation o" his comlaint s&its in the olitical cast!ation o" his suffering;
(or this tee Iesse 3. 1itts, G<ocial 0ont!ol: The 0oncet,G Inte!national EiBclopedia of the
Social <ciesces (196;), 1/:.91.
,6, #. #&e'schmann, GLa Notion d6&ne sociTtT malade,G 1!isms, no. 9/ (1966), . ,58/>.
xxx "otnote sl&tt xxx
((1,,))
and dia*nosed ill8health is in"initel( !e"e!a'le to an( othe! "o!m o" ne*ative la'el o! to no
la'el at all. It is 'ette! than c!iminal o! olitical deviance, 'ette! than la=iness, 'ette! than sel"8
chosen a'sence "!om %o!+. Mo!e and mo!e eole s&'conscio&sl( +no% that the( a!e sic+
and ti!ed o" thei! :o's and o" thei! leis&!e assivities, '&t the( %ant to hea! the lie that h(sical
illness !elieves them o" social and olitical !esonsi'ilities. The( %ant thei! docto! to act as
la%(e! and !iest. 5s a la%(e!, the docto! exemts the atient "!om his no!mal d&ties and
ena'les him to cash in on the ins&!ance "&nd he %as "o!ced to '&ild. 5s a !iest, he 'ecomes
the atient6s accomlice in c!eatin* the m(th that he is an innocent victim o" 'iolo*ical
mechanisms !athe! than a la=(, *!eed(, o! envio&s dese!te! o" a social st!&**le "o! cont!ol ove!
the tools o" !od&ction. <ocial li"e 'ecomes a *ivin* and !eceivin* o" the!a(: medical,
s(chiat!ic, eda*o*ic, o! *e!iat!ic. 0laimin* access to t!eatment 'ecomes a olitical d&t(,
and medical ce!ti"ication a o%e!"&l device "o! social cont!ol.
$ith the develoment o" the the!ae&tic se!vice secto! o" the econom(, an inc!easin*
!oo!tion o" all eole come to 'e e!ceived as deviatin* "!om some desi!a'le no!m, and
the!e"o!e as clients %ho can no% eithe! 'e s&'mitted to the!a( to '!in* them close! to the
esta'lished standa!d o" health o! concent!ated into some secial envi!onment '&ilt to cate! to
thei! deviance. )asa*lia,6. oints o&t that in the "i!st histo!ical sta*e o" this !ocess, the
diseased a!e exemted "!om !od&ction. 5t the next sta*e o" ind&st!ial exansion, a ma:o!it(
come to 'e de"ined as deviant and in need o" the!a(. $hen this haens, the distance
'et%een the sic+ and the health( is a*ain !ed&ced. In advanced ind&st!ial societies the sic+ a!e
once mo!e !eco*ni=ed as ossessin* a ce!tain level o"
xxx "otnote sta!t xxx
,6. )a&*lia, La magioransa da/ia!ke.
xxx "otnote sl&tt xxx
((1,.))
!od&ctivit( %hich %o&ld have 'een denied them at an ea!lie! sta*e o" ind&st!iali=ation. No%
that eve!('od( tends to 'e a atient in some !esect, %a*e la'o! acA&i!es the!ae&tic
cha!acte!istics. Li"elon* health ed&cation, co&nselin*, testin*, and maintenance a!e '&ilt !i*ht
into "acto!( and o""ice !o&tine. The!ae&tic deendencies e!meate and colo! !od&ctive
!elations. %omo sapiens, who a%o+e to m(th in a t!i'e and *!e% into olitics as a citi=en, is
no% t!ained as a li"elon* inmate o" an ind&st!ial %o!ld.,6/ The medicali=ation o" ind&st!ial
societ( '!in*s its ime!ialistic cha!acte! to &ltimate "!&ition.
xxx "otnote sta!t xxx
,6/ Michel -o&ca&lt, Surveiller et &ni!. .aissance de la prison (1a!is: Oallima!d,
1975). Bn the !ise o" the an8the!ae&tic societ( in %hich mo!alit(8cha!*ed !oles a!e
extin*&ished. En*lish t!anslation to 'e &'lished '( 1antheon )oo+s, Ne% No!+.
xxx "otnote sl&tt xxx
((1,/))
P)%, III.Cultural Iatrogenesis
((1,.))
((1,/))
Introduction
$e have dealt so "a! %ith t%o %a(s in %hich the !edominance o" medicali=ed health ca!e
'ecomes an o'stacle to a health( li"e: "i!st, clinical iat!o*enesis, %hich !es&lts %hen o!*anic
coin* caacit( is !elaced '( hete!onomo&s mana*ementR and, second, social iat!o*enesis, in
%hich the envi!onment is de!ived o" those conditions that endo% individ&als, "amilies, and
nei*h'o!8hoods %ith cont!ol ove! thei! o%n inte!nal states and ove! thei! milie&. 0&lt&!al
iat!o*enesis !e!esents a thi!d dimension o" medical health8denial. It sets in %hen the medical
ente!!ise sas the %ill o" eole to suffer thei! !ealit(. 1 It is a s(mtom o" s&ch iat!o*enesis
that the te!m Gs&""e!in*G has 'ecome almost &seless "o! desi*natin* a !ealistic h&man !esonse
'eca&se it evo+es s&e!stition, sadomasochism, o! the !ich man6s condescension to the lot o"
the oo!. 1!o"essionall( o!*ani=ed medicine has come to "&nction as a dominee!in* mo!al
ente!!ise that adve!tises ind&st!ial exansion as a %a! a*ainst all s&""e!in*. It has the!e'(
&nde!mined the a'ilit( o" individ&als to "ace thei! !ealit(, to ex!ess thei! o%n val&es, and to
accet inevita8
xxx "otnote sta!t xxx
1 -. I. I. )&(tendi:+, All; mein Theo!ist der menublichen #a+&n* and )e%e*&n* ()e!lin:
<!in*e!, 1956). Th!o&*h a coma!ison %ith othe! secies, he cos to desc!i'e man as a
h(siolo*icall( and s(cholo*icall( sel"8st!&ct&!in* o!*anism. -o! an o!ientation in En*lish
on the Oe!man lite!at&!e in this "ield see #. B. 1ae, GBn 1hilosohical 5nth!oolo*(,G
5&st!alasian faunal of 1hilosoh( .9 (1961): /786/.
xxx "otnote sl&tt xxx
((1,7))
'le and o"ten i!!emedia'le ain and imai!ment, decline, and death.
To 'e in *ood health means not onl( to 'e s&ccess"&l in coin* %ith !ealit( '&t also to en:o(
the s&ccessR it means to 'e a'le to "eel alive in leas&!e and in ainR it means to che!ish '&t
also to !is+ s&!vival. #ealth and s&""e!in* as exe!ienced sensations a!e henomena that
distin*&ish men "!om 'easts., Bnl( sto!('oo+ lions a!e said to suffer and onl( ets to me!it
comassion %hen the( a!e in ill health. .
#&man health adds oenness to instinct&al e!"o!mance./ It is somethin* mo!e than a
conc!ete 'ehavio! atte!n in c&stoms, &sa*es, t!aditions, o! ha'it8cl&ste!s. It imlies
e!"o!mance acco!din* to a set o" cont!ol mechanisms: lans, !ecies, !&les, and inst!&ctions,
all o" %hich *ove!n e!sonal 'ehavio!. 5 To a la!*e extent c&lt&!e and health coincide. Each
c&lt&!e *ives shae to a &niA&e $estalt o" health and to a &niA&e con"o!mation o" attit&des
to%a!ds ain, disease, imai!ment, and death, each o" %hich desi*nates a class o" that h&man
e!"o!mance that has t!aditionall( 'een called the a!t o" s&""e!in*.6
xxx "otnote sta!t xxx
, 5dol" 1o!tmann, ]oologie das mo&e ,ild des *auchen (#am'&!*: 3o%ohlt, 1956). Man
has no '&ilt8in evol&tiona!( mechanisms that %o&ld lead him to an eA&ili'!i&mR his c!eative
availa'ilit( *ives to his envi!onment 2!mweltA cha!acte!istics di""e!ent "!om those it has "o!
othe! secies: it t&!ns ha'itat into home.
. 1ete! <ed*%ic+, GIllness, Mental and Bthe!%ise: 5ll Illnesses Ex!ess a <ocial I&d*ment,G
%astings Center Studies 9, no. . (197.): 198/>.
/ ?i+to! von $eis=cc+e!, Der $estalt#reisV T sorie der Einheit von "ahrnehmen and
,ewegen, Jth ed; 2Stuttgart= Thieme, 9>?CM 9st ed; 9>JBA;
5 #en!( E. <i*e!ist, A %istory of *edicine, vol; 9, +rimitive and Archaic *edicine 2.ew
<or#= '/ford !niv; +ress, 9>?:A; Erwin %; 5c+e!+necht, G1!imitive Medicine and 0&lt&!e
1atte!ns,G ,ulletin of the %istory of *edicine 9& 2.ovember 9>J&A= @J@4:J; Sigerist states=
DCulture, whether or not primitive, always has a certain configuration; ; ; ; The medicine of a
primitive tribe fits into that pattern; )t is one e/pression of it, and cannot be fully understood
if it is studied separately;D Ac#er#necht e/emplifies this integration of culture and medicine in
three tribes= the Cheyenne, Dobuan, and Thonga; (or a classic description of this integration
see E; E; Evans4+ritchard, "itchcraft, 'racles and *agic Among the A8amdi 2.ew <or#=
'/ford !niv; +ress, 9>0:A, pt; J, 0; ) argue here that health and my ability to remain
responsible for my behavior in suffering are correlated; elief from this responsibility
correlates with a decline in health;
6 It is not eas( to st&d( medical c&lt&!e %itho&t a st!ait:ac+et. -. L. 7&nn, GT!aditional 5sian
Medicine and 0osmoolitan Medicine as 5datative
xxx "otnote "o!tsette! E neste side xxx
((1,;))
Each e!son6s health is a !esonsi'le e!"o!mance in a social sc!it. 7 #o% he !elates to the
s%eetness and the 'itte!ness o" !ealit( and ho% he acts to%a!ds othe!s %hom he e!ceives as
s&""e!in*, as %ea+ened, o! as an*&ished dete!mine each e!son6s sense o" his o%n 'od(, and
%ith it, his health. )od(8sense is exe!ienced as an eve!8!ene%ed *i"t o" c&lt&!e.; In Iava
eole "latl( sa(, GTo 'e h&man is to 'e Iavanese.G <mall child!en, 'oo!s, simletons, the
insane, and the "la*!antl( immo!al a!e said to 'e ndurung d5awa (not (et Iavanese). 5
Gno!malG ad&lt caa'le o" actin* in te!ms o" the hi*hl( ela'o!ate s(stem o" etiA&ette,
ossessed o" the delicate aesthetic e!cetions associated %ith m&sic, dance, d!ama, and
textile desi*n, and !esonsive to the s&'tle !omtin*s o" the divine !esidin* in the stillness o"
each individ&al6s in%a!d8t&!nin* conscio&sness is.am&n d5awa (al!ead( Iavanese). To 'e
h&man is not :&st to '!eatheR it is also to cont!ol one6s '!eathin* '( (o*ali+e techniA&es so as
to hea! in inhalation and exhalation the lite!al voice o" Ood !ono&ncin* his o%n name, hu
Allah;>
xxx "otnote sta!t xxx
<(stems,G mimeo*!ahed, 9niv. o" 0ali"o!nia, n.d. 7&nn indicates an imo!tant 'ias in most
&'lished !esea!ch on medical c&lt&!es. #e claims that 95f o" the ethno*!ahic (and also
anth!oolo*ical) lite!at&!e on health8enhancin* 'ehavio! and on the 'elie"s &nde!l(in* it deals
%ith c&!in* and not %ith the maintenance and exansion o" health. -o! lite!at&!e on medical
c&lt&!e seen %ith the 'lin+e!s o" the 'ehavio!al technician: Ma!ion 1ea!sall, *edical
,ehavioral Science A Selected ,ibliography of Cultural Anthropology, Social +sychology
and Sociology in *edicine 2-e/ington= !niv; of Eentuc#y +ress, 9>?0A; See also Steven
1ol*a!, !e"e!ences in note 19, . 1; a'ove. El"!iede O!a'ne!, 6ol#smedbsin= +roblems and
(orschaags4geschichte (7a!mstadt: $iseenscha"diche )&ch*esellscha"t, 197/), !ovides an
antholo*( o" c!itical st&dies on the histo!( o" ethnomedicine.
7 Bn the c&lt&!al &niA&eness o" health: Ina8Ma!ia O!eve!&s, Der territorials *auch= Ein
literaturanthropologiuher 6ersuch sum %eimatphaomen 2(ran#furt= AthenRum, 9>:&A; $. E.
M&hlmann, G7as 1!o'lem de! 9m%elt 'eim Menschen,G ]eitschrifi iir *orphologic und
Anthropologie // (195,): 15.8;1. 5!nold Oehlen, 7ie Seele im t chnischem ]eitalte,,
So8ialpsychologische +roblems in der ind&st!iellen Oesellscha"t (#am'&!*: 3o%ohlt, 1957).
1. )e!*e!, ). )e!*e!, and #. @ellne!, The %omeless *ind (Ne% No!+: ?inta*e )oo+s, 197/).
; #e!'e!t 1lY*e, Der *auls mid sein -eib 2TGbingen= .iemeyer, 9>?:A; (; 3; 3; ,uytendi5#,
*ensch and Tier 2%amburg= owholt, 9>@CA; (; 3; 3; ,uytendi5#, +rolegomena to an
Anthropological +hysiology 2+ittsburgh, +a;= Duquesne !niversity +ress, 9>:JA;
9 0li""o!d Oee!t=, GThe Imact o" the 0oncet o" 0&lt&!e on the 0oncet o"
xxx "otnote "o!tsette! E neste side xxx
((1,9))
0&lt&!ed health is 'o&nded '( each societ(6s st(le in the a!t o" livin*, "eastin*, s&""e!in*, and
d(in*.1>
5ll t!aditional c&lt&!es de!ive thei! h(*ienic "&nction "!om this a'ilit( to eA&i the individ&al
%ith the means "o! ma+in* ain tole!a'le, sic+ness o! imai!ment &nde!standa'le, and the
shado% o" death meanin*"&l. In s&ch c&lt&!es health ca!e is al%a(s a !o*!am "o! eatin*,11
d!in+in*,1, %o!+in*,1. '!eathin*,1/ lovin*,15 olitic+in*,16 exe!cisin*,17 sin*in*,1;
d!eamin*,19 %a!!in*, and s&""e!in*.
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
Man,G In Neh&di 5. 0ohen, ed., *an in Adaptation= The CuSaaal +resent (0hica*o: 5ldine,
196;).
1> E!%in #. 5c+e!+necht, GNat&!al 7iseases and 3ational T!eatment in 1!imitive Medicine,G
,ulletin of the %istory of *edicine 9> 2*ay 9>J?A= J?:4>:, is a dated but still e/cellent
review of the literature on the functions of medical cultures; Ac#er#necht provides convergent
evidence that medicine plays a social role and has a holistic and unitarian character in
primitive cultures that modern medicine cannot provide;
11 #a!n $is%e, Eulturgeschichte der Eor##unst Eochb3cher und e8epte aus 8wei
Iah!tassesdat (M&nich: Moos, 197>). -!ed )inde!, Die ,rotsahiwsg=V Auswahl4,ibliographie
su ihrer $eschichte und )ede&t&n*, 7ona& <ch!i"t!eihe no. 9 (9lm: 7e&tsches )!otm&se&m
E.?., 197.). L&d%i* Edelstein, Ancient *edicine= Selected +apers of -udwig Edelstein, C;
Lilian and B%sei Tem+in, eds. ()altimo!e: Iohns #o+ins, 1967). <ee the chate! on dietetics
in antiA&it(.
1, <alvato!e 1. L&cia, "ine aid the Digestive System= A Select and Annotated ,ibl ograp#y
(<an -!ancisco: -o!t&ne #o&se, 197>).
1. L&cien Le'v!e, GT!avail: Evol&tion d6&n mot et d6&ne idTe,G Io&!nal de psychologie
normale at atholo*iA&e /1, no. 1 (19/;): 198,;.
1/ 3icha!d ). Bnians, T he B!i*ins of European ::oaght About the ,ody, the *ind, the Soul,
the "ovla Time and (ate (1951R !e!int ed., Ne% No!+: 5!no, 197>). #. E. <i*e!ist, G7isease
and M&sic,G in Civilisation and Disease (0hica*o: 9niv. o" 0hica*o 1!ess, 19/.), cha. 11,
. ,1, "".
15 OYnte! Elscsse!, G5&s"all des 0oit&s als @!an+heits&!sache in de! Medi=in des
Mittelalten,G in 1a&l 7ie*en et al., eds., 5'handl&n* =&! $eschic#te der *aliirin wielder
.atwwissmuha en, no; 0 2,erlin, 9>0JA; obert %; van $uli#, Se/ual -ife in Ancient China
2Atlantic %ighlands, .3;= %umanities +ress, 9>?9A;
16 $e!ne! Iae*e!, +aideia= The )deals of $ree# Culture (Ne% No!+: Bx"o!d 9niv. 1!ess,
19/.), vol. ., cha. 1, GO!ee+ Medicine as 1aideia,G . .8/5.
17 Ed%a!d N. Oa!dine!, Athletics of the Ancient "orld (Ne% No!+: Bx"o!d 9niv. 1!ess,
19.>). M. Michle!, G7as 1!o'lem de! %est*!iechischen #eil+&nde,G <l&dho"s Archiv J?
(196,): 1/1 i".
1; -!idol" @&dlien, G<timmY'&n*en als The!ae&ti+&m in de! anti+en Medi=in,G Ar8tliche
*itteilungen JJ 29>?0A= &&@:4CM for a digest of this article see -; %eyer4$rote, Atanschulung
als Element der +sychotherapie (7a!mstadt: $issenscha"tliche )&ch*esellscha"t, 197>)
Iohanna <chmidt, G1honas+oi,G in 1a&l(8$isso%a eal4Ency#lopRdie (19/1), ,>, t. 1:5,,86.
xxx "otnote sl&tt xxx
((1.>))
Most healin* is a t!aditional %a( o" consolin*, ca!in*, and com"o!tin* eole %hile the( heal,
and most sic+8ca!e a "o!m o" tole!ance extended to the a""licted. Bnl( those c&lt&!es s&!vive
that !ovide a via'le code that is adated to a *!o&6s *enetic ma+e8&, to its histo!(, to its
envi!onment, and to the ec&lia! challen*es !e!esented '( cometin* *!o&s o" nei*h'o!s.
The ideolo*( !omoted '( contemo!a!( cosmoolitan medical ente!!ise !&ns co&nte! to
these "&nctions.,> It !adicall( &nde!mines the contin&ation o" old c&lt&!al !o*!ams and
!events the eme!*ence o" ne% ones that %o&ld !ovide a atte!n "o! sel"8ca!e and s&""e!in*.
$he!eve! in the %o!ld a c&lt&!e is medicali=ed, the t!aditional "!ame%o!+ "o! ha'its that can
'ecome conscio&s in the e!sonal !actice o" the vi!t&e o" h(*iene is !o*!essivel( t!ammeled
'( a mechanical s(stem, a medical code '( %hich individ&als s&'mit to the inst!&ctions
emanatin* "!om h(*ienic c&stodians.,1 Medicali=ation constit&tes a !oli"ic '&!ea&c!atic
!o*!am 'ased on the denial o" each man6s need to deal %ith ain, sic+ness, and death.,, The
mode!n medical ente!!ise !e!esents an
xxx "otnote sta!t xxx
19 5. $. O&'se!, GIst de! Mitta*sschla" schcdlich4G Schweiurische *e sche "ochauchrif >:,
no; 7 (1967): ,1.816. Iane )elo, Trance in ,ali, !e"ace '( Ma!*a!et Mead (Ne% No!+:
0ol&m'ia 9niv. 1!ess, 196>). @itson <te%a!d, G7!eam Theo!( in Mala(a,G Comple/= The
*aga8ine of +sychoanalysis and elated *atters ? (1951): ,18...
,>I'n @hald&n, The *ugaddimah= An )ntroduction to %istory, trans; (ran8 osenthal,
,ollingen Series P-))), 0 vols; 2+rinceton, .3;= +rinceton !niv; +ress, 9>?:A; "riting
towards the end of the 9@th century )bn Ehaldun observed the conflict between the craft of
medicine required by sedentary culture and its lu/ury and ,edouin medicine, which was
based mainly upon tradition and ^)ndividual e/perience; See especially &=0:04: and 0=9J>4
@9;
,1 -. N. L. 1o(nte!, ed;, *edicine and Culture, 1!oceedin*s o" a #isto!ical <(mosi&m
B!*ani=ed Iointl( '( the $ellcome Instit&te o" the #isto!( o" Medicine, London, and the
$enne!8O!en -o&ndations "o! 5nth!oolo*ical 3esea!ch, N.N. (London: $ellcome Instit&te,
1969). <ee "o! the con"lict 'et%een met!oolitan medicine and va!io&s t!aditions. 'n the &se
o" one hosital to c!eate the ne% cate*o!( o" Gmental diseaseG in <ene*al, see 7anielle
<to!e!81e!e=, -a (olie colonisFsV Te/tes d l1appui 2+aris= *aspero, 9>:JA;
,, The $este!n idea that health in the a'st!act is a !oe!t( o" man co&ld not develo excet
a!allel to the idea o" man#ind; 0a!l(le s&**ests that 'oth ideas
xxx "otnote "o!tsette! E neste side xxx
((1.1))
endeavo! to do "o! eole %hat thei! *enetic and c&lt&!al he!ita*e "o!me!l( eA&ied them to
do "o! themselves. Medical civili=ation is lanned and o!*ani=ed to +ill ain, to eliminate
sic+ness, and to a'olish the need "o! an a!t o" s&""e!in* and o" d(in*. This !o*!essive
"lattenin* o&t o" e!sonal, vi!t&o&s e!"o!mance constit&tes a ne% *oal %hich has neve!
'e"o!e 'een a *&ideline "o! social li"e. <&""e!in*, healin*, and d(in*, %hich a!e essentiall( in8
t!ansitive activities that c&lt&!e ta&*ht each man, a!e no% claimed '( technoc!ac( as ne%
a!eas o" olic(8ma+in* and a!e t!eated as mal"&nctions "!om %hich o&lations o&*ht to 'e
instit&tionall( !elieved. The *oals o" met!oolitan medical civili=ation a!e th&s in oosition
to eve!( sin*le c&lt&!al health !o*!am the( enco&nte! in the !ocess o" !o*!essive
coloni=ation.,.
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
"i!st too+ !eco*ni=a'le "o!m in the toast o" the victo!io&s 5lexande! to the hosso8o&sia (li+e8
nat&!edness) o" men. 0om'ined %ith the idea o" !o*!ess, the &toia o" health( man+ind came
to !evail ove! the ideal o" conc!ete and seci"ic atte!ns o" "&nctionin* cha!acte!istic "o! each
t!i'e o! polis; Bn this see #. 0. )ald!(, The !nity of *an#ind in $ree# Thought (0am'!id*e:
9nive!sit( 1!ess, 1965), and Max M&ehl, Die anti#e *enschluitsidee in ihrer geschichtlichen
Ent%ic+l&n* (Lei=i*: 7iet!ichsche ?e!la*s'&chhandl&n*, 19,;). <idne( 1olla!d, The )dea of
(lvgresc %istory and Society (Ne% No!+: )asic )oo+s, 196;), deals %ith the ideolo*( of
human progress in relation to concrete history and the politico4economic aspects
complementing philosophy;
,. To st&d( this clash in Latin 5me!ican histo!(, see, on ethnomedicine, E!%in #.
5c+e!+necht, GMedical 1!actices,G in I&lian #a(nes <te%a!d, %andboo# of South American
)ndians, vol. @, The Comparative Ethnology of South American )ndians (19/9R !e!int ed.,
<aint 0lai! <ho!es, Mich.: <chola!l( 1!ess, 197.), . 6,58/.. Bn medical coloni=ation, see
1e!c( M. 5sh'&!n, The an#s of Death= A *edical %istory of the Conquest of America (Ne%
No!+: 0o%a!d8Mc0ann, 19/7). 5n imo!tant %o!+, th!o%in* li*ht on the histo!( o" medicine
and on the conA&est. -!ancisco O&e!!a, %istoriografta de la medicina colonial hispano4
americana (Mexico: 5'astecedo!a de im!esos, 195.), is mo!e 'i'io*!ahical than
histo!io*!ahical, '&t indisensa'le. No com!ehensive st&d( o" the ime!ialism o" E&!oean
medical ideolo*( in Latin 5me!ica is availa'le. -o! a "i!st o!ientation, see Oon=alo 5*&i!!e
)elts:in, *dicina y magic El proceso de aculturacidn en la estructura colonial (Mexico:
Instit&to Nacional Indi*enista, 196.).
xxx "otnote sl&tt xxx
((1.,))
5. ,he 6illing of Pain
$hen cosmoolitan medical civili=ation coloni=es an( t!aditional c&lt&!e, it t!ans"o!ms the
exe!ience o" ain.1 The same ne!vo&s stim&lation that I shall call Gain sensationG %ill !es&lt
in a distinct exe!ience, deendin* not onl( on e!sonalit( '&t also on c&lt&!e. This
exe!ience, as distinct "!om the ain"&l sensation, imlies a &niA&el( h&man e!"o!mance
called sufering;& Medical civili=ation, ho%eve!, tends to t&!n ain into a technical matte! and
the!e'( de!ives s&""e!in* o" its inhe!ent e!sonal meanin*.. 1eole &nlea!n the accetance o"
s&""e!in* as an inevita'le a!t o" thei! conscio&s coin* %ith !ealit( and lea!n to inte!!et
eve!( ache as an indicato! o" thei! need "o! addin* o! ame!in*. T!aditional c&lt&!es
con"!ont ain, imai!ment, and death '( inte!!etin* them as challen*es solicitin* a !esonse
"!om the individ&al &nde! st!essR medical civili=ation t&!ns them into demands made '(
individ&als on the econom(, into !o'lems that can 'e mana*ed o! produced o&t o"
existence./ 0&lt&!e, a!e s(stems o" meanin*s, cosmoolitan civili=ation a s(stem o"
techniA&es. 0&lt&!e ma+es ain
xxx "otnote sta!t xxx
1 -o! a ve!( sensitive henomenolo*ical anal(sis o" the mode!ni=ation o" the ain exe!ience,
see 1ete! )e!*e!, G1olic( and the 0alc&l&s o" 1ain,G in +yramids of Sacrifice= +olitical Ethics
and Social Change 2.ew <or#= ,asic ,oo#s, 9>:JA, chap; @;
, -. I. I. )&(tendi:+, +ain, )ts *odes and (unctions, t!ans. Eda B6<hiel (0hica*o: 9niv. o"
0hica*o 1!ess, 196,). 3&dol" )il=, +alaoanthropologie, vols. 18,, Studien Ti'e! Angst and
Schmer8 (-!an+"&!t am Main: <&h!+am, 1971).
. ?icto! $ei=siic+e!, Ar8t and Eran#er 2Stuttgart= EUhler, 9>J>A, vol; 9;
J Thomas S; @mm, +ain and +leasure 2.ew <or#= ,asic ,oo#s, 9>@:A;
xxx "otnote sl&tt xxx
((1..))
tole!a'le '( inte*!atin* it into a meanin*"&l settin*R cosmoolitan civili=ation detaches ain
"!om an( s&':ective o! inte!s&':ective context in o!de! to annihilate it. 0&lt&!e ma+es ain
tole!a'le '( inte!!etin* its necessit(R onl( ain e!ceived as c&!a'le is intole!a'le.
5 m(!iad vi!t&es ex!ess the di""e!ent asects o" "o!tit&de that t!aditionall( ena'led eole to
!eco*ni=e ain"&l sensations as a challen*e and to shae thei! o%n exe!ience acco!din*l(.
1atience, "o!'ea!ance, co&!a*e, !esi*nation, sel"8cont!ol, e!seve!ance, and mee+ness each
ex!ess a di""e!ent colo!in* o" the !esonses %ith %hich ain sensations %e!e acceted,
t!ans"o!med into the exe!ience o" s&""e!in*, and end&!ed.5 7&t(, love, "ascination, !o&tines,
!a(e!, and comassion %e!e some o" the means that ena'led ain to 'e 'o!ne %ith di*nit(.
T!aditional c&lt&!es made eve!(one !esonsi'le "o! his o%n e!"o!mance &nde! the imact o"
'odil( ha!m o! *!ie".6 1ain %as !eco*ni=ed as an inevita'le a!t o" the s&':ective !ealit( o"
one6s o%n 'od( in %hich eve!(one constantl( "inds himsel", and %hich is constantl( 'ein*
shaed '( his conscio&s !eactions to it.7 1eole +ne% that the( had to heal on thei! o%n,; to
deal on thei! o%n %ith thei! mi*!aine, thei! lameness, o! thei! *!ie".
xxx "otnote sta!t xxx
5 -o! an anal(sis o" the !eaction to ain on the a!t o" contemo!a!( a&tho!s and hilosohe!s,
see Ida 0e!ma+, Ich #lage nic#= ,egegnungen mit der Eran#heit in Selbstaeugnissen schUpf
Tischer *enschen (?ienna: 5malthea, 197,). In late medieval times it %as almost imossi'le
to !eco*ni=e, "!om the 'ehavio! o" a e!son in ain, i" the o!i*in o" the exe!ience %as *!ie",
comassion, h&!t !ide, o! a %o&nd. $ilhelm <che!e!, Der Ausdruc# des Schmer8es sod der
(reude in der mittelhochdadschen Dichtung der ,liteseit 2Strassburg, 9>BCA;
6 $hen the a!tists o" classical O!eece o!t!a(ed ain, the( %e!e onl( indi!ectl( conce!ned
%ith its h(siolo*ical imact and !inciall( t!ied to !e!esent the mo!e o! less e!sonal %a(
this imact %as exe!ienced. E!nst #annes )!a&e!, Studien 8ur Darstel$ag des Schmer8es in
der anti#en bildenden Eunst $riechenlands and )talians, inaugural dissertation, !niv; of
,reslau 2,reslau= .isch#ows#y, 9>0JA; (or analogous conclusions about the Attic theater,
Earl Eiefer, E_rperlicher Schmer8 auf der attischen )Yhne, ina&*&!al disse!tation
(#eidel'e!*: 0a!l $inte!6s 9nive!sitaets'&chhandl&n*, 19>;).
7 -o! 6> lastic !e!esentations o" h&man 'ein*s in ain, see -!ied!ich <ch&l=e8Mai=ie! and
#. Moehle, Schmer8 ()e!lin: Met=ne!, 19/.). 5lso -. Oa!na&d, GLa 7o&le&! dans 1a!t,G
Aesmlape, 1957, seve!al a*es in s&ccessive iss&es.
; ?icto! $eis=aec+e!, GQ&m )e;; de! 5!'eit: Eine #a'eas80o!&s 5+te de! Medi=in4G in
Ed*a! <alin, ed., . (esigabe f r Alfred "eber (#eidel'e!*:
xxx "otnote "o!tsette! neste side xxx
((1./))
The ain in"licted on individ&als had a limitin* e""ect on the a'&ses o" man '( man.
Exloitin* mino!ities sold liA&o! o! !eached !eli*ion to d&ll thei! victims, and slaves too+ to
the 'l&es o! to coca8che%in*. )&t 'e(ond a c!itical oint o" exloitation, t!aditional
economies %hich %e!e '&ilt on the !eso&!ces o" the h&man 'od( had to '!ea+ do%n. 5n(
societ( in %hich the intensit( o" discom"o!ts and ains in"licted !ende!ed them c&lt&!all(
Gins&""e!a'leG co&ld not '&t come to an end.
No% an inc!easin* o!tion o" all ain is man8made, a side8e""ect o" st!ate*ies "o! ind&st!ial
exansion. 1ain has ceased to 'e conceived as a Gnat&!alG o! Gmetah(sicalG evil. It is a social
c&!se, and to sto the GmassesG "!om c&!sin* societ( %hen the( a!e ain8st!ic+en, the
ind&st!ial s(stem delive!s them medical ain8+ille!s. 1ain th&s t&!ns into a demand "o! mo!e
d!&*s, hositals, medical se!vices, and othe! o&t&ts o" co!o!ate, ime!sonal ca!e and into
olitical s&o!t "o! "&!the! co!o!ate *!o%th no matte! %hat its h&man, social, o! economic
cost. 1ain has 'ecome a olitical iss&e %hich *ives !ise to a sno%'allin* demand en the a!t
o" anesthesia cons&me!s "o! a!ti"iciall( ind&ced insensi'ilit(, &na%a!eness, and even
&nconscio&sness.
T!aditional c&lt&!es and technolo*ical civili=ation sta!t "!om oosite ass&mtions. In eve!(
t!aditional c&lt&!e,the s(chothe!a(, 'elie" s(stems, and d!&*s needed to %ith8stand most
ain a!e '&ilt into eve!(da( 'ehavio! and !e"lect the conviction that !ealit( is ha!sh and death
inevita'le.9 In the t%entieth cent&!( d(stoia, the neces
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
<chneide!, 19/;), . 7>7861. 5 henomenolo*ical desc!ition o" s&""e!in* as a -eistung, i;e;,
an activit( o" the sic+ e!son %hich elicits !esect in all societies and is &s&all( !eco*ni=ed as
a Ge!"o!manceG that, tho&*h di""e!ent "!om %o!+, has a social stat&s analo*o&s to it. 5l'e!t
OZ!!es, ed., Der @!an+e, Argemis der -eistungsgesellschaft (7Yisseldo!": 1atmos, 1971).
5ltho&*h he does not *o that "a!, Eve!ett #&*hes, *en; and Their "or# (Ne% No!+: -!ee
1!ess, 195;), !ovides a 'asis "o! a simila! inte!!etation.
9 )il=, G7ie Menschheits*eschichtlich cltesten M(tholo*eme,G in Studien Gber Angst and
Schmer8, pp; ,7689/.
xxx "otnote sl&tt xxx
((1.5))
sit( to 'ea! ain"&l !ealit(, %ithin o! %itho&t, is inte!!eted as a "ail&!e o" the socio8economic
s(stem, and ain is t!eated as an eme!*ent contin*enc( %hich m&st 'e dealt %ith '(
ext!ao!dina!( inte!ventions.
The exe!ience o" ain that !es&lts "!om ain messa*es !eceived '( the '!ain deends in its
A&alit( and in its A&antit( on *enetic endo%ment1> and on at least "o&! "&nctional "acto!s
othe! than the nat&!e and intensit( o" the stim&l&s: namel(, c&lt&!e, anxiet(, attention, and
inte!!etation. 5ll these a!e shaed '( social dete!minants, ideolo*(, economic st!&ct&!e, and
social cha!acte!. 0&lt&!e dec!ees %hethe! the mothe! o! the "athe! o! 'oth m&st *!oan %hen
the child is 'o!n.11 0i!c&mstances and ha'its dete!mine the anxiet( level o" the s&""e!e! and
the attention he *ives to his 'odil( sensations.1, T!ainin* and conviction dete!mine the
meanin* *iven to 'odil( sensations and in"l&ence the de*!ee to %hich ain is exe!ienced.1.
E""ective ma*ic !elie" is o"ten 'ette! !ovided '(
xxx "otnote sta!t xxx
1> 5senath 1et!ie, Individ&alit( in +ain and Suffeing (0hica*o: 9niv. o" 0hica*o 1!ess,
1967). 1eole di""e! in the intensit( %ith %hich the( mod&late exe!ienceR some !ed&ce and
othe!s inc!ease %hat is e!ceived, incl&din* ain. This !eaction atte!n is a!tiall( dete!mined
*eneticall(. <ee also ). ). $ol"" and M. E. Ia!vi+, G3elationshi )et%een <&e!"icial and
7ee <omatic Th!eshold o" 1ain, %ith a Note on #andedness,G American 5ournal of
+sychology :: (196/): 5;9899.
11 -o! the e!son %ho is s&osed to s&""e! at child'i!th, and the lace in the 'od( %he!e
ain is s&osed to o!i*inate, see O!and( 7ic+83ead, Childbirth "ithout (ear (19//R
ae!'ac+ ed., Ne% No!+: 7ell, 196,). 0ontains m&ch in"o!mation on the imact o" c&lt&!e
on the level o" "ea! and the !elationshi 'et%een "ea! and the ain exe!ience.
1, #en!( @. )eeche!, *easurement of Sub5ective esponses= Wuantitative Effects of Drugs
2.ew <or#= '/ford !niv; +ress, 9>@>A; 'piates e/ert their principal action, not on the pain
impulse, which is transmitted through the nervous system, but on the psychological overlay of
pain; They lower the level of an/iety; +lacebos can achieve the same effect in many people;
Severe postsurgical pain can be relieved in about 0@Y of patients by giving them a sugar or
saline tablet instead of an analgesic; Since only :@Y are relieved under such circumstances
with large doses of morphine, the placebo effect might account for @BY of drug effectiveness;
See also %arris %ill et al;, DStudies on An/iety Associated with Anticipation of +ain= ); Effects
of *orphine,D A;*;A; Archives of . !rvlov and +sychiatry ?: 2*ay 9>@&A= ?9&49>;
1. 3. Mei=ac+ and T. #. <cott, GThe E""ect o" Ea!l( Exe!ience on the 3esonse to 1ain,G
5ournal of Comparative and +hysiological +sychology 5> (5!il 1957): 155861. -o! a
henomenolo*ical anal(sis see ?icto! E. von Oe'sattel,
xxx "otnote "o!tsette! neste side xxx
((1.6))
o&la! s&e!stition than '( hi*h8class !eli*ion.1/ The !osect %hich is oened '( the
ain"&l event dete!mines ho% %ell it %ill 'e s&""e!ed: in:&!ies !eceived nea! the climax o" sex
o! that o" he!oic e!"o!mance a!e "!eA&entl( not even "elt. <oldie!s %o&nded on the 5n=io
)eachhead %ho hoed thei! %o&nds %o&ld *et them o&t o" the a!m( 6and 'ac+ home as he!oes
!e:ected mo!hine in:ections that the( %o&ld have conside!ed a'sol&tel( necessa!( i" simila!
in:&!ies had 'een in"licted '( the dentist o! in the oe!atin* theate!.15
5s c&lt&!e is medicali=ed, the social dete!minants o" ain a!e disto!ted. $he!eas c&lt&!e
!eco*ni=es ain as an int!insic, intimate, and incomm&nica'le Gdisval&e,G medical civili=ation
"oc&ses !ima!il( on ain as a s(stemic !eaction that can 'e ve!i"ied, meas&!ed, and !e*&lated.
Bnl( ain e!ceived '( a thi!d e!son "!om a distance constit&tes a dia*nosis that calls "o!
seci"ic t!eatment. This o':ectivi=ation and A&anti"ication o" ain *oes so "a! that medical
t!eatises sea+ o" ain"&l diseases, oe!ations, o! conditions even in cases %he!e atients
claim to 'e &na%a!e o" ain. 1ain calls "o! methods o" cont!ol '( the h(sician !athe! than an
a!oach that mi*ht hel the e!son in ain ta+e on !esonsi'ilit( "o! his exe!ience.l6 The
medical !o"ession :&d*es %hich ains a!e a&thentic, %hich have a h(sical and %hich a
s(chic 'ase, %hich a!e ima*ined, and %hich a!e sim&lated.9: <ociet( !eco*
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
)mago hominy ,eitrRge 8u einer personalist= Anthropologif, ,nd ed. (<al='&!*: Btto MYlle!,
196;)R IacA&es <a!ano, -a Douleur (L(ons: Editions de l6Ei, 1965).
1/ Thomas @eith, eligion and the Decline of *agic== Studies in +opular ,eliefs in the 9?th
and 9:th Centuries in England (London: $eiden"eld,1971). Bn the imo!tance and !actical
&tilit( o" !eli*ion and s&e!stition in ea!l( mode!n En*land in the !elie" o" s&""e!in*.
15 )eeche!, *easurement of Sub5ective esponses, pp; 9?J ff;
16 -o! in"o!mation on this s&':ect cons&lt Iames 7. #a!d( et al., +ain Sensations and
eactions (195,R !e!int ed., Ne% No!+: #a"ne!, 1967)R #a!old O. and <te%a!t $ol"", +ain,
5me!ican Lect&!es in 1h(siolo*( <e!ies, ,nd ed. (<!in*8"ield, Ill.: Thomas, 195;)R )en:amin
L. 0!&e, +ain and Suffering== Selected Aspects (<!in*"ield, Ill.: Thomas, 197>).
17 Thomas <. <=as=, GThe 1s(cholo*( o" 1e!sistent 1ain: 5 1o!t!ait o" L6#omme
7o&lo&!e&x,G in 5. <o&lai!ac, I. 0ahn, and I. 0ha!entie!, eds., +ain (Ne% No!+: 5cademic
1!ess, 196;), . 9.811..
xxx "otnote sl&tt xxx
((1.7))
ni=es and endo!ses this !o"essional :&d*ment. 0omassion 'ecomes an o'solete vi!t&e. The
e!son in ain is le"t %ith less and less social context to *ive meanin* to the exe!ience that
o"ten ove!%helms him.
The histo!( o" medical e!cetion o" ain has not (et 'een %!itten. 5 "e% lea!ned mono*!ahs
deal %ith the moments d&!in* the last ,5> (ea!s in %hich the attit&de o" h(sicians to%a!ds
ain chan*ed,1; and some histo!ical !e"e!ences can 'e "o&nd in ae!s dealin* %ith
contemo!a!( attit&des to%a!ds ain.l9 The existential school o" anth!oolo*ical medicine has
*athe!ed val&a'le insi*hts into the develoment o" mode!n ain %hile t!acin* the chan*es in
'odil( e!cetion in a technolo*ical a*e.,> The !elationshi 'et%een the medical instit&tions
and the anxiet( s&""e!ed '( thei! atients has 'een exlo!ed '( s(chiat!ists,1 and
occasionall( '( *ene!al h(sicians. )&t the !elationshi o" co!o!ate medicine to 'odil( ain
in its !eal sense is still vi!*in te!!ito!( "o! !esea!ch.
The histo!ian o" ain has to "ace th!ee secial !o'lems. The "i!st is the !o"o&nd
t!ans"o!mation &nde!*one '( the !elationshi o" ain to the othe! ills man can. s&""e!. 1ain has
chan*ed its osition in !elation to *!ie", *&ilt, sin,
xxx "otnote sta!t xxx
1; 3icha!d Toellne!, G7ie 9m'e%e!t&n* des <chme!=es im 17. Iah!h&nde!t in ih!en
?o!!a&sset=&n*en &nd -ol*en,G *edisinhistorisches 3ournal ? 29>:9A= :B:4?9; -e!dinand
<a&e!'!&ch and #ans $en+e, "esen &nd )ede&t&n* des &hmer8es ()e!lin: I&n+e! ;t
7Ynnha&t, 19.6). Thomas Eeys, %istory of Surgical Anesthesia, rev; ed; 2.ew <or#= Dover,
9>?0A;
19 @enneth 7. @ee"e, . Anatomies of +ain (<!in*"ield, Ill.: Thomas, 9>@:A; #e!mann
)&ddensie*, -eid und Schmer8 als SchUpfermacht (#eidel'e!*: n.., 1956).
,> Oe'sattel, Ima*o hominis; <a!ano, -a Doubur; @a!l E. 3othsch&h, +hysiologie= Der
"andel ih!e! Eon8epte, +robleme und *ethoden ta/ 9?; bis &B; 3ahrhundert (-!ei'&!*: 5l'e!,
9>?CA; 5n inval&a'le *&ide to the histo!( o" h(siolo*( since the 16th cent&!(, %hich comes
as dose as ossi'le to a histo!( o" the medical e!cetion o" ain. @a!l E. 3othsch&h, 6on
,oerhaave bis ,erger; Die Entwic#lung der #ontinentalen +sychologie im 9C; und 9>;
3ahrhwsdert mit besonderer ,enuec#sichtigwsg der .europlrysio)ogie 2Stuttgart= (ischer,
9>?JA;
,1 #. Me!s+e( and -. O. <ea!, 1ain: +sychological and +sychiatric Aspects (London:
)aillie!e, Tindall V 0assell, 9>?:A, !evie%s si*ni"icant ae!s and attemts a cla!i"ication o"
the &se o" ain in exe!imental %o!+.
xxx "otnote sl&tt xxx
((1.;))
an*&ish, "ea!, h&n*e!, imai!ment, and discom"o!t. $hat %e call ain in a s&!*ical %a!d is
somethin* "o! %hich "o!me! *ene!ations had no secial name. It no% seems as i" ain %e!e
onl( that a!t o" h&man s&""e!in* ove! %hich the medical !o"ession can claim cometence o!
cont!ol. The!e is no histo!ical !ecedent "o! the contemo!a!( sit&ation in %hich the
exe!ience o" e!sonal 'odil( ain is shaed '( the the!ae&tic !o*!am desi*ned to dest!o(
it.
The second !o'lem is lan*&a*e. The technical matte! %hich contemo!a!( medicine
desi*nates '( the te!m GainG even toda( has no simle eA&ivalent in o!dina!( seech. In most
lan*&a*es the te!m ta+en ove! '( the docto!s cove!s *!ie", so!!o%, an*&ish, shame, and *&ilt.
The En*lish GainG and the Oe!man G<chme!=G a!e still !elativel( eas( to &se in s&ch a %a(
that a mostl(, tho&*h not excl&sivel(, h(sical meanin* is conve(ed. Most Indo8Oe!manic
s(non(ms cove! a %ide! !an*e o" meanin*:,, 'odil( ain ma( 'e desi*nated as Gha!d %o!+,G
Gtoil,G o! Gt!ial,G as Gto!t&!e,G Gend&!ance,G G&nish8ment,G o! mo!e *ene!all(, Ga""liction,G as
Gillness,G Gti!edness,G Gh&n*e!,G Gmo&!nin*,G Gin:&!(,G Gdist!ess,G Gsadness,G Gt!o&'le,G
Gcon"&sion,G o! Go!ession.G This litan( is "a! "!om comlete: it sho%s that lan*&a*e can
distin*&ish man( +inds o" Gevils,G all o" %hich have a 'odil( !e"lection. In some lan*&a*es
'odil( ain is o&t!i*ht Gevil.G I" a -!ench docto! as+s a t(ical -!enchman %he!e he has ain,
the atient %ill oint to the sot and sa(,
xxx "otnote sta!t xxx
,, <ee 0a!l 7a!lin* )&c+, 5 Dictionary of Selected Synonyms in the +rincipal )ndo4
European -anguages= A Contribution to the %istory of )deas (0hica*o: 9niv. o" 0hica*o
1!ess, 19/9), "o! the "ollo%in* "o&! semantic "ields: ain8s&""e!in*, 16..1R *!ie"8so!!o%,
16..,R emotion8"eelin*, 16.1,R assion, 16:1.. <ee also $. -!en=en, Elagebilder und
ElagegebRrden in der deutschen Dichtung des hofeschen *ittelalters, dissertation, !niv; of
,onn 2"Gr8burg= Triltsch, 9>0CA; $eorg ]appert, D`ber den Ausdruc# des geistigen
Schmer8es im *ittelalter= Ein ,eitrag 8ur $eschichte der (Urderungs4*omente des
Ghrenden im oman4tischen,D in Den#schriften der Eaiserlichen A#ademie der
"issenschaften 26ienna= +hilosophisch4historisch Classe, 9C@JA, @= :0490?;
xxx "otnote sl&tt xxx
((1.9))
GI6ai mal ld.G Bn the othe! hand, a -!enchman can sa(, GIe so&""!e dans to&te ma chai!,G and at
the same time tell his docto!, GIe n6ai mal n&lle a!t.G I" the concet o" 'odil( ain has
&nde!*one an evol&tion in medical &sa*e, it cannot 'e *!ased siml( in the chan*in*
si*ni"icance o" an( one te!m.
5 thi!d o'stacle to an( histo!( o" ain. is its excetional axiolo*ical and eistemolo*ical
stat&s.,. No'od( %ill eve! &nde!stand Gm( ainG in the %a( I mean it, &nless he s&""e!s the
same headache, %hich is imossi'le, 'eca&se he is anothe! e!son. In this sense GainG means
a '!ea+do%n o" the clea!8c&t distinction 'et%een o!*anism and envi!on8ment, 'et%een
stim&l&s and !esonse.,/ It does not mean a ce!tain class o" exe!ience that allo%s (o& and
me to coma!e o&! headachesR m&ch less does it mean a ce!tain h(siolo*ical o! medical
entit(, a clinical case %ith ce!tain atholo*ical si*ns. It is not Gain in the
ste!nocleidomastoidG %hich is e!ceived as a s(stematic disval&e "o! the medical scientist.
The excetional +ind o" disval&e that is ain !omotes an excetional +ind o" ce!taint(. I&st as
Gm( ainG 'elon*s in a &niA&e %a( onl( to me, so I am &tte!l( alone %ith it. I cannot sha!e it.
I have no do&'t a'o&t the !ealit( o" the ain exe!ience, '&t I cannot !eall( tell an('od(
xxx "otnote sta!t xxx
,. 3o'e!t <. #a!tman, The Structure of ?al&e: -o&ndation of Sciartific d/iolog (0a!'ondale:
<o&the!n Illinois 9niv. 1!ess, 1967), eseciall( . ,55 i". 5 distinction is made 'et%een Gm(
ain,G an int!insic disval&e a'o&t %hich a totall( &niA&e ce!taint( existsR G(o&! ain,G an
ext!insic disval&e "o! %hich I can exe!ience comassionR and Gthe +ind o" ain "!om %hich a
thi!d e!son is said to s&""e!,G s&ch as the mi*!aines o" &nseci"ied atients, "o! %hich I can at
'est solicit some *ene!al s(math(. The ain a'o&t %hich a histo!( o&*ht to 'e %!itten is the
e!sonali=ed exe!ience o" int!insic ain: the incl&sion in the exe!ience o" ain o" the social
sit&ation in %hich ain occ&!s.
,/ 7avid )a+an, Disease, 1ain and Sacrifice= Toward a +ryer of <a" o n* ()oston: )eacon
1!ess, 196;), deals %ith ain as a '!ea+do%n o" Silos and o" distalH G1ain, havin* no othe!
loc&s '&t the conscio&s e*o, is almost lite!all( the !ice man a(s "o! the ossession o" a
conscio&s e*o . . . &nion the!e is an a%a+e and conscio&s o!*anism, the!e is nothin* one can
sensi'l( !e"e! to as ain.G
xxx "otnote sl&tt xxx
((1/>))
%hat I exe!ience. I s&!mise that othe!s have Gthei!G ains, even tho&*h I cannot e!ceive
%hat the( mean %hen the( tell me a'o&t them. I am ce!tain a'o&t the existence o" thei! ain
onl( in the sense that I am ce!tain o" m( comassion "o! them. 5nd (et, the deee! m(
comassion, the deee! is m( ce!tit&de a'o&t the othe! e!son6s &tte! loneliness in !elation to
his ,exe!ience. Indeed, I !eco*ni=e the si*ns made '( someone %ho is in ain, even %hen
this exe!ience is 'e(ond m( aid o! com!ehension. This a%a!eness o" ext!eme loneliness is a
ec&lia!it( o" the comassion %e "eel "o! 'odil( ainR it also sets this exe!ience aa!t "!om
an( othe! exe!ience, "!om comassion "o! the an*&ished, so!!o%"&l, a**!ieved, alien, o!
c!iled. In an ext!eme %a(, the sensation o" 'odil( ain lac+s the distance 'et%een ca&se and
exe!ience "o&nd in othe! "o!ms o" s&""e!in*.
Not%ithstandin* the ina'ilit( to comm&nicate 'odil( ain, e!cetion o" it in anothe! is so
"&ndamentall( h&man that it cannot 'e &t into a!entheses. The atient cannot conceive that
his docto! is &na%a!e o" his ain, an( mo!e than the man on the !ac+ can conceive this a'o&t
his to!t&!e!. The ce!taint( that %e sha!e the exe!ience o" ain is o" a ve!( secial +ind,
*!eate! than the ce!taint( that %e sha!e h&manit( %ith othe!s. The!e have 'een eole %ho
have t!eated thei! slaves as chattels, (et !eco*ni=ed that this chattel %as a'le to suffer ain.
<laves a!e mo!e than do*s, %ho can 'e h&!t '&t cannot s&""e!. $itt*enstein has sho%n that
o&! secial, !adical ce!taint( a'o&t the existence o" ain in othe! eole can coexist %ith an
inext!ica'le di""ic&lt( in exlainin* ho% this sha!in* o" the &niA&e can come a'o&t.,5
It is m( thesis that 'odil( ain, exe!ienced as an int!insic, intimate, and incomm&nica'le
disval&e, incl&des
xxx "otnote sta!t xxx
,5 L&d%i* $itt*enstein, +hilosophical )nvestigations (Bx"o!d: Bx"o!d 9niv. 1!ess,
195.), . ;9 "".
xxx "otnote sl&tt xxx
((1/1))
in o&! a%a!eness the social sit&ation in %hich those %ho s&""e! "ind themselves. The cha!acte!
o" the societ( shaes to some de*!ee the e!sonalit( o" those %ho s&""e! and th&s dete!mines
the %a( the( exe!ience thei! o%n h(sical aches and h&!ts as conc!ete ain. In this sense, it
sho&ld 'e ossi'le to investi*ate the !o*!essive t!ans"o!mation o" the ain exe!ience that
has accomanied the medicali=ation o" societ(. The act o" s&""e!in* ain al%a(s has a
histo!ical dimension.
$hen I s&""e! ain, I am a%a!e that a A&estion is 'ein* !aised. The histo!( o" ain can 'est 'e
st&died '( "oc&sin* on that A&estion. No matte! i" the ain is m( o%n exe!ience o! i" I see
the *est&!es o" anothe! tellin* me that he is in ain, a A&estion ma!+ is %!itten into this
e!cetion. <&ch a A&e!( is as inte*!al to h(sical ain as the loneliness. 1ain is the si*n "o!
somethin* not ans%e!edR it !e"e!s to somethin* oen, somethin* that *oes on the next moment
to demand, $hat is %!on*4 #o% m&ch lon*e!4 $h( m&st ILo&*ht ILsho&ld ILcan IL s&""e!4
$h( does this +ind o" evil exist, and %h( does it st!i+e me4 B'se!ve!s %ho a!e 'lind to this
!e"e!ential asect o" ain a!e le"t %ith nothin* '&t conditioned !e"lexes. The( a!e st&d(in* a
*&inea i*, not a h&man 'ein*. 5 h(sician, %e!e he a'le to e!ase this val&e8loaded A&estion
shinin* th!o&*h a atient6s comlaints, mi*ht !eco*ni=e ain as the s(mtom o" a seci"ic
'odil( diso!de!, '&t he %o&ld not come close to the s&""e!in* that d!ove the atient to see+
hel. The develoment o" this caacit( to o':ecti"( ain is one o" the !es&lts o" ove!intensive
ed&cation "o! h(sicians. )( his t!ainin* the h(sician is o"ten ena'led to "oc&s on those
asects o" a e!son6s 'odil( ain that a!e accessi'le to mana*ement '( o&tside!s: the
e!ihe!al8ne!ve stim&lation, the t!ansmission, the !eaction to the stim&l&s, o! even the
anxiet( level o" the atient. 0once!n is limited to the mana*ement o" the s(stemic entit(,
%hich is the onl( matte! oen to oe!ational ve!i"ication.
((1/,))
The e!sonal e!"o!mance o" suffering escaes s&ch exe!imental cont!ol and is the!e"o!e
ne*lected in most exe!iments that a!e cond&cted on ain.,6 5nimals a!e &s&all( &sed to test
the Gain8+illin*G e""ects o" ha!macolo*ical o! s&!*ical inte!ventions. Bnce the !es&lts o"
animal tests have 'een ta'&lated, thei! validit( is ve!i"ied in eole. 1ain+ille!s &s&all( *ive
mo!e o! less coma!a'le !es&lts in *&inea i*s and h&mans, !ovided those h&mans a!e &sed
as exe!imental s&':ects and &nde! exe!imental conditions simila! to those &nde! %hich the
animals %e!e tested. 5s soon as the same inte!ventions a!e alied to eole %ho a!e act&all(
sic+ o! have 'een %o&nded, the e""ects o" the d!&*s a!e comletel( o&t o" line %ith those
"o&nd in the exe!imental sit&ation. In the la'o!ato!( eole "eel exactl( li+e mice. $hen
thei! o%n li"e 'ecomes ain"&l, the( &s&all( cannot hel s&""e!in*, %ell o! 'adl(, even %hen
the( %ant to !esond li+e mice.
Livin* in a societ( that val&es anesthesia, 'oth docto!s and thei! otential clients a!e !et!ained
to smothe! ain6s int!insic A&estion ma!+. The A&estion !aised '( intimatel( exe!ienced ain
is t!ans"o!med into a va*&e anxiet( that can 'e s&'mitted to t!eatment. Lo'otomi=ed atients
!ovide the ext!eme examle o" this ex!o!iation o" ain: the( Gad:&st at the level o"
domestic invalids o! ho&sehold ets.G ,7 The lo'otomi=ed e!son still e!ceives ain '&t he
has lost the caacit( to s&""e! "!om itR the exe!ience o" ain is !ed&ced to a discom"o!t %ith a
clinical name.
-o! an exe!ience o" ain to constit&te s&""e!in* in the "&ll sense, it m&st "it into a c&lt&!al
"!ame%o!+.,; To
xxx "otnote sta!t xxx
,6 5. <o&lai!ac, I. 0ahn, and I. 0ha!entie!, eds. 1ain. 1!oceedin*s o" the Inte!national
<(mosi&m B!*ani=ed '( the La'o!ato!( o" 1s(choh(siolo*(, -ac&ltT des <ciences, 1a!is,
5!il 1181., 1967 (Ne% No!+: 5cademic 1!ess, 196;), eseciall( . 1198,.>.
,7 <ee <=as=, G1s(cholo*( o" 1e!sistent 1ain.G
,; Ma!+ Q'o!o%s+i, G0&lt&!al 0omonents in 3esonses to 1ain,G in E. Oa!tl( Iaco, +atients,
+hysicians and )llness (Ne% No!+: -!ee 1!ess, 195;), . ,5686;.
xxx "otnote sl&tt xxx
((1/.))
ena'le individ&als to t!ans"o!m 'odil( ain into a e!sonal exe!ience, an( c&lt&!e !ovides at
least "o&! inte!!elated
s&'!o*!ams: %o!ds, d!&*s, m(ths, and models. 1ain is
shaed '( c&lt&!e into a A&estion that can 'e ex!essed in %o!ds, c!ies, and *est&!es, %hich
a!e o"ten !eco*ni=ed as dese!ate attemts to sha!e the &tte! con"&sed loneliness in %hich ain
is exe!ienced: Italians *!oan and 1!&ssians *!ind thei! teeth.
Each c&lt&!e also !ovides its o%n s(choactive ha!macoeia, %ith c&stoms that desi*nate
the ci!c&mstances in %hich d!&*s ma( 'e ta+en and the accoman(in* !it&al.,9 M&slim
3a(&ts !e"e! alcohol and )!ahmins ma!i:&ana, .> tho&*h the( inte!min*le in the same
villa*es o" %este!n India..1 1e(ote is sa"e "o! Nava:os., and m&sh!ooms "o! the
#&icholes,.. %hile 1e!&vian hi*hland8e!s have lea!ned to s&!vive %ith coca../ Man has not
onl( evolved %ith the a'ilit( to suffer his ain, '&t also %ith the s+ills to mana*e it:.5 o(
*!o%in* d&!in* the middle
xxx "otnote sta!t xxx
,9 ). #olmstedt, G#isto!ical <&!ve(,G in (;thnopharmacologic Search for +sycho4active
Drugs ($ashin*ton, 7.0.: National Instit&te o" Mental #ealth, 1967), . .8.1.
.> -o! alcohol in *ene!al, see <alvato!e 1. L&cia, A %istory of "ine as Therapy (Ne% No!+:
McO!a%8#ill, 196.). Ill&st!ates the social "&nctions o" alcohol as an intoxicant. E. 3.
)loomA&ist, *arihuana ()eve!l( #ills, 0ali".: Olencoe 1!ess, 196;). Bn the settin* and
dist!i'&tion o" ma!i:&ana &se since antiA&it(.
.1 O. M. 0a!stai!s, G7a!& and )han*, 0&lt&!al -acto!s in the 0hoice o" Intoxicant,G Wuarterly
3ournal of Studies on Alcohol 15 (I&ne 195/): ,,>8.7.
., 3o'e!t L. )e!*man, GNava:o 1e(ote 9se: Its 5a!ent <a"et(,G American 3ournal of +si
chiat y 1,; (7ecem'e! 1971): 69589. $hen e(ote is &sed in a !it&al settin* '( mem'e!s o"
the Native 5me!ican 0h&!ch, less than one 'ad t!i occ&!s "o! eve!( 1>,>>> doses ta+en. $.
La )a!!e, The +eyote Cult (#amden, 0onn.: <hoest!in* 1!ess, 196/). 5 tho!o&*h histo!( o"
e(ote &se amon* the 5me!ican Indians, incl&din* an extensive 'i'lio*!ah(.
.. 3. O. $asson, Soma= Divine *ushroom of )mmortality 2.ew <or#= %arcourt ,race,
9>?>A;
./ #. )l(ed81!ieto, G0oca Lea" and 0ocaine 5ddiction: <ome #isto!ical Notes,G 0anadian
*edical Association 3ournal 9. (1965): 7>>8/. <ociolo*ical and histo!ical in"o!mation.
.5 3o'e!t )&!ton, The Anatomy of *elancholy, 0 vols; (Ne% No!+: 7&tton, 196/R o!i*. ed.
16,1). The classic t!eatise on 3enaissance chemothe!a(, %hich Gelevates the mind "!om the
deths o" desai!G '( means o" o(, hen'ane, mand!a+e, ni*htshade, n&tme*, etc.
.6 GBi&m,G in Encyclopaedia )!itannica (1911), ,>:1.>87. The histo!ical *eo*!ah( o"
o(8*!o%in* and the histo!( o" its &se !esented in a ?icto!ian e!sective.
xxx "otnote sl&tt xxx
((1//))
<tone 5*e !o'a'l( !eceded the lantin* o" *!ains. Massa*e, ac&&nct&!e, and anal*esic
incense %e!e +no%n "!om the da%n o" histo!(..7 3eli*io&s and m(thic !ation8ales "o! ain
have aea!ed in all c&lt&!es: "o! the M&slims it is @ismet, .; *od8%illed destin(R "o! the
#ind&s, +a!ma,.9 a '&!den "!om ast inca!nationR "o! the 0h!istians, a sancti"(in* 'ac+lash o"
sin /> -inall(, c&lt&!es al%a(s have !ovided an examle on %hich 'ehavio! in ain co&ld 'e
modeled: the )&ddha, the saint, the %a!!io!, o! the victim. The d&t( to s&""e! in thei! *&ise
dist!acts attention "!om othe!%ise all8a'so!'in* sensation and challen*es the s&""e!e! to 'ea!
to!t&!e %ith di*nit(. The c&lt&!al settin* not onl( !ovides the *!amma! and techniA&e, the
m(ths and examles &sed in its cha!acte!istic Gc!a"t o" s&""e!in* %ell,G '&t also the
inst!&ctions on ho% to inte*!ate this !ee!toi!e. The medicali=ation o" ain, on the othe! hand,
has "oste!ed a h(e!t!oh( o" :&st one o" these modesDmana*ement '( techniA&eDand
!ein"o!ced the deca( o" the othe!s. 5'ove all, it has !ende!ed eithe! incom!ehensi'le o!
shoc+in* the idea that s+ill in the a!t o" s&""e!in* mi*ht 'e the most e""ective and &nive!sall(
acceta'le %a( o" dealin* %ith ain. Medicali=ation de!ives an( c&lt&!e o" the inte*!ation o"
its !o*!am "o! dealin* %ith ain.
xxx "otnote sta!t xxx
.7 1ete! O!a(stone, Acupuncture and +ain Theory= A Comprehensive ,ibliography
26ancouver= ,iomedical Engineering Services, 9>:@A; Complement with ,illy and *iriam
Tam, Acupuncture= An )nternational ,ibliography 2*etuchen, .3;= Scarecrow +ress, 9>:0A;
.; -o! 'i'lio*!ah( cons&lt $. Mont*ome!( $att, (ree "ill and +redestination in Early
)slam 2-ondon= -u8ac, 9>JCA; See also Duncan ,; *acdonald, eligious Attitude and Li"e in
)slam (19>9R !e!int ed., Ne% No!+: 5M< 1!ess, 1969).
.9 #. #. 3o%le(, Submission in Suffering and 'ther Essays on Eastern Thought 2Cardiff=
!niv; of "ales +ress, 9>@9A; E; *; %och, D,haya, Sho#a, *oha= Angst, Leid &nd ?e!%i!!&n*
in den alten indischen <ch!i"ten &nd ih!e )ede&t&n* "i! die Entsteh&n* von @!an+heiten,G in
$ilhelm )itte!, ed., AbendlRndische Therapie und Zstliche "eisheit 2Stuttgart= Elett, 9>?CA;
/> Iohn -e!*&son, The +lace of Suffering 2Cambridge= Clar#e, 9>:&A; A dense history of the
classical and %ebrew bac#ground against which the Christian attitude towards suffering
developed;
xxx "otnote sl&tt xxx
((1/5))
<ociet( not onl( dete!mines ho% docto! and atient meet, '&t also %hat each o" them shall
thin+, "eel, and do a'o&t ain. 5s lon* as the docto! conceived o" himsel" !ima!il( as a
heale!, ain ass&med the !ole o" a ste to%a!ds the !esto!ation o" health. $he!e the docto!
co&ld not heal, he "elt no A&alms a'o&t tellin* his atient to &se anal*esics and th&s mode!ate
inevita'le s&""e!in*. Li+e Blive! $endell #olmes, the *ood docto! %ho +ne% that nat&!e
!ovided 'ette! !emedies "o! ain than medicine co&ld sa( Ga%ith the excetion o"b oi&m,
%hich the 0!eato! himsel" seems to !esc!i'e, "o! %e o"ten see the sca!let o( *!o%in* in
the co!n"ields as i" it %e!e "o!eseen that %he!eve! the!e is h&n*e! to 'e "ed the!e m&st also 'e
ain to 'e soothedR a%ith the excetion o"b a "e% seci"ics %hich o&! docto!6s a!t did not
discove!R a%ith the excetion o"b %ine, %hich is a "ood, and the vao&!s %hich !od&ce the
mi!acle o" anaesthesia . ... I "i!ml( 'elieve that i" the %hole materia medica, as no% &sed,
co&ld 'e s&n+ to the 'ottom o" the sea, it %o&ld 'e all the 'ette! "o! man+indDand all the
%o!se "o! the "ishes.G /1
The ethos o" the heale! *ave the h(sician the caacit( "o! the same di*ni"ied "ail&!e "o!
%hich !eli*ion, "ol+lo!e, and "!ee access to anal*esics had t!ained the common man /, The
"&nctiona!( o" contemo!a!( medicine is in a di""e!ent osition: his "i!st o!ientation is
t!eatment, not healin*. #e is *ea!ed, not to !eco*ni=e the A&estion ma!+s that ain !aises in
him %ho s&""e!s, '&t to de*!ade these ains into a list o" comlaints that can 'e collected in a
dossie!. #e !ides himsel" on the +no%led*e o" ain mechanics and th&s escaes the atient6s
invitation to comassion.
Bne so&!ce o" E&!oean attit&des to%a!ds ain ce!tainl( lies in ancient O!eece. The &ils o"
#ioc!ates/.
xxx "otnote sta!t xxx
/1 Blive! $endell #olmes, *adical Essays 2,oston, 1;;.).
/, IacA&es <a!ano, GL6lchec et le mTdecin,G in Iean Lac!oix, ed., -ss %ommes &sant (idler
(1a!is: 19-, 196;), cha. ., . 698;1.
/. -o! an exha&stive st&d( o" the dia*nostic val&e asc!i'ed to ain in
xxx "otnote "o!tsette! neste side xxx
((1/6))
distin*&ished man( +inds o" disha!mon(, each o" %hich ca&sed its o%n +ind o" ain. 1ain
th&s 'ecame a &se"&l tool "o! dia*nosis. It !evealed to the h(sician %hich ha!mon( the
atient had to !ecove!. 1ain mi*ht disaea! in the !ocess o" healin*, '&t this %as ce!tainl(
not the !ima!( o':ect o" the docto!6s t!eatment. $he!eas the 0hinese t!ied ve!( ea!l( to t!eat
sic+ness th!o&*h the !emoval o" ain, nothin* o" this so!t %as !ominent in the classical $est.
The O!ee+s did not even hin+ a'o&t en:o(in* hainess %itho&t ta+in* ain in thei! st!ide.
1ain %as the so&l6s exe!ience o" evol&tion. The h&man 'od( %as a!t o" an i!!ea!a'l(
imai!ed &nive!se, and the sentient so&l o" man ost&lated '( 5!istotle %as "&ll( coextensive
%ith his 'od(. In this scheme the!e %as no need to distin*&ish 'et%een the sense and the
exe!ience o" ain. The 'od( had not (et 'een divo!ced "!om the so&l, no! had sic+ness 'een
divo!ced "!om ain. 5ll %o!ds that indicated 'odil( ain %e!e eA&all( alica'le to the
s&""e!in* o" the so&l.
In vie% o" that he!ita*e, it %o&ld 'e a *!ave mista+e to 'elieve that !esi*nation to ain is d&e
excl&sivel( to Ie%ish o! 0h!istian in"l&ence. Thi!teen distinct #e'!e% %o!ds %e!e t!anslated
'( a sin*le O!ee+ te!m "o! GainG %hen t%o h&nd!ed Ie%s o" the second cent&!( ).0.
t!anslated the Bld Testament into O!ee+. // $hethe! o! not ain "o! the Ie% %as conside!ed
an inst!&ment o" divine &nishment, it %as al%a(s a c&!se./5 No s&**estion o" ain as a
desi!a'le exe!ience can 'e "o&nd in the <c!it&!es o! the Talm&d./6
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
#ioc!atic lite!at&!e, see 5. <o&A&es, GLa 7o&le&! dans les liv!es hioc!atiA&es:
7ia*nostiA&es !Tt!osecti"s,G ,ulletin de la <ociTtT -!an\aise de l1%istoin de *Fdecine .1
(19.7): ,>981/, ,798.>9R ., (19.;): 17;8;6R .. (19.9): .78;, 1.18//R ./ (19/>):5.89, 7989..
// -o! the evol&tion o" the te!ms &sed to desi*nate 'odil( ain and s&""e!in* in the )i'le, see
Oe!ha!d @ittel, Theologisches "Urterbuch 8um .euen Testament (<t&tt*a!t: @ohlhamme!,
19..), the "ollo%in* a!ticles: 'pt ()&ltmann)R asthenis (<tahlin)R pascho (Michaelis)R noses
(Be+e).
/5 Imman&el Ia+o'ovit=, G5ttit&de to 1ain,G in 3ewish *edical Ethics (Ne% No!+:. )loch,
1967), . 1>..
/6 I&li&s 1!e&ss, ,iblisch4talmodische *edi8in= ,eitrag 8ur $eschichte der %eil#unde und
der Eultur Gberhaupt, .!d ed. ()e!lin: @a!*e!, 19,.). -!ied!ich $ein!e', 6om
xxx "otnote "o!tsette! E "o!!i*e side xxx
((1/7))
It is t!&e that seci"ic o!*ans %e!e a""ected '( ain, '&t those o!*ans %e!e conceived o" also
as seats o" ve!( seci"ic emotionsR the cate*o!( o" mode!n medical ain is totall( alien to the
#e'!e% text. In the Ne% Testament, ain is conside!ed to 'e intimatel( ent%ined %ith sin /7
$hile "o! the classical O!ee+ ain had to accoman( leas&!e, "o! the 0h!istian ain %as a
conseA&ence o" his commitment to :o(./; No c&lt&!e o! t!adition holds a monool( on
!ealistic !esi*nation.
The histo!( o" ain in E&!oean c&lt&!e %o&ld have to t!ace mo!e than these classical and
<emitic !oots to "ind the ideolo*ies that s&o!ted e!sonal accetance o" ain. -o! the Neo8
1latonist, ain %as inte!!eted as the !es&lt o" some de"icienc( in the celestial hie!a!ch(. -o!
the Manichaean, it %as the !es&lt o" ositive mal!actice on the a!t o" an evil demi&!*e o!
c!eato!. -o! the 0h!istian, it %as the loss o" o!i*inal inte*!it( !od&ced '( 5dam6s sin. )&t no
matte! ho% m&ch these !eli*ions oosed each othe! on do*ma and mo!als, all o" them sa%
ain as the 'itte! taste o" cosmic evil, the mani"estation o" nat&!e6s %ea+ness, o" a dia'olical
%ill, o! o" a %ell8dese!ved divine c&!se. This attit&de to%a!ds ain is a &ni"(in* and
distinctive cha!acte!istic o" Medite!!anean ostclassical c&lt&!es %hich lasted &ntil the
seventeenth cent&!(. 5s an alchemic docto! &t it in the sixteenth cent&!(, ain is the G'itte!
tinct&!e added to the sa!+lin* '!e% o" the %o!ld6s seed.G Each e!son %as 'o!n %ith the call
to lea!n to live in a vale o" ain. The Neo81latonist inte!!eted 'itte!ness
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
<inn des E!+!an+en (QY!ich: B!i*o, 197/): the #e'!e% %o!d "o! Gsic+nessG has the same !oot
as the %o!d "o! Go!dina!(.G
/7 -!ied!ich -enne!, Die @!an+heit im Ne&en Testament E!ne religiUse4 &nd aisinge4
schrchtlrche !ntersuchung, 9nte!s&ch&n*en =&m Ne&en Testament, no. 1;, 19.>
(disse!tation, 9niv. o" Iena, 19.>).
/; #a!old 3o%le(, <e!vant of the -ord and 'ther Essays on ehe 'ld Testament, &nd ed;
2.aperville, )99;= Allenson, 9>?@A; Christopher ; .orth, Suffering Servant it Deubro4I!!!ah:
5n #isto!ical and 0!itical <t&d(, ,nd ed. (Ne% No!+: Bx"o!d 9niv. 1!ess, 1956).
xxx "otnote sl&tt xxx
((1/;))
as a lac+ o" e!"ection, the 0atha! as dis"i*&!ement, the 0h!istian as a %o&nd "o! %hich he
%as held !esonsi'le. In dealin* %ith the "&llness o" li"e, %hich "o&nd one o" its ma:o!
ex!essions in ain, eole %e!e a'le to stand & in he!oic de"iance o! stoicall( den( the need
"o! alleviationR the( co&ld %elcome the oo!t&nit( "o! &!i"ication, enance, o! sac!i"ice, and
!el&ctantl( tole!ate the inevita'le %hile see+in* to !elieve it. Bi&m, ac&&nct&!e, o!
h(nosis, al%a(s in com'ination %ith lan*&a*e, !it&al, and m(th, %as alied to the &niA&e
h&man e!"o!mance o" suffering pain; Bne a!oach to ain %as, ho%eve!, &nthin+a'le, at
least in the E&!oean t!adition: the 'elie" that ain o&*ht not to 'e s&""e!ed, alleviated, and
inte!!eted '( the e!son a""ected, '&t that it sho&ld 'eDideall( al%a(sDdest!o(ed th!o&*h
the inte!vention o" a !iest, olitician, o! h(sician.
The!e %e!e th!ee !easons %h( the idea o" !o"essional, technical ain8+illin* %as alien to all
E&!oean civili=ations./9 -i!st: ain %as man6s exe!ience o" a ma!!ed &nive!se, not a
mechanical d(s"&nction in one o" its s&'s(stems. The meanin* o" ain %as cosmic and
m(thic, not individ&al and technical. <econd: ain %as a si*n o" co!!&tion in nat&!e, and man
himsel" %as a a!t o" that %hole. Bne co&ld not 'e !e:ected %itho&t the othe!R ain co&ld not
'e tho&*ht o" as distinct "!om the ailment. The docto! co&ld so"ten the an*s, '&t to eliminate
the need to s&""e! %o&ld have meant to do a%a( %ith the atient. Thi!d: ain %as an
exe!ience o" the. so&l, and this so&l %as !esent all ove! the 'od(. 1ain %as a nonmediated
exe!ience o" evil. The!e co&ld 'e no so&!ce o" ain distinct "!om ain that %as s&""e!ed 5>
xxx "otnote sta!t xxx
/9 <ee !e"e!ences in note 1;, . 1.; a'ove.
5> @. E. 3othsch&h, mOeschichtliches =&! 1h(siolo*ie des <chme!=es,n in Doaanenta $ab=
+roblems of +ain ()asel, 1965), . /. 1ain %as &nde!stood to 'e Ge!ceived th!o&*h the
senso!( "ac&lt( o" the ssntiens animaM (it %asb conceived as a !oe!t( o" the so&l, a !oe!t(
dist!i'&ted th!o&*h the enti!e 'od(.G
xxx "otnote sl&tt xxx
((1/9))
The camai*n a*ainst ain as a e!sonal matte! to 'e &nde!stood and s&""e!ed *ot &nde! %a(
onl( %hen 'od( and so&l %e!e divo!ced '( 7esca!tes. #e const!&cted an ima*e o" the 'od( in
te!ms o" *eomet!(, mechanics, o! %atchma+in*, a machine that co&ld 'e !eai!ed '( an
en*inee!. The 'od( 'ecame an aa!at&s o%ned and mana*ed '( the so&l, '&t "!om an almost
in"inite distance. Theo livin* 'od( exe!ience %hich the -!ench !e"e! to as Gla chai!G and the
Oe!mans as Gde! Lei'G %as !ed&ced to a mechanism that the so&l co&ld insect. 51
-o! 7esca!tes ain 'ecame a si*nal %ith %hich the 'od( !eacts in sel"8de"ense to !otect its
mechanical inte*!it(. These !eactions to dan*e! a!e t!ansmitted to the so&l, %hich !eco*ni=es
them as ain"&l. 1ain %as !ed&ced to a &se"&l lea!nin* device: it no% ta&*ht the so&l ho% to
avoid "&!the! dama*e to the 'od(. Lei'nit= s&ms & this ne% e!sective %hen he A&otes %ith
a!oval a sentence '( 3e*is, %ho %as in t&!n a &il o" 7esca!tes: GThe *!eat en*inee! o" the
&nive!se has made man as e!"ectl( as he co&ld ma+e him, and he co&ld not have invented a
'ette! device "o! his maintenance than to !ovide him %ith a sense o" ain.G 5, Lei'nit=6s
comment on this sentence is inst!&ctive. #e sa(s "i!st that in !incile it %o&ld have 'een even
'ette! i" Ood had &sed ositive !athe! than ne*ative !ein"o!cement, insi!in* leas&!e each
time a man t&!ned a%a( "!om the "i!e that co&ld dest!o( him. #o%eve!, he concl&des that Ood
co&ld have s&cceeded %ith this st!ate*( onl( '( %o!+in* mi!acles, and since, as a matte! o"
!incile, Ood avoids mi!acles, Gain is a necessa!( and '!illiant device to ens&!e man6s
"&nctionin*.G $ithin t%o *ene!ations o" 7esca!tes6s attemt at a scienti"ic anth!oolo*(, ain
has 'ecome &se"&l. -!om 'ein* the exe!ience o" the !eca!io&sness o" existence,5.
xxx "otnote sta!t xxx
51 #e!'e!t 1lY**e, Der *ensch und sein -eib (TY'in*en: Nieme(e!, 19/7).
5, Oott"!ied $ilhelm Lei'nit=, Essais ds ThFodicie sur la bonti de Dieu, la libertF de
l1homme et l1origine du mal (1a!is: Oa!nie!8-lamma!ion, 1969), no. ./,.
5. 1ain came to 'e conside!ed m(ste!io&s and &nmana*ea'le %itho&t technical aids. -o!
o!ientation on the !omantic attit&de to%a!ds ain and the &se
xxx "otnote "o!tsette! neste side xxx
((15>))
it had t&!ned into an indicato! o" seci"ic '!ea+do%n.
)( the end o" the last cent&!(, ain had 'ecome a !e*&lato! o" 'od( "&nctions, s&':ect to the
la%s o" nat&!eR it needed no mo!e metah(sical exlanation 5/ It had ceased to dese!ve an(
m(stical !esect and co&ld 'e s&':ected to emi!ical st&d( in o!de! to do a%a( %ith it. )(
1;5., 'a!el( a cent&!( and a hal" a"te! ain %as !eco*ni=ed as a me!e h(siolo*ical sa"e*&a!d,
a medicine la'eled as a Gain8+ille!G %as ma!+eted in La 0!osse, $isconsin.55 5 ne%
sensi'ilit( had develoed %hich %as dissatis"ied %ith the %o!ld, not 'eca&se it %as d!ea!( o!
sin"&l o! lac+in* in enli*htenment o! th!eatened '( 'a!'a!ians, '&t 'eca&se it %as "&ll o"
s&""e!in* and ain.56 1!o*!ess in civili=ation 'ecame s(non(mo&s %ith the !ed&ction o" the
s&m total o" s&""e!in*. -!om then on, olitics %as ta+en to 'e an activit( not so m&ch "o!
maximi=in* hainess as "o! minimi=in* ain. The !es&lt is a tendenc( to see ain as
essentiall( a assive haenin* in"licted on helless victims 'eca&se the tool'ox o" the
medical co!o!ation is not 'ein* &sed in thei! "avo!.
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
o" na!cotics, see 5lethea #a(te!, Bi&m and the omantic )magination 2,er#eley= !niv; of
California +ress, 9>?>A; Also *; %; Abrams, The *il# of +aradise 2.ew <or#= %arper &
ow, 9>:BA; )ts avoidance became paramount= obert *au8i, -1)die du bonheur dens la
litterature et la pensFe franfaises au *ime dic# 2+aris= Colin, 9>?BA, especially pp; 0BB;49B
on the appearance of the conviction that pain is the only true evil;
5/ 0ha!les 3ichet, G7o&le&!,G in 7ictionnai!e de physiologie (1a!is: -Tlix 5lcan,
19>,), 5:17.89.. In his "ive8vol&me standa!d dictiona!( o" h(siolo*( he anal(=es ain as a
h(siolo*ical and s(cholo*ical "act %itho&t conside!in* eithe! the ossi'ilit( o" its t!eatment
o! its dia*nostic si*ni"icance. 9ltimatel( he comes to the concl&sion that ain is s&!emel(
&se"&l (so& e!aine!nent veils) 'eca&se it ma+es &s t&!n a%a( "!om dan*e!. Eve!( a'&se is
immediatel( "ollo%ed "o! o&! &nishment '( ain, %hich is clea!l( s&e!io! in intensit( to the
leas&!e that a'&se !od&ced.
55 Mit"o!d M. Mathe%s, ed., 5 Dictionary of 5me!icanisms on %istorical 1!inciles
(0hica*o: 9niv. o" 0hica*o 1!ess, 1966): Dpain4#iller; 5n( one o" va!io&s medicines o!
!emedies "o! a'olishin* o! !elievin* ain. 1;5. La 0!osse 7emoc!at 7 I&ne ,L/ 5(e!6s 0he!!(
1ecto!al, 1e!!( 7avis6 1ain @ille!. 1;;6 E''&tt Emi*!ant Li"e 119. $e +et a 'ottle o" 1ain8
+ille! in the ho&se . . . "o! medicinal &!oses.G
56 @enneth Mino*&e, The -iberal *ind (London: Meth&en, 196.).
xxx "otnote sl&tt xxx
((151))
In this context it no% seems !ational to "lee ain !athe! than to "ace it, even at the cost o"
*ivin* & intense aliveness. It seems !easona'le to eliminate ain, even at the cost o" losin*
indeendence. It seems enli*htened to den( le*itimac( to all nontechnical iss&es that ain
!aises, even i" this means t&!nin* atients into ets.57 $ith !isin* levels o" ind&ced
insensitivit( to ain, the caacit( to exe!ience the simle :o(s and leas&!es o" li"e has
eA&all( declined. Inc!easin*l( st!on*e! stim&li a!e needed to !ovide eole in an anesthetic
societ( %ith an( sense o" 'ein* alive. 7!&*s, violence, and ho!!o! t&!n into inc!easin*l(
o%e!"&l stim&li that can still elicit an exe!ience o" sel". $ides!ead anesthesia inc!eases the
demand "o! excitation '( noise, seed, violenceDno matte! ho% dest!&ctive.
This !aised th!eshold o" h(siolo*icall( mediated exe!ience, %hich is cha!acte!istic o" a
medicali=ed societ(, ma+es it ext!emel( di""ic&lt toda( to !eco*ni=e in the caacit( "o!
s&""e!in* a ossi'le s(mtom o" health. The !eminde! that s&""e!in* is a !esonsi'le activit( is
almost &n'ea!a'le to cons&me!s, "o! %hom leas&!e and deendence on ind&st!ial o&t&ts
coincide. )( eA&atin* all e!sonal a!ticiation in "acin* &navoida'le ain %ith Gmasochism,G
the( :&sti"( thei! assive li"e8st(le. Net, %hile !e:ectin* the accetance o" s&""e!in* as a "o!m
o" masochism, anesthesia cons&me!s tend to see+ a sense o" !ealit( in eve! st!on*e!
sensations. The( tend to see+ meanin* "o! thei! lives and o%e! ove! othe!s '( end&!in*
&ndia*nosa'le ains and &n!elieva'le anxieties: the hectic li"e o" '&siness exec&tives, the sel"8
&nishment o" the !at8!ace, and the intense exos&!e to violence and sadism in "ilms and on
television. In s&ch a societ( the advocac( o" a !ene%ed st(le in the a!t o" s&""e!in* that
inco!o!ates the
xxx "otnote sta!t xxx
57 ?icto! E. -!an+l, %omo atina. <asuub tine 1athodis& (?ienna: 7e&ti+e, 195>).
xxx "otnote sl&tt xxx
((15,))
cometent &se o" ne% techniA&es %ill inevita'l( 'e misinte!!eted as a sic+ desi!e "o! ain: as
o'sc&!antism, !omanticism, dolo!ism, o! sadism.
9ltimatel(, the mana*ement o" ain mi*ht s&'stit&te a ne% +ind o" ho!!o! "o! s&""e!in*: the
exe!ience o" a!ti"icial ainlessness. Li"ton desc!i'es the imact o" mass death on s&!vivo!s
'( st&d(in* eole %ho had 'een close to *!o&nd =e!o in #i!oshima.5; #e "o&nd that eole
movin* amon*st the in:&!ed and d(in* siml( ceased to "eelR the( %e!e in a state o"
n&m'ness, %itho&t emotional !esonse. #e 'elieved that a"te! a %hile this emotional clos&!e
me!*ed %ith a de!ession %hich, t%ent( (ea!s a"te! the 'om', still mani"ested itsel" in the
*&ilt o! shame o" havin* s&!vived %itho&t exe!iencin* an( ain at the time o" the exlosion.
These eole live in an inte!mina'le enco&nte! %ith death %hich has sa!ed them, and the(
s&""e! "!om a vast '!ea+do%n o" t!&st in the la!*e! h&man mat!ix that s&o!ts each individ&al
h&man li"e. The( exe!ienced thei! anestheti=ed assa*e th!o&*h this event as somethin* :&st
as monst!o&s as the death o" those a!o&nd them, as a ain too da!+ and too ove!%helmin* to
'e con"!onted, o! s&""e!ed 59
$hat the 'om' did in #i!oshima mi*ht *&ide &s to an &nde!standin* o" the c&m&lative e""ect
on a societ( in %hich ain has 'een medicall( Gex!o!iated.G 1ain loses its !e"e!ential
cha!acte! i" it is d&lled, and *ene!ates a
xxx "otnote sta!t xxx
5; 3o'e!t I. Li"ton, Death in -ife= Survivors of %iroshima (Ne% No!+: 3andom #o&se,
1969).
59 Te!!ence 7es 1!es, G<&!vivo!s and the $ill to )ea! $itness,G Social esearch /> (%inte!
197.): 66;89>, *ives a const!&ctive c!itiA&e o" 3o'e!t Li"ton. 5cco!din* to him, the s&!vivo!s
o" concent!ation cams have the &!*e to !ende! si*ni"icant a nameless exe!ience the( have
+no%n: ain %hich is &tte!l( senseless. 5cco!din* to 7es 1!es thei! messa*e is deel(
o""ensive 'eca&se since the middle o" the 19th cent&!( the s&""e!in* o" othe!s has 'ecome
cha!*ed %ith mo!al stat&s. @ie!+e*aa!d !eached salvation th!o&*h ain, Niet=sche cele'!ated
the a'(ss, Ma!x the do%nt!odden and o!essed. The s&!vivo! excites env( o" his s&""e!in*,
and sim&ltaneo&sl( testi"ies that ain can 'e val&ed onl( '( the !ivile*ed "e%.
xxx "otnote sl&tt xxx
((15.))
meanin*less, A&estionless !esid&al ho!!o!. The s&""e!in*s "o! %hich t!aditional c&lt&!es have
evolved end&!ance sometimes *ene!ated &n'ea!a'le an*&ish, to!t&!ed im!ecations, and
maddenin* 'lashemiesR the( %e!e also sel"8limitin*. The ne% exe!ience that has !elaced
di*ni"ied s&""e!in* is a!ti"iciall( !olon*ed, oaA&e, dee!soniii=ed maintenance.
Inc!easin*l(, ain8+illin* t&!ns eole into &n"eelin* sectato!s o" thei! o%n deca(in* selves.
((15/))
7. ,he In$ention and 'limination of -isease
The -!ench 3evol&tion *ave 'i!th to t%o *!eat m(ths: one, that h(sicians co&ld !elace the
cle!*(R the othe!, that %ith olitical chan*e societ( %o&ld !et&!n to a state o" o!i*inal health. 1
<ic+ness 'ecame a &'lic a""ai!. In the name o" !o*!ess, it has no% ceased to 'e the conce!n
o" those %ho a!e ill.,
-o! seve!al months in 179,, the National 5ssem'l( in 1a!is t!ied to decide ho% to !elace
those h(sicians %ho !o"ited "!om ca!e o" the sic+ %ith a the!ae&tic '&!ea&c!ac( desi*ned
to mana*e an evil that %as destined to disaea! %ith the advent o" eA&alit(, "!eedom, and
"!ate!nit(. The ne% !iesthood %as to 'e "inanced '( "&nds ex!o!iated "!om the 0h&!ch. It
%as to *&ide the nation in a militant conve!sion to health( livin* %hich %o&ld ma+e medical
sic+8ca!e less necessa!(. Each "amil( %o&ld a*ain 'e a'le to ta+e ca!e o" its mem'e!s, and
each villa*e to !ovide "o! the sic+ %ho %e!e %itho&t !elatives. 5 national health se!vice
%o&ld 'e in cha!*e o" health ca!e and %o&ld s&e!vise the enactment o" dieta!( la%s and o"
stat&tes comellin* citi=ens to &se thei! ne% "!eedoms "o!
xxx "otnote sta!t xxx
1 In this chate! I A&ote "!eel( "!om doc&ments *athe!ed in Michel -o&ca&lt, The ,irth of the
Clinic= An Archaeology of *edical +erception, t!ans. 5. M. <he!idan <mith (Ne% No!+:
1antheon, 197.).
, $alte! 5!telt, EinfiJ, ng in die *edisinhistori# )hr "esen, ihre Arbeitswei1se und ihre
%ilfsmittel 2Stuttgart= En#e, 9>J>A; An e/cellent introduction to the methodology of medical
history and its tools;
xxx "otnote sl&tt xxx
((155))
"!&*al livin* and %holesome leas&!es. Medical o""ice!s %o&ld s&e!vise the comliance o"
the citi=en!(, and medical ma*ist!ates %o&ld !eside ove! health t!i'&nals to *&a!d a*ainst
cha!latans and exloite!s.
Even mo!e !adical %e!e the !oosals "!om a s&'committee "o! the elimination o" 'e**a!(. In
content and st(le the( a!e simila! to 3ed O&a!d and )lac+ 1anthe! mani"estos demandin* that
cont!ol ove! health 'e !et&!ned to the eole. 1!ima!( ca!e, it %as asse!ted, 'elon*s onl( to
the nei*h'o!hood. 1&'lic "&nds "o! sic+8ca!e a!e 'est &sed to s&lement the income o" the
a""licted. I" hositals a!e needed, the( sho&ld 'e seciali=ed: "o! the a*ed, the inc&!a'le, the
mad, o! "o&ndlin*s. <ic+ness is a s(mtom o" olitical co!!&tion and %ill 'e eliminated %hen
the *ove!nment is cleaned &.
The identi"ication o" hositals %ith estholes %as c&!8!ent and eas( to exlain. The( had
aea!ed &nde! 0h!istian a&sices in late antiA&it( as do!mito!ies "o! t!avele!s, va*!ants, and
de!elicts. 1h(sicians 'e*an to visit hositals !e*&la!l( at the time o" the c!&sades, "ollo%in*
the examle o" the 5!a's.. 7&!in* the late Middle 5*es, as cha!ita'le instit&tions "o! the
c&stod( o" the destit&te, the( 'ecame a!t and a!cel o" &!'an a!chitect&!e./ 9ntil the late
ei*hteenth cent&!( the t!i to the hosital %as ta+en, t(icall(, %ith no hoe o" !et&!n.5
No'od( %ent to
xxx "otnote sta!t xxx
. #ein!ich <chie!*es, G7ie a!a'ische Medi=in als 1!axis &nd als Theo!ie,G Sudho, f 5s
Archiv /. (1959): .178,;, !ovides a histo!io*!ahic e!sective.
/ Bn the evol&tion o" the hosital as an a!chitectonical element in &!'ani=ation, cons&lt a
dated mon&ment: #en!( )&!dett, %ospitals and Asylums of the "orld Their B!i*in, %istory,
0onst!&ction, Administration ; ; ; and -egislation, / vols. (London: 0h&!chill, 1;9.). 5lso
7iete! Iotte!, $uchichte des %ospitals, vol. 1, "estdeutschland von den Anfingen bis 9C@B
($ies'aden: <teine!, 1966)R seve!al vol&mes lanned.
5 -e!nando da <ilva 0o!eia, 'npnes e formaQai das mise!icg!dias portuguesas (Lis'on:
To!!es, 19//). The "i!st t%o6h&nd!ed a*es deal %ith the hosital in antiA&it( and d&!in* the
Middle 5*es in the B!ient and in E&!oe. Iean Im'e!t, %istoire des hpita&x "!an\aisR
contribution O l1Ftude des rapports de l1Fglise et de l1Ftat dans )t domaine de l6assistance
publique= les hUpitoug en droit canonique, 0ollection
xxx "otnote "o!tsette! E neste side xxx
((156))
a hosital to !esto!e his health. The sic+, the mad, the c!iled, eiletics, inc&!a'les,
"o&ndlin*s, and !ecent am&tees o" all a*es and 'oth sexes %e!e :&m'led to*ethe!R6
am&tations %e!e e!"o!med in the co!!ido!s 'et%een the 'eds. Inmates %e!e *iven some
"ood, chalains and io&s la( "ol+ came to o""e! consolation, and docto!s made cha!it( visits.
The cost o" !emedies made & less than . e!cent o" the mea*e! '&d*et. Mo!e than hal" %ent
"o! the hosital so&R the n&ns co&ld *et alon* on a ittance. Li+e !isons, hositals %e!e
conside!ed a last !eso!tR7 no'od( tho&*ht o" them as tools "o! administe!in* the!a( to
im!ove the inmates.;
Lo*icall(, some ext!emists %ent 'e(ond the !ecommendations made '( the committee on
'e**a!(. <ome demanded the o&t!i*ht a'olition o" all hositals, sa(in* that the( Ga!e
inevita'l( laces "o! the a**!e*ation o" the sic+ and '!eed mise!( %hile the( sti*mati=e the
atient. I" a societ( contin&es to need hositals, this is a si*n that its !evol&tion has "ailed.G 9
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
L6l*lise et l6Ttat a& mo(en C*e, no. ; (1a!is: ?!in, 19/7). $ell8doc&mented *&ide to the
so&!ces o" the medieval hosital and the t!ansition of &'lic assistance "!om ecclesiastic to
civilian cont!ol. -. N. L. 1o(nte!, ed., The Evolution of %ospitals in ,ritain 2-ondon= +itman,
9>?JAM see the classified bibliography of ,ritish hospital history, pp; &@@4:>; (or the hospital
in the .ew "orld consult 3osefina *uriel de la Torre, #ositales de la N&eva Esaia (vol. 1),
(undaciones de los siglos P6lly P6))) 2vol; ,), &'lications of the Instit&to de #isto!ia,
9nive!sidad National, se!. 1, nos. .5, 6, (Mexico, 195686>).
6 Bn the histo!( o" the hosital 'ed, cons&lt -. )oinet, -e -it d1h_pital en (rance= Etude
historique 2+aris= (oulton, 9>J@AM 3ames .; ,lyth, .otes on ,eds and ,edding= %istorical
and Annotated 2-ondon= Simp#in *arstall, 9C:0A; *ore general, but also more pleasant
reading= -aurence "right, "arm and Snug= The %istory of the ,ed (London: 3o&tled*e,
196,). Bn *ood 'ehavio! %hen in 'ed, see %o!+ '( No!'e!t Elias cited in note ,;, . 166
'elo%.
7 Ma!cel -osse(e&x, -1%_tel Dieu awe P 6lle et P 6llle slides 2+aris= -evrault, 9>9&A;
; -o! the o!i*ins and the evol&tion o" the idea: 7avid 3othman, The Discovery of the Asylum
2,oston= -ittle, ,rown, 9>:9A; *ilton Eotler, .eighborhood $overn4ment The -ocal
(oundations of +olitical -ift 2)ndianapolis= ,obbs4*errill, 9>?>A, ma#es a clear case for
,oston; See also (oucault, ,irth of the Clinic;
9It %as en:oined on 0h!istian !inces not to &se li"e im!isonment as a &nishment 'eca&se it
%as m&ch too c!&el. 1!isons mi*ht 'e &sed to +ee
xxx "otnote "o!tsette! E neste side xxx
((157))
5 mis&nde!standin* o" 3o&ssea& vi'!ates in this desi!e to !esto!e sic+ness to its Gnat&!al
state,G 1> to '!in* societ( 'ac+ to G%ild sic+ness,G %hich is sel"8limitin* and can 'e 'o!ne
%ith vi!t&e and st(le and ca!ed "o! in the homes o" the oo!, :&st as !evio&sl( the sic+nesses
o" the !ich had 'een ta+en ca!e o". <ic+ness 'ecomes comlex, &nt!eata'le, and &n'ea!a'le
onl( %hen exloitation '!ea+s & the "amil(,11 and it 'ecomes mali*nant and demeanin* onl(
%ith the advent o" &!'ani=ation and civili=ation. -o! 3o&ssea&6s "ollo%e!s the sic+ness seen in
hositals %as man8made, li+e all "o!ms o" social in:&stice, and it th!ived amon* the sel"8
ind&l*ent and those %hom the( had imove!ished. GIn the hosital, sic+ness is totall(
co!!&tedR it t&!ns into J!ison "eve!6 cha!acte!i=ed '( sasms, "eve!, indi*estion, ale &!ine,
de!essed !esi!ation, and &ltimatel( leads to death: i" not on the ei*hth o! eleventh da(, then
on the thi!teenth.G 1, It is this +ind o" lan*&a*e that made medicine "i!st 'ecome a olitical
iss&e. The lans to en*inee! a societ( into health 'e*an %ith the call "o! a social
!econst!&ction that %o&ld eliminate the ills o" civili=ation. $hat 7&'os has called Gthe mi!a*e
o" healthG 'e*an as a olitical !o*!am.
In the &'lic !heto!ic o" the 179>s, the idea o" &sin* 'iomedical inte!ventions on eole o! on
thei! envi!on8ment %as totall( a'sent. Bnl( %ith the 3esto!ation %as the tas+ o" eliminatin*
sic+ness t&!ned ove! to the medical
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
c!iminals &ntil thei! hea!in*, thei! exec&tion, o! thei! :&dicial m&tilation. 5nd!eas 1e!nede!,
6on Straff und +een aller und 5eder *alcfite handlungat ait hunter ,ericht, ed; "; %unger
2)ngolstadt, 9@JJA;
1> -o! doc&mentation on the ca!e"&ll( A&ali"ied and !ich tho&*ht o" 3o&ssea& on medicine,
see Oe!ha!d 3&dol", GIean8IacA&es 3o&ssea& (171,q177;) &nd die Medi=in,G Sudhoffs Archiv
5. (1969): .>867. 3o&ssea& %as !o'a'l( mis&nde!stood even mo!e on medicine than on
ed&cation.
11 Bn the d!eam o" G%ildG health cons&lt Ed%a!d 7&dle( and Maximilian E. Nova+, eds., The
"ild *an "ithin= An )mage in "estern Thought front the enaissance to omanticism
2+ittsburgh= +ittsburgh !niv; +ress, 9>:&A;
1, IacA&es83enT Tenon, *Fmoires sur les hJ,itaac (1a!is, 17;;), . /51R cited in -o&ca&lt,
,irth of the Clinic, p; 17.
xxx "otnote sl&tt xxx
((15;))
!o"ession. 5"te! the 0on*!ess o" ?ienna, hositals !oli"e!ated and medical schools
'oomed.1. <o did the discove!( o" diseases. Illness %as still !ima!il( nontechnical. In 177>,
*ene!al !actice +ne% o" little 'esides the la*&e and the ox,1/ '&t '( 1;6> even the
o!dina!( citi=en !eco*ni=ed the medical names o" a do=en diseases. The s&dden eme!*ence o"
the docto! as savio! and mi!acle %o!+e! %as d&e not to the !oven e""icac( o" ne% techniA&es
'&t to the need "o! a ma*ical !it&al that %o&ld lend c!edi'ilit( to a &!s&it at %hich a olitical
!evol&tion had "ailed. I" Gsic+nessG and GhealthG %e!e to la( claim to &'lic !eso&!ces, then
these concets had to 'e made oe!ational. 5ilments had to 'e t&!ned into o':ective diseases
that in"ested man+ind, co&ld 'e t!anslanted and c&ltivated in the la'o!ato!(, and co&ld 'e
"itted into %a!ds, !eco!ds, '&d*ets, and m&se&ms. 7isease %as th&s accommodated to
administ!ative mana*ementR one '!anch o" the elite %as ent!&sted '( the dominant class %ith
a&tonom( in its cont!ol and elimination. The o':ect o" medical t!eatment %as de"ined '( a
ne%, tho&*h s&'me!*ed, olitical ideolo*( and acA&i!ed the stat&s o" an entit( that existed
A&ite sea!atel( "!om 'oth docto! and atient. 15
$e tend to "o!*et ho% !ecentl( disease entities %e!e 'o!n. In the mid8nineteenth cent&!(, a
sa(in* att!i'&ted to #ioc!ates %as still A&oted %ith a!oval: GNo& can
xxx "otnote sta!t xxx
1. )!ian 5'el8<mith, T hs %ospitals, 9?BB49>9C=V A Study in Social 5dminist!ation in
England and "ales (London: #einemann, 196/). 0a!e"&ll( doc&mented on economic and
!o"essional chan*es. Leona!d @. Eaton, .ew England #ositals, 179>81;. (5nn 5!'o!:
9niv. o" Michi*an 1!ess, 1957). <ee eseciall( the 'i'lio*!ahical essa(, . ,.98/6.
1/ -!an\ois Milleie!!es, La ?ie A&otidiss&a des mFdecins ass temps de *ohire 2+aris=
%achette, 9>?JA; +opular but reliableM a composite picture of the day4by4day life of the
physician at the time of MoliX!e.
15 Iean81ie!!e 1ete!, GMalades et maladies : la "in d& [?IIIe siXcle,G in Iean81a&l 7essaive et
al., Midai!6s, climat st FpidFmies d la 3in du P6llls si#le 2+aris= *outon, 9>:&A, pp; 90@4:B=
DDuring the (rench evolution the hospital, li#e the laboratory, both discovered around
9::B, would play the midwife1s role in the birth of these pree/isting ideas;D
xxx "otnote sl&tt xxx
((159))
discove! no %ei*ht, no "o!m no! calc&lation to %hich to !e"e! (o&! :&d*ment o" health and
sic+ness. In the medical a!ts the!e exists no ce!taint( excet in the h(sician6s senses.G
<ic+ness %as still e!sonal s&""e!in* in the mi!!o! o" the docto!6s vision.16 The t!ans"o!mation
o" this medical o!t!ait into a clinical entit( !e!esents an event in medicine that co!!esonds
to the achievement o" 0oe!nic&s in ast!onom(: man %as cata&lted and est!an*ed "!om the
cente! o" his &nive!se. Io' 'ecame 1!omethe&s.
The hoe o" '!in*in* to medicine the ele*ance that 0oe!nic&s had *iven ast!onom( dates
"!om the time o" Oalileo. 7esca!tes t!aced the coo!dinates "o! the imlementation o" the
!o:ect. #is desc!ition e""ectivel( t&!ned the h&man 'od( into cloc+%o!+s and laced a ne%
distance, not onl( 'et%een so&l and 'od(, '&t also 'et%een the atient6s comlaint and the
h(sician6s e(e. $ithin this mechani=ed "!ame%o!+, ain t&!ned into a !ed li*ht and sic+ness
into mechanical t!o&'le. 5 taxonom( o" diseases 'ecame ossi'le. 5s mine!als and lants
co&ld 'e classi"ied, so diseases co&ld 'e isolated and cate*o!i=ed '( the docto!8taxonomist.
The lo*ical "!ame%o!+ "o! a ne% &!ose in medicine had 'een laid. Instead o" s&""e!in* man,
sic+ness %as laced in the cente! o" the medical s(stem and co&ld 'e s&':ected to (a)
oe!ational ve!i"ication '( meas&!ement, (') clinical st&d( and exe!iment, and (c) eval&ation
acco!din* to en*inee!in* no!ms.
5ntiA&it( +ne% no (a!dstic+ "o! disease.17 Oalileo6s
xxx "otnote sta!t xxx
16 #elm&t ?o*t, Das ,ild des Eran#en= Die Darstellung Russerer 6erRnderungen durch
innere -eiden und ihre %eilmassnahmen von der enaissance bis 8u unserer ]eit (M&nich:
Lehmann, 196>). Mo!e than 5>> !e!od&ctions o" a!tistic !e!esentations o" sic+ eole since
the 3enaissanceR allo%s a st&d( o" e!cetion. -o! a medical st&d( o" e!*otism in the ast
'ased on its !e!esentation in aintin*s, see ?eit #a!old )a&e!, Das 5ntonins (euer in @&nst
und *edisin (#eidel'e!*: <!in*e!, 197.)R 'i'lio*., . 11;8,5R a"te!%o!d '( $ol"*an*
Iaco', . 1,789. 1aintin* and lastic a!ts !ovide an inval&a'le comlement to the histo!( o"
atient8docto! !elations: E&*en #ollcnde!, Die *edi8in in der #lassischen *alerei, /th ed.
(<t&tt*a!t: En+e, 195>). E&*en #ollcnde!, +lasti# und *edi8in (<t&tt*a!t: En+e,
191,).
17 $. M&!i, G7e! Mass*edan+e 'ei *!iechischen 5!a6. ten,G $ymnasium 57 (195>): 1;.8,>1.
#. La&e, *ass und *itte Eine problemgeschichtliche !ntersuclsung 8ur
xxx "otnote "o!tsette! E neste side xxx
((16>))
contemo!a!ies %e!e the "i!st to t!( to al( meas&!ement to the sic+, '&t %ith little s&ccess.
<ince Oalen had ta&*ht that &!ine %as sec!eted di!ectl( "!om the vena cava and that its
comosition %as a di!ect indication o" the nat&!e o" the 'loodR docto!s had tasted and smelled
&!ine and assa(ed it '( the li*ht o" s&n and moon. 5"te! the sixteenth cent&!(, alchemists had
lea!ned to meas&!e seci"ic *!avit( %ith conside!a'le !ecision, and the( s&':ected the &!ine
o" the sic+ to thei! methods. 7o=ens o" distinct and di""e!in* meanin*s %e!e asc!i'ed to
chan*es in the seci"ic *!avit( o" &!ine. $ith this "i!st meas&!ement, docto!s 'e*an to !ead
dia*nostic and c&!ative meanin* into an( ne% meas&!ement the( lea!ned to e!"o!m.1;
The &se o" h(sical meas&!ements !ea!ed "o! a 'elie" in the !eal existence o" diseases and
thei! ontolo*ical a&tonom( "!om the e!cetion o" docto! and atient. The &se o" statistics
&nde!inned this 'elie". It Gsho%edG that diseases %e!e !esent in the envi!onment and co&ld
invade and in"ect eole. The "i!st clinical tests &sin* statistics, %hich %e!e e!"o!med in the
9nited <tates in 17,1 and &'lished in London in 17,,, !ovided ha!d data indicatin* that
smallox %as th!eatenin* Massach&setts and that eole %ho had 'een inoc&lated %e!e
!otected a*ainst its
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
fruehen griechischen +hilosophie und Ethi# (MYnste!: Bsna'!&ec+, 196>). Meas&!e in
antiA&it( %as !elated to vi!t&e and !oo!tion, not to oe!ational ve!i"ication. Bn the
!ehisto!ic Indo8Oe!manic semantic "ield %hich incl&des 'oth meas&!e and medicine see
Emil\ )enveniste, GMTdecine et la notion de mes&!e,G in -e 6ocabulaire des instit&tions
indo4europFennes, vol. ,, 1o&voi!, droit, religion, 1969, . 1,.8.,. The En*lish ve!sion is
)ndo4European -anguage and Society (Miami: 9nive!sit( o" Miami 1!ess, 197.).
1; -o! the histo!( o" meas&!ements cons&lt t%o s(mosia: #a!!( $ool", ed., S,]uanhf cation=
A %istory of the *eaning of *easurement in the .atural and Social Sciences 2)ndianapolis=
,obbs4*errill, 9>?9A, and Daniel -erner, Wuantity and Wuality= The %ayden Colloquium on
Scientific Method and 0oncet (Ne% No!+: -!ee 1!ess, 1961). 1a!tic&la!l( cons&lt, in $ool",
the ae! '( 3icha!d <h!(oc+, GThe #isto!( o" 2&anti"ication in Medical <cience,G . ;58
1>7. -o! the alication o" meas&!ement to nonmedical asects o" man, see <. <. <tevens,
GMeas&!ement and Man,G Science 1,7 (195;): .;.89, and <. <. <tevens, %andboo# o"
Exe!imental 1(cholo*( (Ne% No!+: $ile(, 1951).
xxx "otnote sl&tt xxx
((161))
attac+s. The( %e!e cond&cted '( 7!. 0otton Mathe!, %ho is 'ette! +no%n "o! his inA&isito!ial
"&!( at the time o" the <alem %itch t!ials than "o! his si!ited de"ense o" smallox
!evention.19
7&!in* the seventeenth and ei*hteenth cent&!ies, docto!s %ho alied meas&!ements to sic+
eole %e!e lia'le to 'e conside!ed A&ac+s '( thei! collea*&es. 7&!in* the -!ench 3evol&tion,
En*lish docto!s still loo+ed as+ance at clinical the!momet!(. To*ethe! %ith the !o&tine ta+in*
o" the &lse, it 'ecame acceted clinical !actice onl( a!o&nd 1;/5, nea!l( thi!t( (ea!s a"te!
the stethoscoe %as "i!st &sed '( Larnnec.
5s the docto!6s inte!est shi"ted "!om the sic+ to sic+ness, the hosital 'ecame a m&se&m o"
disease. The %a!ds %e!e "&ll o" indi*ent eole %ho o""e!ed thei! 'odies as exhi'its to an(
h(sician %illin* to t!eat them.QB The !eali=ation that the hosital %as the lo*ical lace to
st&d( and coma!e GcasesG develoed to%a!ds the end o" the ei*hteenth cent&!(. 7octo!s
visited hositals %he!e all +inds o" sic+ eole %e!e min*led, and t!ained themselves to ic+
o&t seve!al GcasesG o" the same disease. The( develoed G'edside vision,G o! a clinical e(e.
7&!in* the "i!st decades o" the nineteenth cent&!(, the medical attit&de to%a!ds hositals %ent
th!o&*h a "&!the! develoment. 9ntil then, ne% docto!s had 'een t!ained mostl( '( lect&!es,
demonst!ations, and dis&tations. No% the G'edsideG 'ecame the
xxx "otnote sta!t xxx
19 3icha!d #. <h!(oc+ and Btho T. )eall, Cotton *ather The (irst <i*niaseet (igure 'e 5n
*ica& *edicine ()altimo!e: Iohns #o+ins 9niv. 1!ess, 195/).
,> $hen disease 'ecame an entit( that co&ld 'e sea!ated "!om man and dealt %ith '( the
docto!, othe! asects o" man s&ddenl( 'ecame detacha'le, &sa'le, sala'le. The sale o" the
shado% is a t(icall( 19th8cent&!( lite!a!( moti" (5. ?. 0hand!a, +eter <clilemihls
wundersame $eschichte, 1;1/). 5 demoniacal docto! can de!ive man o" his mi!!o!8ima*e
(E. T. 5. #o""man, G7ie Oeschichte vom ve!lo!enen <ie*el'ild,G in Die Abenbwr einer
Sylversnacht, 1;15). In $. #a&"", G7es steine!ne #e!t=,G in Das "irtshaus in Spessat (1;,;),
the he!o exchan*es his hea!t "o! one o" stone to save himsel" "!om 'an+!&tc(. $ithin the
next t%o *ene!ations, lite!a!( t!eatment %as *iven to the sale o" aetite, name, (o&th, and
memo!ies.
xxx "otnote sl&tt xxx
((16,))
clinic, the lace %he!e "&t&!e docto!s %e!e t!ained to see and !eco*ni=e diseases.,1 The
clinical a!oach to sic+ness *ave 'i!th to a ne% lan*&a*e %hich so+e a'o&t diseases at the
'edside, and to a hosital !eo!*ani=ed and classi"ied '( disease "o! the exhi'ition o" ailments
to st&dents.,,
The hosital, %hich at the ve!( 'e*innin* o" the nineteenth cent&!( had 'ecome a lace "o!
dia*nosis, %as no% t&!ned into a lace "o! teachin*. <oon it %o&ld 'ecome a la'o!ato!( "o!
exe!imentin* %ith t!eatments, and to%a!ds the t&!n o" the cent&!( a lace conce!ned %ith
the!a(. Toda( the estho&se has 'een t!ans"o!med into a coma!tmentali=ed !eai! sho. 5ll
this haened in sta*es. 7&!in* the nineteenth cent&!(, the clinic 'ecame the lace %he!e
disease ca!!ie!s %e!e assem'led, diseases %e!e identi"ied, and a cens&s o" diseases %as +et.
Medical e!cetion o" !ealit( 'ecame hosital8'ased m&ch ea!lie! than medical !actice. The
seciali=ed hosital demanded '( the -!ench 3evol&tiona!ies "o! the sa+e o" the atient
'ecame a !ealit( 'eca&se docto!s needed to classi"( sic+ness. 7&!in* the enti!e nineteenth
cent&!(, atholo*( !emained ove!%helmin*l( the classi"ication o" anatomical anomalies. Bnl(
to%a!ds the end o" the cent&!( did the &ils o" 0la&de )e!na!d also 'e*in to la'el and
catalo*&e the atholo*( o" "&nctions. ,. Li+e
xxx "otnote sta!t xxx
,1 -o! this evol&tion in -!ance, see Ma&!ice 3ochaix, Essai s&! l6eZol&tion des questions
hospitaliires de la "in de l1Ancien Fgime F nos 5ours (<aintes: -TdT!ation hositaliX!e de
-!ance, 1959), the onl( %ell8doc&mented histo!( o" &'lic assistance to the sic+ in -!ance.
<ee Iean Im'e!t, -es hfUpitau/ en (rance, G2&e sais8:e4G (1a!is: 1!esses 9nive!sitai!es de
-!ance, 195;), on the adatation o" the -!ench hosital to chan*in* medical techniA&es d&!in*
the 19th cent&!(. B" co&!se, cons&lt also -o&ca&lt, ,irth of the Clinic;
,, Bn the histo!( o" the concet o" disease, see 1. 7ie*en, O. ). O!&'e!, and #.
<chade%aldt, G7e! @!an+heits'e*!is, seine Oeschichte &nd 1!o'lemati+,G in +rologamaia
*ins6 allgemeines +athologie ()e!lin: <!in*e!, 1969), 1:185>. Eman&el )e!*ho"", Eatw
c#lungsgeschiclde des Eran#heitsbegri fes= In seinen #as(tsi*ea dargestellt, ,nd ed., $iene!
)eit!c*e =&! Oeschichte de! Medi=in, vol. 1 (?ienna: Ma&d!ich, 19/7). 1ed!o Lain Ent!al*o,
El mTdico, el enferra (Mad!id: Ediciones O&ada!!ama, 197>).
,. Mi!+o 7. O!me+, GLa 0oncetion de la maladie et de la santT che= 0la&de
xxx "otnote "o!tsette! neste side xxx
((16.))
sic+ness, health acA&i!ed a clinical stat&s, 'ecomin* the a'sence o" clinical s(mtoms, and
clinical standa!ds o" no!malit( 'ecame associated %ith %ell8'ein*.,/
7isease co&ld neve! have 'een associated %ith a'no!malit( i" the val&e o" &nive!sal standa!ds
had not come to 'e !eco*ni=ed in one "ield a"te! anothe! ove! a e!iod o" t%o h&nd!ed (ea!s.
In 16.5, at the 'ehest o" 0a!dinal 3ichelie&, the +in* o" -!ance "o!med an academ( o" the
"o!t( s&osedl( most distin*&ished men o" -!ench lette!s "o! the &!ose o" !otectin* and
e!"ectin* the -!ench lan*&a*e. In "act, the( imosed the lan*&a*e o" the !isin* 'o&!*eoisie
%hich %as also *ainin* cont!ol ove! the exandin* tools o" !od&ction. The lan*&a*e o" the
ne% class o" caitalist !od&ce!s 'ecame no!mative "o! all classes. <tate a&tho!it( had
exanded 'e(ond stat&te la% to !e*&late means o" ex!ession. 0iti=ens lea!ned to !eco*ni=e
the no!mative o%e! o" an elite in a!eas le"t &nto&ched '( the canons o" the 0h&!ch and the
civil and enal codes o" the state. B""enses a*ainst the codi"ied la%s o" -!ench *!amma! no%
ca!!ied thei! o%n sanctionsR the( &t the sea+e! in his laceDthat is, de!ived him o" the
!ivile*es o" class and !o"ession. )ad -!ench %as that %hich "ell 'elo% academic standa!ds,
as 'ad health %o&ld soon 'e that %hich %as not & to the clinical no!m.
In Latin norma means GsA&a!e,G the ca!ente!6s sA&a!e. 9ntil the 1;.>s the En*lish %o!d
Gno!malG meant standin* at a !i*ht an*le to the *!o&nd. 7&!in* the 1;/>s it came to desi*nate
con"o!mit( to a common t(e. In the 1;;>s, in 5me!ica, it came to mean the &s&al state o!
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
)e!na!d,G in 5lexand!e @o(!T, *Flanges Ale/andre Eo,ri. -1Aventure de la science 2+aris=
%ermann, 9>?JA, 9=&BC4&:;
,/ Oeo!*es 0an*&ilhem, -e .ormal et le pathologique (1a!is: 1!esses 9nive!sitai!es de
-!ance, 197,), is a thesis on the histo!( o" the idea o" no!malc( in 19th8cent&!( atholo*(,
"inished in 19/. %ith a ostsc!it in 1966. Bn the histo!( o" Gno!malit(G in s(chiat!( see
Michel -o&ca&lt, *adness and Civilisation= A %istory of )nsanity in the Age of eason (Ne%
No!+: 1antheon, 1965).
xxx "otnote sl&tt xxx
((16/))
condition not onl( o" thin*s '&t also o" eole. In -!ance, the %o!d %as t!ansosed "!om
*eomet!( to societ(DTcole normale desi*nated a school at %hich teache!s "o! the Emi!e
%e!e t!ainedDand %as "i!st *iven a medical connotation a!o&nd 1;/> '( 5&*&ste 0omte. #e
ex!essed his hoe that once the la%s !elative to the no!mal state o" the o!*anism %e!e
+no%n, it %o&ld 'e ossi'le to en*a*e in the st&d( o" coma!ative atholo*(.,5
7&!in* the last decade o" the nineteenth cent&!(, the no!ms and standa!ds o" the hosital
'ecame "&ndamental c!ite!ia "o! dia*nosis and the!a(. -o! this to haen, it %as not
necessa!( that all a'no!mal "eat&!es 'e conside!ed atholo*icalR it %as s&""icient that disease
as deviance "!om a clinical standa!d ma+e medical inte!vention le*itimate '( !ovidin* an
o!ientation "o! the!a(.,6
The a*e o" hosital medicine, %hich "!om !ise to "all lasted no mo!e than a cent&!( and a hal",
is comin* to an end.,7 0linical meas&!ement has 'een di""&sed th!o&*ho&t
xxx "otnote sta!t xxx
,5 -o! the histo!( o" medical ideas d&!in* the 19th cent&!(, see 1ed!o Lain Ent!al*o, -a
medicine hipocrdtica (Mad!id: 3evista de Bccidente, 197>). $e!ne! Lei'!and, #eil+&nde:
Eine +mb#msgeschichte der *edi8in (-!ei'&!*: 5l'e!, 195.). -!it= #a!tmann, Der Zr8tliche
5&"t!a*: Die Entwic#lung der )dee des abend#indischen Ar8ttums aus ih!en weltanschaulich4
anthropologischen 6orausset8ungen bis 8um ,eginn der .eu8eit (OZttin*en: M&ste!schmidt,
1956). M. Me!lea&81ont(, GL6Beil de l6es!it,G -es Temps Mode!nes, nos. 1;/85 (1961), .
19. i". M. Me!lea&81ont(, +hFnomFnologie de la perception (1a!is: Oallima!d, 19/5). $e!ne!
Lei''!and, Spe#ulative *edi8in der 3omanti+ (#am'&!*: 0laassen, 1956). #ans -!e(e!, G7e!
5!=t &nd die Oesellscha"t,G in Der 5!=t und der Staat (Lei=i*: Thieme 19,9). 3enT -iilo8
Mille!, Eulturgeschichte der %eil#unde (M&nich: )!&e+mann, 19.7). @. E. #!a* 3othsch&h,
"as ist Eran#heit7 Erscheinung, Er#lRrung, Sinngebung, $e*e de! -o!sch&n*, vol. .6,
(7a!mstadt: $issenscha"tliche )&ch*esellscha"t, 1976): 1;. histo!icall( imo!tant c!itical
cont!i'&tions o" the 19th and ,>th cent&!ies to the eistemolo*( o" sic+ness, amon* them 0.
$. #&"eland, 3. ?i!cho%, 3. @och, and -. 5lexande!. 3icha!d Toellne! %ill &'lish a
a!allel vol&me, Erfahrung und Den#en in der *edi8in;
,6 Bn this develoment, eseciall( as it cente!ed a!o&nd the in"l&ence o" ?i!cho%, see
$ol"*an* Iaco', GMedi=inische 5nth!oolo*ie im 19. Ih.: Mensch, Nat&!, Oesellscha"t:
)eit!a* =& eine! theo!etischen 1atholo*ie,G in ,eitrRge aus der allgemeinen *edi8in, no. ,>
(<t&tt*a!t: En+e, 1967).
,7 Ianine -e!!(81ie!!et and <e!*e @a!sent(, +ratiques mFdicales et %a!ns hospitalier (1a!is:
0E3E)E, 197/), an economic anal(sis o" the !isin* ma!*inal
xxx "otnote "o!tsette! neste side xxx
((165))
societ(. <ociet( has 'ecome a clinic, and all citi=ens have 'ecome atients %hose 'lood
!ess&!e is constantl( 'ein* %atched and !e*&lated to "all G%ithinG no!mal limits. The ac&te
!o'lems o" mano%e!, mone(, access, and cont!ol that 'eset hositals eve!(%he!e can 'e
inte!!eted as s(mtoms o" a ne% c!isis in the concet o" disease. This is a t!&e c!isis 'eca&se
it admits o" t%o oosin* sol&tions, 'oth o" %hich ma+e !esent hositals o'solete. The "i!st
sol&tion is a "&!the! sic+enin* medicali=ation o" health ca!e, exandin* still "&!the! the clinical
cont!ol o" the medical !o"ession ove! the am'&lato!( o&lation. The second is a c!itical,
scienti"icall( so&nd demedicali=ation o" the concet o" disease.
Medical eistemolo*( is m&ch mo!e imo!tant "o! the health( sol&tion o" this c!isis than
eithe! medical 'iolo*( o! medical technolo*(. <&ch an eistemolo*( %ill have to cla!i"( the
lo*ical stat&s and the social nat&!e o" dia*nosis and the!a(, !ima!il( in h(sicalDas
oosed to mental Dsic+ness. 5ll disease is a sociall( c!eated !ealit(. Its meanin* and the
!esonse it has evo+ed have a histo!(.,9 The st&d( o" this histo!( %ill ma+e &s &nde!stand the
de*!ee to %hich %e a!e !isone!s o" the medical ideolo*( in %hich %e %e!e '!o&*ht &.
5 n&m'e! o" a&tho!s have !ecentl( t!ied to de'&n+ the stat&s o" mental deviance as a
Gdisease.G ,9 1a!adoxicall(,
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
dis&dlities to health ca!e which have !es&lted "!om a ta+e8ove! '( the hosital in medical ca!e
(the ta+eove! %as ossi'le 'eca&se o" a hosital8cente!ed e!cedon o" disease). -o! a do=en
sociolo*ical e!sectives on the contemo!a!( hosital, cons&lt Eliot -!eidson, ed., The
%ospital * Mode <ociet( (Ne% No!+: -!ee 1!ess, 196.). <ee also Iohann I. 3hode,
Saaiologie des x!an+enha&& Q&! Ei!(15n!a* in die So8iologie der Medi=i ! . . . (<t&tt*a!t:
En+e, 196,), e!has the most com!ehensive sociolo*( o" the hosital.
&C 'n the histo!( o" 'od( e!cetion in E&!oean c&lt&!es, see No!'e!t Elias, 'ber doe -
o=ess der Qiailisation. So8iogendische aid ps5diogenetische 9nte!o%ls ngen, vol. 9,
"msdlangen des 6erhaltens in dan "eitlich en des AbaedlandesM vol; &, "oodbines da
Caellschaft Entwurf 8u sines Theorie der ]ivilisatson 2,ernS*unich= (ranc#e, 9>?>A; 2(rench
translation, +aris= Calmmann4-evy, 9>:0A;
,9 5n examle: 7. L. 3osenhan, GBn )ein* <ane in Insane 1laces,G <cience 179 (197.): ,5>8
5;. GBnce ei*ht se&doatients had *ained admission to mental
xxx "otnote "o!tsette! E neste side xxx
((166))
the( have !ende!ed it mo!e and not less di""ic&lt to !aise the same +ind o" A&estion a'o&t
disease in general; Lei"e!, Oo""man, <=as=, Lain*, and othe!s a!e all inte!ested in the olitical
*enesis o" mental illness and its &se "o! olitical &!oses..> In o!de! to ma+e thei! oint, the(
all cont!ast G&n!ealG mental %ith G!ealG h(sical disease: in thei! vie% the lan*&a*e o" nat&!al
science, no% alied to all conditions that a!e st&died '( h(sicians, !eall( "its h(sical
sic+ness onl(. 1h(sical sic+ness is con"ined to the 'od(, and it lies in an anatomical,
h(siolo*ical, and *enetic context. The G!ealG existence o" these conditions can 'e con"i!med
'( meas&!ement and exe!iment, %ith8o&t an( !e"e!ence to a val&e8s(stem. None o" this
alies to mental sic+ness: its stat&s as a Gsic+nessG deends enti!el( on s(chiat!ic :&d*ment.
The s(chiat!ist acts as the a*ent o" a social, ethical, and olitical milie&. Meas&!ements and
exe!iments on these GmentalG conditions can 'e cond&cted onl( %ithin an ideolo*ical
"!ame%o!+ %hich de!ives its consistenc( "!om the *ene!al social !e:&dice o" the s(chiat!ist.
The !evalence o" sic+ness is 'lamed on li"e in an alienated societ(, '&t %hile olitical
!econst!&ction mi*ht eliminate m&ch s(chic sic+ness, it %o&ld me!el( !ovide 'ette! and
mo!e eA&ita'le technical t!eat8ment "o! those %ho a!e h(sicall( ill.
This antis(chiat!ic stance, %hich le*itimi=es the non
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
instit&tions ('( sa(in* the( hea!d voices), the( "o&nd themselves indeli'l( la'eled %ith a
dia*nosis o" schi=oh!eniaDin site o" thei! s&'seA&ent no!mal 'ehavio!. I!onicall(, it %as
onl( the othe! inmates %ho s&sected that the se&doatients %e!e no!mal. The hosital
e!sonnel %e!e not a'le to ac+no%led*e no!mal 'ehavio! %ithin the hosital milie&.G
.> Thomas <. <=as=, The *yth of *ortal )llness 2.ew <or#= %arper tit ow, 9>?9A; Thomas
S; Sum, *anufacture of *adness= A Comparative Study of the InA&isition and the Mental
#ealth Movement (Ne% <or#= #a!e! V 3o%, 197>). 3onald Lei"e!, In the Name o" Mental
#ealth: <ocial 5mnions o" 1s(chiat!( (Ne% <or#= 5!onson, 1969). E!vin* Oo"man, Any
Essays on the Social Situation o" Mental 1atients and Bthe! Inmates (1961R ae!'ac+ ed.,
Ne% No!+: 7o&'leda(, 197.). 3. 7. Lain* and 5. Estenon, <anit(, Madness, and the -amil(
()altimo!e: 1en*&in, 197>).
xxx "otnote sl&tt xxx
((167))
olitical stat&s o" h(sical disease '( den(in* to mental deviance the cha!acte! o" disease, is a
mino!it( osition in the $est, altho&*h it seems to 'e close to an o""icial doct!ine in mode!n
0hina, %he!e mental illness is e!ceived as a olitical !o'lem. Maoist oliticians a!e laced
in cha!*e o" s(chotic deviants. )e!mann.1 !eo!ts that the 0hinese o':ect to the !evisionist
3&ssian !actice o" deolitici=in* the deviance o" class enemies '( loc+in* them into
hositals and t!eatin* them as i" the( had a sic+ness analo*o&s to an in"ection. The( !etend
that onl( the oosite a!oach can *ive !es&lts: the intensive olitical !e8ed&cation o" eole
%ho a!e no%, e!has &nconscio&sl(, class enemies. Thei! sel"8c!iticism %ill ma+e them
oliticall( active and th&s health(. #e!e a*ain, the insistence on the !ima!il( nonclinical
nat&!e o" mental deviance. !ein"o!ces the 'elie" that anothe! +ind o" sic+ness is a mate!ial
entit(..,
5dvanced ind&st!ial societies have a hi*h sta+e in maintaining the eistemolo*ical le*itimac(
o" disease entities. 5s lon* as disease is somethin* that ta+es ossession o" eole, somethin*
the( GcatchG o! G*et,G the victims o" these nat&!al !ocesses can 'e exemted "!om
!esonsi'ilit( "o! thei! condition; The( can 'e itied !athe! than 'lamed "o! slo(, vile, o!
incometent e!"o!mance in s&""e!in* thei! s&':ective !ealit(R the( can 'e !e*a!ded as
e!sec&ted !athe! than acc&!sed i" the( h&m'l( accet thei! disease as the ex!ession o" Gho%
thin*s a!eGR and the( can 'e discha!*ed "!om an( olitical
xxx "otnote sta!t xxx
.1 O!e*o!ia )e!mann, -a SantF mental; en Chine, trans; A; ,arbaste 2+aris= *aspero, 9>:JA;
'riginal title= -a salad mental en China 2,uenos Aires= Ed; 3orge Alvare8, 9>:BA;
., 1ete! <ed*%ic+, GIllness, Mental and Bthe!%ise: 5ll Illnesses Ex!ess a <ocial
I&d*ement,G %astings Center Studies 1, no. . (197.): 198/>, oints o&t that events constit&te
sic+ness and disease onl( a"te! man la'els them 'oth as deviances and as conditions that a!e
&nde! social cont!ol. #e !omises to !aise the eistomolo*ical A&estion a'o&t sic+ness in
*ene!al in a 'oo+ soon to 'e &'lished '( #a!e! V 3o%.
xxx "otnote sl&tt xxx
((16;))
!esonsi'ilit( "o! havin* colla'o!ated in inc!easin* the sic+enin* st!ess o" hi*h8intensit(
ind&st!(. 5n advanced ind&st!ial societ( is sic+8ma+in* 'eca&se it disa'les eole "!om
coin* %ith thei! envi!onment and, %hen the( '!ea+ do%n, "!om s&'stit&tin* a GclinicalG
!osthesis "o! the '!o+en relationships; 1eole %o&ld !e'el a*ainst s&ch an envi!onment i"
medicine did not exlain thei! 'iolo*ical diso!ientation as a de"ect in thei! health, !athe! than
as a de"ect in the %a( o" li"e %hich is imosed on them o! %hich the( imose on
themselves... The ass&!ance o" e!sonal olitical innocence that a dia*nosis o""e!s the atient
se!ves as a h(*ienic mas+ that :&sti"ies "&!the! s&':ection to !od&ction and cons&mtion.
The medical dia*nosis o" s&'stantive disease entities that s&osedl( ta+e shae in the
individ&al6s 'od( is a s&!!etitio&s and amo!al %a( o" 'lamin* the victim. The h(sician,
himsel" a mem'e! o" the dominatin* class, :&d*es that the individ&al does not "it into an
envi!onment that has 'een en*inee!ed and is administe!ed '( othe! !o"essionals, instead o"
acc&sin* his collea*&es o" c!eatin* envi!onments into %hich the h&man o!*anism cannot "it.
<&'stantive disease can th&s 'e inte!!eted as the mate!iali=ation o" a oliticall( convenient
m(th, %hich ta+es on s&'stance %ithin the individ&al6s 'od( %hen this 'od( is in !e'ellion
a*ainst the demands that ind&st!ial societ( ma+es &on it.
In eve!( societ( the classi"ication o" diseaseDthe osolo*(Dmi!!o!s social o!*ani=ation. The
sic+ness that societ( !od&ces is 'ati=ed '( the docto! %ith names that '&!ea&c!ats che!ish.
GLea!nin* disa'ilit(,G Gh(e!+inesis,G o! Gminimal '!ain d(s"&nctionG exlains to a!ents %h(
thei! child!en do not lea!n, se!vin* as an ali'i "o!
xxx "otnote sta!t xxx
.. 5l'e!t Oc!!es, G<inn &nd 9nsinn de! @!an+heit: #io' &nd -!e&d,G in 5l'e!t OZ!!es, ed.,
Der Eran#e, Trgernis der -eistungsgesellseha5) (7Ysseldo!": 1atmos, 1971), . 7/8;;.
xxx "otnote sl&tt xxx
((169))
school6s intole!ance o! incometenceR hi*h 'lood !ess&!e se!ves as an Uali'i "o! mo&ntin*
st!ess, de*ene!ative disease "o! de*ene!atin* social o!*ani=ation. The mo!e convincin* the
dia*nosis, the mo!e val&a'le the the!a( aea!s to 'e, the easie! it is to convince eole that
the( need 'oth, and the less li+el( the( a!e to !e'el a*ainst ind&st!ial *!o%th. 9nioni=ed
%o!+e!s demand the most costl( the!a( ossi'le, i" "o! no othe! !eason than "o! the e!ve!se
leas&!e o" *ettin* 'ac+ some o" the mone( the( have &t into taxes and ins&!ance, and
del&din* themselves that this %ill c!eate mo!e eA&alit(.
)e"o!e sic+ness came to 'e e!ceived !ima!il( as an o!*anic o! 'ehavio!al a'no!malit(, he
%ho *ot sic+ co&ld still "ind in the e(es o" the docto! a !e"lection o" his o%n an*&ish and some
!eco*nition o" the &niA&eness o" his s&""e!in*. No%, %hat he meets is the *a=e o" a 'iolo*ical
acco&ntant en*a*ed in in&tLo&t&t calc&lations. #is sic+ness is ta+en "!om him and t&!ned
into the !a% mate!ial "o! an instit&tional ente!!ise. #is condition is inte!!eted acco!din* to a
set o" a'st!act !&les in a lan*&a*e he cannot &nde!stand. #e is ta&*ht a'o&t alien entities that
the docto! com'ats, '&t onl( :&st as m&ch as the docto! conside!s necessa!( to *ain the
atient6s cooe!ation. Lan*&a*e is ta+en ove! '( the docto!s: the sic+ e!son is de!ived o"
meanin*"&l %o!ds "o! his an*&ish, %hich is th&s "&!the! inc!eased '( lin*&istic
m(sti"ication../
xxx "otnote sta!t xxx
./ ). L. $ho!", -anguage, Thought and eality (Ne% No!+: $ile(, 1956), desc!i'es the
lan*&a*e 'a!!ie! that technical te!minolo*( c!eates 'et%een the !o"essional in*!o& and the
clients de"ined as the o&t*!o&. @. En*elha!dt et al., Eran#e im Eran#enhaus (<t&tt*a!t: En+e,
197.). $hile at the hosital, atients a!e intensivel( and !o*!essivel( m(sti"ied. 5t the time
o" dismissal less than one8thi!d have &nde!stood %hat disease the( have 'een t!eated "o!, and
less than one8"o&!th, %hat the!a( the( have 'een s&':ected to. M. ). @o!ach and ?. -.
Ne*!ete, G7octo!81atient 0omm&nication,G Scientific 5me!ican ,,7 (5&*&st 197,): 6689. In
Los 5n*eles 0hild!en6 #osital, ,>f o" mothe!s do not &nde!stand %hat ails thei! child!en,
5>f do not *!as the o!i*ins o" thei! disease,
xxx "otnote "o!tsette! neste side xxx
((17>))
)e"o!e scienti"ic slan* had come to dominate lan*&a*e a'o&t the 'od(, the !ee!to!( o"
o!dina!( seech in this "ield %as excetionall( !ich..5 1easant lan*&a*e !ese!ved m&ch o"
this t!eas&!e into o&! cent&!(..6 1!ove!'s and sa(in*s +et inst!&ctions !eadil( availa'le..7
The %a( comlaints to the docto! %e!e "o!m&lated '( )a'(lonians and O!ee+s has 'een
coma!ed %ith the ex!essions &sed '( Oe!man 'l&e8colla! %o!+e!s. 5s in antiA&it( the
atient st&tte!s, "lo&nde!s, and sea+s a'o&t %hat G*!is himG o! %hat he Ghas ca&*ht.G )&t
%hile the ind&st!ial %o!+e! !e"e!s to his ache as a d!a' GitG that h&!ts, his !edecesso!s had
man( colo!"&l and ex!essive names "o! the demons.; that 'it o! st&n* them. -inall(,
inc!easin* deendence o" sociall( acceta'le seech on the secial lan*&a*e o" an elite
!o"ession ma+es disease into an inst!&ment o" class domination. The &nive!sit(8t!ained and
the '&!ea&c!at th&s 'ecome thei! docto!6s collea*&e in the t!eatment he disenses, %hile the
%o!+e! is &t in his lace as a s&':ect %ho does not sea+ the lan*&a*e o" his maste!..9
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
and /,f do not "ollo% the advice the( !eceive, "!eA&entl( 'eca&se the( cannot *!as it. 3ao&l
0a!son, in -es 6ieille Douleurs, rev; ed; 2+aris= 3ulliard, 9>?BA, confirms in a more intuitive
fashion that the same is true for his (rench patients;
.5 -o! the lan*&a*e o" disease in Medite!!anean antiA&it( see Nadia van )!oc+, echerches
sur le vocabulaire medical du $rec ancien= <oins et guFrison (1a!is: @linc+siec+, 1961).
#e!mann O!ao%, Eran#er, Eran#heiten und Ar8t 6om *es&nden &nd +!an+en Agypter, von
den Eran#heiten, tom Ar8t und von der Rr8tlichen Tatig#eit ()e!lin: 5+ademie8?e!la*, 1956),
7:16;. Oeo!*es 0ontena&, -a *edicine en Assyrie et en ,abylonie (1a!is: Li'!ai!ie Maloine,
19.;). -o! the lan*&a*e o" the )i'le on disease, see !e"e!ences o" note //, . 1/7 a'ove.
.6 Max #Z"le!, Deutsches Eran#heitsnomen4,uch (M&nich: 1ilot( V LZhle, 1;99). 5
mon&mental collection o" Oe!man o&la! ex!essions !elatin* to o!*ans, thei! "&nctions, and
disease in man and domestic animals, as %ell as those %hich desi*nate !emedies, nat&!al o!
ma*icalR 9,, ac+ed a*es.
.7 Btto E. Moll, SprichwUrterX,ibliographie (-!an+"&!t am Main: @loste!mann, 195;), lists
5; collections o" !ove!'s in all lan*&a*es dealin* %ith Ghealth, sic+ness, medicine, h(*iene,
st&idit(, and la=inessG (. 5./87). In cont!ast, "o! a histo!( o" medical lan*&a*e see
Iohannes <te&del, Die Sprache des Ar8tes= Ethyntologie und $eschichte medi8inischer
Termini (seen onl( in ext!acts).
.; 7ietlinde Oolt=, G@!an+heit &nd <!ache,G Sudhof 5s Archiv 5., no. . (1969): ,,5869.
.97&!in* the 19th cent&!( the ne% middle classes develoed a sense o" *&ilt o! shame a'o&t
disease, %hile the &e! 'o&!*eoisie and no'ilit( t&!ned thei! need
xxx "otnote "o!tsette! neste side xxx
((171))
5s soon as medical e""ectiveness is assessed in o!dina!( lan*&a*e, it immediatel( aea!s that
most e""ective dia*nosis and t!eatment do not *o 'e(ond the &nde!standin* that an( la(man
can develo. In "act, the ove!%helmin* ma:o!it( o" dia*nostic and the!ae&tic inte!ventions
that demonst!a'l( do mo!e *ood than ha!m have t%o cha!acte!istics: the mate!ial !eso&!ces
"o! them a!e ext!emel( chea, and the( can 'e ac+a*ed and desi*ned "o! sel"8&se o!
alication '( "amil( mem'e!s. -o! examle, the !ice o" %hat is si*ni"icantl( health8
"&!the!in* in 0anadian medicine is so lo% that these same !eso&!ces co&ld 'e made availa'le
to the enti!e o&lation o" India "o! the amo&nt o" mone( no% sA&ande!ed the!e on mode!n
medicine. The s+ills needed "o! the alication o" the most *ene!all( &sed dia*nostic and
the!ae&tic aids a!e so elementa!( that the ca!e"&l "ollo%in* o" inst!&ctions '( eole %ho
a!e. e!sonall( conce!ned %o&ld !o'a'l( *&a!antee mo!e e""ective and !esonsi'le &se than
medical
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
"o! constant health ca!e into an exc&se "o! "ashiona'le Gc&!es,G a!tic&la!l( at sas. The
GseasonG at the *!eat sas la(ed a olitical "&nction analo*o&s to s&mmit meetin*s toda(. <ee
$alte! 3Ye**, G7e! @!an+e in de! <icht de! 'Y!*e!lichen Oesellscha"t an de! <ch%elle des 19.
Iah!h&nde!ts,G and Iohannes <te&del, GThe!ae&tische &nd so=iolo*ische -&n+tion de!
Mine!al'ide! im 19. Iah!h&nde!t,G 'oth in $alte! 5!telt and $alte! 3Ye**, eds., Der Ant wed
der Eran#e in der $esellschaf des 9>; 3ahrhunderts= 6ortrGge eines Symposions vom 9;40;
April, 9>?0 in (ran#furt a;*;, Studien 8ur *edi8ingeschichte des 9>; 3ahrhunderts, vol; 9
2Stuttgart= En#e, 9>?:A; ; %; Shryoc#, D*edicine and Society in the 9>th Century,D Cahiers
d1histoire mondiale @ 29>@>A= 99?4J?; -uc ,oltans#i, D-a DFcouverte de la maladie= -a
Diffusion du savoir mFdical,D mimeographed, Centre de Sociologie EuropFenne 2+aris,
9>?CA; ,ased on much empirical data, this paper gathers evidence for the class4specific
diffusion of medical civili8ation, and shows the economic origin of the poor man1s
DhardinessD in the face of suffering and contrasts it with the middle4class Dstruggle against
pain;D
Bne %a( to exlo!e !eactions a*ainst the medicali=ation o" disease e!cetion is to st&d( the
histo!( o" h&mo! %hose '&tt is the docto!. Mate!ials on ca!icat&!es can 'e "o&nd in 9.<.
National Li'!a!( o" Medicine, Caricatures from the Art 0ollection, com. <heila 7&!lin*
($ashin*ton, 7.0., 1959)R #elm&t ?o*t, *edisinische @a!i+at&!en von 9CBB bis 8ur
$egenwart (M&nich: Lehmann, 196>)R 0&!t 1!os+a&e! and -!it= $itt, +ictorial %istory of
Dentistry (0olo*ne: 7&mont, 197>)R 5. $e'e!, Tableau de la caricature mFdicale depuis les
origines 5usqu1Z nos 5ours (1a!is: Editions #ioc!ate, 19.6).
xxx "otnote sl&tt xxx
((17,))
!actice eve! co&ld. Most o" %hat !emains co&ld !o'a'l( 'e handled 'ette! '( G'a!e"ootG
non!o"essional amate&!s %ith dee e!sonal commitment than '( !o"essional h(sicians,
s(chiat!ists, dentists, mid%ives, h(siothe!aists, o! oc&lists.
$hen the evidence a'o&t the simlicit( o" e""ective mode!n medicine is disc&ssed,
medicali=ed eole &s&all( o':ect '( sa(in* that sic+ eole a!e anxio&s and emotion8all(
incometent "o! !ational sel"8medication, and that even docto!s call in a collea*&e to t!eat thei!
o%n sic+ childR and "&!the!mo!e, that malevolent amate&!s co&ld A&ic+l( o!*ani=e into
monool( c&stodians o" sca!ce and !ecio&s medical +no%led*e. These o':ections a!e all
valid i" !aised %ithin a societ( in %hich cons&me! exectations shae attit&des to se!vice, in
%hich medical !eso&!ces a!e ca!e"&ll( ac+a*ed "o! hosital &se, and in %hich the m(tholo*(
o" medical e""icienc( !evails. The( %o&ld ha!dl( 'e valid in a %o!ld that aimed at the
e""ective &!s&it o" e!sonal *oals that an a&ste!e &se o" technolo*( had &t %ithin the !an*e
o" almost eve!(one.
((17.))
!. -eath )gainst -eath
-eath as Commodity
In eve!( societ( the dominant ima*e o" death dete!mines the !evalent concet o" health.1
<&ch an ima*e, the c&lt&!all( conditioned anticiation o" a ce!tain event at an &nce!tain date,
is shaed '( instit&tional st!&ct&!es, dee8seated m(ths, and the social cha!acte! that
!edominates. 5 societ(6s ima*e o" death !eveals the level o" indeendence o" its eole, thei!
e!sonal !elatedness, sel"8!eliance, and aliveness., $he!eve! the met!oolitan
xxx "otnote sta!t xxx
1 3o'e!t O. Blson, G7eath,G in Encyclopedia of +hilosophy, ed. 1. Ed%a!ds (Ne% No!+:
Macmillan, 1967), ,:.>789, *ives a sho!t and l&cid int!od&ction to the +no%led*e o" death and
o" the "ea! o" death. #e!man -ei"el, ed., The *eaning of Death (Ne% No!+: McO!a%8#ill,
1959), *ave a ma:o! imet&s to the s(cholo*ical !esea!ch on death in the 9.<. 3o'e!t -&lton,
ed., 7eath and )dentity (Ne% No!+: $ile(, 1965), is an o&tstandin* antholo*( o" sho!t
cont!i'&tions %hich to*ethe! !e"lect the sta*e o" En*lish8lan*&a*e !esea!ch in 1965. 1a&l
Lands'e!*, Essai sur l1e/pFrience de la mort, s&ivi de +roblKme moral de suicide (1a!is:
<e&il, 1951), is a classic anal(sis. IosT Echeve!!ia, Ffle/ions mFtaphysiques sur la mo!t et le
!o'lime d& s&:et (1a!is: I. $in, 1957), is a l&cid attemt at a henomenolo*( o" death.
0h!istian von -e!'e!, G<o=iolo*ische 5se+te des Todes: Ein ?e!s&ch Y'e! eini*e
)e=ieh&n*en de! <o=iolo*ie =&! hilosohischen 5nth!oolo*ie,G ]eitschrift fir evangelische
Ethnie 7 (196.): ..;86>. 5 st!on* a!*&ment to !ende! death a*ain a se!io&s &'lic !o'lem.
The a&tho! 'elieves that death !e!essed, !ende!ed !ivate and a matte! "o! !o"essionals onl(,
!ein"o!ces the exloitative class st!&ct&!e o" societ(. 5 ve!( imo!tant a!ticle. <ee also
?ladimi! Ian+elevitch, -a mort (1a!is: -lamma!ion, 1966), and Ed*a! Mo!in, -1%omme et la
most (1a!is: <e&il, 197>).
, -o! the st&d( o" the antiA&e death8ima*e in o&! *ene!al context, the "ollo%in* a!e &se"&l:
-ieldin* #. Oa!!ison, GThe O!te+ 0&lt o" the 7ead and the 0hthonian 7eities in 5ncient
Medicine,G 5nnals of *edical %istory 9 (1917): .585.. 5lice $alton, The Cult of As#iepios,
0o!nell <t&dies in 0lassical 1hilolo*( no. . (1;9/R !e!int ed., Ne% No!+: Iohnson 3e!int
0o!., 1965). E!nst )en=,
xxx "otnote "o!tsette! E neste side xxx
((17/))
medical civili=ation has enet!ated, a novel ima*e o" death has 'een imo!ted. Inso"a! as this
ima*e deends on the ne% techniA&es and thei! co!!esondin* ethos, it is s&!anational in
cha!acte!. )&t these ve!( techniA&es a!e not c&lt&!all( ne&t!alR the( ass&med conc!ete shae
%ithin $este!n c&lt&!es and ex!ess a $este!n ethos. The %hite man6s ima*e o" death has
s!ead %ith medical civili=ation and has 'een a ma:o! "o!ce in c&lt&!al coloni=ation.
The ima*e o" a Gnat&!al death,G a death %hich comes &nde! medical ca!e6 +nd "inds &s in *ood
health and old a*e, is a A&ite !ecent ideal.. In "ive h&nd!ed (ea!s it has evolved th!o&*h "ive
distinct sta*es, and is no% !ead( "o! a sixth. Each sta*e has "o&nd its icono*!ahic ex!ession:
(1) the "i"teenth8cent&!( Gdance o" the deadGR (,) the 3enaissance dance at the 'iddin* o" the
s+eleton man, the so8called G7ance o" 7eathGR (.) the 'ed!oom scene o" the a*in* leche!
&nde! the 5ncien 3T*imeR (/) the nineteenth8cent&!( docto! in his st!&**le a*ainst the
!oamin*
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
Das Todesprobiem sn der stoischen +hilosophie 2Stuttgart= Eohlhammer, 9>&>A, P), TGbinger
,eitrRge 8ur Altertwnswiss; :; -udwig "achter, Der Tod im altar Testament 2Stuttgart=
Calwer, 9>?:A; 3ocelyn*ary Catherine Toynbee, Death and ,urial in the oman "orld
2-ondon= Thames & %udson, 9>:9A; E; Sauer, !ntersuchungen 8ur Darstellung des Todes in
der griechisch4rimischen $eschichtsschreibung 2(ran#furt, 9>0BA; 3; Eroll, DTod und Teufel
in4der Anti#e,D 6erhandhmgen der 6ersamnslung deutscher +hilologen @? 29>&?A; %ugo
,lummer, DDie Schilderung des Sterbens in der griechischen Dicht#unst,D .eue fahrbilcher
da #lauischen Alumina, 9>9:, pp; J>>4;@9&;
. This chate! leans heavil( on the maste!"&l essa(s '( 1hilie 5!iTs: GLe 0&lte des mo!ts d
l6ToA&e mode!ne,G evue de l1AcadFmie des Sciences morales et politiques, 1967, . ,58/>R
GLa Mo!t inve!sTe: Le 0han*ement des attit&des devant la mo!t dans les sociTtTs
occidentales,G Archives eurapeennes de sociologie C, no. , (1967)R GLa ?ie et la mo!t che= les
"!an\ais d6a&:o&!d6h&i,G Ethmopasychologie ,7 (Ma!ch 197,): .98//R GLa Mo!t et le mo&!ant
dans not!e civilisation,G 3ev&e "!an\aise de sociologie 1/ (Ian&a!(8Ma!ch 197.)R GLes
TechniA&es de la mo!t,G in %istoire des populations franQaises et de leurs attitudes devant la
vie depuis le P 6llle sac+ (19/;R 1a!is: <e&il, 1971), . .7.89;. 5 s(nosis in En*lish:
1hilie 5!iTs, "estern Attitudes To%a!ds Death= (rame the *iddle Ages to the +resent,
t!ans. 1at!icia 3an&m ()altimo!e: Iohns #o+ins, 197/R London: Ma!ion )o(a!s, 1976). GLa
Mo!t inve!sTeG aea!ed in a t!anslation '( )e!na!d M&!chland as G7eath Inside B&tG in
#astin*s Center <t&dies , (Ma( 197/): .81; (the 'i'lio*!ah( is a'sent "!om the t!anslation).
xxx "otnote sl&tt xxx
((175))
hantoms o" cons&mtion and estilenceR (5) the mid8t%entieth8cent&!( docto! %ho stes
'et%een the atient and his deathR and (6) death &nde! intensive hosital ca!e. 5t each sta*e o"
its evol&tion the ima*e o" nat&!al death has elicited a ne% set o" !esonses that inc!easin*l(
acA&i!ed a medical cha!acte!. The histo!( o" nat&!al death is the6 histo!( o" the medicali=ation
o" the st!&**le a*ainst death./
,he -e$otional -ance of the -ead
-!om the "o&!th cent&!( on%a!ds, the 0h&!ch st!&**led a*ainst a a*an t!adition in %hich
c!o%ds, na+ed, "!en=ied, and '!andishin* s%o!ds, danced on the tom's in the ch&!ch(a!d.
Neve!theless, the "!eA&enc( o" ecclesiastical !ohi'itions testi"ies that the( %e!e o" little avail,
and "o! a tho&sand (ea!s 0h!istian ch&!ches and cemete!ies !emained dance "loo!s. 7eath %as
an occasion "o! the !ene%al o" li"e. 7ancin* %ith the dead on thei! tom's %as an occasion "o!
a""i!min* the :o( o" 'ein* alive and a so&!ce o" man( e!otic son*s and oems.5 )( the late
xxx "otnote sta!t xxx
/ In this chate! I am inte!ested, a'ove all, in the ima*e o" Gnat&!al death.G I am &sin* the
te!m Gnat&!al deathG 'eca&se I "ind it %idel( &sed 'et%een the sixteenth and ea!l( t%entieth
cent&!ies. I oose it to G!imitive death,G %hich comes th!o&*h the activities o" some "e(,
ee!ie, s&e!nat&!al, o! divine a*ent, and to Gcontemo!a!( death,G %hich mo!e o"ten than not
is conceived as a !es&lt o" a social in:&stice, as the o&tcome o" class st!&**le o! o" ime!ial
domination. I am inte!ested in the image o" this nat&!al death, and its evol&tion d&!in* the
"o&! cent&!ies in %hich it %as common in $este!n civili=ations. I o%e the idea o" a!oachin*
m( s&':ect in this %a( to $e!ne! -&chs, Todesbildsr in der mode!nen $esellschat (-!an+"&!t:
<&h!+am, 1969). Bn m( disa*!eement %ith the a&tho!, see note 5/, . ,>, 'elo%.
5Thomas Bhm, Die $ebetsgebRrden der 6Ul#er und das Christentum (Leiden: )!ill, 19/;),
. .7, i"., eseciall( . .;989>, collects evidence on dances held in cemete!ies and the
st!&**le o" the ch&!ch a&tho!ities a*ainst them. 5 medical histo!( o" Bccidental !eli*io&s
cho!eomania: E. L. )ac+man, eligious Dances in the Christian Church and in +opular
*edicine)Diction aire de spiritualitF, "ascicles 1;819, . ,18.7. 5. <chimmel, GTan=: I.
3eli*ion*eschichtlich,G in Die eligion
xxx "otnote "o!tsette! neste side xxx
((176))
"o&!teenth cent&!(, ho%eve!, the sense o" these dances seems to have chan*ed:6 "!om an
enco&nte! 'et%een the livin* and those %ho %e!e al!ead( dead, it %as t!ans8"o!med into a
meditative, int!osective exe!ience. In 1/,/ the "i!st 7ance o" the 7ead %as ainted on a
cemete!( %all in 1a!is. The o!i*inal o" the 0imetiX!e des Innocents is lost, '&t ,*ood coies
allo% &s to !econst!&ct it: +in*, easant, oe, sc!i'e, and maiden each dance %ith a co!se.
Each a!tne! is a mi!!o! ima*e o" the othe! in d!ess and "eat&!e. In the shae o" his 'od(
Eve!(man ca!!ies his o%n death %ith him and dances %ith it th!o&*h his li"e. 7&!in* the late
Middle 5*es, ind%ellin* death7 "aces manR each death comes %ith the s(m'ol co!!esondin*
to his victim6s !an+: "o! the +in* a c!o%n, "o! the easant a itch"o!+. -!om dancin* %ith dead
ancesto!s ove! thei! *!aves, eole t&!ned to !e!esentin* a %o!ld in %hich eve!(one dances
th!o&*h li"e em'!acin* his o%n mo!talit(. 7eath %as !e!esented, not as an anth!oomo!hic
"i*&!e, '&t as a maca'!e sel"8conscio&sness, a constant a%a!eness o" the *ain* *!ave. It %as
not (et the s+eleton man o" the
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
in $eschichte and $egenwart (TY'in*en: 196,), 6:61,81/: -o! the histo!( o" dances in o!
a!o&nd 0h!istian ch&!ches, see L. Oo&*a&d, GLa 7anse dans les T*lises,G evue d1histoire
ecclFsiastique 15 (191/): 58,,, ,,98/5. I. )aloch, GTan=e in @i!che and @i!chhZ"en,G
.iederdeutsche ]eitschrift fir 6ol#s#unde, 9>&C; %; Span#e, DTan8musi# in der Eirche des
*ittelalters,D .euphilosophische *itteilungen .1 (19.>). Oe!manic !ecedents to 0h!istian
cemete!( dances: 3icha!d $ol"!am, Schwerttan8 mid *innerbund (@assel: )i!en!eite!, 19.7)R
onl( a!tl( in !int. $e!ne! 7anc+e!t, GToten*!i'e!,G in !nehrliche -ute= Die verfehinten
,errie ()e!n: -!an+e, 196.), . 5>86.
6 Iohan #&i=in*a, GThe ?ision o" 7eath,G in The "aning of the *iddle Ages= A Study of the
(orms of -ife, Art, and Thought in (rance and the .etherlands in the P)6th and P6th
Centuries 2.ew <or#= St; *artin, 9>&JA, chap; 99, pp; 9&J40@;
: Oe!ha!t ). Ladne!, The )dea of eform= )ts )mpact on Christian Thought and Action in the
Age of the (athers 2Cambridge= %arvard !niv; +ress, 9>@>A; Consult p; 9?0 for the two
currents within the Church about the relation of death to nature since the fourth century; (or
+elagius death was not a punishment for sin, and Adam would have died even had he not
sinned; )n this he differs from Augustine1s doctrine that Adam had been given immortality as
a special gift from $od, and even more from those $ree# Church (athers according to whom
Adam had a spiritual, or Dresurrectional,D body before he transgressed;
xxx "otnote sl&tt xxx
((177))
next cent&!( to %hose m&sic men and %omen %ill soon dance th!o&*h the a&t&mn o" the
Middle 5*es, '&t !athe! each one6s o%n a*in* and !ottin* sel".; 5t this time the mi!!o!9
'ecame imo!tant in eve!(da( li"e, and in the *!i o" the Gmi!!o! o" deathG the G%o!ldG 1>
acA&i!ed a hall&cinatin* oi*nanc(. $ith 0ha&ce! and ?illon, death 'ecomes as intimate and
sens&al as leas&!e and ain.
1!imitive societies conceived o" death as the !es&lt o" an inte!vention '( an alien acto!. The(
did not att!i'&te e!sonalit( to death. 7eath is the o&tcome o" someone6s
xxx "otnote sta!t xxx
; <o "a! the deceased had aea!ed a*eless on his "&ne!al mon&ment. #e no% aea!s as a
deca(in* co!se. @athleen 0ohen, *etamorphosis of a Death Symbol= The Transi4Tomb in
the -ate *iddle Ages and the enaissance (Los 5n*eles: 9niv. o" 0ali"o!nia 1!ess, 197.).
O!&esome tom's meant to teach the livin* aea! "i!st in the last (ea!s o" the 1/th cent&!(. I.
1. #o!n&n*, Ein ,eitrag 8ur )#onographie des Todes, disse!tation, 9niv. o" -!ei'&!*, 19>,.
The enco&nte! 'et%een the livin* and the dead ta+es on imo!tance in a ne% lite!a!( *en!e:
<te"an Olixelli, -es Cinq +oKmes des trois morts et des trois vifs (1a!is: #. 0hamion, 191/)R
3; S; Egils ud, -e Dialogue des morts dans les littFratures frarnQaise, allemande et anglaise
(1a!is: L6Entente linot(iste, 19./)R @a&l"&ss87iesch, GToten*es!iche,G in 3eallexi+on de!
de&tschen Lite!at&!*eschichte, .:.79 "".R and "inds a ne% vis&al ex!ession: @a!l @&nste, Die
-egende der drei -ebenden und der drei Toten (-!ei'&!*: #e!de!, 19>;)R $ill( 3ot=ie!, Die
,egegnung der drei -ebenden und der drei Toten= Eis ,eitrag 8ur (orschung Gber
mittelalterliche 6erganglicli#eitsdarstellung ($inte!s&!: @elle!, 1961)R 1ie!!e Micha&lt, 1as
de la mo!t, ed. I&les 1etit (<ociTtT des )i'liohiles de )el*iA&e, 1;69)R 5l'e!t -!e('e, Das
memento mori in deutscher Sitte, bildlichuer Darstellung und 6ol#sglauben, deutsche
Sprache, Dichtung und Seelsorge (Ootha: 1e!thes, 19>9). The "act that a!o&nd 15>> death
ass&mes st!on* s+eletal "eat&!es and a ne% a&tonom( does not mean that it had not al%a(s
'o!ne anth!oomo!hic "eat&!es, i" not in a!t, then in le*end and oet!(. 1a&l Oei*e!, GTod: /.
7e! Tod als 1e!son,G in %andwirterbuch des deutschen Aberglaubens ()e!lin: $. de O!&(te!,
19,78/,), ;:9768;5.
9 The one *!eat 'oo+ on the mi!!o! in aintin* is O. -. #a!tla&', ]auber des Spelt $eschichte
und ,edeutung des Spiegels in der @&nd (M&nich: 1ie!, 1951). 0ha. 7, sec. iii, G<ie*el de!
?a!tas,G deals a!tic&la!l( %ith the mi!!o! as !eminde! o" t!ansito!i*est. <ee also O. -.
#a!tla&', G7ie <ie*el8'ilde! des Oiovanni )ellini,G 1antheon 15 (Novem'e! 19/,): ,.58/1.
The inte!!etation o" )el ini6s &se o" the mi!!o! to deict the intensit( o" the ne% a%a!eness o"
the am'i*&it( o" h&man anatom(. #en!ich <ch%a!=, GThe Mi!!o! in 5!t,G Art Wuartery 15
(195,): 96811;. <eci"icall( on Gvanit(.G
1> $ol"*an* <tamme!, (rau "eltM Eine mittelalterliche Allegorie, -!ei'&!*e!
9nivenitats!eden, 1959. The G%o!ldG deicted as a "emale "i*&!e in medieval a!tDhal" an*el,
hal" demonD!e!esents the o%e! o" this8%o!ldl( *oods, the 'ea&t( o" nat&!e, '&t also the
deca( o" all that is h&man.
xxx "otnote sl&tt xxx
((17;))
evil intention. This some'od( %ho ca&ses death mi*ht 'e a nei*h'o! %ho, in env(, loo+s at
(o& %ith an evil e(e, o! it mi*ht 'e a %itch, an ancesto! %ho comes to ic+ (o& &, o! the
'lac+ cat that c!osses (o&! ath.11 Th!o&*ho&t the 0h!istian and Islamic6Middle 5*es, death
contin&ed to 'e !e*a!ded as the !es&lt o" a deli'e!ate e!sonal inte!vention o" Ood. No "i*&!e
o" GaG death aea!s at the death'ed, :&st an an*el and a devil st!&**lin* ove! the so&l
escain* "!om the mo&th o" the d(in*. Bnl( d&!in* the "i"teenth cent&!( %e!e the conditions
!ie "o! a chan*e in this ima*e,1, and "o! the aea!ance o" %hat %o&ld late! 'e called a
Gnat&!al death.G The dance o" the dead !e!esents this !eadiness. 7eath can no% 'ecome an
inevita'le, int!insic a!t o" h&man li"e, !athe! than the decision o" a "o!ei*n a*ent. 7eath
'ecomes a&tonomo&s and "o! th!ee cent&!ies coexists as a sea!ate a*ent %ith the immo!tal
so&l, %ith divine !ovidence, and %ith an*els and demons.
xxx "otnote sta!t xxx
11 -o!a 'i'lio*!ah( on attit&des to%a!ds death amon* !imitive eole, see Ed*a! #e!=o*,
+sycho and Death= Archaic *yths and *odern Dreams in Analytical +sychology 2.ew <or#=
+utnam, 9>?:A; +rimitive death is always conceived of as the result of intervention by an
agent; (or the purposes of my argument, the nature of this agent is unimportant; Though
dated, obert %ert8, DContribution Z &ne Tt&de s&! la !e!Tsentation collective de la mo!t,G
-1Anne sociologique 1> (19>58/9>6): /;81.7, !emains the 'est !eosito!( "o! olde! lite!at&!e
on this oint. 0omlement %ith E. <. #a!tland et al., G7eath and the 7isosal o" the 7ead,G in
Encyclopaedia of eligion and Ethics (19,58.,), /:/118511. 3osalind Moss, The -ift After
Death in 'ceania and the *alay Archipelago (19,5R 5nn 5!'o!, Mich.: 9nive!sit(
Mic!o"ilms, 197,), sho%s that the '&!ial "o!ms tend to in"l&ence 'elie"s a'o&t the ca&se o"
death and the nat&!e o" the a"te!li"e. #ans @elsen, G<eele &nd 3echt,G in AufsRt8e sur
)deologie#riti# (Ne&%iedL)e!lin: L&chte!hand, 196/), s&**ests that the &nive!sal "ea! o"
m&!de!o&s ancesto!s &nde!ins social cont!ol. 0ons&lt also the "ollo%in* %o!+s '( Iames
Oeo!*e -!a=e!: *an, $od and )mmortality (London: MacMillan, 19,7)R The ,elief in
)mmortality and the "orship of the Dead, vol; 1, The ,elief Among the Aborigines o"
Australia, the Tones Straits )slands, .ew $uinea and *elanesia (1911R !e!int ed., Ne%
No!+: )a!nes V No'le, 196;)R The (ear of the Dead in +rimitive eligion (Ne% No!+: )i'lo
V Tannen, 19..). 5lso 0la&de LTvi8<t!a&ss, The Savage *ind (0hica*o: 9niv. o" 0hica*o
1!ess, 1966), eseciall( . .>8., ,.785,. <i*m&nd -!e&d, Totem and Taboo (Ne% No!+:
No!ton, 195,).
1, 3o'e!t )oss&at, *anuel bibliographique de le littFrature franQaise du moyen ige 2*elun=
-ibrairie d1Argences, 9>@9A, DDanse macabre,D nos; 0@::4CB, :B90;
xxx "otnote sl&tt xxx
((179))
,he -anse &acabre
In the mo!alit( la(s,l. death aea!s in a ne% cost&me and !ole. )( the end o" the "i"teenth
cent&!(, no lon*e! :&st a mi!!o! ima*e, he ass&mes the leadin* !ole amon* the Glast "o&!
thin*s,G !ecedin* :&d*ment, heaven, and hell.1/ No! is he an( lon*e! :&st one o" the "o&!
aocal(tic !ide!s "!om 3omanesA&e 'as8!elie"s, o! the 'atli+e Mae*e!a %ho ic+s & so&ls
"!om the cemete!( o" 1isa,, o! a me!e messen*e! exec&tin* the o!de!s o" Ood. 7eath has
'ecome an indeendent "i*&!e %ho calls each man, %oman, and child, "i!st as a messen*e!
"!om Ood '&t soon insistin* on his o%n sove!ei*n !i*hts. )( 15.; #ans #ol'ein the
No&n*e!15 had &'lished the "i!st ict&!e8'oo+ o" death, %hich %as to 'ecome a 'est8selle!:
%oodc&ts on the 7anse Maca'!e.16 The dance a!tne!s have shed thei! &t!id
xxx "otnote sta!t xxx
1. -o! the evol&tion o" the Iedennan moti" see #. Lindne!, %ugo von %of fanannstahls
D3eeGmeanD und seine 6orgRnger, dissertation, !niv; of -eip8ig, 9>&C;
1/ 5l'e!to Tenenti, 99 so&U della morte e +amirs ne!e vita dd insch to 2Turin= Einaudi,
9>@:A; Alberto Tenenti, -a 6ie et la mort Z travers l1art du P6s sac# 2+aris= Colin, 9>?&A;
15 #ans #ol'ein the No&n*e!, The Dance of Death= A Complete (acsimile of the 'riginal
9@0C Edition of -es Simulachres et histoires faces de la most 2.ew <or#= Dover, 9>:9A;
16 $alte! 3ehm, Der Todssgedan#s in der deutschen Dichtung vom *ittsSalter bis 8ur
omanti# 2TGbingen= .iemeyer, 9>?:A, gives evidence of a ma5or change in the image of
death in literature around the year 9JBB and then again around 9@&B; See also Edelgard
Dubruc#, The Theme of Death in (rench +oetry of the *iddle Ages and the enaissance
2Atlantic %ighlands, . ;3;= %umanities +ress, 9>?@A, and -; +; Eurt8, The Dance of Death
and the *acabre Spirit in European -iterature 2.ew <or#= )nstitute of (rench Studies, 9>0JA;
(or the new death image of the rising middle lasses of the late *iddle Ages see Erna %irsch,
Tod und 3enseits ine SpGtinittelalter= ]ugleich ein ,eitrag 8ur Eulturgeschichte des deutschen
,tirgertans, dissertation, !niv; of *arburg 2,erlin, 9>&:A; Specifically on the Dance of
Death= %elmut osenfeld, Der mittelalterliche Totentaus= Entstehung, Entwic#lung, ,andung
2*Gnster EUln= ,ohlau, 9>@JA, illustrated; %ellmut osenfeld, DDer Totentan8 in
Deutschland, (ran#reich und )talien,D -ittFrature *odems @ 29>@JA= ?&4CB; osenfeld is the
best introduction to the research and gives a detailed up4to4date bibliography; (or older
literature complement with %; (; *assman, -iteratur der TorartZnss 2-eip8ig= "eipel, 9CJBA;
See also $en ,uchheit, Der Totes s8, seins Entstehung und Eatwwic#heng 2,erlin= %oren,
9>&CA, "olfgang Stammler, Dis Totent#nas des *ittelalters 2*unich= Stobbe, 9>&&A, and
3ames *; Clar#, The Dance of Death in the *iddle Ages and the enaissance 2$lasgow=
3ac#son, 9>@BA; Stephen +; Eosa#y1s
xxx "otnote "o!tsette! neste side xxx
((1;>))
"lesh and t&!ned into na+ed s+eletons. The !e!esentation o" each man as ent%ined %ith his
o%n mo!talit( has no% chan*ed tto sho% his "!en=ied exha&stion in the *!i o" death ainted
as a "o!ce o" nat&!e. The intimate mi!!o!8ima*e o" the Gsel"G %hich had 'een colo!ed '( the
Gne% devotionG,o" the Oe!man m(stics has 'een !elaced '( a death ainted as the e*alita!ian
exec&tione! o" a la% that %hi!ls eve!(one alon* and then mo%s them do%n. -!om a li"elon*
enco&nte!, death has t&!ned into the event o" a moment.
7&!in* the Middle 5*es ete!nit(, to*ethe! %ith Ood6s !esence, had 'een immanent in histo!(.
No% death 'ecomes the oint at %hich linea! cloc+8time ends and ete!nit( meets man. The
%o!ld has ceased to 'e a sac!ament o" this !esenceR %ith L&the! it 'ecame the lace o"
co!!&tion that Ood saves. The !oli"e!ation o" cloc+s s(m'oli=es this chan*e in
conscio&sness. $ith the !edominance o" se!ial time, conce!n "o! its exact meas&!e8ment, and
the !eco*nition o" the sim&ltaneit( o" events, a
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
th!ee vol&mes: $eschichte der Totentin8e, vol. 9, Lie"enm*: AnfZnge der 7a!stell&n*en des
?e!*cn*lich+eits!o'lem sR vol; &, -ieferong= Danse macabre Einleitung=V Die Todesdida#ti#
der 6ortotentan88eitM vol; 0, -iefeerung= Der Totentan8 von heute, ,ibliotheca %umanitatis
%istorica, vols; 9, @, and : 2,udapest= *agyar TUrtFniti *n8eum, 9>0?4JJA, contains a mine
of information, quotations from ancient te/ts, and nearly :BB pictures 2greatly reduced and
badly reproducedA of the Dance of Death up to "orld "ar )); 3; Saugnieu/, -1)conographie
de la mort che8 les graveurs fanyais du P6e siKcle 29>:JA, and Danses macabres de (rance et
d1Espagne et leurs prolongements littFraires, fasc; 0B, ,ibliothKque de la (acultF des -ettres
de -yon 2+aris= -es ,elles -ettres, 9>:&A; Dietrich ,riesenmeister, ,ilder des Todes
2!nterscheidheim= "; Elf, 9>:BA= reproductions are very clear and are organi8ed according
to different themes; Consult the standard iconographies on "estern Christian art= Earl
Eunstle, )#onographie der christlicher Eunst, &w vols; 2(reiburg= %erder, 9>&?4&CAM Emile
*ale, -1Art religieu/ !i la fin du moyen age en -!ance: Etude sur l1iconographie du moyen
Zge et sur ses sources d1inspiration (1a!is: 0olin, 19>;), vol. 1, cha. ,, GLa Mo!t,G . ./6
(see also the th!ee othe! vol&mes on !eli*io&s a!t in -!ance). 0oma!e Easte!n icono*!ah(
(Mo&nt 5thos): 7ion(sios o" -o&ina, *anuel d1iconographie chrFtienne, grieque et latine,
%ith int!od&ction and notes '( 5. N. 7id!on, t!ans. '( 1. 7&!and "!om a )(=antine
man&sc!it (1;/5R !e!int ed., Ne% No!+: ). -!an+lin, 196.). T. <. 3. )osse, Death in the
*iddle Ages= *ortality, 3udgement and emembrance (Ne% No!+: McO!a%8#ill, 197,).
xxx "otnote sl&tt xxx
((1;1))
ne% "!ame%o!+ "o! the !eco*nition o" e!sonal identit( is man&"act&!ed. The identit( o" the
e!son is so&*ht in !e"e!ence to a seA&ence o" events !athe! than in the comleteness o" one6s
li"e san. 7eath ceases to 'e the end o" a %hole and 'ecomes an inte!!&tion in the
seA&ence.l7
<+eleton men !edominate on the title a*es o" the "i!st "i"t( (ea!s o" the %oodc&t, as na+ed
%omen no% !edominate on ma*a=ine cove!s. 7eath holds the ho&!*lass o! st!i+es the to%e!
cloc+.1; Man( a 'ell clae! %as shaed li+e a 'one. The ne% machine, %hich can ma+e time
o" eA&al len*th, da( and ni*ht, also &ts all eole &nde! the same la%. )( the time o" the
3e"o!mation, ostmo!tem s&!vival has ceased to 'e a t!ans"i*&!ed contin&ation o" li"e he!e
'elo%, and has 'ecome eithe! a "!i*ht"&l &nishment in the "o!m o" hell o! a totall( &nme!ited
*i"t "!om Ood in heaven. Ind%ellin* *!ace has 'een t&!ned into :&sti"ication '( "aith alone.
Th&s d&!in* the sixteenth cent&!(, death ceases to 'e conceived o" !ima!il( as a t!ansition
into the next %o!ld, and the accent is laced on the end o" this li"e.19 The oen *!ave looms
m&ch la!*e! than the doo!s o" heaven o! hell and the enco&nte! %ith death has 'ecome mo!e
ce!tain than immo!talit(, mo!e :&st than +in*, oe, o! even Ood. 3athe! than li"e6s aim, it has
'ecome the end o" li"e.
xxx "otnote sta!t xxx
17 <ee #elm&th 1lessne!, GBn the 3elation o" Time to 7eath,G in Ioseh 0am'ell, ed.,
+apers from the E!anos <earboo#s, vol. 0, *an and Time, ,ollingen Series PPP 2+rinceton,
.3;= +rinceton !niv; +ress, 9>@:A, pp; &004?0, especially p; &@@; 'n the impact of time on the
(rench death4image, see ichard $lasser, Time in -!ench Li"e and Tho&*ht, t!ans. 0. O.
1ea!son (Mancheste!: 9nive!sit( 1!ess, 197,), in a!tic&la! . 15; and cha. ., GThe 0oncet
o" Time in the Late! Middle 5*es,G . 7>81.,. Bn the *!o%in* imact o" time conscio&sness
on the sense o" "init&de and death, see 5lois #ahn, Einstellungen 8wn Tod &nd ih!e so=iale
,edingtheit= Eine so8iologische !ntersuchung 2Stuttgart= En#e, 9>?CA, especially pp; &94CJ;
3oost A; *; Eeerloo, DThe Time Sense in +sychiatry,D in 3; T; (raser, ed;, The 6oices of Time
2.ew <or#= ,ra8iller, 9>??A, pp; &0@4@&, Siegfried $iedion, Space, Time and ArchitectureV
The $rowth of a .ew Tradition, Jth ed; 2Cambridge, *ass;= %arvard !nv; +ress, 9>?&A;
1; I&!*is )alt!&saitis, -e *oyen Age fantastiquc AntiquitFs et exotisme dans l1art *othiA&e
(1a!is: 0olin, 1955).
19 Ma!tin L&the!, inte!!etation o" 1salm 9>, $5 />LIII: /;5 "i.
xxx "otnote sl&tt xxx
((1;,))
The "inalit(, imminence, and intimac( o" e!sonal death %e!e not onl( a!t o" the ne% sense
o" time '&t also o" the eme!*ence o" a ne% sense o" individ&alit(. Bn the il*!im6s ath "!om
the 0h&!ch Militant on ea!th to the 0h&!ch T!i&mhant in heaven, death %as exe!ienced ve!(
m&ch as an event that conce!ned 'oth comm&nities. No% each man "aced his o%n and "inal
death. B" co&!se, once death had 'ecome s&ch a nat&!al "o!ce, eole %anted to maste! it '(
lea!nin* the a!t o! the s+ill o" d(in*. Ars *oriendi, one o" the "i!st !inted do8it8(o&!sel"
man&als on the ma!+et, !emained a 'est8selle! in va!io&s ve!sions "o! the next t%o h&nd!ed
(ea!s. Man( eole lea!ned to !ead '( decihe!in* it. The most %idel( ci!c&lated ve!sion %as
&'lished '( 0axton at the $estminste! !ess in 1/91: ove! one h&nd!ed inc&na'&la editions
%e!e made 'e"o!e 15>> "!om %ood'loc+s and "!om mova'le t(e, &nde! the title Art and
Craft to #nowe ye well to dye; The small "olio !inted in neat Oothic lette!s %as a!t o" a
se!ies to inst!&ct the Gcomlete *entlemanG in G'ehavio&!, *entle and devo&t,G "!om
mani&latin* a ta'le +ni"e to cond&ctin* a conve!sation, "!om the a!t o" %eein* and 'lo%in*
the nose to the a!t o" la(in* chess, o" !a(in*, and o" d(in*.
This %as not a 'oo+ o" !emote !ea!ation "o! death th!o&*h a vi!t&o&s li"e, no! a !eminde! to
the !eade! o" an inevita'le stead( decline o" h(sical "o!ces and the constant dan*e! o" death.
It %as a Gho%8toG 'oo+ in the mode!n sense, a comlete *&ide to the '&siness o" d(in*, a
method to 'e lea!ned %hile one %as in *ood health and to 'e +et at one6s "in*e!tis "o! &se in
that inescaa'le ho&!. The 'oo+ is not %!itten "o! mon+s and ascetics '&t "o! Gca!nall and
sec&la!G men "o! %hom the minist!ations o" the cle!*( %e!e not availa'le. It se!ved as a model
"o! simila! inst!&ctions, o"ten %!itten in m&ch less matte!8o"8"act si!it, '( eole li+e
<avona!ola, L&the!, and Ie!em(
((1;.))
Ta(lo!. Men "elt !esonsi'le "o! the ex!ession thei! "ace %o&ld sho% in death.,> @&enstle!
has sho%n that a'o&t this ve!( time an &n!ecedented a!oach %as develoed in the aintin*
o" h&man "aces: the $este!n o!t!ait o" co&ntenance, %hich t!ies to !e!esent m&ch mo!e than
:&st the li+eness o" "acial t!aits. The "i!st o!t!aits, in "act, !e!esent !inces and %e!e exec&ted
immediatel( a"te! thei! death, "!om memo!(, in o!de! to !ende! the individ&al, atemo!al
e!sonalit( o" the deceased !&le! !esent at his state "&ne!al. Ea!l( 3enaissance h&manists
%anted to !emem'e! thei! dead, not as *ho&ls o! *hosts, saints o! s(m'ols, '&t as a
contin&in*, e!sonal, histo!ical !esence.,1
In o&la! devotion a ne% +ind o" c&!iosit( a'o&t the a"te!li"e develoed. -antastic ho!!o!
sto!ies a'o&t dead 'odies and a!tistic !e!esentations o" &!*ato!( 'oth m&ltilied.,, The
*!otesA&e conce!n o" the seventeenth cent&!( %ith *hosts and so&ls &nde!sco!es the *!o%in*
anxiet( o" a c&lt&!e "aced %ith the call o" death !athe! than the :&d*ment o" Ood.,. In man(
a!ts o" the 0h!istian %o!ld
xxx "otnote sta!t xxx
,> The !esonse to Gnat&!alG death %as a !o"o&nd t!ans"o!mation o" 'ehavio! at the ho&! o"
death. -o! contemo!a!( lite!at&!e, see Ma!( 0athe!ine B60onno!, The Art of Dying "ell= The
Development of the Ars *oriendi 2.ew <or#= A*S +ress, 9>??A; -; Elein, Die ,ereitung 8um
Sterben= Studien 8u den evangelischen SterbebGchern des 9?; 3ahrhunderts, dissertation,
!niv; of $Uttingen, 9>@C; (or customs see +lacidus ,erger, DeligiUser ,rauchtum im
!m#reis der Sterbeliturgie in 7e&tschland,G ]eitschrift fur *issionswissenschaft und
eligionswissenschaft @ 29>JCA= 9BC4&JC; <ee also Man"!ed )am'ec+, GTod &nd
9nste!'lich+eit: <t&dien =&m Le'ens*e"Yhl de! "!an=Zsischen 3enaissance nach dem $e!+e
3onsa!de,G ms. disse!tation, 9niv. o" -!an+"&!t, 9>@J; #ilde*a!d 3ei"schneide!, G7ie
?o!stell&n* des Todes &nd des Ienseits in de! *eistlichen Lite!at&! des [II Ih.,G ms.
disse!tation, 9niv. o" TY'in*en, 9>JC; E'e!ha!d @lass, Die Schilderung des Sterbens im
mittelhochedeutschen Epos= Ein ,eitrag 8ur mittelhochdeutschen Stilgeschichte, disse!tation,
9niv. o" O!ei"s%ald, 19.1.
,1 O&stav @&nstle!, G7as )ildnis 3&dol" des <tillens #e!=o*s von Bste!!eich, &nd seine
-&n+tion,G exce!t "!om *itteilungen der 'sterreichischen $alerie 9>:& (?ienna:
@&nsthisto!iches M&se&m, 197,), a'o&t the ve!( "i!st s&ch o!t!ait.
,, O. and M. ?o(elle, GLa Mo!t et 1a&8deli en 1!ovence d6a!Xs les a&tels des Cmes d&
&!*atoi!e: [?e8[[e slides,G Cahiers des Annales &> 29>:BA= 9?B&40J; #o%a!d 3. 1atch,
The 'ther "orld According to Descriptions in *edieval -iterature (0am'!id*e, Mass.:
#a!va!d 9niv. 1!ess, 195>).
,. -o! the G:&d*mentG in the histo!( o" !eli*ions, see <o&!ces B!ientales, -; 3ugement des
morts 2+aris= Seuil, 9>?&AM -eopold Eret8enbacher, Die Seelenwaage=
xxx "otnote "o!tsette! neste side xxx
((1;/))
the dance o" death 'ecame a standa!d deco!ation in the ent!ance o" a!ish ch&!ches. The
<ania!ds '!o&*ht the s+eleton man to 5me!ica, %he!e he "&sed %ith the 5=tec idol o" death.
Thei!8mesti=o o""s!in*,,/ on its !e'o&nd to E&!oe, in"l&enced the "ace o" death th!o&*ho&t
the #as'&!* Emi!e "!om #olland to the T(!ol. 5"te! the 3e"o!mation, E&!oean death
'ecame and !emained maca'!e.
<im&ltaneo&sl(, medical "ol+8!actices m&ltilied, all desi*ned to hel eole meet thei!
death %ith di*nit( as individ&als. Ne% s&e!stitio&s devices %e!e develoed so that one mi*ht
!eco*ni=e %hethe! one6s sic+ness !eA&i!ed the accetance o" a!oachin* death o! some +ind
o" t!eatment. I" the "lo%e! th!o%n into the "o&ntain o" the sanct&a!( d!o%ned, it %as &seless to
send mone( on !emedies. 1eole t!ied to 'e !ead( %hen death came, to have the stes %ell
lea!ned "o! the last dance. 3emedies a*ainst a ain"&l a*on( m&ltilied, '&t most o" them
%e!e still to 'e e!"o!med &nde! the conscio&s di!ection o" the d(in*, %ho la(ed a ne% !ole
and la(ed it conscio&sl(. 0hild!en co&ld hel a mothe! o! "athe! to die, '&t onl( i" the( did
not hold them 'ac+ '( c!(in*. 5 e!son %as s&osed to indicate %hen he %anted to 'e
lo%e!ed "!om his 'ed onto the ea!th %hich %o&ld soon en*&l" him, and %hen the !a(e!s %e!e
to sta!t. )&t '(stande!s +ne% that the( %e!e to +ee the doo!s oen to ma+e it eas( "o! death
to come, to avoid noise so as not to "!i*hten death a%a(, and "inall( to t&!n thei! e(es
!esect"&ll( a%a( "!om the d(in* man in o!de! to leave him alone d&!in* this most e!sonal
event.,5
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
]ur religiisen )dea vom fenseitsgericht auf der Schic#salwaage in %ochreligion, ,ild#unst
und 6ol#sglaube 2Elagenfurt= -andesmuseums fir Eirten, 9>@CA;
,/ Me!lin #. -o!ste!, ed., -a muerte en la ponde me/icana= (rologo y selecci_n de *erlin
(orster (Mexico: Edito!ial 7io*enes, 197>). Emi! 3od!i*&e= Mone*al, G7eath as a @e( to
Mexican 3ealit( in the $o!+s o" Bctavio 1a=,G mimeo*!ahed, Nale 9niv., n.d. (a'o&t 197.).
,5 In !&!al a!eas these c&stoms live on: 5!nold van Oenne, *anuel de fol#lore "!an\ais
contemo!ain, vol. 9, Du berceau d la tombs (1a!is: 1ica!d, 19/.8/6). Len=
xxx "otnote "o!tsette! E neste side xxx
((1;5))
Neithe! !iest no! docto! %as exected to assist the oo! man in t(ical "i"teenth8 and
sixteenth8cent&!( death.G In !incile, medical %!ite!s !eco*ni=ed t%o oosite se!vices the
h(sician co&ld e!"o!m. #e co&ld eithe! assist healin* o! hel the comin* o" an eas( and
seed( death. It %as his d&t( to !eco*ni=e the fades hippocratica,,7 the secial t!aits %hich
indicated that the atient %as al!ead( in the *!i o" death. In healin* as in %ithd!a%al, the
docto! %as anxio&s to %o!+ hand8in8*love %ith nat&!e. The A&estion %hethe! medicine eve!
co&ld G!olon*G li"e %as heatedl( dis&ted in the medical schools o" 1ale!mo, -e=, and even
1a!is. Man( 5!a' and Ie%ish docto!s denied this o%e! o&t8!i*ht, and decla!ed s&ch an,
attemt to inte!"e!e %ith the o!de! o" nat&!e to 'e 'lashemo&s.,;
?ocational =eal teme!ed '( hilosohical !esi*nation comes th!o&*h clea!l( in the %!itin*s
o" 1a!acels&s.G GNat&!e +no%s the 'o&nda!ies o" he! co&!se. 5cco!din* to he! o%n aointed
te!m, she con"e!s &on each o" he! c!eat&!es its !oe! li"e san, so that its ene!*ies a!e
cons&med d&!in* the time that elases 'et%een the moment o" its 'i!th and its !edestined
end. . . . 5 man6s
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
@!iss83etten'ec+, GTod and #eilse!%a!t&n*,G in ,ilder and Qeichen !ds*iCsen 6o&sglanbens
(M&nich: 0all%e(, 196.), . /9856. <ee a!ticles '( 1a&lin Oei*e!, on G<te!'e*ali&te,G
G<te!'en,G G<te!'ende!, G G<te!'e+e!=e,G GTod,G GTod ansa*en,GG!ote (de!),G GToten'ah!e,G in
%asdw_rterbuch des deutschen Aberglaubens ()e!lin: $. de O!&(te!, 19.68.7), vol. ;. 5l'e!t
-!e('e, Das alts deutsche l eiehenmahl in suer Art %ed Enta!t&n* (Oiitenloh: )e!teMnann,
19>9), . 58;6.
,7 -o! an int!od&ction to the "&nction o" the 0atholic !iest at the death'ed, see 0. 3&ch,
GExt!]me onction,G in Dictionnaire de ThFologie Catholique 29>0>A, @, pt; &=9>&:4C@; %enri
ondet, DE/trNme onction,D in Dictimmaire de SpOHualits 29>?BA, J=&9C>4&&BB
,; Ma*n&s <chmid, GQ&m 1hcnomen de! Lei'lich+eit in de! 5nti+e da!*estent an de! J-acia
#ioc!atica,6 G Sdhffs Archie, suppl; :, 9>??, pp; 9?C4::; Earl Sudhoff, DEine #leine deutsche
Todesprognosti#,D Archiv fair $eschichte der *edi8in @ 29>99A= &JB, and DAbermal eine
deutsche -eber1s4 and Todesprognostic,D ibid, ? 29>99A= &09;
,9 Iosh&a B. Lei'o%it=, G5 3esons&m o" Maimonides 0once!nin* the Te!mination o" Li"e,G
@oevth (Ie!&salem) 5 (<etem'e! 196.): 18,. ss 1a!aeels&s, <elected "ritings, t!ans. No!'e!t
O&te!man, )ollin*en <e!ies [[?III (1!inceton, NI.: 1!inceton 9niv. 1!ess, 1969).
xxx "otnote sl&tt xxx
((1;6))
death is nothin* '&t the end o" his dail( %o!+, an exi!ation o" ai!, the cons&mmation o" his
innate 'alsamic sel"8c&!in* o%e!, the extinction o" the !ational li*ht o" nat&!e, and a *!eat
sea!ation o" the th!ee: 'od(, so&l, and si!it. 7eath is a !et&!n to the %om'.G $itho&t
excl&din* t!anscendence, death has 'ecome a nat&!al henomenon, no lon*e! !eA&i!in* that
'lame 'e laced on some evil a*ent.
The ne% ima*e o" death heled to !ed&ce the h&man 'od( to an o':ect. 9 to this time, the
co!se had 'een conside!ed somethin* A&ite &nli+e othe! thin*s: it %as t!eated almost li+e a
e!son. The la% !eco*ni=ed its standin*: the dead co&ld s&e and 'e s&ed '( the livin*, and
c!iminal !oceedin*s a*ainst the dead %e!e common. 1oe 9!'an ?III, %ho had 'een
oisoned '( his s&ccesso!, %as d&* &, solemnl( :&d*ed a simonist, had his !i*ht hand c&t o"",
and %as th!o%n into the Ti'e!. 5"te! 'ein* han*ed as a thie", a man mi*ht still have his head
c&t o"" "o! 'ein* a t!aito!. The dead co&ld also 'e called to %itness. The %ido% co&ld still
!e&diate he! h&s'and '( &ttin* the +e(s and his &!se on his cas+et. Even toda( the
exec&to! acts in the name o" the dead, and %e still sea+ o" the Gdesec!ationG o" a *!ave o! the
sec&la!i=ation o" a &'lic cemete!( %hen it is t&!ned into a a!+. The aea!ance o" nat&!al
death %as necessa!( "o! the co!se to 'e de!ived o" m&ch o" its le*al standin*..>
xxx "otnote sta!t xxx
.> #ein!ich )!&nne!, Deutsche echtsgeschichte 2,erlin= 6on Dunc#er & %um4bolt, 9>?9A,
9=&@J if; +aul (ischer, Strafes and sic#enede *assnahmen gegen Tote ire gern anischen wed
deutschen echt 2DGsseldorf .olte, 9>0?A; %; (ehr, DTod and Teufel im alten echt,D
]eitsclaifl der Savign, Safung 5ia echtsgeschichte ?: 29>@BA= @B4:@; +aul $eiger, D-eiche,D
in %andwaterbach des deutschen Aberglaubens 2,erlin= "; de $ruyter, 9>0&400A, vol; @; Earl
EUnig, DDie ,ehandlung der Toten in (ran#reich im spRteren *ittelalter and 8u ,eginn der
.eu8eit 290@B49@@BA,D ms; dissertation, !niv; of -eip8ig, 9>&9; %ans von %eutig, Der
ne#rotrope *auch= 6an Totenglauben sus morbiden Totemn_he 2Stuttgart= En#e, 9>?JA; +aul
3; Doll, D-es Droits de la science aprKs la mort,D Diog3ae, no; :@, 3uly4September 9>:9, pp;
9&J4J&;
xxx "otnote sl&tt xxx
((1;7))
The a!!ival o" nat&!al death also !ea!ed the %a( "o! ne% attit&des to%a!ds death and disease
%hich 'ecame common in the late seventeenth cent&!(. 7&!in* the Middle 5*es, the h&man
'od( had 'een sac!edR no% the h(sician6s scalel had access to the co!se itsel"..1 Its
dissection had 'een conside!ed '( the h&manist Oe!son to 'e Ga sac!ile*io&s !o"anation, a
&seless c!&elt( exe!cised '( the livin* a*ainst the dead.G ., )&t at the same time that
Eve!(man6s 7eath 'e*an to eme!*e in e!son in the mo!alit( la(s, the co!se "i!st aea!ed
as a teachin* o':ect in the amhitheate! o". the 3enaissance &nive!sit(. $hen the "i!st
a&tho!i=ed &'lic dissection too+ lace in Montellie! in 1.75, this ne% lea!ned activit( %as
decla!ed o'scene, and the e!"o!mance co&ld not 'e !e8 . eated "o! seve!al (ea!s. 5
*ene!ation late!, e!mission %as *iven "o! one co!se a (ea! to 'e dissected %ithin the 'o!de!s
o" the Oe!man Emi!e. 5t the 9nive!sit( o" )olo*na, also, one 'od( %as dissected each (ea!
:&st 'e"o!e 0h!istmas, and the ce!emon( %as ina&*&!ated '( a !ocession, accomanied '(
exo!cisms, and too+ th!ee da(s. 7&!in* the "i"teenth cent&!(, the 9nive!sit( o" LT!ida in <ain
%as entitled to the co!se o" one c!iminal eve!( th!ee (ea!s, to 'e dissected in the !esence o"
a nota!( assi*ned '( the InA&isition. In En*land in 15/>, the "ac&lties o" the &nive!sities %e!e
a&tho!i=ed to claim "o&! co!ses a (ea! "!om the han*man. 5ttit&des chan*ed so !aidl( that
'( 1561 the ?enetian <enate o!de!ed the
xxx "otnote sta!t xxx
.1 The cont!ast aea!s clea!l( %hen Lo!en 0. Mac@inne(, *edical )llustrations in *edieval
*anuscripts 2,er#eley= !niv; of California +ress, 9>?@A, is compared with *illard *eiss,
+ainting in -lo!ence and <sna a"te! the )lac+ 7eath: The 5!ts, 3eli*ion and <ociet( in the
*id4(ourteenth Cm#ery (1!inceton, N .I.: 1!inceton 9niv. 1!ess, 1951). 5!t, li'e!ated "!om
the need to !e!esent do*ma, no% sho%s the h&man "i*&!e, its actions, and even the dead
thin*s %hich s&!!o&nd it as intimatel( inte!%oven in the !e!esentation o" the "leetin* moment
(?e!*cn*lich+eitA;
., Ma&!ice )a!iet( and 0ha!les 0o&!(, GLa 7issection,G in %istoire de la mFdecine 2+aris=
(ayard, 9>?0A, pp; JB>499;
xxx "otnote sl&tt xxx
((1;;))
han*man to ta+e inst!&ction "!om 7!. -alloi&s in o!de! to !ovide him %ith co!ses %ell
s&ited "o! Ganatomi=in*.G 3em'!andt ainted G7!. T&l6s LessonG in 16.,. 1&'lic dissection
'ecame a "avo!ed s&':ect "o! aintin*s and, in the Nethe!lands, a common event at ca!nivals.
The "i!st ste to%a!ds s&!*e!( on television and in the movies had 'een ta+en. The h(sician
had advanced his +no%led*e o" anatom( and his o%e! to exhi'it his s+ill, '&t 'oth %e!e
dis!oo!tionate to an advance in his a'ilit( to heal. Medical !it&als heled to o!ient, !e!ess,
o! alla( the "ea! and an*&ish *ene!ated '( a death that had 'ecome maca'!e. The anatom( o"
?esali&s !ivaled #ol'ein6s 7anse Maca'!e some%hat as scienti"ic sex8*&ides no% !ival
+layboy and +enthouse ma*a=ines.
Bourgeois -eath
)a!oA&e death co&nte!ointed an a!istoc!aticall( o!*ani=ed heaven... The ch&!ch va&lt mi*ht
deict a last :&d*ment %ith sea!ate saces !ese!ved "o! sava*es, commone!s, and no'les, '&t
the 7ance o" 7eath 'eneath deicted the mo%e! %ho &sed his sc(the !e*a!dless o" ost o!
!an+. 1!ecisel( 'eca&se maca'!e eA&alit( 'elittled %o!ldl( !ivile*e, it also made it mo!e
le*itimate../ #o%eve!, %ith the !ise o" the 'o&!*eois "amil(,.5 eA&alit(
xxx "otnote sta!t xxx
.. #e!mann )a&e!, Der %immel in o#o#o= Das (res#o im deutschen Eirchenraum in 9C; ,
fahrhundert 2*unich= +ustet, 9>?@A;
./ 3e"lection o" death in 17th and 1;th cent&!( lite!at&!e: 3icha!d <exa&, 7e! Tod in
deutschen Drama des 9:; und 9C; 3ahrhunderts= 6on Cn[hius bis 8um Sturm und Drang
2,ern= -!anc+e, 19>6). -!ied!ich8$ilhelm E**e'e!t, Das +roblem des Todes in der deutschen
-yri# des 17. Iah!h&nde!ts (Lei=i*, 19.1). $. M. Thomson, Der Tod in der englische -yri#
des 17. Iah!h&nde!ts ()!esla&: 1!ie'atsch, 19.5).
.5 5!iXs, GLa mo!t inve!sTeG: GIn the late Middle 5*es (in oosition to the "i!st Middle 5*es,
the a*e o" 3oland, %hich lives on in the easants o" Tolsto() and the 3enaissance, a man
insisted &on a!ticiatin* in his o%n death 'eca&se he sa% in it an excetional moment Da
moment %hich *ave his individ&alit( its de"initive "o!m. #e %as onl( the maste! o" his li"e to
the extent that he %as the m&te! o" his death. #is death 'elon*ed to him, and to him
xxx "otnote "o!tsette! E neste side xxx
((1;9))
in death came to an end: those %ho co&ld a""o!d it 'e*an to a( to +ee death a%a(.
-!ancis )acon %as the "i!st to sea+ a'o&t the !olon*ation o" li"e as a ne% tas+ "o!
h(sicians. #e divided medicine into th!ee o""ices: G-i!st, the !ese!vation o" health, second,
the c&!e o" disease, and thi!d, the !olon*ation o" li"e,G and extolled the Gthi!d a!t o"
medicine, !e*a!din* the !olon*ation o" li"e: this is a ne% a!t, and de"icient, altho&*h the
most no'le o" all.G The medical !o"ession did not even conside! "acin* this tas+, &ntil, some
one h&nd!ed and "i"t( (ea!s late!, the!e aea!ed a host o" clients %ho %e!e anxio&s to a( "o!
the attemt. This %as a ne% t(e o" !ich man %ho !e"&sed to die in !eti!ement and insisted on
'ein* ca!!ied a%a( '( death "!om nat&!al exha&stion %hile still on the :o'. #e !e"&sed to
accet death &nless he %as in *ood health in an active old a*e. Montai*ne had al!ead(
!idic&led s&ch eole as excetionall( conceited: G 6Tis the last and ext!eme "o!m o" d(in* . . .
%hat an idle conceit is it to exect to die o" a deca( o" st!en*th %hich is the e""ect o" the
ext!emest a*e, and to !oose to o&!selves no sho!te! lease on li"e . . . as i" it %e!e cont!a!( to
nat&!e to see a man '!ea+ his nec+ %ith a "all, 'e d!o%ned '( shi%!ec+, 'e snatched a%a(
%ith le&!is( o! the la*&e . . . %e o&*ht to call nat&!al death that %hich is *ene!al, common
and &nive!sal.G .6 <&ch eole %e!e "e% in his timeR soon thei! n&m'e!s %o&ld inc!ease. The
!eache! exectin* to *o to heaven, the hilosohe! den(in* the existence o" the so&l, and the
me!chant %antin* to see his caital do&'le once mo!e %e!e all in a*!eement that the onl(
death that acco!ded
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
alone. -!om the 17th cent&!( on%a!d, one 'e*an to a'dicate sole sove!ei*nt( ove! li"e, as %ell
as ove! death. These matte!s came to 'e sha!ed %ith the "amil( %hich had !evio&sl( 'een
excl&ded "!m the se!io&s decisionsR all decisions had 'een made '( the d(in* e!son, alone
and %ith "&ll +no%led*e o" his imendin* death.G
.6 Michel de Montai*ne, Essays, '+. 1, cha. 57.
xxx "otnote sl&tt xxx
((19>))
%ith nat&!e %as one %hich %o&ld ove!ta+e them at thei! des+s. .7
The!e is no evidence to sho% that the a*e8seci"ic li"e exectanc( o" most eole in thei!
sixties had inc!eased '( the middle o" the ei*hteenth cent&!(, '&t the!e is no do&'t that ne%
technolo*( had made it ossi'le "o! the old and !ich to han* on %hile doin* %hat the( had
done in middle a*e. The ame!ed co&ld sta( on the :o' 'eca&se thei! livin* and %o!+in*
conditions had eased. The Ind&st!ial 3evol&tion had 'e*&n to c!eate emlo(ment
oo!t&nities "o! the %ea+, sic+l(, and old. <edenta!( %o!+, hithe!to !a!e, had come into its
o%n. .;3isin* ent!e!ene&!shi and caitalism "avo!ed the 'oss %ho had had the time to
acc&m&late caital and exe!ience. 3oads had im!oved: a *ene!al a""ected '( *o&t co&ld
no% command a 'attle "!om his %a*on, and dec!eit dilomats co&ld t!avel "!om London to
?ienna o! Mosco%. 0ent!ali=ed nation8states inc!eased the need "o! sc!i'es and an enla!*ed
'o&!*eoisie. The ne% and small class o" old men had a *!eate! chance o" s&!vival 'eca&se
thei! lives at home, on the st!eet, and at %o!+ had 'ecome h(sicall( less demandin*. 5*in*
had 'ecome a %a( o" caitali=in* li"e. Nea!s at the des+, eithe! at the co&nte! o! the school
'ench, 'e*an to 'ea! inte!est on the ma!+et. The (o&n* o" the middle class, %hethe! *i"ted o!
not, %e!e no% "o! the "i!st time sent to school, th&s allo%in* the old to sta( on the :o'. The
'o&!*eoisie %ho co&ld a""o!d to eliminate Gsocial deathG '( avoidin* !eti!ement, c!eated
GchildhoodG to +ee thei! (o&n* &nde! cont!ol. .9
xxx "otnote sta!t xxx
.7 O. 1ei*not, Choi/ de testaments anciens st modernes, remarquables par lets importance,
leur singulariti ou leur bi8arrerie, , vols. (1a!is. 3eno&a!d, 1;,9). Michel ?o(elle, Mo&!i!
a&t!e"ois: Attitudes collectives decant la mort au/ P6))e et P6)))e siKcles (1a!is: 5!chives
Oallima!d I&llia!d, 197/), and +iFtF baroque et dFchristianisation en +rovence au P6)))e
siKcle= -es Attitudes devant la mort d1aprKs les clauses des testaments (1a!is: 1ion, 197/).
-!ede!ic+ 1olloc+ and -!ede!ic $. Maitland, GThe Last $ill,G in The %istory of the English
-aw ,efore the Time of Edward ) (0am'!id*e: 9nive!sit( 1!ess, 196;), vol. 1, cha. 6, .
.1/856.
.; 5!iTs, GLes TechniA&es de la mo!t.G
.9 1hilie 5!iTs, 0ent&!ies of Childhood A <ocial %istory of (amily -ife (Ne% No!+: @no",
196,), cha. ,.
xxx "otnote sl&tt xxx
229>9AA
5lon* %ith the economic stat&s o" the old, the val&e o" thei! 'odil( "&nctions inc!eased. In the
sixteenth cent&!( Ga (o&n* %i"e is death to an old man,G and in the seventeenth, Gold men %ho
la( %ith (o&n* maids dance %ith death.G 5t the co&!t o" Lo&is [I? the old leche! %as a
la&*hin*stoc+R '( the time o" the 0on*!ess o" ?ienna he had t&!ned into an o':ect o" env(. To
die %hile co&!tin* one6s *!andson6s mist!ess 'ecame the s(m'ol o" a desi!a'le end.
5 ne% m(th a'o&t the social val&e o" the old %as develoed. 1!imitive h&nte!s, *athe!e!s, and
nomads had &s&all( +illed them, and easants had &t them into the 'ac+ !oom,/> '&t no% the
at!ia!ch aea!ed as a lite!a!( ideal. $isdom %as att!i'&ted to him :&st 'eca&se o" his a*e. It
"i!st 'ecame tole!a'le and then a!o!iate that the elde!l( sho&ld attend %ith solicit&de to the
!it&als deemed necessa!( to +ee & thei! totte!in* 'odies. No h(sician %as (et in attendance
to ta+e on this tas+, %hich la( 'e(ond the cometence claimed '( aotheca!( o! he!'alist,
'a!'e! o! s&!*eon, &nive!sit(8t!ained docto! o! t!avelin* A&ac+. )&t it %as this ec&lia!
demand that heled to c!eate a ne% +ind o" sel"8st(led heale!./1
xxx "otnote sta!t xxx
/> @illin* the a*ed %as a %ides!ead c&stom &ntil !ecent times. Iohn @ot(, Die ,ehandlung
der Alten und Eran#en bei den .aturvol#ern 2Stuttgart= %irschfeld, 9>0JA; "ill4Eich
+euc#ert, DAltentUtung,D in %andwUrterbuch der Sage= .amens des 6erbandes der 6ereine
fGr 6ol#s#unde (Oottin*en: ?andenhoec+ V 3&!echt, 1961). I. $isse, <el'stmo!d und
Todesfurcht bei den .aturvU#em (Q&then: Thieme, 19..). In"anticide !emained imo!tant
eno&*h to in"l&ence o&lation t!ends &ntil the 9th cent&!(. Emil( 3. 0oleman, GL6In"anticide
dans le ha&t mo(en i*e,G t!ans. 5. 0hamo&x, Annales Economies, So i3 Fs, 0ivilisations,
197/, no. ,, . .158.5.
/1 E!%in #. 5c+e!+necht, G7eath in the #isto!( o" Medicine,G ,ulletin of the %istory of
*edicine J& 29>?CA= 9>4&0; Death remained a marginal problem in medical literature from
the old $ree#s until $iovanni *aria -ancisi 29?@J49:&BA during the first decade of the
eighteenth century; Then quite suddenly the Dsigns of deathD acquired e/traordinary
importance; Apparent death became a ma5or evil feared by the Enlightenment; *argot
Augener, DScheintod als medi8inisches +roblem im 9C; 3ahrhundert,D *itteilungen s&s
Oeschichte der Medi=in, nos. 6 and 7, 1967. The same hilosohe!s %ho %e!e the mino!it(
%hich ositivel( denied the s&!vival o" a so&l also develoed a sec&la!i=ed "ea! o" hell
xxx "otnote "o!tsette! neste side xxx
((19,))
-o!me!l(, onl( +in* o! oe had 'een &nde! an o'li*ation to !emain in command &ntil the da(
o" his death. The( alone cons&lted the "ac&lties: the 5!a's "!om <ale!no in the Middle 5*es,
o! the 3enaissance men "!om 1ad&a o! Montellie!. @in*s, ho%eve!, +et co&!t h(sicians to
do %hat 'a!'e!s did "o! the commone!: 'leed them and &!*e them, and in addition, !otect
them "!om oisons. @in*s neithe! set o&t to live lon*e! than othe!s, no! exected thei!
e!sonal h(sicians to *ive secial di*nit( to thei! declinin* (ea!s. In cont!ast, the ne% class
o" old men sa% in death the a'sol&te !ice "o! a'sol&te economic val&e./, The a*in*
acco&ntant %anted a docto! %ho %o&ld d!ive a%a( deathR %hen the end a!oached, he
%anted to 'e "o!mall( G*iven &G '( his docto! and to 'e se!ved his last !east %ith the
secial 'ottle !ese!ved "o! the occasion. The !ole o" the Gvalet&dina!ianG %as the!e'( c!eated,
and %ith *enteel dec!eit&de, the ei*hteenth8cent&!( *!o&nd%o!+ %as laid "o! the economic
o%e! o" the contemo!a!( h(sician.
The a'ilit( to s&!vive lon*e!, the !e"&sal to !eti!e 'e"o!e death, and the demand "o! medical
assistance in an inc&!a'le condition had :oined "o!ces to *ive !ise to a ne% concet o"
sic+ness: the t(e o" health to %hich old a*e co&ld asi!e. In the (ea!s :&st 'e"o!e the -!ench
3evol&tion this had 'ecome the health o" the !ich and the o%e!"&lR %ithin a *ene!ation
ch!onic disease 'ecame
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
%hich mi*ht th!eaten them i" the( %e!e '&!ied %hile onl( aa!entl( dead. 1hilanth!oists
"i*htin* "o! those in dan*e! o" aa!ent death "o&nded societies dedicated to the s&cco! o" the
d!o%nin* o! '&!nin*, and tests %e!e develoed "o! ma+in* s&!e that the( had died. Eli=a'eth
Thomson, GThe 3ole o" the 1h(sician in #&man <ocieties o" the 1;th 0ent&!(,G ,ulletin of
the %istory of *edicine 0: (196.): /.851. Bne o" these tests consisted o" 'lo%in* %ith a
t!&met into the dead man6s ea!. The h(ste!ia a'o&t aa!ent death disaea!ed %ith the
-!ench 3evol&tion as s&ddenl( as it had aea!ed at the da%n o" the cent&!(. 7octo!s 'e*an
to 'e conce!ned %ith !eanimation a cent&!( 'e"o!e the( %e!e emlo(ed in the hoe o"
prolonging the li"e o" the old.
/, Theodo! $. 5do!no, *inima *oralia= efle/ionen aus dent beschRdigten -eben
2(ran#furt am *ain= Suhr#amp, 9>:BA;
xxx "otnote sl&tt xxx
((19.))
"ashiona'le "o! the (o&n* and !etentio&s, cons&mtive "eat&!es/. the si*n o" !emat&!e
%isdom, and the need "o! t!avel into %a!m climates a claim to *eni&s. Medical ca!e "o!
!ot!acted ailments, even tho&*h the( mi*ht lead to &ntimel( death, had 'ecome a ma!+ o"
distinction.
)( cont!ast, a !eve!se :&d*ment no% co&ld 'e made on the ailments o" the oo!, and the ills
"!om %hich the( had al%a(s died co&ld 'e de"ined as &nt!eated sic+ness. It did not matte! at
all i" the t!eatment docto!s co&ld !ovide "o! these ills had an( e""ect on the !o*!ess o" the
sic+nessR the lac+ o" s&ch t!eatment 'e*an to mean that the( %e!e condemned to die an
&nnat&!al death, an idea that "itted the 'o&!*eois ima*e o" the oo! as &ned&cated and
&n!od&ctive. -!om no% on the a'ilit( to die a Gnat&!alG death %as !ese!ved to one social
class: those %ho co&ld a""o!d to die as atients.
#ealth 'ecame the !ivile*e o" %aitin* "o! timel( death, no matte! %hat medical se!vice %as
needed "o! this &!ose. In an ea!lie! eoch, death had ca!!ied the ho&!*lass. In. %oodc&ts,
'oth s+eleton and onloo+e! *!in %hen the victim !e"&ses death. No% the middle class sei=ed
the cloc+ and emlo(ed docto!s to tell death %hen to st!i+e.// The Enli*htenment att!i'&ted a
ne% o%e! to the docto!, %itho&t 'ein* a'le to ve!i"( %hethe! o! not he had acA&i!ed an( ne%
in"l&ence ove! the o&tcome o" dan*e!o&s sic+ness.
xxx "otnote sta!t xxx
/. E; E'stein, G7ie L&n*ensch%inds&cht in de! $eltlite!at&!,G bitschrift fen ,Gc amds @
(191.).
// 5l"!ed <cott $a!thin, GThe +hysician of the 7ance o" 7eath,G Annals of *edical %ideo,
2new se!ies) , (I&l( 19.>): .5>871R , (<etem'e! 19.>): /5.869R , (Novem'e! 19.>): 6978
71>R . (Ian&a!( 19.1): 7581>9R . (Ma!ch 19.1): 1./865. 7eals excl&sivel( %ith the h(sician
in the 7ance o" 7eath. $e!ne! )loc+, Dor Ar8t Hend der Tod in ,ildern aus sales
fahrliurdsrtea 2Stuttgart= En#e, 9>??A, studies the doctor1s encounter with death in and
outside a formal dance;
xxx "otnote sl&tt xxx
((19/))
Clinical -eath
The -!ench 3evol&tion ma!+ed a sho!t inte!!&tion in the medicali=ation o" death. Its
ideolo*&es 'elieved that &ntimel( death %o&ld not st!i+e in a societ( '&ilt on its t!ile ideal.
)&t the docto!6s ne%l( acA&i!ed clinical e(e*lasses made him loo+ at death in a ne%
e!sective. $he!eas the me!chants o" the ei*hteenth cent&!( had dete!mined the o&tloo+ on
death %ith the hel o" the cha!latans the( emlo(ed and aid, no% the clinicians 'e*an to
shae the &'lic6s vision. $e have seen death t&!n "!om Ood6s call into a Gnat&!alG event and
late! into a G"o!ce o" nat&!eGR in a "&!the! m&tation it had t&!ned into an G&ntimel(G event %hen
it came to those %ho %e!e not 'oth health( and old. No% it had 'ecome the o&tcome o"
seci"ic diseases ce!ti"ied '( the docto! /5
7eath had aled into a metaho!ical "i*&!e, and +ille! diseases had ta+en his lace. The
*ene!al "o!ce o" nat&!e that had 'een cele'!ated as GdeathG had t&!ned into a host o" seci"ic
ca&sations o" clinical demise. Man( GdeathsG no% !oamed the %o!ld. 5 n&m'e! o" 'oo+ lates
"!om !ivate li'!a!ies o" late nineteenth8cent&!( h(sicians sho% the docto! 'attlin* %ith
e!soni"ied diseases at the 'edside o" his atient. The hoe o" docto!s to cont!ol the o&tcome
o" seci"ic diseases *ave !ise to the m(th that the( had o%e! ove! death. The ne% o%e!s
att!i'&ted to the !o"ession *ave !ise to the ne% stat&s o" the clinician./6
$hile the cit( h(sician 'ecame a clinician, the co&nt!( h(sician 'ecame "i!st sedenta!( and
then a mem'e! o" the local elite. 5t the time o" the -!ench 3evol&tion he had still 'elon*ed to
the t!avelin* "ol+. The s&!l&s o" a!m( s&!*eons "!om the Naoleonic %a!s came home %ith
xxx "otnote sta!t xxx
/5 <ee a'ove, note 1.>, . 77.
/6 3icha!d #. <h!(oc+, The Development of *odem *edicine= An )nterpretation of the
Social and Scientifu (actors )nvolved, &nd ed; 2.ew <or#= Enopf, 9>J:A;
xxx "otnote sl&tt xxx
((195))
a vast exe!ience, loo+in* "o! a livin*. Milita!( men t!ained on the 'attle"ield, the( soon
'ecame the "i!st !esident heale!s in -!ance, Ital(, and Oe!man(. The simle eole did not
A&ite t!&st thei! techniA&es and staid '&!*he!s %e!e shoc+ed '( thei! !o&*h %a(s, '&t still the(
"o&nd clients 'eca&se o" thei! !e&tation amon* vete!ans o" the Naoleonic %a!s. The( sent
thei! sons to the ne% medical schools s!in*in* & in the cities, and these &on thei! !et&!n
c!eated the !ole o" the co&nt!( docto!, %hich !emained &nchan*ed & to the time o" $o!ld
$a! IL The( de!ived a stead( income "!om la(in* the "amil( docto! to the middle class %ho
co&ld %ell a""o!d them. 5 "e% o" the cit( o! to%n !ich acA&i!ed !esti*e '( livin* as atients
o" "amo&s clinicians, '&t in the ea!l( nineteenth cent&!( a m&ch mo!e se!io&s cometition "o!
the to%n docto! still came "!om the medical technicians o" oldDthe mid%i"e, the tooth8&lle!,
the vete!ina!ian, the 'a!'e!, and sometimes the &'lic n&!se. Not%ithstandin* the ne%ness o"
his !ole and !esistance to it "!om a'ove and 'elo%, the E&!oean co&nt!( docto!, '( mid8
cent&!(, had 'ecome a mem'e! o" the middle class. #e ea!ned eno&*h "!om la(in* lac+e( to
a sA&i!e, %as "amil( "!iend to othe! nota'les, aid occasional visits to the lo%l( sic+, and sent
his comlicated cases to his clinical collea*&e in to%n. $hile Gtimel(G death had o!i*inated in
the eme!*in* class conscio&sness o" the 'o&!*eois, GclinicalG death o!i*inated in the eme!*in*
!o"essional conscio&sness o" the ne%, scienti"icall( t!ained docto!. #ence"o!th, a timel(
death %ith clinical s(mtoms 'ecame the ideal o" middle8class docto!s,/7 and it %as soon to
'ecome inco!o!ated into the asi!ations o" t!ade &nions.
xxx "otnote sta!t xxx
/7 #ilde*a!d <tein*iesse!, "as die Tr8te aller ]eiten vorn Sterben %&ssten, 5!'eiten de!
de&tsch8no!dischen Oesellscha"t "i! Oeschichte de! Medi=in, de! Qahnheil+&nde &nd de!
Nat&!%issenscha"ten (O!ei"s%ald: 9niv. ?e!la* 3ats'&chhandl&n* L. )am'e!*, 19.6).
xxx "otnote sl&tt xxx
((196))
,rade /nion Claims to a Natural -eath
In o&! cent&!( a valet&dina!ian6s death %hile &nde!*oin* t!eatment '( clinicall( t!ained
docto!s came to 'e e!ceived, "o! the "i!st time, as a civil !i*ht. Bld8a*e medical ca!e %as
%!itten into &nion cont!acts. The caitalist !ivile*e o" nat&!al extinction "!om exha&stion in a
di!ecto!6s chai! *ave %a( to the !oleta!ian demand "o! health se!vices d&!in* !eti!ement. The
'o&!*eois hoe o" contin&in* as a di!t( old man in the o""ice %as o&sted '( the d!eam o" an
active sex li"e on social sec&!it( in a !eti!ement villa*e. Li"elon* ca!e "o! eve!( clinical
condition soon 'ecame a e!emto!( demand "o! access to a nat&!al death. Li"elon*
instit&tional medical ca!e had 'ecome a se!vice that societ( o%ed all its mem'e!s.
GNat&!al deathG no% G aea!ed in dictiona!ies. Bne ma:o! Oe!man enc(cloedia &'lished in
19>9 de"ines it '( means o" cont!ast: G5'no!mal death is oosed to nat&!al death 'eca&se it
!es&lts "!om sic+ness, violence, o! mechanical and ch!onic dist&!'ances.G 5 !e&ta'le
dictiona!( o" hilosohical concets states that Gnat&!al death comes %itho&t !evio&s
sic+ness, %itho&t de"ina'le seci"ic ca&se.G It %as this maca'!e hall&cinato!( death8concet
that 'ecame inte!t%ined %ith the concet o" social !o*!ess. Le*all( valid claims to eA&alit(
in clinical death s!ead the cont!adictions o" 'o&!*eois individ&alism amon* the %o!+in*
class. The !i*ht to a nat&!al death %as "o!m&lated as a claim to eA&al cons&mtion o" medical
se!vices, !athe! than as a "!eedom "!om the evils o" ind&st!ial %o!+ o! as a ne% li'e!t( and
o%e! "o! sel"8ca!e. This &nioni=ed concet o" an GeA&al clinical deathG is th&s the inve!se o"
the ideal !oosed in the National 5ssem'l( o" 1a!is in 179,: it is a deel( medicali=ed ideal.
-i!st o" all, this ne% ima*e o" death endo!ses ne% levels o" social cont!ol. <ociet( has 'ecome
!esonsi'le "o!
((197))
!eventin* each man6s death: t!eatment, e""ective o! not, can 'e made into a d&t(. 5n( "atalit(
occ&!!in* %itho&t medical t!eatment is lia'le to 'ecome a co!one!6s case. The enco&nte! %ith
a docto! 'ecomes almost as inexo!a'le as the enco&nte! %ith death. I +no% o" a %oman %ho
t!ied, &ns&ccess"&ll(, to +ill he!sel". <he %as '!o&*ht to the hosital in a coma, %ith a '&llet
lod*ed in he! sine. 9sin* he!oic meas&!es the s&!*eon +et he! alive, and he conside!s he!
case a s&ccess: she lives, '&t she is totall( a!al(=edR he no lon*e! has to %o!!( a'o&t he! eve!
attemtin* s&icide a*ain.
B&! ne% ima*e o" death also 'e"its the ind&st!ial ethos./; The *ood death has i!!evoca'l(
'ecome that o" the standa!d cons&me! o" medical ca!e. I&st, as at the t&!n o" the cent&!( all
men %e!e de"ined as &ils, 'o!n into o!i*inal st&idit( and standin* in need o" ei*ht (ea!s o"
schoolin* 'e"o!e the( co&ld ente! !od&ctive li"e, toda( the( a!e stamed "!om 'i!th as
atients %ho need all +inds o" t!eatment i" the( %ant to lead li"e the !i*ht %a(. I&st as
com&lso!( ed&cational cons&mtion came to 'e &sed as a device to o'viate conce!n a'o&t
%o!+, so medical cons&mtion 'ecame a device to alleviate &nhealth( %o!+, di!t( cities, and
ne!ve8!ac+in* t!anso!tation /9 $hat need is the!e to %o!!( a'o&t a m&!de!o&s envi!onment
%hen docto!s a!e ind&st!iall( eA&ied to act as li"e8save!sj
-inall(, Gdeath &nde! com&lso!( ca!eG enco&!a*es the !e8eme!*ence o" the most !imitive
del&sions a'o&t the ca&ses o" death. 5s %e have seen, !imitive eole do not die o" thei! o%n
death, the( do not ca!!( "init&de in thei! 'ones, and the( a!e still close to the s&':ective
immo!talit(
xxx "otnote sta!t xxx
/; )e!na!d 3on=e, GL65ntit!a*iA&e o& l6homme A&i e!d so mo!t,G 5ndes, Novem'e! 197/,
. 5118,;, a!*&es that the endeavo! to !o*!am death is an attemt to sa the h&man caacit(
"o! hoe and an*&ish, "o! solit&de and t!anscendence.
/9 <ie*"!ied Oiedion, Mechani=ation Ta#es 0ommaesV 5 Contribution to 5non(mo&s
%istory (Ne% Na+: No!ton, 1969). Bn mechani=ation and death, see . ,>98/>.
xxx "otnote sl&tt xxx
((19;))
o" the 'east. 5mon* them, death al%a(s !eA&i!es a s&e!nat&!al exlanation, some'od( to
'lame: the c&!se o" an enem(, the sell o" a ma*ician, the '!ea+in* o" the (a!n in the hands o"
the 1a!cae, o! Ood disatchin* his an*el o" death. In the dance %ith his8o! he! mi!!o!8ima*e,
E&!oean death eme!*ed as an a*ent indeendent o" anthe!6s %ill, an inexo!a'le "o!ce o"
nat&!e that men and %omen had to "ace on thei! o%n. The imminence o" death %as an
exA&isite and constant !eminde! o" the "!a*ilit( and tende!ness o" li"e. 7&!in* the late Middle
5*es, the discove!( o" Gnat&!alG death 'ecame one o" the main8s!in*s o" E&!oean l(!ic and
d!ama. )&t the same imminence o" death, once e!ceived as an ext!insic th!eat comin* "!om
nat&!e, 'ecame a ma:o! challen*e "o! the eme!*in* en*inee!. I" the civil en*inee! had lea!ned
to mana*e ea!th, and the eda*o*&e8'ecome8ed&cato! to mana*e +no%led*e, %h( sho&ld the
'iolo*ist8h(sician not mana*e death4 5> $hen the docto! cont!ived to ste 'et%een
h&manit( and death, the latte! lost the immediac( and intimac( *ained "o&! h&nd!ed (ea!s
ea!lie!. 7eath that had lost "ace and shae had lost its di*nit(.
The chan*e in the docto!8death !elationshi can 'e %ell ill&st!ated '( "ollo%in* the
icono*!ahic t!eatment o" this theme.51 In the a*e o" the 7ance o" 7eath, the h(sician is
!a!e. In the onl( ict&!e I have located in %hich death t!eats the docto! as a collea*&e, he has
ta+en an old man '( one hand, %hile in the othe! he ca!!ies a *lass o" &!ine, and seems to 'e
as+in* the h(sician to con"i!m his dia*nosis. In the a*e o" the 7ance o" 7eath, the s+eleton
man ma+es the docto! the main '&tt o" his :o+es. In the ea!lie! e!iodR %hile death still %o!e
some "lesh, he as+s the
xxx "otnote sta!t xxx
5> 5l"!ed 5dle!, GEin )eit!a* =&! 1s(cholo*ie de! )e!&"s%ahl,G in 5l"!ed $e'e! and 0a!l
-&!tmiille!, eds., %eilen und ,ilden (-!an+"&!t: -ische!, 197.).
51 <ee eseciall( )loc+, Der Ar8t und der TodM "arthin, DThe +hysician of the Dance of
DeathDM ,riesenmeister, ,ilder des Todes;
xxx "otnote sl&tt xxx
((199))
docto! to con"i!m in the latte!6s o%n mi!!o!8ima*e %hat he tho&*ht he +ne% a'o&t man6s
inna!ds. Late!, as a "leshless s+eleton, he teases the docto! a'o&t his imotence, :o+es a'o&t o!
!e:ects his hono!a!ia, o""e!s medicine as e!nicio&s as that the h(sician disensed, and t!eats
the docto! as :&st one mo!e common mo!tal '( snatchin* him into the dance. )a!oA&e death
seems to int!&de constantl( into the docto!6s activities, ma+in* "&n o" him %hile he sells his
%a!es at a "ai!, inte!!&tin* his cons&ltation, t!ans"o!min* his medicine 'ottles into
ho&!*lasses, o! ta+in* the docto!6s lace on a visit to the estho&se. In the ei*hteenth cent&!( a
ne% moti" aea!s: death seems to en:o( teasin* the h(sician a'o&t his essimistic
dia*noses, a'andonin* those sic+ e!sons %hom the docto! has condemned, and d!a**in* the
docto! o"" to the tom' %hile leavin* the atient alive. 9ntil the nineteenth cent&!(, death deals
al%a(s %ith the docto! o! %ith the sic+, &s&all( ta+in* the initiative in the action. The
contestants a!e at oosite ends o" the sic+'ed. Bnl( a"te! clinical sic+ness and clinical death
had develoed conside!a'l( do %e "ind the "i!st8ict&!es in %hich the docto! ass&mes the
initiative and inte!oses himsel" 'et%een his atient and death. $e have to %ait &ntil a"te!
$o!ld $a! I 'e"o!e %e see h(sicians %!an*lin* %ith the s+eleton, tea!in* a (o&n* %oman
"!om its em'!ace, and %!estin* the sc(the "!om death6s hand. )( 19.> a smilin* %hite8coated
man is !&shin* a*ainst a %hime!in* s+eleton and c!&shin* it li+e a "l( %ith t%o vol&mes o"
Ma!ie6s -e/icon of Therapy; In othe! ict&!es, the docto! !aises one hand and %a!ds o"" death
%hile holdin* & the a!ms o" a (o&n* %oman %hom death *!is '( the "eet. Max @lin*e!
!e!esents the h(sician cliin* the "eathe!s o" a %in*ed *iant. Bthe!s sho% the h(sician
loc+in* the s+eleton into !ison o! even +ic+in* its 'on( 'ottom. No% the docto! !athe! than
the atient st!&**les %ith death. 5s in !imitive c&lt&!es, some'od( can a*ain
((,>>))
'e 'lamed %hen death t!i&mhs. This some'od( is no lon*e! a e!son %ith the "ace o" a
%itch, an ancesto!, o! a *od, '&t the enem( in the shae o" a social "o!ce.5, Toda(, %hen
de"ense a*ainst death is incl&ded in social sec&!it(, the c&l!it l&!+s %ithin societ(. The
c&l!it mi*ht 'e the class enem( %ho de!ives the %o!+e! o" s&""icient medical ca!e, the
docto! %ho !e"&ses to ma+e a ni*ht visit, the m&ltinational conce!n that !aises the !ice o"
medicine, the caitalist o! !evisionist *ove!nment that has lost cont!ol ove! its medicine men,
o! the administ!ato! %ho a!tl( t!ains h(sicians at the 9nive!sit( o" 7elhi and then d!ains
them o"" to London. The %itch8h&nt that %as t!aditional at the death o" a t!i'al chie" is 'ein*
mode!ni=ed. -o! eve!( !emat&!e o! clinicall( &nnecessa!( death, some'od( o! some 'od(
can 'e "o&nd %ho i!!esonsi'l( dela(ed o! !evented a medical inte!vention.
M&ch o" the !o*!ess o" social le*islation d&!in* the "i!st hal" o" the t%entieth cent&!( %o&ld
have 'een imossi'le %itho&t the !evol&tiona!( &se o" s&ch an ind&st!iall( *!aven death8
ima*e. Neithe! the s&o!t necessa!( to a*itate "o! s&ch le*islation no! *&ilt "eelin*s st!on*
eno&*h to en"o!ce its enactment co&ld have 'een a!o&sed. )&t the claim to eA&al medical
n&!t&!in* to%a!ds an eA&al +ind o" death has also se!ved to consolidate the deendence o" o&!
contemo!a!ies on a limitlessl( exandin* ind&st!ial s(stem.
-eath /nder Intensi$e Care
$e cannot "&ll( &nde!stand the deel( !ooted st!&ct&!e o" o&! social o!*ani=ation &nless %e
see in it a m&lti"aceted exo!cism o" all "o!ms o" evil death. B&! ma:o! instit&tions
xxx "otnote sta!t xxx
5, I have selected these examles "!om amon* h&nd!eds o" !e!od&ctions collected '(
?alentina )o!!emans in 0&e!navaca, all !e!esentin* the t!aits and *est&!es o"
anth!oomo!hic death.
xxx "otnote sl&tt xxx
((,>1))
constit&te a *i*antic de"ense !o*!am %a*in* %a! on 'ehal" o" Gh&manit(G a*ainst death8
dealin* a*encies and classes 5. This is a total %a!. Not onl( medicine '&t also %el"a!e,
inte!national !elie", and develoment !o*!ams a!e enlisted in this st!&**le. Ideolo*ical
'&!ea&c!acies o" all colo!s :oin the c!&sade. 3evol&tion, !e!ession, and even civil and
inte!national %a!s a!e :&sti"ied in o!de! to de"eat the dictato!s o! caitalists %ho can 'e 'lamed
"o! the %anton c!eation and tole!ance o" sic+ness and death 5/
0&!io&sl(, death 'ecame the enem( to 'e de"eated at !ecisel( the moment at %hich
me*adeath came &on the scene. Not onl( the ima*e o" G&nnecessa!(G death is ne%, '&t also
o&! ima*e o" the end o" the %o!ld.55 7eath, the end o" m( %o!ld, and aocal(se, the end o"
the world, a!e
xxx "otnote sta!t xxx
5. -o! a 'i'lio*!ah( on death in contemo!a!( societ( cons&lt a'ove, notes 1;6 (. 97), 1;;
(. 97), 191 (. 9;), ,>7 (. 1>,), ,>9 (. 1>.). 5lso Iohn Mc@ni*ht, G5 )i'lio*!ah( o" ,,5
Items o" <&**ested 3eadin*s "o! a 0o&!se on 7eath in Mode!n <ociet( in a Theolo*ical
1e!sective,G mimeo*!ahed, 197., lists contemo!a!( 0h!istian %!itin*s on death in an
ind&st!ial societ(. Iohn iley, 3r;, and 3o'e!t $. #a'enatein, G7eath: 1. 7eath and
)e!eavementR ,. The Social B!*ani=ation o" 7eath,G in )nternational Encydopsdia of the
Social Sciences (Ne% No!+: Macmillan, 196;), /: 198,;. Ioel I. ?e!nic+, Selected
,ibtiogrgplsy on Death and Dying, !;S; 7ea!tment o" #ealth, Ed&cation and $el"a!e,
1&'lic #ealth <e!vice, National Instit&tes o" #ealth, 1971. 0omlements @alish and @&tsche!.
5/ $e!ne! -&chs, Todesbilder in der modernen $emlischaft, denies that death is repressed in
modern society; $eoffrey $orer, Death, $rief and *ourning (Ne% No!+: 7o&'leda(, 1965):
Oo!e!6s thesis that death has ta+en the lace o" sex as the !incial ta'oo seems to -&chs
&n"o&nded and misleadin*. The thesis o" death !e!ession is &s&all( !omoted '( eole o"
!o"o&ndl( anti8ind&st!ial e!s&asions "o! the &!ose o" demonst!atin* the &ltimate
o%e!lessness o" the ind&st!ial ente!!ise in the "ace o" death. Tal+ a'o&t death !e!ession is
&sed %ith insistence to const!&ct aolo*ies in "avo! o" Ood and the a"te!li"e. The "act that
eole have to die is ta+en as !oo" that the( %ill neve! a&tonomo&sl( cont!ol !ealit(. -&chs
inte!!ets all theo!ies that den( the A&alit( o" death as !elics o" a !imitive ast. #e conside!s
as scienti"ic onl( those co!!esondin* to his idea o" a mode!n social st!&ct&!e. #is ima*e o"
contemo!a!( death is a !es&lt o" his st&d( o" the lan*&a*e &sed in Oe!man o'it&a!ies. #e
'elieves that %hat is called the G!e!essionG o" death is d&e to a lac+ o" e""ective accetance o"
the inc!easin*l( *ene!al 'elie" in death as an &nA&estiona'le and "inal end.
55 The i!!ational a!oach o" a societ( in dealin* %ith death is !e"lected in its ina'ilit( to deal
%ith aocal(se. @la&s @och, atios vor der Apo#aBpti# (OYte!sloh: Mohn, 197>).
xxx "otnote sl&tt xxx
((,>,))
intimatel( !elatedR o&! attit&de to%a!ds 'oth has clea!l( 'een deel( a""ected '( the atomic
sit&ation. The aocal(se has ceased to 'e :&st a m(tholo*ical con:ect&!e and has 'ecome a
!eal contin*enc(. Instead o" 'ein* d&e to the %ill o" Ood, o! man6s *&ilt, o! the la%s o" nat&!e,
5!ma*eddon has 'ecome a ossi'le conseA&ence o" man6s di!ect decision. 0o'alt, li+e
h(d!o*en 'om's, c!eates an ill&sion o" cont!ol ove! death. Medicali=ed social !it&als !e!esent
one asect o" social cont!ol '( means o" the sel"8"!&st!atin* %a! a*ainst death.
Malino%s+i56 has a!*&ed that death amon* !imitive eole th!eatens the cohesion and
the!e"o!e the s&!vival o" the %hole *!o&. It t!i**e!s an exlosion o" "ea! and i!!ational
ex!essions o" de"ense. O!o& solida!it( is saved '( ma+in* o&t o" the nat&!al event a social
!it&al. The death o" a mem'e! the!e'( 'ecomes an occasion "o! an excetional cele'!ation.
The dominance o" ind&st!( has dis!&ted and o"ten dissolved most t!aditional 'onds o"
solida!it(. The ime!sonal !it&als o" ind&st!iali=ed medicine c!eate an e!sat= &nit( o" man+ind.
The( tie all its mem'e!s into a atte!n o" Gdesi!a'leG death '( !oosin* hosital death as the
*oal o" economic develoment. The m(th o" !o*!ess o" all eole to%a!ds the same +ind o"
death diminishes the "eelin* o" *&ilt on the a!t o" the GhavesG '( t!ans"o!min* the &*l(
deaths that the Ghave8notsG die into the !es&lt o" !esent &nde!develoment, %hich o&*ht to 'e
!emedied '( "&!the! exansion o" medical instit&tions.
B" co&!se, medicali=ed 57 death has a di""e!ent "&nction in hi*hl( ind&st!iali=ed societies than
it has in mainl(
xxx "otnote sta!t xxx
56 )!onislav Malino%s+i, G7eath and the 3einte*!ation o" the O!o&,G in *agic, Science and
eligion (Ne% No!+: 7o&'leda(, 19/9), . /785..
57 E!ic I. 0assel, G7(in* in a Technical <ociet(,G %astings Center Studies & 2*ay 197/): .18
.6: GThe!e has 'een a shi"t o" death "!om %ithin the mo!al o!de! to the technical o!de!. . . . I
do not 'elieve that men %e!e inhe!entl( mo!e mo!al in the ast %hen the mo!al o!de!
!edominated ove! the technical.G
xxx "otnote sl&tt xxx
((,>.))
!&!al nations. $ithin an ind&st!ial societ(, medical inte!vention in eve!(da( li"e does not
chan*e the !evailin* ima*e o" health and death, '&t !athe! cate!s to it. It di""&ses the death8
ima*e o" the medicali=ed elite amon* the masses and !e!od&ces it "o! "&t&!e *ene!ations. )&t
%hen Gdeath !eventionG is alied o&tside o" a c&lt&!al context in %hich cons&me!s
!eli*io&sl( !ea!e themselves "o! hosital deaths, the *!o%th o" hosital8'ased medicine
inevita'l( constit&tes a "o!m o" ime!ialist inte!vention. 5 socioolitical ima*e o" death is
imosedR eole a!e de!ived o" thei! t!aditional vision o" %hat constit&tes health and death.
The sel"8ima*e that *ives cohesion to thei! c&lt&!e is dissolved, and atomi=ed individ&als can
no% 'e inco!o!ated into an inte!national mass o" hi*hl( Gsociali=edG health cons&me!s. The
exectation o" medicali=ed death hoo+s the !ich on &nlimited ins&!ance a(ments and l&!es
the oo! into a *ilded deatht!a. The cont!adictions o" 'o&!*eois individ&alism a!e
co!!o'o!ated '( the ina'ilit( o" eole to die %ith an( ossi'ilit( o" a !ealistic attit&de
to%a!ds death 5; The c&stoms man *&a!din* the "!ontie! 'et%een 9e! ?olta and Mali
exlained to me this imo!tance o" death in !elation to health. I %anted to +no% "!om him
ho% eole alon* the Ni*e! co&ld &nde!stand each othe!, tho&*h almost eve!( villa*e so+e a.
di""e!ent ton*&e. -o! him this had nothin* to do %ith lan*&a*e: G5s lon* as eole c&t the
!e&ce o" thei! 'o(s the %a( %e do, and die o&! death, %e can &nde!stand them %ell.G
In man( a villa*e in Mexico I have seen %hat haens %hen social sec&!it( a!!ives. -o! a
*ene!ation eole contin&e in thei! t!aditional 'elie"sR the( +no% ho% to deal %ith death,
d(in*, and *!ie".59 The ne% n&!se and the
xxx "otnote sta!t xxx
5; Ed*a! Mo!in, -1%omme et la mort (1a!is: <e&il, 197>), develos the a!*&ment.
59 7o!a Bcamo, G0&ando la t!iste=a se me=cla con la ale*!ia,G man&sc!it, Mexico,
Novem'e! 197/.
xxx "otnote sl&tt xxx
((,>/))
docto!, thin+in* the( +no% 'ette!, teach them a'o&t an evil antheon o" clinical deaths, each
one o" %hich can 'e 'anned, at a !ice. Instead o" mode!ni=in* eole6s s+ills "o! sel"8ca!e,
the( !each the ideal o" hosital death. )( thei! minist!ation the( &!*e the. easants to an
&nendin* sea!ch "o! the *ood death o" inte!national desc!ition, a sea!ch that %ill +ee them
cons&me!s "o!eve!.
Li+e all othe! ma:o! !it&als o" ind&st!ial societ(, medicine in !actice ta+es the "o!m o" a
*ame. The chie" "&nction o" the h(sician 'ecomes that o" an &mi!e. #e is the a*ent o!
!e!esentative o" the social 'od(, %ith the d&t( to ma+e s&!e that eve!(one la(s the *ame
acco!din* to the !&les.6> The !&les, o" co&!se, "o!'id leavin* the *ame and d(in* in an(
"ashion that has not 'een seci"ied '( the &mi!e. 7eath no lon*e! occ&!s excet as the sel"8
"&l"illin* !ohec( o" the medicine man.61
Th!o&*h the medicali=ation o" death, health ca!e has 'ecome a monolithic %o!ld !eli*ion6,
%hose tenets a!e
xxx "otnote sta!t xxx
6> Ind&st!iali=ed h&manit( needs the!a( "!om c!i' to te!minal %a!d. 5 ne% +ind o" te!minal
the!a( is s&**ested '( Elisa'eth @&'le!83oes in 'n Death and Dying (Ne% No!+:
Macmillan, 1969). <he maintains that the d(in* ass th!o&*h seve!al t(ical sta*es and that
a!o!iate t!eatment can ease this !ocess "o! %ell8mana*ed Gmo!it&!i.G 1a&l 3amse(, GThe
Indi*nit( o" J7eath %ith 7i*nit(,6 G %astings Center Studies & (Ma( 197/): /786,. The!e is a
*!o%in* a*!eement amon* mo!alists in the ea!l( 197>s that death has a*ain to 'e acceted
and all that can 'e done "o! the d(in* is to +ee them coman( in thei! "inal moments. )&t
'eneath this acco!d the!e is an inc!easin*l( m&ndane, nat&!alistic, and antih&manistic
inte!!etation o" h&man li"e. 3o'e!t <. Mo!ison, GThe Last 1oem: The 7i*nit( o" the
Inevita'le and Necessa!(: 0ommenta!( on 1a&l 3amse(,G %astings Center Studies , (Ma(
197/): 6,86. Mo!ison c!itici=es 3amse(, %ho s&**ests that an(one &na'le to sea+ as a
0h!istian ethicist m&st do so as some Gh(othetical common denominato!.G
61 7avid Leste!, G?oodoo 7eath: <ome Ne% Tho&*hts on an Bld 1henomenon,G American
Anthropologist 7/ (I&ne 197,): .;689>.
;, 1ie!!e 7eloo=, G$ho )elieves in the #e!ea"te!4G in 5nd!T Oodin, ed., Death and +resence
()!&ssels: L&men ?itae 1!ess, 197,), . 178.;, sho%s that contemo!a!( -!ench &'lic
sea+e!s have e""ectivel( sea!ated 'elie" in Ood "!om 'elie" in the he!ea"te!. 1a&l 7an'lon
and 5nd!T Oodin, G#o% 7o 1eole <ea+ o" 7eath4G in Oodin, i'id., . .986,. 7an'lon
st&died inte!vie%s %ith 6> -!ench8sea+in* &'lic "i*&!es. The c!oss8denominational
6analo*ies in thei! ex!essions, "eelin*s, and attit&des to%a!ds death a!e m&ch st!on*e! than
thei!
xxx "otnote "o!tsette! E neste side xxx
((,>5))
ta&*ht in com&lso!( schools and %hose ethical !&les a!e alied to a '&!ea&c!atic
!est!&ct&!in* o" the envi!onment: sex has 'ecome a s&':ect in the s(lla'&s and sha!in* one6s
soon is disco&!a*ed "o! the sa+e o" h(*iene. The st!&**le a*ainst death, %hich dominates the
li"e8st(le o" the !ich, is t!anslated '( develoment a*encies into a set o" !&les '( %hich the
oo! o" the ea!th shall 'e "o!ced to cond&ct themselves.
Bnl( a c&lt&!e that evolved in hi*hl( ind&st!iali=ed societies co&ld ossi'l( have called "o!th
the comme!ciali=ation o" the death8ima*e that I have :&st desc!i'ed. In its ext!eme "o!m,
Gnat&!al deathG is no% that oint at %hich the h&man o!*anism !e"&ses an( "&!the! in&t o"
t!eat8ment. 1eole 6. die %hen the elect!oencehalo*!am indicates that thei! '!ain %aves
have "lattened o&t: the( do not ta+e a last '!eath, o! die 'eca&se thei! hea!t stos. <ociall(
a!oved death haens %hen man has 'ecome &seless not onl( as a !od&ce! '&t also as a
cons&me!. It is the oint at %hich a cons&me!, t!ained at *!eat exense,
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
di""e!ences d&e to va!(in* !eli*io&s 'elie"s o! !actices. Ioseh -. -letche!, G5ntid(sthanasia:
The 1!o'lem o" 1!olon*in* 7eath,G 3ournal o" 1asto!al Care 1; (196/): 778;/, a!*&es a*ainst
the i!!esonsi'le !olon*ation o" li"e "!om the oint o" vie% o" a hosital chalain: GI %o&ld
m(sel" a*!ee %ith 1i&s [II and %ith at least t%o 5!ch'ishos o" 0ante!'&!(, Lan* and -ishe!,
%ho have add!essed themselves to this A&estion, that the docto!6s technical +no%led*e and his
Jed&cated *&esses6 and exe!ience sho&ld 'e the 'asis "o! decidin* the A&estion as to %hethe!
the!e is an( 6!easona'le hoe.6 That dete!mination is o&tside a la(man6s cometence )&t
havin* dete!mined that the condition is hoeless, I cannot a*!ee that it is eithe! !&dent o! "ai!
to h(sicians as a "!ate!nit( to saddle them %ith the on&s o" alone decidin* %hethe! to let the
atient *o.G The thesis is common. It sho%s ho% even ch&!ches s&o!t !o"essional
:&d*ment. This !actical conve!*ence o" 0h!istian and medical !actice is in sta!+ oosition
to the attit&de to%a!ds death in 0h!istian theolo*(. Ladisla&s )o!os, *ysteriwn mo!tis: Der
*ensch in der leteen Entscheidung (-!ei'&!*: $alte!, 196,)R @a!l 3ahne!, ]ur Theologie des
Todes (-!ei'&!*: #e!de!, 196.).
6. 7aniel Ma*&i!e, GThe -!eedom to 7ie,G Commonweal, 5&*&st 11, 197,, . /,.8;. )(
%o!+in* c!eativel( and in %a(s as (et &ntho&*ht o", the lo''( o" the d(in* and the *!avel( ill
co&ld 'ecome a healin* "o!ce in societ(. Ionas ). 3o'itsche!, GThe 3i*ht To 7ie: 7o $e
#ave a 3i*ht Not To )e T!eated4G %astings 0ente! Studies , (<etem'e! 197,): 118//.
xxx "otnote sl&tt xxx
((,>6))
m&st "inall( 'e %!itten o"" as a total loss. 7(in* has 'ecome the &ltimate form of cons&me!
!esistance 6/
T!aditionall( the e!son 'est !otected "!om death %as the one %hom societ( had condemned
to die. <ociet( "elt th!eatened that the man on 7eath 3o% mi*ht &se his tie to han* himsel".
5&tho!it( mi*ht 'e challen*ed i" he too+ his li"e 'e"o!e the aointed ho&!. Toda(, the man
'est !otected a*ainst settin* the sta*e "o! his o%n d(in* is the sic+ e!sonJ in c!itical
condition. <ociet(, actin* th!o&*h the medical s(stem, decides %hen and a"te! %hat
indi*nities and m&tilations he shall die . 65 The medicali=ation o" societ( has '!o&*ht the
eoch o" nat&!al death to an end. $este!n man has lost the !i*ht to !eside at his act o" d(in*.
#ealth, o! the a&tonomo&s o%e! to coe, has 'een ex!o!iated do%n to the last '!eath.
Technical death has %on its victo!( ove! d(in* .66 Mechani8
xxx "otnote sta!t xxx
6/ B!ville )!im, et al., eds., The Dying 1atient (Ne% No!+: 3&mmell <a*e, 196>). The( deal
"i!st %ith the sect!&m o" technical anal(sis and decision8maltin* in %hich health
!o"essionals en*a*e %hen "aced %ith the tas+ o" dete!minin* the ci!c&mstances &nde! %hich
an individ&al6s death sho&ld occ&!. The( !ovide a se!ies o" !ecommendations "o! ma+in* this
en*inee!ed !ocess Gsome%hat less *!aceless and less distaste"&l "o! the atient, his "amil(
and most o" all, the attendin* e!sonnel.G In this antholo*( the maca'!e t&!ns into a ne% +ind
o" !o"essionall( cond&cted o'scenit(. <ee also 7avid <&dno%, G7(in* in a 1&'lic #osital,G
in i'id., . 1918,>;.
65 7avid <&dno%, in his st&d( o" the social o!*ani=ation, !eo!ts: G5 n&!se %as o'se!ved
sendin* t%o o! th!ee min&tes t!(in* to close the e(elids o" a %oman atient. The n&!se
exlained that the %oman %as d(in*. <he %as t!(in* to *et the lids to !emain in a closed
osition. 5"te! seve!al &ns&ccess"&l attemts, the n&!se *ot them sh&t and said, %ith a si*h o"
accomlishment, JNo% the(6!e !i*ht.6 $hen A&estioned a'o&t %hat she %as doin*, she said
that a atient6s e(es m&st 'e closed a"te! death, so that the 'od( %ill !esem'le a sleein*
e!son. It %as mo!e di""ic&lt to accomlish this, she exlained, a"te! the m&scles and s+in had
'e*&n to sti""en. <he al%a(s t!ied, she said, to close them before death. This made "o! *!eate!
e""icienc( %hen it came time "o! %a!d e!sonnel to %!a the 'od(. It %as a matte! o"
conside!ation to%a!ds those %o!+e!s %ho !e"e!!ed to handle dead 'odies as little as ossi'leG
(i'id., . 19,8.).
66 )!illat8<ava!in, GMTditation [[?I, de la mo!t,G in 1llsiolo*ie du goat; )!illat8<ava!in
attended his 9.8(ea!8old *!eat8a&nt %hen she %as d(in*. G<he had +et all he! "ac&lties and
one %o&ld not have noticed he! state '&t "o! he! smalle! aetite and he! "ee'le voice. 65!e
(o& the!e, nehe%46 6Nes a&nt, I am at (o&! se!vice and I thin+ it %o&ld 'e a *ood idea i" (o&
had some o" this lovel(
xxx "otnote "o!tsette! E neste side xxx
((,>7))
cal death has conA&e!ed and dest!o(ed all othe! deaths.
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
old %ine.GOive it to me, m( "!iend, liA&ids al%a(s *o do%n.6 I made he! s%allo% hal" a *lass
o" m( 'est %ine. <he e!+ed & immediatel( and t&!nin* he! once 'ea&ti"&l e(es to%a!ds me,
she said, 6Than+ (o& "o! this last "avo!. I" (o& eve! *et to m( a*e (o& %ill see that death
'ecomes as necessa!( as slee.6 These %e!e he! last %o!ds and hal" an ho&! late! she %as
aslee "o!eve!.G
xxx "otnote sl&tt xxx
((,>;))
P)%, I4. ,he Politics of Health
((,>9))
((,1>))
8. Specific Counterproducti$ity
Iat!o*enesis %ill 'e cont!olled onl( i" it is &nde!stood as '&t one asect o" the dest!&ctive
dominance o" ind&st!( ove! societ(, as '&t one instance o" that a!adoxical
co&nte!!od&ctivit( %hich is no% s&!"acin* in all ma:o! ind&st!ial secto!s. Li+e time8
cons&min* accele!ation, st&e"(in* ed&cation, sel"8dest!&ctive milita!( de"ense, diso!ientin*
in"o!mation, o! &nsettlin* ho&sin* !o:ects, atho*enic medicine is the !es&lt o" ind&st!ial
ove!!od&ction that a!al(=es a&tonomo&s action. In o!de! to "oc&s on this seci"ic
co&nte!!od&ctivit( o" contemo!a!( ind&st!(, "!&st!atin* ove!!od&ction m&st 'e clea!l(
distin*&ished "!om t%o othe! cate*o!ies o" economic '&!dens %ith %hich it is *ene!all(
con"&sed, namel(, declinin* ma!*inal &tilit( and ne*ative exte!nalit(. $itho&t this distinction
o" the seci"ic "!&st!ation that constit&tes co&nte!!od&ctivit( "!om !isin* !ices and
o!essive social costs, the social assessment o" an( technical ente!!ise, 'e it medicine,
t!anso!tation, the media, o! ed&cation, %ill !emain limited to an acco&ntin* o" cost8e""icienc(
and not even a!oach a !adical c!itiA&e o" the inst!&mental e""ectiveness o" these va!io&s
secto!s.
7i!ect costs !e"lect !ental cha!*es, a(ments made "o! la'o!, mate!ials, and othe!
conside!ations. The !od&ction cost o" a assen*e!8mile incl&des the a(ments made to '&ild
and oe!ate the vehicle and the !oad, as %ell as the
((,11))
!o"it that acc!&es to those %ho have o'tained cont!ol ove! t!anso!tation: the inte!est cha!*ed
'( the caitalists %ho o%n the tools o" !od&ction, and the e!A&isites claimed '( the
'&!ea&c!ats %ho monooli=e the stoc+ o" +no%led*e that is alied in the !ocess. The !ice
is the s&m o" these va!io&s !entals, no matte! %hethe! it is aid '( the cons&me! o&t o" his
o%n oc+et o! '( a tax8s&o!ted social a*enc( that &!chases on his 'ehal".
.egative, e/ternality is the name o" the social costs that a!e not incl&ded in the moneta!(
!iceR it is the common desi*nation "o! the '&!dens, !ivations, n&isances, and in:&!ies that I
imose on othe!s '( each assen*e!8mile I t!avel. The di!t, the noise, and the &*liness m( ca!
adds to the cit(R the ha!m ca&sed '( collisions and oll&tionR the de*!adation o" the total
envi!onment '( the ox(*en I '&!n and the oisons I scatte!R the inc!easin* costliness o" the
olice dea!tmentR and also the t!a""ic8!elated disc!imination a*ainst the oo!: all a!e ne*ative
exte!nalities associated %ith each assen*e!8mile. <ome can easil( 'e internali8ed in the
&!chase !ice, as "o! instance the dama*es done '( collisions, %hich a!e aid "o! '(
ins&!ance. Bthe! exte!nalities that do not no% sho% & in the ma!+et !ice co&ld 'e
inte!nali=ed in the same %a(: the cost o" the!a( "o! cance! ca&sed '( exha&st "&mes co&ld 'e
added to each *allon o" "&el, to 'e sent "o! cance! detection and s&!*e!( o! "o! cance!
!evention th!o&*h antioll&tion devices and *as mas+s. )&t most exte!nalities cannot 'e
A&anti"ied and inte!nali=ed: i" *asoline !ices a!e !aised to !ed&ce deletion o" oil stoc+s and
o" atmoshe!ic ox(*en, each assen*e!8mile 'ecomes mo!e costl( and mo!e o" a !ivile*eR
envi!onmental dama*e is lessened '&t social in:&stice is inc!eased. )e(ond a ce!tain level o"
intensit( o" ind&s8t!ial !od&ction, exte!nalities cannot 'e !ed&ced '&t onl( shi"ted a!o&nd.
0o&nte!!od&ctivit( is somethin* othe! than eithe! an
((,1,))
individ&al o! a social costR it is distinct "!om the declinin* &tilit( o'tained "o! a &nit o"
c&!!enc( and "!om all "o!ms o" exte!nal disse!vice. It exists %heneve! the &se o" an instit&tion
a!adoxicall( ta+es a%a( "!om societ( those thin*s the instit&tion %as desi*ned to !ovide. It
is a "o!m o" '&ilt8in social "!&st!ation. The !ice o" a commodit( o! a se!vice meas&!es %hat
the &!chase! is. %illin* to send "o! %hateve! he *etsR exte!nalities indicate %hat societ( %ill
tole!ate to allo% "o! this cons&mtionR co&nte!!od&ctivit( *a&*es the de*!ee o" !evalent
co*nitive dissonance !es&ltin* "!om the t!ansaction: it is a social indicato! "o! the '&ilt8in
co&nte!&!osive "&nctionin* of an economic secto!. The iat!o*enic intensit( o" o&! medical
ente!!ise is onl( a a!tic&la!l( ain"&l examle o" ho% "!&st!atin* ove!!od&ction aea!s in
eA&al meas&!e as time8cons&min* accele!ation o" traffic, static in comm&nications, t!ainin*
"o! %ell8!o&nded incometence in ed&cation, &!ootin* as a !es&lt o" ho&sin* develoment,
and dest!&ctive ove!"eedin*. This seci"ic co&nte!!od&ctivit( constit&tes an &n%anted side8
e""ect o" ind&st!ial !od&ction %hich cannot 'e exte!nali=ed "!om the a!tic&la! economic
secto! that !od&ces it. -&ndamentall( it is d&e neithe! to technical mista+es no! to class
exloitation '&t to ind&st!iall( *ene!ated dest!&ction o" those envi!onmental, social, and
s(cholo*ical conditions needed "o! the develoment o" nonind&st!ial o! non!o"essional &se8
val&es. 0o&nte!!od&ctivit( is the !es&lt o" an ind&st!iall( ind&ced a!al(sis o" !actical sel"8
*ove!nin* activit(.
The ind&st!ial disto!tion o" o&! sha!ed e!cetion o" !ealit( has !ende!ed &s 'lind to the
co&nte!&!osive level o" o&! ente!!ise. $e live in an eoch in %hich lea!nin* is lanned,
!esidence standa!di=ed, t!a""ic moto!i=ed, and comm&nication !o*!ammed, and in %hich, "o!
the "i!st time, a la!*e a!t o" all "oodst&""s cons&med '( h&manit( asses th!o&*h
inte!!e*ional ma!+ets. In s&ch an intensel(
((,1.))
ind&st!iali=ed societ(, eole a!e conditioned to get thin*s !athe! than to do themR the( a!e
t!ained to val&e %hat can 'e &!chased !athe! than %hat the( themselves can c!eate. The(
%ant to 'e ta&*ht, moved, t!eated, o! *&ided !athe! than to lea!n, to heal, and to "ind thei! o%n
%a(. Ime!sonal instit&tions a!e assi*ned e!sonal "&nctions. #ealin* ceases to 'e conside!ed
the tas+ "o! the sic+. It "i!st 'ecomes the d&t( o" the individ&al 'od( !eai!men, and then soon
chan*es "!om a e!sonal se!vice into the o&t&t o" an anon(mo&s a*enc(. In the !ocess,
societ( is !ea!!an*ed "o! the sa+e o" the health8ca!e s(stem, and it 'ecomes inc!easin*l(
di""ic&lt to ca!e "o! one6s o%n health. Ooods and se!vices litte! the domains o" "!eedom.
<chools !od&ce ed&cation, moto! vehicles !od&ce locomotion, and medicine !od&ces
health ca!e. These o&t&ts a!e stales that have all the cha!acte!istics o" commodities. Thei!
!od&ction costs can 'e added to o! s&'t!acted "!om the ON1, thei! sca!cit( can 'e meas&!ed
in te!ms o" ma!*inal val&e, and thei! costs can 'e esta'lished in c&!!enc( eA&ivalents. )( thei!
ve!( nat&!e these stales c!eate a ma!+et. Li+e school ed&cation and moto! t!anso!tation,
clinical ca!e is the !es&lt o" a caital8intensive commodit( !od&ctionR the se!vices !od&ced
a!e desi*ned "o! othe!s, not %ith othe!s no! "o! the !od&ce!.
B%in* to the ind&st!iali=ation o" o&! %o!ld8vie%, it is o"ten ove!loo+ed that each o" these
commodities still cometes %ith a nonma!+eta'le &se8val&e that eole "!eel( !od&ce, each
on his o%n. 1eole lea!n '( seein* and doin*, the( move on thei! "eet, the( heal, the( ta+e
ca!e o" thei! health, and the( cont!i'&te to the health o" othe!s. These activities have &se8
val&es that !esist ma!+etin*. Most val&a'le lea!nin*, 'od( movement, and healin* do not
sho% & on the ON1. 1eole lea!n thei! mothe! ton*&e, move a!o&nd, !od&ce thei! child!en
and '!in*
((,1/))
them &, !ecove! the &se o" '!o+en 'ones, and !ea!e the local diet, and do these thin*s %ith
mo!e o! less cometence and en:o(ment. These a!e all val&a'le activities %hich most o" the
time %ill not and cannot 'e &nde!ta+en "o! mone(, '&t %hich can 'e deval&ed i" too m&ch
mone( is a!o&nd.
The achievement o" a conc!ete social *oal cannot 'e meas&!ed in te!ms o" ind&st!ial o&t&ts,
neithe! in thei! amo&nt no! in the c&!ve that !e!esents thei! dist!i'&tion and thei! social costs.
The e""ectiveness o" each ind&st!ial secto! is dete!mined '( the co!!elation 'et%een the
!od&ction o" commodities '( societ( and the a&tonomo&s !od&ction o" co!!esondin* &se8
val&es. #o% e""ective a societ( is in !od&cin* hi*h levels o" mo'ilit(, ho&sin*, o! n&t!ition
deends on the meshin* o" ma!+eted stales %ith inaliena'le, sontaneo&s action.
$hen most needs o" most eole a!e satis"ied in a domestic o! comm&nit( mode o"
!od&ction, the *a 'et%een exectation and *!ati"ication tends to 'e na!!o% and sta'le.
Lea!nin*, locomotion, o! sic+8ca!e a!e the !es&lts o" hi*hl( decent!ali=ed initiatives, o"
a&tonomo&s in&ts and sel"8limitin* total o&t&ts. 9nde! the conditions o" a s&'sistence
econom(, the tools &sed in !od&ction dete!mine the needs that the alication o" these same
tools can "&l"ill. -o! instance, eole +no% %hat the( can exect %hen the( *et sic+.
<ome'od( in the villa*e o! the nea!'( to%n %ill +no% all the !emedies that have %o!+ed in
the ast, and 'e(ond this lies the &n!edicta'le !ealm o" the mi!acle. 9ntil late in the
nineteenth cent&!(, most "amilies, even in $este!n co&nt!ies, !ovided most o" the the!a(
that %as +no%n. Most lea!nin*, locomotion, o! healin* %as e!"o!med '(. each man on his
o%n, and the tools needed %e!e !od&ced in his "amil( o! villa*e settin*.
5&tonomo&s !od&ction can, o" co&!se, 'e s&le
((,15))
mented '( ind&st!ial o&t&ts that %ill have to 'e desi*ned and o"ten man&"act&!ed 'e(ond
di!ect comm&nit( cont!ol. 5&tonomo&s activit( can 'e !ende!ed 'oth mo!e e""ective and mo!e
decent!ali=ed '( &sin* s&ch ind&st!iall( made tools as 'ic(cles, !intin* !esses, !eco!de!s, o!
[8!a( eA&iment. )&t it can also 'e hame!ed, deval&ed, and 'loc+ed '( an a!!an*ement o"
societ( that is totall( in "avo! o" ind&st!(. The s(ne!*( 'et%een the a&tonomo&s and the
hete!onomo&s modes o" !od&ction then ta+es on a ne*ative cast. The a!!an*ement o" societ(
in "avo! o" mana*ed commodit( !od&ction has t%o &ltimatel( dest!&ctive asects: eole a!e
t!ained "o! cons&mtion !athe! than "o! action, and at the same time thei! !an*e o" action is
na!!o%ed. The tool sea!ates the %o!+man "!om his la'o!. #a'it&al 'ic(cle comm&te!s a!e
&shed o"" the !oad '( intole!a'le levels o" t!a""ic, and atients acc&stomed to ta+in* ca!e o"
thei! o%n ailments "ind (este!da(6s !emedies availa'le onl( on !esc!ition and hence la!*el(
&no'taina'le. $a*e la'o! and client !elationshis exand %hile a&tonomo&s !od&ction and
*i"t !elationshis %ithe!.
E""ectivel( achievin* social o':ectives deends on the de*!ee to %hich the t%o "&ndamental
modes o" !od&ction s&lement o! hame! each othe!. E""ectivel( comin* to +no% and to
cont!ol a *iven h(sical and social envi!on8ment deends on eole6s "o!mal ed&cation and on
thei! oo!t&nit( and motivation to lea!n in a non!o*!ammed %a(. E""ective t!a""ic deends
on the a'ilit( o" eole to *et %he!e the( m&st *o A&ic+l( and convenientl(. E""ective sic+8
ca!e deends on the de*!ee to %hich ain and d(s"&nction a!e made tole!a'le and !ecove!( is
enhanced. The e""ective satis"action o" these needs m&st 'e clea!l( distin*&ished "!om the
e""icienc( %ith %hich ind&st!ial !od&cts a!e made and ma!+eted, "!om the n&m'e! o"
ce!ti"icates, assen*e!8miles, ho&sin* &nits, o! medical
((,16))
inte!ventions e!"o!med. )e(ond a ce!tain th!eshold, these o&t&ts %ill all 'e needed onl( as
!emediesR the( %ill s&'stit&te "o! e!sonal activities that !evio&s ind&st!ial o&t&ts have
a!al(=ed. The social c!ite!ia '( %hich e""ective need8satis"action can 'e eval&ated do not
match the meas&!ements &sed to eval&ate the !od&ction and ma!+etin* o" ind&st!ial *oods.
<ince meas&!ements dis!e*a!d the cont!i'&tions made '( the a&tonomo&s mode to%a!ds the
total e""ectiveness %ith %hich an( ma:o! social *oal ma( 'e achieved, the( cannot indicate i"
this total e""ectiveness is inc!easin* o! dec!easin*. The n&m'e! o" *!ad&ates, "o! instance,
mi*ht 'e inve!sel( !elated to *ene!al cometence. M&ch less can technical meas&!ements
indicate %ho a!e the 'ene"icia!ies and %ho a!e the lose!s "!om ind&st!ial *!o%th, %ho a!e the
"e% that *et mo!e and can do mo!e, and %ho "all into the ma:o!it( %hose ma!*inal access to
ind&st!ial !od&cts is como&nded '( thei! loss o" a&tonomo&s e""ectiveness. Bnl( olitical
:&d*ment can assess the 'alance.
The e!sons most h&!t '( co&nte!!od&ctive instit&tionali=ation a!e &s&all( not the oo!est in
moneta!( te!ms. The t(ical victims o" the dee!sonali=ation o" val&es a!e the o%e!less in a
milie& made "o! the ind&st!iall( en!iched. 5mon* the o%e!less ma( 'e eole %ho a!e
!elativel( a""l&ent %ithin thei! societ( o! those %ho a!e inmates o" 'enevolent total
instit&tions. 7isa'lin* deendence !ed&ces them to mode!ni=ed ove!t(. 1olicies meant to
!emed( the ne% sense o" !ivation %ill not onl( 'e "&tile '&t %ill a**!avate the dama*e. )(
!omisin* mo!e stales !athe! than !otectin* a&tonom(, the( %ill intensi"( disa'lin*
deendence.
The oo! in )en*al o! 1e!& still s&!vive %ith occasional emlo(ment and an occasional di
into the ma!+et econom(: the( live '( the timeless a!t o" ma+in* do. The( still can st!etch o&t
!ovisions, alte!nate 'et%een "at and
((,17))
lean e!iods, +nit *i"t !elationshis %he!e'( the( 'a!te! o! othe!%ise exchan*e *oods and
se!vices neithe! made "o! no! acco&nted "o! '( the ma!+et. In the co&nt!(, in the a'sence o"
television, the( en:o( livin* in homes '&ilt on t!aditional models. 7!a%n o! &shed into to%n,
the( sA&at on the ma!*ins o" the steel8and8et!ole&m secto!, %he!e the( '&ild a !ovisional
econom( %ith sc!as o" %aste that can se!ve as '&ildin* 'loc+s "o! sel"8made shac+s. Thei!
exos&!e to ext!eme "amine *!o%s %ith thei! deendence on ma!+eted "ood.
Oiven s&""icient *ene!ations, d&!in* its enti!e evol&tion %omo sapiens has sho%n hi*h
cometence in develoin* a *!eat va!iet( o" c&lt&!al "o!ms, each meant to +ee the total
o&lation o" a !e*ion %ithin the limits o" !eso&!ces that co&ld 'e sha!ed o! "o!mall(
exchan*ed in its limited milie&. The %o!ld%ide and homo*eneo&s disa'lin* o" the comm&nal
coin* a'ilit( o" local o&lations has develoed %ith ime!ialism and its contemo!a!(
va!iants o" ind&st!ial develoment and comassionate chic.
The invasion o" the &nde!develoed co&nt!ies '( ne% inst!&ments o" !od&ction o!*ani=ed "o!
"inancial e""icienc( !athe! than local e""ectiveness and "o! !o"essional !athe! than la( cont!ol
inevita'l( disA&ali"ies t!adition and a&tonomo&s lea!nin* and c!eates the need "o! the!a(
"!om teache!s, docto!s, and social %o!+e!s. $hile !oad and !adio mold the lives o" those
%hom the( !each to ind&st!ial standa!ds, the( de*!ade thei! handic!a"ts, ho&sin*, o! health
ca!e m&ch "aste! than the( c!&sh the s+ills the( !elace. 5=tec massa*e *ives !elie" to man(
%ho %o&ld no lon*e! admit it 'eca&se the( 'elieve it o&tdated. The common "amil( 'ed
'ecomes dis!e&ta'le m&ch "aste! than its occ&ants 'ecome a%a!e o" discom"o!t. $he!e
develoment lans have %o!+ed, the( have o"ten s&cceeded 'eca&se o" the &n"o!eseen
!esilience o" the ado'ec&m8oild!&m secto!. The contin&ed a'ilit( to !od&ce
((,1;))
"oods on ma!*inal land and in cit( 'ac+(a!ds has saved !od&ctivit( camai*ns "!om the
9+!aine to ?ene=&ela. The a'ilit( to ca!e "o! the sic+, the old, and the insane %itho&t n&!ses
o! %a!dens has '&""e!ed the ma:o!it( a*ainst the !isin* < seci"ic dis&tilities %hich s(m'olic
en!ichment has '!o&*ht. 1ove!t( in the s&'sistence secto!, even %hen this s&'sistence is
!et!enched '( conside!a'le ma!+et deendence, does not c!&sh a&tonom(. 1eole !emain
motivated to sA&at on tho!o&*h"a!es, to ni''le at !o"essional monoolies, o! to ci!c&mvent
the '&!ea&c!ats.
$hen e!cetion o" e!sonal needs is the !es&lt o" !o"essional dia*nosis, deendence t&!ns
into ain"&l dis8a'ilit(. The a*ed in the 9nited <tates can a*ain se!ve as the a!adi*m. The( 8
have 'een t!ained to exe!ience &!*ent needs that no level o" relative !ivile*e can ossi'l(
satis"(. The mo!e tax mone( that is sent to 'olste! thei! "!ailt(, the +eene! is thei! a%a!eness
o" deca(. 5t the same time, thei! a'ilit( to ta+e ca!e o" themselves has %ithe!ed, as social
a!!an*ements allo%in* them to exe!cise a&tonom( have !acticall( disaea!ed. The a*ed a!e
an examle o" the seciali=ation o" ove!t( %hich the ove!8seciali=ation o" se!vices can
'!in* "o!th. The elde!l( in the 9nited <tates a!e onl( one ext!eme examle o" s&""e!in*
!omoted '( hi*h8cost de!ivation. #avin* lea!ned to conside! old a*e a+in to disease, the(
have develoed &nlimited economic needs in o!de! to a( "o! inte!mina'le the!aies, %hich
a!e &s&all( ine""ective, a!e "!eA&entl( demeanin* and ain"&l, and call mo!e o"ten than not "o!
!ecl&sion in a secial milie&.
-ive "aces o" ind&st!iall( mode!ni=ed ove!t( aea! ca!icat&!ed in the ame!ed *hettos o"
!ich men6s !eti!e8ment: the incidence o" ch!onic disease inc!eases as "e%e! eole die in thei!
(o&thR mo!e eole s&""e! clinical dama*e "!om health meas&!esR medical se!vices *!o% mo!e
slo%l( than the s!ead and &!*enc( o" demandR eole
((,19))
"ind "e%e! !eso&!ces in thei! envi!onment and c&lt&!e to hel them come to te!ms %ith thei!
s&""e!in*, and th&s a!e "o!ced to deend on medical se!vices "o! a %ide! !an*e o" t!iviaR eole
lose the a'ilit( to live %ith imai!ment o! ain and 'ecome deendent on the mana*ement o"
eve!( discom"o!t '( seciali=ed se!vice e!sonnel. The c&m&lative !es&lt o" ove!exansion in
the health8ca!e ind&st!( has th%a!ted the o%e! o" eole to !esond to challen*es and to coe
%ith chan*es in thei! 'odies o! in thei! envi!on8ment.
The dest!&ctive o%e! o" medical ove!exansion does not, o" co&!se, mean that sanitation,
inoc&lation, and vecto! cont!ol, %ell8dist!i'&ted health ed&cation, health( a!chitect&!e, and
sa"e machine!(, *ene!al cometence in "i!st aid, eA&all( dist!i'&ted access to dental and
!ima!( medical ca!e, as %ell as :&dicio&sl( selected comlex se!vices, co&ld not all "it into a
t!&l( mode!n c&lt&!e that "oste!ed sel"8ca!e and a&tonom(. 5s lon* as en*inee!ed inte!vention
in the !elationshi 'et%een individ&als and envi!onment !emains 'elo% a ce!tain intensit(,
!elative to the !an*e o" the individ&al6s "!eedom o" action, s&ch inte!vention co&ld enhance the
o!*anism6s cometence in coin* and c!eatin* its o%n "&t&!e. )&t 'e(ond a ce!tain level, the
hete!onomo&s mana*ement o" li"e %ill inevita'l( "i!st !est!ict, then c!ile, and "inall(
a!al(=e the o!*anism6s nont!ivial !esonses, and %hat %as meant to constit&te health ca!e
%ill t&!n into a seci"ic "o!m o" health denial. 1
xxx "otnote sta!t xxx
1 5'o&t atho*enic !ole8assi*nment, a!tic&la!l( in contemo!a!( ind&st!ial societ(, see #. 1.
7!eit=el, Die gesellschaftlichen -eiden und das -eiden an der $esellschaft; 6orstudien 8u
einer +athologie des ollenverhaltens 2Stuttgart= En#e, 9>:&A;
xxx "otnote sl&tt xxx
((,,>))
9. Political Countermeasures
-i"teen (ea!s a*o it %o&ld have 'een imossi'le to *et a hea!in* "o! the claim that medicine
itsel" mi*ht 'e a dan*e! to health. In the ea!l( 196>s, the )!itish National #ealth <e!vice still
en:o(ed a %o!ld%ide !e&tation, a!tic&la!l( amon* 5me!ican !e"o!me!s. 1 The se!vice,
c!eated '( 5l'e!t )eve!id*e, %as 'ased on the ass&mtion that the!e exists in eve!(
o&lation a st!ictl( limited amo&nt o" mo!'idit( %hich, i" t!eated &nde! conditions o" eA&it(,
%ill event&all( decline., Th&s )eve!id*e had calc&lated that the ann&al cost o" the #ealth
<e!vice %o&ld "all as the!a( !ed&ced the. !ate o" illness.. #ealth
xxx "otnote sta!t xxx
1 0ha!les E. 5. $inslo%, The 0ost of <ic+ness and the +rice of %ealth (Oeneva: $o!ld
#ealth B!*ani=ation., 1951). 7aniel <. #i!sh"ield, The -ost eform= The Campaign for
Compulsory %ealth )nsurance in the !nited States from 9>0& to 9>J0 (0am'!id*e, Mass.:
#a!va!d 9niv. 1!ess, 197>), desc!i'es the "ail&!e so "a! o" the &nins&!ed mino!it( o" the a*ed,
oo!, and ch!onicall( ill to m&ste! s&o!t "o! !otective la%s "!om the la!*el( contented
ma:o!it(. #e sho%s that the ea!lie! !o'lems, attit&des to%a!ds them, and a!oaches !emain
la!*el( &nchan*ed in the 197>s. It seems that at no time has &'lic8olic( disc&ssion o" health
ca!e t!anscended the ind&st!ial a!adi*m o" medicine as a 'iolo*ical and social ente!!ise.
, -o! a histo!( o" %el"a!e le*islation see #en!( E. <i*e!ist, G-!om )isma!c+ to )eve!id*e:
7eveloments and T!ends in <ocial <ec&!it( Le*islation,G ,ulletin of the %istory of *edicine
90 2April 9>J0A= 0?@4 ; (or a rather nabvely enthusiastic evaluation of analogous legislation
in ussia, see %enry E; Sigerist, Sociali8ed *edicine in the Soviet !nion 29>0:M rev; ed;, as
*edicine and %ealth in the Soviet !nion, .ew <or#= Citadel +ress, 9>J:A;
. B""ice o" #ealth Economics, +rospects in %ealth, +ublication no; 0: 2-ondon, 1971).
xxx "otnote sl&tt xxx
((,,1))
lanne!s and %el"a!e economists neve! exected that the se!vice6s !ede"inition o" health %o&ld
'!oaden the scoe o" medical ca!e and that onl( '&d*eta!( !est!ictions %o&ld +ee it "!om
exandin* inde"initel(. It %as not !edicted that soon, in a !e*ional sc!eenin*, onl( sixt(8
seven o&t o" one tho&sand eole %o&ld 'e "o&nd comletel( "it and that 5> e!cent %o&ld 'e
!e"e!!ed to a docto!, %hile acco!din* to anothe! st&d(, one in six eole sc!eened %o&ld 'e
de"ined as s&""e!in* "!om one to nine se!io&s illnesses./ No! had the health lanne!s "o!ecast
that the th!eshold o" tole!ance "o! eve!(da( !ealit( %o&ld decline as "ast as the cometence "o!
sel"8ca!e %as &nde!mined, and that one8A&a!te! o" all visits to the docto! "o! "!ee se!vice
%o&ld 'e "o! the &nt!eata'le common cold. )et%een 19/. and 1951, 75 e!cent o" the e!sons
A&estioned claimed to have s&""e!ed "!om illness d&!in* the !ecedin* month. 5 )( 197,, 95
e!cent o" those s&!ve(ed in one st&d( conside!ed themselves &n%ell d&!in* the "o&!teen da(s
!io! to A&estionin*, and in anothe! st&d(6 in %hich 5 e!cent conside!ed themselves "!ee o"
s(mtoms, 9 e!cent claimed to have s&""e!ed "!om mo!e than six di""e!ent s(mtoms in the
t%o %ee+s :&st ast. Least o" all did the health lanne!s ma+e !ovision "o! the ne% diseases
that %o&ld 'ecome endemic th!o&*h the same !ocess that made medicine at least a!tiall(
e""ective.7 The( did not
xxx "otnote sta!t xxx
/ 3. O. <. )!o%n, The 0han*in* National %ealth Service (London: 3o&tled*e, 197.), and <.
Is!ael and O. Teelin* <mith, GThe <&'me!*ed Ice'e!* o" <ic+ness in <ociet(,G <ocial and
Economic 5dminist!ation, vol. 1, no. 1 (1967). -o! eve!( case o" dia'etes, !he&matism, o!
eiles( +no%n to the *ene!al !actitione!, the!e aea!s to 'e anothe! case &ndia*nosed. -o!
each +no%n case o" s(chiat!ic illness, '!onchitis, hi*h 'lood !ess&!e, *la&coma, o! &!ina!(8
t!act in"ection, the!e a!e li+el( to 'e "ive cases &ndiscove!ed. The cases o" &nt!eated anemia
!o'a'l( exceed those t!eated ei*ht"old.
5 $. 1. 7. Lo*an and E. )!oo+e, Swve, of <ic+ness, 9>B4@9 (London: #e! Ma:est(6s
<tatione!( B""ice, 1957).
6 @a!en 7&nnell and 5nn 0a!t%!i*ht, *edicine Ta#ers, +rescribers and %oarders (London:
3o&tled*e, 197,).
7 This %as the e!iod o" mass sc!eenin* "o! diso!de!s that ed&cato!s, economists, o!
h(sicians co&ld detect. It %as still conside!ed G!o*!essG %hen
xxx "otnote "o!tsette! neste side xxx
((,,,))
"o!ecast the need "o! secial hositals dedicated to the soothin* o" te!minal ain, &s&all(
suffered '( the victims o" &nso&nd o! ine""ective s&!*e!( "o! cance!,; o! the need "o! othe!
hosital 'eds "o! those a""ected '( medicine8ind&ced disease .9
The sixties also %itnessed the !ise and "all o" a m&ltinational conso!ti&m "o! the exo!t o"
otimism to the thi!d %o!ld %hich too+ shae in the 1eace 0o!s, the 5lliance "o! 1!o*!ess,
Is!aeli aid to 0ent!al 5"!ica, and in the last '!&sh8"i!es o" medical8missiona!( =eal. The
$este!n 'elie" that its medicines co&ld c&!e the ills o" the nonind&st!iali=ed t!oics %as then
at its hei*ht. Inte!national cooe!ation had :&st %on ma:o! 'attles a*ainst mosA&itoes,
mic!o'es, and a!asites, &ltimatel( 1(!!hic victo!ies %hich %e!e adve!tised as the 'e*innin*
o" a "inal sol&tion to t!oical disease.1> The !ole that economic and technolo*ical
develoment %o&ld la( in s!eadin* and a**!avatin* sleein* sic+ness, 'ilha!=iasis, and
even mala!ia, %as not (et s&sected. 11 Those %ho sa% %o!ld h&n*e! and ne%
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
tests cond&cted on 1,7>9 eole !evealed mo!e than 9>f to 'e s&""e!in* "!om some disease. I.
E. <hental, GM&ltihasic <c!eenin* o" the $ell 1atient,G "e%nal of the American *edical
5ssociation 17, (196>): 18/.
; -!an+ T&!n'&ll, G1ain and <&""e!in* in 0ance!,G 0am:dins .uns, 5&*&st 1971, . ,;8.1.
T&!n'&ll a!*&es that tho&*h si!*ical o! !adiolo*ical t!eatment ma( ca&se a !ecession in the
!ima!( s(mtoms that mi*ht have led to a ainless death, it ma( also allo% develoment o"
seconda!( disease that is mo!e ain"&l.
9 Estimated at 1,81;f o" all 9<. hosital 'eds.
1> M. 6Ma*i -a!va! and Iohn 1. Milton, eds., The Careless Ted*olo5 (Oa!den 0it(, N.N.:
Nat&!al #isto!( 1!ess, 197,). <cienti"ic ae!s "!om a con"e!ence held in 196;, indicatin* that
the ost8$o!ld $a! II idea that t!aditional societies can and sho&ld 'e ove!ha&led ove!ni*ht
has !oved not onl( vi!t&all( &nachieva'le '&t also &ndesi!a'le in vie% o" the se!io&s
conseA&ences "o! man6s o!*anism.
11 0ha!les 0. #&*hes and Iohn M. #&nte!, G7isease and 7eveloment in 5"!ica,G Social
Science and *edicine 0, no. / (197>): //.8;;. 5n imo!tant s&!ve( o" the lite!at&!e on
disease conseA&enoXs o" develomental activities. 3alh I. 5nd(, G5sects o" #&man
)ehavio! Inte!"e!in* %ith ?ecto! 0ont!ol,G in ?ecag Control and the ecrudescence of
6ector4bone Diseases, 1!oceedin*s o" a <(mosi&m #eld 7&!in* the Tenth Meetin* o" the
15#B 5dviso!( 0ommittee on Medical 3esea!ch, I&ne 15, 1971, 1an85me!ican #ealth
B!*ani=ation <cienti"ic 1&'lication no. ,.; ($ashin*ton, 7.0., 197,), . 678;,.
xxx "otnote sl&tt xxx
((,,.))
estilence on the ho!i=on %e!e t!eated li+e !ohets o" doom1, o! !omanticsRl. the O!een
3evol&tion %as still conside!ed the oenin* hase o" a healthie! and mo!e eA&ita'le %o!ld.1/
It %o&ld have seemed &n'elieva'le that %ithin ten (ea!s malnutrition in t%o "o!ms %o&ld
'ecome '( "a! the most imo!tant th!eat to mode!n man.15 The ne% hi*h8calo!ic
&nde!no&!ishment o" oo! o&lations %as not "o!eseen,16 no! %as the "act that ove!"eedin*
%o&ld 'e
xxx "otnote sta!t xxx
1, 3enT 7&mont, -a (aim du monde, comlete text o" a con"e!ence held in LiX*e Novem'e!
;, . 1965, "ollo%ed '( !esonses to the ,5 A&estions disc&ssed (LiX*eL)!&ssels: 0e!cle
d6Ed&cation 1o&lai!e, 1966). 5n imassioned aeal "o! %o!ld solida!it( at the eleventh
ho&!. 5 late! En*lish ve!sion is 3enT 7&mont and )e!na!d 3osie!, The %ungry (uture (Ne%
No!+: 1!ae*e!, 1969). -o! a !i*ht8%in* comlement to this vie% "!om the le"t, cons&lt
$illiam and 1a&l 1addoc+, (amine .ineteen Seventy4fivec America1s Decision= "ho "ill
Survive7 ()oston: Little, )!o%n, 1967). Ea!l( de'&n+e!s o" the d!eams o" thei! decade, s&ch
as h(d!oonics, desalini=ation, s(nthetic "oods, and ocean "a!min*, the a&tho!s a!e also
convinced that land !e"o!m, i!!i*ation, and "e!tili=e! !od&ction cannot ave!t "amine. The(
"o!esee inc!eased deendence o" the %o!ld on 9.<. o&t&ts, and !oose Gt!ia*e,G i.e.,
selection, '( the 9.<. o" those to 'e +et alive.
1. Ma!shall <ahlins, <tone Age Economics (0hica*o: 5ldine85the!ton, 197,), oints o&t that
the instit&tionali=ed h&n*e! o" the 196>e is an &n!ecedented henomenon, and acc&m&lates
evidence that in a t(ical <tone 5*e c&lt&!e a m&ch smalle! e!centa*e o" eole than toda(
%ent to 'ed malno&!ished and h&n*!(.
1/ Oeo!*e )o!*st!om, GThe O!een 3evol&tion,G in (ocal +oints (Ne% No!+: Macmillan,
197,), t. ,, . 17,8,>1. 5n anal(sis and a!aisal o" a do=en ill&sions a'o&t the O!een
3evol&tion, man( o" %hich a!e constantl( !ein"o!ced '( misleadin* statements "!om
inte!national a*encies. Bn the dan*e!s o" *enetic deletion, cons&lt National 5cadem( o"
<ciences, $enetic 6ulnerability of *a5or Crops ($ashin*ton, 7.0., 197,). <ince aleolithic
times, each h&man societ( has develoed a !ich va!iet( o" ce!eals and othe! "ood c!os. The
st!ains that have s&!vived a!e those "avo!ed '( o&lations "ed la!*el( on *!ains and le*&mes.
5ltho&*h in"e!io! in (ield e! ac!e to en*inee!ed h('!ids, these st!ains a!e adata'le, a!e
indeendent o" "e!tili=e!s, i!!i*ation, and est cont!ol, and have a hi*h otential "o! "&t&!e
adatation. Enti!e o&lations o" s&ch !ich *enetic mixt&!es have 'een %ied o&t '(
!elacement %ith h('!ids. The dama*e done in a ten8(ea! e!iod is i!!ea!a'le and o"
&n"o!eseea'le conseA&ences.
15 -o! an int!od&ction to the state o" disc&ssion on %o!ld n&t!ition, see 5lan )e!*, The
.utrition (actor= )ts ole in .ational Development 2"ashington, D;C;= ,roo#ings )nstitution,
9>:0A; The valuable bibliography must be mined out of the footnotes; See also 3;
%emardinquer, D+our &ne histoi!e de l6alimentation,G Cahiers des 5nnales ,; (1a!is: 0olin,
197>).
16 Bn one conseA&ence o" exo!tin* 7!. <oc+ to the t!oics, see 5. E. 7avis and T. 7.
)olin, GLactose Tole!ance in <o&theast 5sia,G in -a!va! and Milton, eds., The Careless
Technology;
xxx "otnote sl&tt xxx
((,,/))
identi"ied as the main ca&se "o! the eidemic diseases o" the !ich.17 In the 9nited <tates the
ne% "!ontie!s had not (et 'een o'st!&cted '( cometin* '&!ea&c!atic schemes.l; #oes "o!
'ette! health still "oc&sed on eA&alit( o" access to the a*encies that %o&ld do a%a( %ith
seci"ic diseases. Iat!o*enesis %as still an iss&e "o! the a!anoid.
)&t '( 1975 m&ch o" this had chan*ed.19 5 *ene!ation a*o, child!en in +inde!*a!ten had
ainted the docto! as a %hite8coated "athe!8"i*&!e.,> Toda(, ho%eve!, the( %ill :&st as !eadil(
aint him as a man "!om Ma!s o! a -!an+enstein.,1 M&c+!ac+in* "eeds on medical cha!ts and
docto!s6 tax !et&!ns, and a ne% mood o" %a!iness amon* atients has ca&sed medical and
ha!mace&tical comanies to t!ile thei! exenses "o! &'lic !elations.,, 3alh
xxx "otnote sta!t xxx
17 5delle 7avis, -et1s Eat ight To Eeep (it (Ne% No!+: #a!co&!t )!ace, 197>). 5 %ell8
doc&mented !eo!t on the A&alitative decline o" 9.<. diet %ith the !ise o" ind&st!iali=ation and
on the !e"lection o" this decline in 9.<. health.
1; -o! o!ientation on the cont!ove!s(, cons&lt Ed%a!d M. @enned(, In Critical Condition=
The Crisis in America6s %ealth Care (Ne% No!+: 1oc+et )oo+s, 197.). -o! a s&mma!( o" the
cont!ove!s(, see <tehen Ionas, GIss&es in National #ealth Ins&!ance in the 9nited <tates o"
5me!ica,G -ancet, 197/, ,:1/.86, $illiam 3. 3o(, The +roposed %ealth *aintenance
'rgani8ation Act of 9>:&, Science and %ealth Communications $roup Sourceboo# Series,
vol; & 2"ashington, D;C;, 9>:&A; A Eansas congressman e/plains and defends the bill he
int!od&ced in 0on*!ess and ma!shals conc&!!in* oinion.
19 5n excellent, i" no% dated, "o!ecast is Michael Michaelson, GThe 0omin* Medical $a!,G
.ew <or# eview of ,oo#s, I&l( 1, 1971. <ee also 3o'e!t )!emne!, (rom the Depths= The
Discovery of +overty in the !;S; (Ne% No!+: Ne% No!+ 9niv. 1!ess, 1956), an int!od&ction to
the o!i*ins o" the 9.<. social %el"a!e movement.
,> )a!'a!a M(e!ho"" and $illiam 3. La!son, GThe 7octo! as 0&lt&!al #e!o: The
3o&tini=ation o" 0ha!isma,G %uman B!*ani=ation ,/ ("all 1965): 1;;891. The a&tho!s.
!edicted that the docto! %o&ld soon aea! in an inc!easin*l( !osaic li*ht, th&s losin* the
s(cholo*ical o%e! he t!aditionall( had to *ain the Ctient6s con"idence and to act as a
heale!.
,1 Michel Macco'(, e!sonal comm&nication to the a&tho!.
,, Iohn 1e++anen, The American 0onnection: +rofiteering and +olitic#ing in the DEthicalD
Drug )ndustry (0hica*o: -ollett, 197.). 5 !eo!t on the %ill"&l mani&lation o" olitical
o%e!, in"l&ence, and e!sonalities '( the 9<. 1ha!mace&tical Man&"act&!e!s 5ssociation
(1M5) and the d!&* lo''( to maintain !o"its '( ove!!od&cin* and ove!sellin* d!&*s and
s(stematicall( hidin* ha=a!ds 'ehind adve!tisin*, !omotion, and the s(stematic co!!&tion o"
hi*hl( laced h(sicians. 0ites seci"ic cha!*es a*ainst t%o do=en named ma:o! "i!ms.
xxx "otnote sl&tt xxx
((,,5))
Nade! has made the cons&me!s o" health stales mone( and A&alit(8conscio&s. The ecolo*ical
movement has c!eated an a%a!eness that health deends on the envi!on8mentDon "ood and
%o!+in* conditions and ho&sin*Dand 5me!icans have come to accet the idea that the( a!e
th!eatened '( esticides,,. additives, ,/ and m(cotoxins,5 and othe! health !is+s d&e to
envi!onmental de*!adation. $omen6s li'e!ation has hi*hli*hted the +e( !ole that the cont!ol
ove! one6s 'od( la(s in health ca!e. ,6 5 "e% sl&m comm&nities have ass&med !esonsi'ilit(
"o! 'asic health ca!e and have t!ied to &nhoo+ thei! mem'e!s "!om deendence on o&tside!s.
The class8seci"ic nat&!e o" 'od( e!cetion, ,7 lan*&a*e, ,; concets, ,9 access to health
se!v8
xxx "otnote sta!t xxx
,. 1a&l 3. and 5nne #. Eh!lich, 1o&lation, esowces, Envi!onment )ssues in #&man
Ecology (<an -!ancisco: -!eeman, 197,), a!tic&la!l( cha. 7 on ecos(stems in :eoa!d(,
!ovides a *ood int!od&ction to the lite!at&!e on the s&':ect <am&el Estein and Ma!vin
Le*ato!, eds., The *utagenicigJ of +esticides= 0oncets and Eval&ation (0am'!id*e, Mass.:
MIT 1!ess, 1971), (ields man( seci"ic data. #a!!ison $ell"o!d, Sowing the $ind eport on
the +olitics of (ood <a( 3alh Nade!6s <t&d( O!o& 3eo!ts (Ne% No!+: O!ossman, 197,). 5
!eo!t on esticide concent!ations in "ood. The mis&se o" esticides th!eatens the "a!me! even
mo!e than it does the cit( d%elle!R it dest!o(s his health, !aises the cost o" !od&ction, and
tends to lo%e! lon*8te!m (ields. I. L. 3adoms+i, $. ). 7eichman, and E. E. 0li=e!, G1esticide
0oncent!ation in the Live!, )!ain, and 5diose Tiss&e o" Te!minal #osital 1atients,G (ood
and Cosmetics To/icology ? (196;): ,>98,>. 5 ve!( "!i*htenin* A&antitative anal(sis.
,/ Iames <. T&!ne!, The Chemical (east A eport on the (ood and Dug Agi, alph .ader1s
Study $roup eports 2.ew <or#= $rossman, 9>:BA; This report indicates that the trend
described by Addle Davis in -et1s Eat ight to Eap (it is accelerating and that the damage
done to health by bad nutrition increased during the 9>?Bs; )t points out that less than half
the more than &,BBB food additives in use have been tested for safety;
,5 5!t&!o 5ldama, GLos ce!eales envenenados: Bt!a en"e!medad del !o*!eso,G 0I7B0
7oc&ment IL? 7/L5;, 0&e!navaca, 197/.
,6 )oston $omen6s #ealth 0ollective, 'ur ,odies, 'urselves= A ,oo# ,y and (or "omen
(Ne% No!+: <imon V <ch&ste!, 197.). 0an 'e conside!ed a model *&ide "o! limited sel"8ca!e
ela'o!ated '( a *!o& o" %omen %ho !emain deel( committed to a 'asicall( medicali=ed
societ(.
,7 L&c )oltans+i, 0onsommation mTdicale et rapport au corps= 0omte8!esdm afin de
cont!at d1une !eche!che "inances a! la DFtgation $FnFrale s la echerche Sciant paw et
Technique (1a!is: 0ent!e de <ociolo*ie E&!oTenne, 1969). 5 sociolo*( o" the body= a
ionee! st&d( o" the social dete!minants o" the individ&al6s !elationshi to his o%n body
deendin* on his social class.
xxx "otnote sl&tt xxx
((,,6))
ices,.> in"ant mo!talit(,.1 and act&al, seci"icall( ch!onic, mo!'idit(., has 'een %idel(
doc&mented, and the class8seci"ic o!i*ins.. and !e:&dices./ o" h(sicians a!e 'e*innin* to
'e &nde!stood. The $o!ld #ealth B!*ani=ation, mean%hile, is movin* to a concl&sion that
%o&ld have shoc+ed most o" its "o&nde!s: in a !ecent &'lication $#B advocates the
de!o"essionali=ation o" !ima!( ca!e as the most imo!tant sin*le ste in !aisin* national
health levels. .5
xxx "otnote sta!t xxx
,; Liselotte von -e!'e!, G7ie 7ia*nose des !a+tischen 5!=tes im <ie*el de!
1atientenan*a'en,G in Schri,3leareihe= 5!'eitsmedi=in, <o=iahneli!in, Arbeit hygiene, vol. /.
(<t&tt*a!t: Oentne!, 1971), on the dan8seci"ic lan*&a*e in Oe!man *ene!al !actice.
,9 0ha!les @ad&shin, G<ocial 0lass and the Exe!ience o" Ill #ealth,G <ociolo*ical )ngaity ./
(196/): 678;>, challen*es the sociolo*ical do*ma o" an association 'et%een socio8economic
stat&s and the occ&!!ence o" ch!onic disease. 7avid Mechanic, *edical <ociolo*(: 5
Selective 6iew 2.ew No!+: -!ee 1!ess, 196;), . ,59 i"., !ovides cont!adicto!( a!*&ments
and lite!at&!eR see also ,/5 on in"ant mo!talit(, . ,5. on socio8economic stat&s.
.> 3a(mond <. 7&"" and 5&*&st ). #ollin*shead, <ic+ness and <ociet( (Ne% No!+: #a!e!
V 3o%, 1961). <. #. @in*, +erceptions of )llness and *edical +ractice 2.ew <or#= ussell
Sage, 9>?&A;
.1 Mechanic, *edical Sociology; <ee eseciall( . ,67D; as an int!od&ction to the 9.<.
National #ealth <e!vice statistics on socio8economic stat&s and the &se o" health se!vices.
)e%a!e o" ta+in* these data at "ace val&e: see 7avid Mechanic and M. Ne%ton, G<ome
1!o'lems in the 5nal(sis o" Mo!'idit( 7ata,G foamsd o, 5 Chronic Diseases 1; (I&ne 1965):
5698;>. Lee 3ain%ate! and $. L. Nance(, The M*nihan eport and the +olitics of
Controversy (0am'!id*e, Mass.: MIT 1!ess, 1967), disc&ss the comlexit( o" associations
'et%een in"ant mo!talit( and socio8economic de!ivation.
., )a!'a!a )lac+%ell, The -iterature of Delay in See#ing *edical Care for Chronic
)llnesses, #ealth Ed&cation Mono*!ah no. 16 (<an -!ancisco: <ociet( "o! 1&'lic #ealth
Ed&cation, 196.). <ee eseciall( . 1/D17 "o! dela( !elated to e!sonal, h(sical, and social
att!i'&tes. 3enT Lenoi!, -es E/clus 2+aris= <e&il, 197/), "oc&ses attention on the instit&tional
c!eation o" need( d!oo&ts "!om va!io&s health8ca!e s(stems in -!ance.
.. O. @lein'ach, G<ocial 0lass and Medical Ed&cation,G thesis, 7ea!tment o" Ed&cation,
#a!va!d 9nive!sit(, 197/. 0ha!les -. <ch&mache!, GThe 196> Medical <chool O!ad&ate: #is
)io*!ahical #isto!(,G Io&!nal of *edical Amain 0? 29>?9A= JB9 if;, shows that more than
half of medical students are children o professionals or managers=
./ #o%a!d )ec+e! et al., ,oys in "hile;V Student Culture in *edical <chool (1961R !e!int
ed., 7&'&A&e, Io%a: $illiam 0. )!o%n, 197,).
.5 @enneth $. Ne%ell, ed., %ealth by the +eople (Oeneva: $o!ld #ealth B!*ani=ation,
1975).
xxx "otnote sl&tt xxx
((,,7))
7octo!s themselves a!e 'e*innin* to loo+ as+ance at %hat docto!s do..6 $hen h(sicians in
Ne% En*land %e!e as+ed to eval&ate the t!eatment thei! atients had !eceived "!om othe!
docto!s, most %e!e dissatis"ied. 7eendin* on the method o" ee! eval&ation &sed, 'et%een
1./ e!cent and 6. e!cent o" atients %e!e 'elieved to have !eceived adequate ca!e..7
1atients a!e told eve! mo!e "!eA&entl( '( thei! docto!s that the( have 'een dama*ed '(
!evio&s medication and that the t!eatment no% !esc!i'ed is made necessa!( '( the e""ects o"
s&ch !io! medication, %hich in some cases %as *iven in a li"e8savin* endeavo!, '&t m&ch
mo!e o"ten "o! %ei*ht cont!ol, mild h(e!tension, "l&, o! mosA&ito 'ite o! :&st to &t a
m&t&all( satis"acto!( concl&sion to an inte!vie% %ith the docto!. .; In 197. a !eti!in* senio!
o""icial o" the 9.<. 7ea!tment o" #ealth, Ed&cation, and $el"a!e co&ld sa( that ;> e!cent o"
all "&nds channeled th!o&*h his o""ice !ovided no demonst!a'le 'ene"its to health and that
m&ch o" the !est %as sent to o""set iat!o*enic dama*e. #is s&ccesso! %ill have to deal %ith
these data i" he %ants to maintain &'lic t!&st..9
xxx "otnote sta!t xxx
.6 Bn the eme!*ence o" social medicine as a disciline, see "i!st Thomas Mc@eon and 0. 3.
Lo%e, 5n )ntroduction to Social *edicine (Bx"o!dLEdin'&!*h: )lac+%ell <cienti"ic
1&'lications, 1966), . ixqxiii. Then see Oo!don McLachlan, ed., +ortfolio for %ealth ,
(Ne% No!+LTo!onto: N&""ield 1!ovincial #ositals T!&st and Bx"o!d 9nive!sit( 1!ess, 197.).
-o! the Oe!man lite!at&!e in the "ield o see #ans <chae"e! and Ma!ia )lohm+e, <o=iahnedi=in:
Ein"eh!&n* in die ErgebnRse &nd + obleme der *edi8in4So8iologie &nd <o=ialmnedi=in
(<t&tt*a!t: Thieme, 197,). -o! Easte!n E&!oe see 3icha!d E. and <hi!le( ). $eine!man,
<ocial Medicine in Eastern Europe= The 'rgani8ation of #ealth <e!vices and the Ed&cation
of the *edical +ersonnel in C8echoslova#ia, %ungary and +oland (0am'!id*e, Mass.:
#a!va!d 9nive!sit( 1!ess, 1969). -o! Ital(, see Oiovanni )e!lin*&e!, *edicie e politica ()a!i:
7e 7onato, 1976).
.7 3o'e!t #. )!oo+ and -!ancis 5. 5el, G2&alit(8o"80a!e 5ssessment: 0hoosin* a Method
"o! 1ee! 3evie%,G .ew England 3ournal of Medicine ,;; (197.): 1.,.89. I&d*ments 'ased
on *!o& consens&s, as oosed to the c!ite!ia selected '( individ&al !evie%e!s, (ielded the
"e%est acceta'le cases. 3o'e!t #. )!oo+ and 3o'e!t <tevenson, I!., GE""ectiveness o" 1atient
0a!e in an Eme!*enc( 3oom,G .ew England 3ournal of *edicine ,;. (197>): 9>/86.
.; Iean81ie!!e 7&&(, GLe MTdicament dans la !elation mTdecin8malade,G +ro5et, no. 75
(Ma( 197.), . 5.,8/6.
.9 Arnold ); Eisch and Leo O. 3eede!, G0lient Eval&ation o" 1h(sician 1e!"o!mance,G
3ournal of %ealth and Social ,ehavior 9B 29>?>A= @94C; "hile it is
xxx "otnote "o!tsette! neste side xxx
((,,;))
1atients a!e sta!tin* to listen, and a *!o%in* n&m'e! o" movements and o!*ani=ations a!e
'e*innin* to demand !e"o!m. The attac+s a!e "o&nded on "ive ma:o! cate*o!ies o" c!iticism
and a!e di!ected to "ive cate*o!ies o" !e"o!m: (1) 1!od&ction o" !emedies and se!vices has
'ecome sel"8se!vin*. 0ons&me! lo''ies and cons&me! cont!ol o" hosital 'oa!ds sho&ld
the!e"o!e "o!ce docto!s to im!ove thei! %a!es. (,) The delive!( o" !emedies and access to
se!vices is &neA&al and a!'it!a!(R it deends eithe! on the atient6s mone( and !an+, o! on
social and medical !e:&dices %hich "avo!, "o! examle, attention to hea!t disease ove!
attention to maln&t!ition. The nationali=ation o" health !od&ction o&*ht to cont!ol the hidden
'iases o" the clinic. (.) The o!*ani=ation o" the medical *&ild e!et&ates ine""icienc( and
!ivile*e, %hile !o"essional licensin* o" secialists "oste!s an inc!easin*l( na!!o% and
seciali=ed vie% o" disease. 5 com'ination o" caitation a(ment %ith instit&tional licensin*
o&*ht to com'ine cont!ol ove! docto!s %ith the inte!est o" atients. (/) The s%a( o" one +ind
o" medicine de!ives societ( o" the 'ene"its cometin* sects mi*ht o""e!. Mo!e &'lic s&o!t
"o! alha %aves, enco&nte! *!o&s, and chi!o!actic o&*ht to co&nte!vail and comlement the
scalel and the oison. (5) The main th!&st o" !esent medicine is the individ&al, in sic+ness
o! in health. Mo!e !eso&!ces "o! the en*inee!in* o" o&lations and envi!onments o&*ht to
st!etch the health dolla!.
These !oosed !emedial olicies co&ld cont!ol to some de*!ee the social costs c!eated '(
ove!medicali=ation. )( :oinin* to*ethe!, cons&me!s do have o%e! to *et mo!e "o! thei!
mone(R %el"a!e '&!ea&c!acies do have the o%e! to
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
*ene!all( ass&med that A&alit( cont!ol in !o"essional se!vice m&st deend on sel"8olicin*D
'ad as this mi*ht 'eDthe !es&lts o" a st&d( cond&cted in Los 5n*eles indicate that atients6
!atin* o" h(sician e!"o!mance closel( co!!esonded %ith a n&m'e! o" c!ite!ia o" A&alit( in
medical ca!e *ene!all( acceted as valid '( health !o"essionals.
xxx "otnote sl&tt xxx
((,,9))
!ed&ce ineA&alitiesR chan*es in licensin* and in modes o" "inancin* can !otect the o&lation
not onl( a*ainst non!o"essional A&ac+s '&t also, in some cases, a*ainst !o"essional a'&seR
mone( t!ans"e!!ed "!om the !od&ction o" h&man sa!e a!ts to the !ed&ction o" ind&st!ial
!is+s does '&( mo!e GhealthG e! dolla!. )&t all these olicies, &nless ca!e"&ll( A&ali"ied, %ill
tend to !ed&ce the e/ternalities c!eated '( medicine at the cost o" a "&!the! inc!ease o"
medicine6s a!adoxical co&nte!!od&ct, its ne*ative e""ect on health. 5ll tend to stim&late
"&!the! medicali=ation. 5ll consistentl( lace the im!ovement o" medical se!vices a'ove
those "acto!s %hich %o&ld im!ove and eA&ali=e oo!t&nities, cometence, and con"idence
"o! sel"8ca!eR the( den( the civil li'e!t( to live and to heal, and s&'stit&te !omises o" mo!e
consic&o&s social entitlements to ca!e '( a !o"essional.
In the "ollo%in* "ive sections I %ill deal %ith some o" these ossi'le co&nte!meas&!es and
examine thei! !elative me!its.
Consumer Protection for )ddicts
$hen eole 'ecome a%a!e o" thei! deendence on the medical ind&st!(, the( tend to 'e
t!aed in the 'elie" that the( a!e al!ead( hoelessl( hoo+ed. The( "ea! a li"e o" disease
%itho&t a docto! m&ch as the( %o&ld "eel immo'ili=ed %itho&t a ca! o! a '&s. In this state o"
mind the( a!e !ead( to 'e o!*ani=ed "o! cons&me! !otection and to see+ solace "!om
oliticians %ho %ill chec+ the hi*h8handedness o" medical !od&ce!s. /> The need "o! s&ch
sel"8!otec8
xxx "otntoe sta!t xxx
/> -o! examles o" &'lic !eo!ts on !esea!ch in the se!vice o" cons&me! advocac( in the
health "ield, see 3o'e!t <. Mc0lee!(, 'ne -ife 4 'ne +hysician 2"ashington, D;C;= +ublic
Affairs +ress, 9>:9AM also 3oseph +age and *ary4"in '1,rien, ,itter "ages= The eport on
Disease and )n5ury on the 3ob, alph .ader1s Study $roup eports (Ne% No!+: O!ossman,
197.), an indictment o" ind&st!ial and occ&ational medicine as !acticed & to 196;. 0!ass
&nde!!eo!tin* o"
xxx "otnote "o!tsette! E neste side xxx
((,.>))
tion is o'vio&s, the imlicit dan*e!s o'sc&!e. The sad t!&th "o! cons&me! advocates is that
neithe! cont!ol o" cost no! ass&!ance o" A&alit( *&a!antees that health %ill 'e se!ved '(
medicine that meas&!es & to !esent medical standa!ds.
0ons&me!s %ho 'and to*ethe! to "o!ce Oene!al Moto!s to !od&ce an acceta'le ca! have
'e*&n to "eel cometent to loo+ &nde! the hood and to develo c!ite!ia "o! estimatin* the cost
o" a cleane! exha&st s(stem. $hen the( 'and to*ethe! "o! 'ette! health ca!e, the( still
'elievemista+enl(Dthat the( a!e &nA&ali"ied to decide %hat o&*ht to 'e done "o! thei! 'o%els
and +idne(s and 'lindl( ent!&st themselves to the docto! "o! almost an( !eai!. 0!oss8c&lt&!al
coma!ison o" !actices !ovides no *&ide. 1!esc!itions "o! vitamins a!e seven times mo!e
common in )!itain than in <%eden, *amma *lo'&lin medication ei*ht times mo!e common in
<%eden than in )!itain. 5me!ican docto!s oe!ate, on the ave!a*e, t%ice as o"ten as )!itonsR
-!ench s&!*eons am&tate almost & to the nec+. Median hosital sta(s va!( not %ith the
a""liction '&t %ith the h(sician: "o! etic &lce!s, "!om six to t%ent(8six da(sR "o! m(oca!dial
in"a!ction, "!om ten to thi!t( da(s. The ave!a*e len*th o" sta( in a -!ench hosital is t%ice that
in the 9nited <tates. 5endectomies a!e e!"o!med and deaths "!om aendicitis a!e
dia*nosed th!ee times mo!e "!eA&entl( in Oe!man( than an(%he!e else /1
Titm&ss /, has s&mmed & the di""ic&lt( o" cost8'ene"it
xxx "otnote "o!tsette!" !a "o!!i*e side xxx
in:&!ies s&stained on the :o' has "oste!ed the 'elie" that ca!elessness o" %o!+e!s is thei! main
ca&se.
/1 -o! mo!e data and !e"e!ences see Michael #. 0ooe!, ationing %ealth Care 2-ondon=
%alsted +ress, 9>:@A, and )nternational ,an# for econstruction and Development, %ealth
Sector +olicy +aper, "ashington, D;C;, *arch 9>:@; .ote also that the average number of
days spent by a patient in the hospital varies greatly among countries with comparable $.+,
even when these countries are poor; )n Senegal it is &J days, in Thailand @;C;
/, 3icha!d M. Titm&ss, GThe 0&lt&!e o" *edical Care and Consumer )ehavio&!,G in -. .; -;
1o(nte!, ed;, *edicine and Culture (London: $ellcome Instit&te, 1969), cha. ;, . 1,98.5.
xxx "otnote sl&tt xxx
22&09AA
acco&ntin* in medicine, eseciall( at a time %hen medical ca!e is losin* the cha!acte!istics it
&sed to ossess %hen it consisted almost %holl( in the e!sonal docto!8atient !elationshi.
Medical ca!e is &nce!tain and &n!edicta'leR man( cons&me!s do not desi!e it, do not +no%
the( need it, and cannot +no% in advance %hat it %ill cost them. The( cannot lea!n "!om
exe!ience. The( m&st !el( on the s&lie! to tell them i" the( have 'een %ell se!ved, and the(
cannot !et&!n the se!vice to the selle! o! have it !eai!ed. Medical se!vices a!e not adve!tised
as a!e othe! *oods, and the !od&ce! disco&!a*es coma!ison. Bnce he has &!chased, a
cons&me! cannot chan*e his mind in mid8t!eatment. )( de"inin* %hat constit&tes illness the
medical !od&ce! has the o%e! to select his cons&me!s and to ma!+et some !od&cts that %ill
'e "o!ced on the cons&me!, i" need 'e, '( the inte!vention o" the olice: the !od&ce!s can
even sell "o!ci'le inte!nment "o! the disa'led and as(l&ms "o! the mentall( !eta!ded.
Mal!actice s&its have miti*ated the la(man6s sense o" imotence on seve!al o" these
oints,/. '&t 'asicall(, the( have !ein"o!ced the atient6s dete!mination to insist on t!eatment
that is conside!ed adeA&ate '( in"o!med medical oinion. $hat "&!the! comlicates matte!s is
that the!e is no Gno!malG cons&me! o" medical se!vices. No'od( +no%s ho% m&ch health ca!e
%ill 'e %o!th to him in te!ms o" mone( o! ain. In addition, no'od( +no%s i" the most
advanta*eo&s "o!m o" health ca!e is o'tained "!om medical !od&ce!s, "!om a t!avel a*ent, o!
'( !eno&ncin* %o!+ on the ni*ht shi"t. The "amil( that "o!*oes a ca! to move into a Manhattan
aa!tment can "o!esee ho% the s&'stit&tion o" !ent "o! *as %ill a""ect thei! availa'le timeR '&t
the e!son
xxx "otnote sta!t xxx
/. Bn the imact that mal!actice s&its have on the atient6s e!cetion o" his 'od( as a "o!m
o" caital investment, see, e.*., Nathan #e!she(, GThe 7e"ensive 1!actice o" MedicineDM(th
o! 3ealit(4G *ilban# *emorial (und WuartsH @B (Ian&a!( 197,): 6989;.
xxx "otnote sl&tt xxx
((,.,))
%ho, &on the dia*nosis o" cance!, chooses an oe!ation ove! a 'in*e in the )ahamas does not
+no% %hat e""ect his choice %ill have on his !emainin* time o" *!ace. The economics o"
health is a c&!io&s disciline, some%hat !eminiscent o" the theolo*( o" ind&l*ences %hich
"lo&!ished 'e"o!e L&the!. No& can co&nt %hat the "!ia!s collect, (o& can loo+ at the temles
the( '&ild, (o& can ta+e a!t in the lit&!*ies the( ind&l*e in, '&t (o& can onl( *&ess %hat the
t!a""ic in !emission "!om &!*ato!( does to the so&l a"te! death. Models develoed to acco&nt
"o! the %illin*ness o" taxa(e!s to "oot !isin* medical 'ills constit&te simila! scholastic
*&ess%o!+ a'o&t the ne% %o!ld8sannin* ch&!ch o" medicine. To *ive an examle: it is
ossi'le to vie% health as d&!a'le caital stoc+ &sed to !od&ce an o&t&t called Ghealth(
time.G// Individ&als inhe!it an initial stoc+, %hich can 'e inc!eased '( investment in health
caitali=ation th!o&*h the acA&isition o" medical ca!e, o! th!o&*h *ood diet and ho&sin*.
G#ealth( timeG is an a!ticle in demand "o! t%o !easons. 5s a cons&me! commodit(, it di!ectl(
ente!s into the individ&al6s &tilit( "&nctionR eole &s&all( %o&ld !athe! 'e health( than sic+. It
also ente!s the ma!+et as an investment commodit(. In this "&nction, Ghealth( timeG
dete!mines the amo&nt o" time an individ&al can send on %o!+ and on la(, on ea!nin* and
on !ec!eation. The individ&al6s Ghealth( timeG can th&s 'e vie%ed as a decisive indicato! o" his
val&e to the comm&nit( as a !od&ce!./5
B!ientation on olic( and theo!ies on the dolla! val&e o" GhealthG !od&ction divide the
adhe!ents o" sA&a''lin* academic "actions m&ch as !ealism and nominalism divided medieval
divines./6 )&t to the oint that conce!ns
xxx "otnote sta!t xxx
// Michael O!ossman, GBn the 0oncet o" #ealth 0aital and the 7emand "o! #ealth,G
:o&!nal of +olitical Econom( ;> (Ma!ch85!il 197,): ,,.855.
/5 1. E. Ente!line, G<ic+ 5'sence in 0e!tait+ $este!n 0o&nt!ies,G Ind&st!ial Medicine and
Surgery .. (Bcto'e! 196/): 7.;.
/6 -o! o!ientation on the lite!at&!e, cons&lt @athleen N. $illiams, com., %ealth and
Dareloprnent= An Annotated )nde/ed ,ibliography ()altimo!e: Iohns
xxx "otnote "o!tsette! neste side xxx
22&00AA
the cons&me!, the( :&st state in a !o&nda'o&t %a( %hat eve!( Mexican '!ic+la(e! +no%s: onl(
on those da(s %hen he is healthy eno&*h to %o!+ can he '!in* 'eans and to!tillas to his
child!en and have a teA&ila %ith his "!iends. /7 The 'elie" in a ca&sal !elationshi 'et%een
docto!6s 'ills and healthD%hich %o&ld othe!%ise 'e called mode!ni=ed s&e!stitionDis a
'asic technical ass&mtion "o! the medical economist. /;
7i""e!ent s(stems have 'een &sed to le*itimi=e the economic val&e o" the seci"ic activities in
%hich h(sicians en*a*e. <ocialist nations ass&me the "inancin* o" all ca!e and leave it to the
medical !o"ession to de"ine %hat is needed, ho% it m&st 'e done, %ho ma( do it, %hat it
sho&ld cost, and %ho shall *et it. Mo!e '!a=enl( than else%he!e, in&tLo&t&t calc&lations o"
s&ch investments in h&man caital seem to dete!mine 3&ssian allocations.> Most %el"a!e
states inte!vene %ith la%s and incentives in the o!*ani=ation o" thei! health8ca!e ma!+ets,
altho&*h onl( the 9nited <tates. has la&nched a national le*islative !o*!am &nde! %hich
committees o" !od&ce!s dete!mine %hat o&t&ts o""e!ed on the G"!ee ma!+etG the state shall
a!ove as G*ood ca!e.G In late 197. 1!esident Nixon
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
#o+ins 9nive!sit( <chool o" #(*iene and 1&'lic #ealth, 7ea!tment o" Inte!national
#ealth, 197,), 9.1 items on health, ho%eve! measd!ed, and its s&osed !elationshi to
economic develoment. 0onst!&cted as a %o!+in* inst!&ment "o! health8!eso&!ces allocation,
it is a!tic&la!l( val&a'le "o! its 8 !e"e!ences and s&mma!ies o" Easte!n E&!oean st&dies.
/7 #e!'e!t 1ollac+ and 7onald 3. <heldon, 6The -acto! o" 7isease in the $o!ld -ood
1!o'lem,G Io&!nal of the 5me!ican *edical 5ssociation ,1, (197>): 59;86>.. <ic+ eole
'&!n mo!e "ood e! &nit o" %o!+ done and also !od&ce less %o!+. In 'oth %a(s, endemic
disease adds to the %o!ld "ood sho!ta*e.
/; 3alh 5&d(, G#ealth as 2&anti"ia'le 1!oe!t(,G ,ritish *edical :o&!nal, 197., /:/;687.
5&d( is one o" the !a!e a&tho!s %ho *o 'e(ond t!ivial econom( and develo a model "o! the
dimensional anal(sis o" man in !elation to his envi!onment. #e !e*a!ds health as a contin&in*
!oe!t( that can otentiall( 'e meas&!ed in te!ms o" one6s a'ilit( to G!all( "!om challen*es to
adat.G <eed and s&ccess in !all(in* deend on the amo&nt o" !otection !ovided '( a
e!son6s ha'it&al GcocoonsG and on societ(6s GhealthG in *ene!al.
/9 <ee $illiams, %ealth and Dwolopnrant, chate! on <oviet medical econom(.
xxx "otnote sl&tt xxx
((,./))
si*ned 1&'lic La% 9,86>. esta'lishin* mandato!( cost and A&alit( cont!ols ('( 1!o"essional
<tanda!d 3evie% B!*ani=ations) "o! Medicaid and Medica!e, the tax8s&o!ted secto! o" the
health8ca!e ind&st!(, %hich since 197> has 'een second in si=e onl( to the milita!(8ind&st!ial
comlex. #a!sh "inancial sanctions th!eaten h(sicians %ho !e"&se to oen thei! "iles to
*ove!nment insecto!s sea!chin* "o! evidence o" ove!8&tili=ation o" hositals, "!a&d, o!
de"icient t!eatment. The la% !eA&i!es the medical !o"ession to esta'lish *&idelines "o! the
dia*nosis and t!eatment o" a lon* list o" in:&!ies, illnesses, and health conditions, mandatin*
the %o!ld6s most costl( !o*!am "o! the medicali=ation o" health !od&ction th!o&*h le*islated
cons&me! !otection 5> The ne% la% *&a!antees the standa!d set '( industry "o! the
commodit(. It does not as+ i" its delive!( is ositivel( o! ne*ativel( !elated to the health o"
eole.
5ttemts to exe!cise !ational olitical, cont!ol ove! the !od&ction o" medical health ca!e have
consistentl( "ailed. The !eason lies in the nat&!e o" the !od&ct no% called Gmedicine,G a
ac+a*e made & o" chemicals, aa!at&s, '&ildin*s, and secialists, and delive!ed to the
client. The &!ve(o! !athe! than his clients o! olitical 'oss dete!8mines the si=e o" the
ac+a*e. The atient is !ed&ced to an o':ectDhis 'od(D'ein* !eai!edR he is no lon*e! a
s&':ect 'ein* heled to heal. I" he is allo%ed to a!ticiate in the !eai! !ocess, he acts as the
lo%est a!entice in a hie!a!ch( o" !eai!men.51 B"ten he is not even t!&sted to ta+e a ill
%itho&t the s&e!vision o" a n&!se.
xxx "otnote sta!t xxx
5> 0la&de $elch, G1!o"essional <tanda!ds 3evie% B!*ani=ationsD1!os and 0ons,G .ew
England :o&!nal of *edicine ,9> (197/): 1.19 il.R idem, ,;9 (197.): ,9185. 7avid E. $illett,
G1<3B Toda(: 5 La%(e!6s 5ssessment,G .ew England 5ournal of *edicine &>& 29>:@A= 0JB4
0M see also editorial about this article in same number, p; 0?@;
51 Tom 7e%a!, G<ome Notes on the 1!o"essionali=ation o" the 0lient,G 0I7B0 7oc&ment IL?
7.L.7, 0&e!navaca, 197..
xxx "otnote sl&tt xxx
((,.5))
The a!*&ment that instit&tional health ca!e (!emedial o! !eventive) ceases a"te! a ce!tain oint
to co!!elate %ith an( ."&!the! G*ainsG in health can 'e mis&sed "o! t!ans8"o!min* clients
hoo+ed on docto!s into clients o" some othe! se!vice he*emon(: n&!sin* homes, social
%o!+e!s, vocational co&nselo!s, schools. 5, $hat sta!ted o&t as a de"ense o" cons&me!s
a*ainst inadeA&ate medical se!vice, %ill, "i!st, !ovide the medical !o"ession %ith ass&!ance
o" contin&ed demand and then %ith the o%e! to dele*ate some o" these se!vices to othe!
ind&st!ial '!anches: to the !od&ce!s o" "oods, matt!esses, vacations, o! t!ainin*. 0ons&me!
!otection th&s t&!ns A&ic+l( into a c!&sade to t!ans"o!m indeendent eole into clients at all
cost.
9nless it disa'&ses the client o" his &!*e to demand and ta+e mo!e se!vices, cons&me!
!otection onl( !ein"o!ces the coll&sion 'et%een *ive! and ta+e!, and can la( onl( a tactical
and a t!ansito!( !ole in an( olitical movement aimed at the health8o!iented limitation o"
medicine. 0ons&me!8!otection movements can t!anslate in"o!mation a'o&t medical
ine""ectiveness no% '&!ied in medical :o&!nals into the lan*&a*e o" olitics, '&t the( can
ma+e s&'stantive cont!i'&tions onl( i" the( develo into de"ense lea*&es "o! civil li'e!ties and
move 'e(ond the cont!ol o" A&alit( and cost into the de"ense o" &nt&to!ed "!eedom to ta+e o!
leave the *oods. 5n( +ind o" deendence soon t&!ns into an o'stacle to a&tonomo&s m&t&al
ca!e, coin*, adatin*, and healin*, and %hat is %o!se, into a device '( %hich eole a!e
stoed "!om t!ans"o!min* the conditions at %o!+ and at home that ma+e them sic+. 0ont!ol
ove! the !od&ction side o" the medical comlex can %o!+ to%a!ds 'ette! health onl( i" it
leads to at least a ve!( si=a'le !ed&ction o" its total o&t&t, !athe! than siml( to technical
im!ovements in the %a!es that a!e o""e!ed.
xxx "otnote sta!t xxx
5, 3o'e!t I. #a**e!t(, GThe )o&nda!ies o" #ealth 0a!e,G 1ha!os, I&l( 197,, . 1>6811.
xxx "otnote sl&tt xxx
((,.6))
':ual )ccess to ,orts
The most common and o'vio&s olitical iss&e !elated to health is 'ased on the cha!*e that
access to medical ca!e is ineA&ita'le, that it "avo!s the !ich ove! the oo!, 5. the in"l&ential
ove! the o%e!less. $hile the level o" medical se!vices !ende!ed to the mem'e!s o" technical
elites does not va!( si*ni"icantl( "!om one co&nt!( to anothe!, sa( "!om <%eden and
0=echoslova+ia to Indonesia and <ene*al, the val&e o" the se!vices !ende!ed to the t(ical
citi=en in di""e!ent co&nt!ies va!ies '( "acto!s exceedin* the !oo!tion o" one to one
tho&sand. 5/ In man( oo! co&nt!ies, the "e% a!e sociall( !edete!mined to *et m&ch mo!e
than the ma:o!it(, not so m&ch 'eca&se the( a!e !ich as 'eca&se the( a!e child!en o" soldie!s
o! '&!ea&c!ats o! 'eca&se the( live close to the one la!*e hosital. In !ich co&nt!ies mem'e!s
o" di""e!ent mino!ities a!e &nde!!ivile*ed, not 'eca&se, in te!ms o" mone( e! caita, the(
necessa!il( *et less than thei! sha!e, 55 '&t 'eca&se the( *et
xxx "otnote sta!t xxx
5. #ealth 1olic( 5dviso!( 0ommittee, The American %ealth Empire= +ower, +rof its, and
1olitics, ed; ,arbara and 3ohn Eh!en!eich (Ne% No!+: 3andom #o&se, 197>). <ince the late
196>s the #ealth 1olic( 5dviso!( 0ente!, 17 M&!!a( <t., Ne% No!+ 1>>>7, has la(ed an
imo!tant !ole in exosin* those technical and o!*ani=ational diso!de!s '&ilt into the 9.<.
medical s(stem as a conseA&ence o" its caitalist exloitative cha!acte!. The %ealth4+AC
,ulletin, published at the same address, is a valuable record of the evolution of this critique;
The Eh!en!eichs a!e !o'a'l( !e!esentative o" thei! *!o&6s thin+in* at the time o"
&'lication. The inte*!ation o" a health !o"ession, health ind&st!ies, and *ove!nment health
'&!ea&c!acies !omotes in each o" these 'odies cha!acte!istics t(ical o" an( t!ansnational
co!o!ation. These common cha!acte!istics amal*amate them into a GcomlexG *ea!ed to
!ein"o!ce in"antile, !acist, and sexist !esonses in those it ame!s %ith s&'tle o! *!oss
a!'it!a!iness. The elimination o" the !o"it motive and %ide a!ticiation '( health( and sic+
in olic(8ma+in* %o&ld !ende! the s(stem acco&nta'le, eA&ita'le, and mo!e e""ective "o!
health ca!e.
5/ 9e! ?olta in 0ent!al 5"!ica, a'o&t M,5 million is sent ann&all( "o! all medical se!vices,
incl&din* d!&*s, cons&med %ithin the co&nt!(. T%ice this amo&nt in *ove!nment exendit&!e
*oes to t!anso!t a "e% o" the sic+ to 1a!is and to hositali=e them the!e. This coma!es %ith a
total *!ant8in8aid "o! all nonmilita!( &!oses o" M5> million (ea!l( '( -!ance to its ex8
colon(. -!om the eve! imecca'l( in"o!med h&mo! sheet "o! -!ench '&!ea&c!ats, -e Canard
mchaini, Ian&a!( 1, 1975.
55 Nathan Ola=e!, G1a!adoxes o" #ealth 0a!e,G +ublic )nterest ,, (%inte! 1971): 6,877. Lo%8
income "amilies in the 9.<. !eceive not less '&t mo!e health dolla!s than the income *!o&
immediatel( a'ove them.
xxx "otnote sl&tt xxx
((,.7))
s&'stantiall( less than the( have 'een t!ained to need. The sl&m d%elle! cannot !each the
docto! %hen he needs him, and %hat is %o!se, the old, i" the( a!e oo! and loc+ed in a
Ghome,G cannot *et a%a( "!om him. -o! these and simila! !easons, olitical a!ties conve!t the
desi!e "o! health into demands "o! eA&al access to medical "acilities. 56 The( &s&all( do not
A&estion the *oods the medical s(stem !od&ces '&t insist that thei! constit&ents have a !i*ht
to all that is !od&ced "o! the !ivile*ed. 57
In the oo! co&nt!ies, the oo! ma:o!ities clea!l( have less access to medical se!vices than the
!ich: 5; the se!vices availa'le to the "e% cons&me most o" the health '&d*et and de!ive the
ma:o!it( o" se!vices o" an( +ind. In all o" Latin 5me!ica, excet 0&'a, onl( one child in "o!t(
"!om
xxx "otnote sta!t xxx
56 -o! a "!ame%o!+ &se"&l in the c!eation o" needs, see Ionathan )!adsha%, G5 Taxonom( o"
<ocial Need,G in Oo!don McLachlan, ed., 1!o'lems and +rogress in *edical Can= Essays on
Current esearch (Ne% No!+: Bx"o!d 9nive!sit( 1!ess, 197,), 7:698;,. To cla!i"( and ma+e
exlicit %hat is done %hen '&!ea&c!ats conce!ned %ith a social se!vice lan to meet a social
need, )!adsha% distin*&ishes 1, distinct sit&ations acco!din* to the !esence or a'sence o"
an( o" "o&! need8"acto!s: 29A normative need, de"ined '( exe!t or !o"essional +no%led*eR
2&A felt need, de"ined '( %antR 20A e/pressed need, o! demandR 2JA comparative need, o'tained
'( st&d(in* the cha!acte!istics o" a o&lation in !eceit o" se!vice (those %ith simila!
cha!acte!istics not in !eceit o" se!vice a!e then de"ined as standin* in need). <ee also @enneth
)o&ldin*, GThe 0oncet o" Need "o! #ealth <e!vices,G *ilban# *emorial (und Wuarterly //
(Bcto'e! 1966): ,>,8,.. -o! 3icha!d M. Titm&ss6s testament on this s&':ect, see Social
+olicy= 5n Int!od&ction (Ne% No!+: 1antheon )oo+s, 1975), eseciall( cha. 1>, G?al&es and
0hoices,G . 1.,8/1.
57 @ad&shin, G<ocial 0lass and the Exe!ience o" Ill #ealth.G Mem'e!s o" the &e! class a!e
al%a(s mo!e cometent in ma+in* &se o" &'licl( "inanced medical se!vices, 'eca&se o" thei!
*!eate! sohistication and sometimes 'eca&se o" thei! a'ilit( to &se small a(ments "o!
*ainin* leve!a*e on la!*e e!A&isites.
5; Iesus M. de Mi*&el, G-!ame%o!+ for the <t&d( o" National #ealth <(stems,G ae!
s&'mitted to the Ei*hth $o!ld 0on*!ess o" <ociolo*(, 5&*&st 197/, mimeo*!ahed. T!ies to
lin+ !e*ional di""e!ences %ithin nations to the anal(sis o" di""e!ences ac!oss nations. <ee ta'le
1 for a ch!onot(olo*( o" coma!ative health s(stems !esea!ch since 19.>. @e!! L. $hite et
al., GInte!national 0oma!isons o" Medical80a!e 9tili=ation,G .ew England 3ournal of
*edicine &:: (1967): 5168,,. $hite oints to the methodolo*ical di""ic&lties involved in
sim&ltaneo&s meas&!ement o" a deendent va!ia'le li+e G&tili=ationG in settin*s as di""e!ent as
En*land, N&*oslavia, and the 9.<.5.
xxx "otnote sl&tt xxx
((,.;))
the oo!est "i"th o" the o&lation "inishes the "ive (ea!s o" com&lso!( schoolin*R 59 a
simila! !oo!tion o" the oo! can exect hosital t!eatment i" the( 'ecome se!io&sl( ill. In
?ene=&ela, one da( in a hosital costs ten times the ave!a*e dail( incomeR in )olivia, a'o&t
"o!t( times the ave!a*e dail( income 6> Eve!(%he!e in Latin 5me!ica, the !ich constit&te the
. e!cent o" the o&lation %ho a!e colle*e *!ad&ates, la'o! leade!s, olitical a!t( o""icials,
and mem'e!s o" "amilies %ho have access to se!vices eithe! th!o&*h mone( o! siml( th!o&*h
connections. These "e% !eceive costl( t!eatment, o"ten "!om the docto!s o" thei! choice. Most
o" the h(sicians, %ho come "!om the same social class as thei! atients, %e!e t!ained to
inte!national standa!ds on *ove!nment *!ants. 61
Not%ithstandin* &neA&al access to hosital ca!e, the availa'ilit( o" medical se!vice does not
inevita'l( co!!elate %ith e!sonal income. In Mexico a'o&t . e!cent o" the o&lation has
access to the Instit&to de <e*&!idad ( <e!vicios <ociales de las T!a'a:ado!es del Estado
(I<<<TE), that secial a!t o" the social sec&!it( s(stem %hich still holds a !eco!d "o!
com'inin* e!sonal n&!sin* ca!e %ith advanced technolo*ical sohistication. This "o!t&nate
*!o& is made & o" *ove!nment emlo(ees %ho !eceive t!&l( eA&al t!eatment, %hethe! the(
a!e ministe!s o! o""ice 'o(s, and can co&nt on hi*h8A&alit( ca!e 'eca&se the( a!e a!t o" a
demonst!ation model. The ne%sae!s,
xxx "otnote sta!t xxx
59 7avid )a!+in, G5ccess to and )ene"its "!om #i*he! Ed&cation in Mexico,G !elimina!(
d!a"t "o! comments. 0I7B0 7oc&ment 5LE. ,;5, 0&e!navaca, 197>.
6> 5!noldo Oa'aldpn, G#ealth <e!vice and <ocio8economic 7eveloment in Latin 5me!ica,G
La&d, 1969, 1:7.98//. O&nna! 5dle!8@a!lsson, G9neA&al 5ccess to #ealth $ithin and
)et%een Nations,G ae! %!itten "o! the Oottlie' 7&tt%ei+! Instit&te6s <(mosi&m on GThe
Limits to Medicine,G 7avos, Ma!ch ,/8,6, 1975, mimeo*!ahed.
61 Ioseh 'en 7avid, G1!o"essions in the 0lass <(stem o" 1!esent87a( <ocieties: 5 T!end
3eo!t and )i'lio*!ah(,G 0&!!ent <ociolo*( 1, (196.86/): ,/78..>.
xxx "otnote sl&tt xxx
((,.9))
acco!din*l(, in"o!m the schoolmaste! in a !emote villa*e that Mexican s&!*e!( is as %ell
endo%ed as its co&nte!a!t in 0hica*o and that the s&!*eons %ho oe!ate on him meas&!e &
to the standa!ds o" thei! collea*&es in #o&ston. $hen hi*h8level o""icials a!e hositali=ed,
the( ma( 'e anno(ed 'eca&se "o! the "i!st time in thei! lives the( have to sha!e a hosital
!oom %ith a %o!+man, '&t the( a!e also !o&d o" the hi*h level o" socialist commit8ment thei!
nation sho%s in !ovidin* the same "o! 'oss and c&stodian. )oth +inds o" atient tend to
ove!loo+ the "act that the( a!e eA&all( !ivile*ed exloite!s. 1!ovidin* the . e!cent %ith
'eds, eA&iment, administ!ation, and technical ca!e ta+es one8thi!d o" the &'lic8health8ca!e
'&d*et o" the enti!e co&nt!(. To 'e a'le to a""o!d to *ive all o" the oo! eA&al access to
medicine o" &ni"o!m A&alit( in oo! co&nt!ies, most o" the !esent t!ainin* and activit( o" the
health !o"essions %o&ld have to 'e discontin&ed. #o%8eve!, delive!( o" e""ective 'asic
health se!vices "o! the enti!e o&lation is chea eno&*h to 'e 'o&*ht "o! eve!(one, !ovided
no one co&ld *et mo!e, !e*a!dless o" the social, economic, medical, o! e!sonal !easons
advanced "o! secial t!eatment. I" !io!it( %e!e *iven to eA&it( in oo! co&nt!ies and se!vice
limited to the 'asics o" e""ective medicine, enti!e o&lations %o&ld 'e enco&!a*ed to sha!e in
the demedicali=ation o" mode!n health ca!e and to develo the s+ills and con"idence "o! sel"8
ca!e, th&s !otectin* thei! co&nt!ies "!om social iat!o*enic disease.
In the !ich co&nt!ies, the economics o" health a!e some%hat di""e!ent 6, 5t "i!st si*ht, conce!n
"o! the oo!
xxx "otnote sta!t xxx
6, -o! a simli"ied vis&al !e!esentation, Eli=ah L. $hite, G5 O!ahic 1!esentation on 5*e
and Income 7i""e!entials in <elected 5sects o" Mo!'idit(, 7isa'ilit( and 9tili=ation o"
#ealth <e!vices,G )nquiry @, no; 1 (1966): 1;8.>. -o! a mo!e detailed and &8to8date anal(sis,
3. 5nde!son and Iohn -. Ne%man, G<ocietal and Individ&al 7ete!minants o" #ealth 0a!e in
the 9.<.5.,G *ilban# *emorial (und Wuarterly 51 (%inte! 197.): >@49&J;
xxx "otnote sl&tt xxx
((,/>))
aea!s to demand "&!the! inc!eases in the total health '&d*et 6. Net the mo!e eole come to
deend on ca!e '( se!vice instit&tions, the mo!e di""ic&lt it is to identi"( eA&it( %ith eA&al
access and eA&al 'ene"its. 6/ Is eA&it( !eali=ed %hen eA&al n&m'e!s o" dolla!s a!e availa'le
"o! the ed&cation o" !ich and oo!4 B! does it !eA&i!e that the oo! *et the same Ged&cationG
altho&*h mo!e %ill have to 'e sent on thei! acco&nt to achieve eA&al !es&lts4 B! m&st the
ed&cational s(stem, in o!de! to 'e eA&ita'le, ass&!e that the oo! a!e not h&miliated and h&!t
mo!e than the !ich %ith %hom the( comete on the academic ladde!4 B! is eA&it( in lea!nin*
oo!t&nities !ovided onl( %hen all citi=ens sha!e the same +ind o" lea!nin* envi!onment4
This 'attle o" eA&it( ve!s&s eA&alit( in the access to instit&tional ca!e, al!ead( 'ein* %a*ed in
ed&cation, is no% shain* & in the medical "ield. 65 In cont!ast to ed&cation, ho%eve!, the
iss&e in health can easil( 'e !esolved on availa'le evidence. The e! caita
xxx "otnote sta!t xxx
6. Bn the lin+ 'et%een ove!t( and ill8health in the 9.<., see Iohn @osa et al., eds., +overty
and %ealth= A Sociological Analysis, a 0ommon%ealth -&nd )oo+ (0am'!id*e, Mass.:
#a!va!d 9niv. 1!ess, 1969). This collection o" ae!s is a lea "o! "ede!al health ins&!ance.
#e!'e!t T. )i!ch and Ioan 7(e O&sso%, Disadvantaged Children= %ealth, .utrition and
School (ailure (Ne% No!+: #a!co&!t )!ace, 197>). Tho&*h the a&tho!s 'elieve in the val&e o"
mo!e medical ca!e "o! the oo!, the non8t!eatment8!elated "acto!s that disc!iminate a*ainst the
health o" oo! child!en a!e indicated as 'ein* '( "a! the most imo!tant.
6/ The !elationshi o" mo!talit( to 'oth medical ca!e and envi!onmental va!ia'les is examined
in a !e*!ession anal(sis '( 3icha!d 5&ste! et al., GThe 1!od&ction o" #ealth: 5n Exlo!ato!(
<t&d(,G 3ournal of %uman esources J ("all 1969): /118.6. I" ed&cation and medical ca!e a!e
cont!olled, hi*h income is associated %ith hi*h mo!talit(. This !o'a'l( !e"lects &n"avo!a'le
diet, lac+ o" exe!cise, and s(cholo*ical tension in the !iche! *!o&s. 5dve!se "acto!s
associated %ith the *!o%th o" income ma( n&lli"( the 'ene"icial e""ects o" an inc!ease in the
A&antit( and A&alit( o" medical ca!e. <ecial !is+s "o! the s&e!!ich a!e not somethin* enti!el(
ne%. <. Oil"illan, G3oman 0&lt&!e and <(stemic Lead 1oisonin*,G *an#ind Wuarterly @
(Ian&a!( 1965): 5589. 5nal(sis o" 'ones "!om .!d8cent&!( 3oman cemete!ies !evealed hi*h
concent!ations o" lead. The oisonin* %as !o'a'l( d&e to the lead &sed "o! sealin* amho!as
in %hich %ine %as imo!ted 1..)m O!eece.
65 3ashi -ein, GBn 5chievin* 5ccess and EA&it( in #ealth 0a!e,G *ilban# *emorial (und
Wuarterly 5> (Bcto'e! 197,): ./.
((,/1))
exendit&!e on health ca!e, even "o! the oo!est secto! %ithin the 9nited <tates o&lation,
indicates that the 'ase line at %hich s&ch ca!e t&!ns iat!o*enic has lon* since 'een assed. In
!ich co&nt!ies, the total '&d*et o" se!vices "o! the oo!, i" &sed "o! that %hich !ein"o!ces sel"8
ca!e, is mo!e than amle. Mo!e access, even tho&*h !est!icted to those %ho no% !eceive less,
%o&ld onl( eA&ali=e the delive!( o" !o"essional ill&sions and to!ts.
The!e a!e t%o asects to health: "!eedom and !i*hts. 5'ove all, health desi*nates the !an*e o"
a&tonom( %ithin %hich a e!son exe!cises cont!ol ove! his o%n 'iolo*ical states and ove! the
conditions o" his immediate envi!on8ment. In this sense, health is identical %ith the de*!ee o"
lived "!eedom. 1!ima!il( the la% o&*ht to *&a!antee the eA&ita'le dist!i'&tion o" health as
"!eedom, %hich, in t&!n, deends on envi!onmental conditions that onl( o!*ani=ed olitical
e""o!ts can achieve. )e(ond a cX!tain level o" intensit(, health ca!e, ho%eve! eA&ita'l(
dist!i'&ted, %ill smothe! health8as8"!eedom. In this "&ndamental sense, health ca!e is a matte!
o" %ell8o!de!ed li'e!t(. Imlicit in this concet is a !e"e!!ed osition o" inaliena'le "!eedoms
to do ce!tain thin*s, and he!e 8civil li'e!t( m&st 'e distin*&ished "!om civil !i*hts. The li'e!t(
to act %itho&t !est!aint "!om *ove!nment has a %ide! scoe than the civil !i*hts the state ma(
enact to *&a!antee that eole %ill have eA&al o%e!s to o'tain ce!tain *oods o! se!vices.
0ivil li'e!ties o!dina!il( do not "o!ce othe!s to ca!!( o&t m( %ishesR a e!son ma( &'lish his
o! he! oinion "!eel( as "a! as the *ove!nment is conce!ned, '&t this does not iml( a d&t( "o!
an( one ne%sae! to !int that oinion. 5 e!son ma( need to d!in+ %ine in his +ind o"
%o!shi, '&t no mosA&e has to %elcome him to do so %ithin its %alls. 5t the same time, the
state as a *&a!anto! o" li'e!ties can enact la%s that !otect eA&al !i*hts %itho&t %hich its
mem'e!s %o&ld not en:o( thei! "!eedoms. <&ch
((,/,))
!i*hts *ive meanin* to eA&alit(, %hile li'e!ties *ive shae to "!eedom. Bne s&!e %a( to
extin*&ish "!eedom to sea+, to lea!n, o! to heal is to delimit them '( t!ansmo*!i"(in* civil
!i*hts into civic d&ties. The "!eedoms o" the sel"8ta&*ht %ill 'e a'!id*ed in an ove!ed&cated
societ( :&st as the "!eedom to health ca!e can 'e smothe!ed '( ove!medication. 5n( secto! o"
the econom( can 'e so exanded that "o! the sa+e o" mo!e costl( levels o" eA&alit(, "!eedoms
a!e extin*&ished.
$e a!e conce!ned he!e %ith movements that t!( to !emed( the e""ects o" sociall( iat!o*enic
medicine th!o&*h olitical and le*al cont!ol o" the mana*ement, allocation, and o!*ani=ation
o" medical activities. Inso"a! as medicine is a &'lic &tilit(, ho%eve!, no !e"o!m can 'e
e""ective &nless it *ives !io!it( to t%o sets o" limits. The "i!st !elates to the vol&me o"
instit&tional t!eatment an( individ&al can claim: no e!son is to !eceive se!vices so extensive
that his t!eatment de!ives othe!s o" an oo!t&nit( "o! conside!a'l( less costl( ca!e e! caita
i", in thei! :&d*ment (and not :&st in the oinion o" an exe!t), the( ma+e a !eA&est o"
coma!a'le &!*enc( "o! the same &'lic !eso&!ces. 0onve!sel(, no se!vices a!e to 'e "o!ci'l(
imosed on an individ&al a*ainst his %ill: no man, %itho&t his consent, shall 'e sei=ed,
im!isoned, hositali=ed, t!eated, o! othe!8%ise molested in the name o" health. The second
set o" limits !elates to the medical ente!!ise as a %hole. #e!e the idea o" health8as8"!eedom
has to !est!ict the total o&t&t o" health se!vices %ithin s&'iat!o*enic limits that maximi=e the
s(ne!*( o" a&tonomo&s and hete!onomo&s modes o" health !od&ction. In democ!atic
societies, s&ch limitations a!e !o'a'l( &nachieva'le %itho&t *&a!antees o" eA&it(D%itho&t
eA&al access. In that sense, the olitics o" eA&it( is !o'a'l( an essential element o" an
e""ective !o*!am "o! health. 0onve!sel(, i" conce!n %ith eA&it( is not lin+ed to const!aints on
total !od&ction, and i" it is
((,/.))
not &sed as a co&nte!vailin* "o!ce to the exansion o" instit&tional medical ca!e, it %ill 'e
"&tile. 66
Public Controls o$er the Professional &afia
5 thi!d cate*o!( o" olitical !emedies "o! &nhealth( medicine "oc&ses di!ectl( on how docto!s
do thei! %o!+. Li+e cons&me! advocac( and le*islation o" access, this attemt to imose la(
cont!ol on the medical o!*ani=ation has inevita'le health8den(in* e""ects %hen it is chan*ed
"!om an ad hoc tactic into a *ene!al st!ate*(.
-o&! and a hal" million men and %omen in t%o h&nd!ed occ&ations a!e emlo(ed in the
!od&ction and delive!( o" medicall( a!oved health se!vices in the 9nited <tates. (Bnl( ;
e!cent a!e h(sicians, %hose net income a"te! ded&ctions "o! !ent, e!sonnel, and s&lies
!e!esents 15 e!cent o" total health exendit&!es and %hose ave!a*e income in 197. %as
M5>,>>>. 67) The total does not incl&de osteoaths, chi!o!acto!s, and othe!s %ho mi*ht have
seciali=ed &nive!sit( t!ainin* and !eA&i!e a license to !actice, '&t %ho, &nli+e ha!macists,
otomet!ists, la'o!ato!( technicians, and simila! h(sicians6 &nde!lin*s, do not !od&ce health
ca!e o" the same !esti*e. 6;
xxx "otnote sta!t xxx
66 Eman&el de @adt, GIneA&alit( and #ealth,G 9niv. o" <&ssex, Ian&a!( 1975, *oes "a! 'e(ond
most othe! a&tho!s in st!essin* the oint I %ant to ma+e: G1!o"essional ideolo*ies that "oc&s
on the maintenance o" hi*h standa!ds o" medical ca!e +ee in 'ein* a health s(stem %hich
ne*lects the simle needs o" the man( in o!de! to concent!ate on the comlex and8costl(
conditions o" a "e%G (. 5 and ,/).
67 -o! the medical ente!!ise at the se!vice o" seciali=ation, see 3osema!( <tevens,
5me!ican *edicine and the +ublic )nterest (Ne% #aven, 0onn.: Nale 9niv. 1!ess, 197.). -o!
the a!allel in Oe!man(: #ans8#ein= E&lne!, G7ie Ent%ic+l&n* de! medi=inischen
<e=ial"cche! an den 9nive!sitcten des de&tschen <!ach*e'ietes,G in Studien 8ur
*edisingeschichte des 9>; fh; (<t&tt*a!t: En+e, 197>).
6; #o%a!d -!eeman, <ol Levine, and Leo 3eede!, %andboo# of *edical Sociology
(En*le%ood 0li""s, NI.: 1!entice8#all, 196.), . ,16817, "o! in"o!mation on the !elative
n&m'e! o" A&ali"ied chi!o!acto!s and h(sicians (1 to 1>), on the "i!st &nive!sit(8a""iliated
colle*es "o! h(sicians (1765), dentists (1;6;), and otomet!ists (19>1).
xxx "otnote sl&tt xxx
((,//))
Even "&!the! !emoved "!om the esta'lishment, and the!e8"o!e excl&ded "!om these statistics,
a!e tho&sands o" &!ve(o!s o" nonconventional health ca!e, !an*in* "!om mail8o!de! he!'alists
and masse&!s to teache!s o" (o*a. 69
B" the man( claimants to cometence %ho a!e mo!e o! less inte*!ated into the o""icial
esta'lishment, a'o&t thi!t( cate*o!ies a!e licensed in the 9nited <tates.7> In no state o" the
&nion is a license !eA&i!ed "o! "e%e! than "o&!teen +inds o" !actitione!s.71 These licenses a!e
iss&ed on comletion ca! "o!mal ed&cational !o*!ams and sometimes on the evidetice o" a
s&ccess"&l examinationR in !a!e instances, !o"icienc( o! exe!ience is a !e!eA&isite "o!
admission to indeendent !actice.7, 0ometent o! s&ccess"&l %o!+ is no%he!e a condition
"o! contin&in* in !actice. 3ene%al is a&tomatic, &s&all( &on a(ment o" a "eeR onl( "i"teen
o&t o" "i"t( states e!mit a h(sician6s license to 'e challen*ed on *!o&nds o" incometence.7.
xxx "otnote sta!t xxx
69 Michael Ma!ien, GThe 1s(chic -!ontie!: To%a!d Ne% 1a!adi*ms "o! Man: O&ide to ,>>
)oo+s, 5!ticles, and Io&!nals,G d!a"t, Ma!ch 197/, $o!ld Instit&te 0o&ncil, 777 9nited
Nations 1la=a, Ne% No!+ 1>>17. 5 !eadin* *&ide to a'o&t ,>> !ecent 'oo+s, :o&!nals, and
instit&te ne%slette!s, man( %ith indications o" content and eval&ations, all conce!ned %ith
alte!nate modes o" sta(in* health( o! healin*. 0an *ive to the &ninitiated to this a!ea a sense
o" the sect!&m "!om the doct!inai!e to the se!io&s and the omo&s. 5cadem( o"
1a!as(cholo*( and Medicine, The Dimensions of %ealing= A <(mosi&m (Los 5ltos, 0ali".:
the 5cadem(, 197,). <heila Bst!ande! and L(nn <ch!oede!, +sychic Discoveries ,ehind the
)ron Curtain 2Englewood Cliffs, .3;= +rentice4%all, 9>:BM .ew <or#= ,antam, 9>:9A;
7> #en!( E. <i*e!ist, GThe #isto!( o" Medical Licens&!e,G 3ournal of the American *edical
Association 1>/ (19.5): 1>5786>, on the t!ansition "!om occ&ational l&!alism to the
!o"essional dominance o" the ne% h(sician %hose cometence in Gscienti"icG dia*nosis and
the!a( %as *&a!anteed '( attendance at a medical school that had %eathe!ed -lexne!6s !eo!t.
71 3onald 5+e!s and 3icha!d 2&inne(, G7i""e!ential B!*ani=ation o" #ealth 1!o"essions: 5
0oma!ative 5nal(sis,G American Sociological eview .. (-e'!&a!( 196;): 1>/8,1. Bn the
inte!nal social o!*ani=ation o" licensed h(sicians, dentists, otomet!ists, ha!macists, and
thei! !elative cohesion, %ealth, and o%e!.
7, $illiam L. -!ede!ic+, GThe #isto!( and 1hilosoh( o" Bcc&ational Licensin* Le*islation
in the 9nited <tates,G 3ournal of the American Dental Association 5; (Ma!ch 1959): 1;8,5.
7. 9.<. 7ea!tment o" #ealth, Ed&cation, and $el"a!e, *edical *alpractice, 3eo!t o" the
<ec!eta!(6s 0ommission on Medical 1!actice, Ian&a!( 16, 197..
xxx "otnote sl&tt xxx
((,/5))
$hile claims to secialist standin* come and *o on the "!in*es, the secialties !eco*ni=ed '(
the 5me!ican Medical 5ssociation have steadil( inc!eased, do&'lin* in the last "i"teen (ea!s:
hal" the !acticin* 5me!ican h(sicians a!e secialists in one o" sixt( cate*o!ies, and the
!oo!tion is exected to inc!ease to 55 e!cent 'e"o!e 19;>.7/ $ithin each o" these "ields a
"ie"dom has develoed %ith seciali=ed n&!ses, technicians, :o&!nals, con*!esses, and some8
times o!*ani=ed *!o&s o" atients !essin* "o! mo!e &'lic "&nds.75 The cost o" coo!dinatin*
the t!eatment o" the same atient '( seve!al secialists *!o%s. exonentiall( %ith each added
cometence, as does the !is+ o" mista+es and the !o'a'ilit( o" dama*e d&e to the &nexected
com'ination o" di""e!ent the!aies. 5s the n&m'e! o" atient !elationshis o&t*!o%s the
elements in the total o&lation, the occ&ations dealin* %ith medical in"o!mation, ins&!ance,
and atient de"ense m&ltil( &nchec+ed. B" co&!se, h(sicians lo!d it ove! these "ie"s and
dete!mine %hat %o!+ these se&do8!o"essions shall do. )&t %ith the !eco*nition o" some
a&tonom( man( o" these seciali=ed *!o&s o" medical a*es, &she!s, "ootmen, and sA&i!es
have also *ained some o%e! to eval&ate ho% %ell the( do thei! o%n %o!+. )( *ainin* the
!i*ht to sel"8eval&ation acco!d
xxx "otnote sta!t xxx
7/ #ealth <e!vices 3esea!ch 0ente!, Instit&te "o! Inte!discilina!( <t&dies, Medical
Mano%e! <ecialt( 7ist!i'&tion 1!o:ect 19758;>, %o!+in* ae! 1971.
75 -o! st&dies on the limits to "&!the! !oli"e!ation, see $illiam I. Ooode, GThe Theo!etical
Limits o" 1!o"essionali=ation,G in 5mitai Et=ioni, ed., The Semi4+rofessions and Their
B!*ani=ation (Ne% No!+: -!ee 1!ess, 1969), . ,668.1.. Ooode 'elieves that tho&*h
techniA&es contin&e to m&ltil(, "e%e! o" them !eA&i!e "o! thei! exec&tion that t!&st on the a!t
o" the client on %hich !o"essional a&tonom( is '&ilt. -&!the! seciali=ation o" cometence
mi*ht the!e"o!e concent!ate !o"essional o%e! a*ain in "e%e! hands. <ee also $il'e!t Moo!e
and Oe!ald $. 3osen'l&m, The +rofession= oles and ides (Ne% No!+: 3&ssell <a*e, 197>),
cha. .. #a!old $ilens+(, GThe 1!o"essionali=ation o" Eve!(one4G American Io&!nal of
Sociology 7> (<etem'e! 196/): 1.785;. The !ocess o" !o"essionali=ation cannot 'e
ext!aolated, 'eca&se '&!ea&c!ati=ation th!eatens the ideal o" dedicated se!vice even mo!e
intensel( than it &nde!mines the a&tonom( o" the one %ho e!"o!ms se!vices.
xxx "otnote sl&tt xxx
((,/6))
in* to secial c!ite!ia that "it its o%n vie% o" !ealit(, each ne% secialt( *ene!ates "o! societ(
at la!*e a ne% imediment to eval&atin* %hat its %o!+ act&all( cont!i'&tes to the health o"
atients. B!*ani=ed medicine has !acticall( ceased to 'e the a!t o" healin* the c&!a'le, and
consolin* the hoeless has t&!ned into a *!otesA&e !iesthood conce!ned %ith salvation and
has 'ecome a la% &nto itsel". The olicies that !omise the &'lic some cont!ol ove! the
medical endeavo! tend to ove!loo+ the "act that to achieve thei! &!ose the( m&st cont!ol a
church, not an ind&st!(.
7o=ens o" conc!ete st!ate*ies a!e no% 'ein* disc&ssed and !oosed to ma+e the health
ind&st!( mo!e health8se!vin* and less sel"8se!vin*: decent!ali=ation o" delive!(R &nive!sal
&'lic ins&!anceR *!o& !actice '( secialistsR health8maintenance !o*!ams !athe! than sic+8
ca!eR a(8ment o" a "ixed amo&nt e! atient e! (ea! (caitation) !athe! than "ee8"o!8se!viceR
elimination o" !esent !est!ictions on the &se o" health mano%e!R mo!e !ational o!*ani=ation
and &tili=ation o" the hosital s(stemR !e8lacement o" the licensin* o" individ&als '( the
licensin* o" instit&tions held to e!"o!mance standa!dsR and the o!*ani=ation o" atient
cooe!atives to 'alance o! s&o!t a !o"essional medical o%e!.
Each o" these !oosals %o&ld indeed im!ove medical e""icienc(, '&t at the cost o" a "&!the!
decline in societ(6s e""ective health ca!e. To inc!ease e""icienc( '( &%a!d mo'ilit( o"
e!sonnel and do%n%a!d assi*nment o" !esonsi'ilit( co&ld not '&t ti*hten the inte*!ation o"
the medical8ca!e ind&st!( and %ith it social ola!i=ation.
5s the t!ainin* o" middle8level !o"essionals 'ecomes mo!e exensive, n&!sin* e!sonnel in
the lo%e! !an+s is 'ecomin* sca!ce. 1oo! sala!ies, *!o%in* disdain "o! se!vant and
ho&se+eein* !oles, an inc!ease in ch!onic atients (and conseA&ent *!o%in* tedi&m in thei!
ca!e), disaea!ance o" the !eli*io&s motivation "o! n&ns and deacons, and
((,/7))
ne% oo!t&nities "o! %omen in othe! "ields all cont!i'&te to a mano%e! c!isis. In En*land
nea!l( M o" all lo%8level hosital e!sonnel come "!om ove!seas, &s&all( "!om "o!me!
coloniesR in Oe!man(, "!om T&!+e( and N&*oslaviaR in -!ance, "!om No!th 5"!icaR in the
9.<., "!om the !an+s o" !acial mino!ities. The c!eation o" ne% !an+s, titles, c&!!ic&la, !oles, and
secialties at the 'ottom level is a do&'t"&ll( e""ective !emed(. The hosital onl( !e"lects the
la'o! econom( o" a hi*h8technolo*( societ(: t!ansnational seciali=ation on the to,
'&!ea&c!acies in the middle, and at the 'ottom, a ne% s&'!oleta!iat made & o" mi*!ants and
the !o"essionali=ed client.76
The m&ltilication o" a!a!o"essional secialists "&!the! dec!eases %hat the dia*nostician
does "o! the e!son %ho see+s his hel, %hile the m&ltilication o" *ene!alist a&xilia!ies tends
to !ed&ce %hat &nce!ti"ied eole ma( do "o! each othe! o! "o! themselves.77 )nstitutional
licensin*7; %o&ld indeed e!mit a mo!e e""icient delo(ment o" e!sonnel, a mo!e !ational
health8mano%e! mix, and *!eate! oo!t&nit( "o! advancement: it %o&ld no do&'t *!eatl(
im!ove the delive!( o" medical stales s&ch as dental %o!+, 'onesettin*, and the delive!( o"
'a'ies. )&t i" it 'ecame the model "o! ove!8all health ca!e, it %o&ld 'e eA&ivalent to the
c!eation o" a medical Ma )e11.79 La(
xxx "otnote sta!t xxx
76 -o! the c&!!ent c!isis in the 9.<. n&!sin* !o"ession, see National 0ommission "o! the
<t&d( o" N&!sin* Ed&cation, 5n Abstract for Action (Ne% No!+: McO!a%8#ill, 197>).
77 The a&tonomo&s and indeendent health technician, "!ee o" cont!ol '( the medical
hie!a!ch(, is still ta'oo: Bsca! Oish, ed., %ealth, *anpower and the *edical Au/iliary= Some
.otes and an Annotated ,ibliography, Inte!mediate Technolo*( 7eveloment O!o&
(London, 1971). Oish t!ies to distin*&ish 'et%een the costl(, !esti*io&s, intensel( s+illed
!o"essional, %ith his lon* t!ainin* and his !eadiness to move a%a( "!om the comm&nit(R the
a!a!o"essional n&!se, %hose t!ainin* is academic and theo!eticalR and the health a&xilia!(,
%ho has the s+ills that a!e needed most o" the time.
7; ?icto! -&chs, .o Shall -ive7 %ealth Economics and Social Choice (Ne% No!+: )asic
)oo+s, 197/). Nathan #e!she( and $alte! <. $heele!, #ealth +ersonnel 3e*&lation in the
+ublic )nterestM Wuestions and Answers on Instit&tional -iceuure, &'lished '( the 0ali"o!nia
#osital 5ssociation as a se!vice to the health8ca!e "ield, 197..
79 <. @elman, GTo%a!ds a 1olitical Econom( o" Medical 0a!e,G )nquiry C, no. . (1971): .>8;.
@elman claims that the !edominance o" "inancial caital in the
xxx "otnote "o!tsette! E neste side xxx
((,/;))
cont!ol ove! an exandin* medical technoc!ac( is not &nli+e the !o"essionali=ation o" the
atient: 'oth enhance medical o%e! and inc!ease its nocebo e""ect. 5s lon* as the &'lic
'o%s to the !o"essional monool( in assi*nin* the sic+8!ole, it cannot cont!ol hidden health
hie!a!chies that m&ltil( atients. ;> The medical cle!*( can 'e cont!olled onl( i" the la% is
&sed to !est!ict and disesta'lish its monool( on decidin* %hat constit&tes disease, %ho is
sic+, and %hat o&*ht to 'e done to him o! he!. ;1
Misdi!ection o" 'lame "o! iat!o*enesis is the most se!io&s olitical o'stacle to &'lic cont!ol
ove! health ca!e. To t&!n docto!8'aitin* into !adical chic %o&ld 'e the s&!est %a( to de"&se
an( olitical c!isis "&eled '( the ne% health conscio&sness. I" h(sicians %e!e to 'ecome
consic&o&s scae*oats, the *&lli'le atient %o&ld 'e !elieved "!om 'lame "o! his the!ae&tic
*!eed. <chool8'aitin* did save the instit&tional ente!!ise %hen c!isis last hit in ed&cation. The
samX st!ate*( co&ld no% save the medical s(stem and +ee it essentiall( as it is.
2&ite s&ddenl( in the 197>s the schools lost thei! stat&s as sac!ed co%s. 7!iven '( <&tni+,
!acial con"lict, and ne% "!ontie!s, the school '&''le had o&t*!o%n all nonmilita!( '&d*ets and
had '&!st. -o! a sho!t %hile, the hidden c&!!ic&l&m o" the school s(stem la( exosed. It
'ecame
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
health secto! mi*ht "o!eshado% a decline in the a&tonom( o" the !o"essional, as he is "o!ced
to &nioni=e. Instit&tional licensin*, %hich %o&ld t&!n even the medical8team catain into an
emlo(ee, %o&ld ce!tainl( accent&ate this t!end. 0oma!e this %ith note 75, . ,/6 a'ove.
;> 0o!inne Lath!o Oil', %idden #ie!a!chies.. The +rofessions and $overnment (Ne% No!+:
#a!e! V 3o%, 1966). Bn the st!ate*ies &sed '( 5me!ican h(sicians, la%(e!s, and ed&cato!s
to acA&i!e olitical o%e! '( o!*ani=in* !o"essional associations and '( claimin* as a !i*ht
%hat, at the o&tset, had 'een an hono!ed !e!o*ative.
;1 I o%e the idea that !o"essions a!e 'ased on a *!ant to Eliot -!eidson, +rofession of
*edicine= A Study of the Sociology of Applied Enowledge 2.ew <or#= Dodd, *ead, 9>:9A,
whom ) follow closely; (or an orientation on the status of the discussion, besides (reidson
see %oward S; ,ec#er, DThe .ature of +rofession,D in %enry .elson, ed;, Education for the
+rofessions 2Chicago= .ational Society for the Study of Education, 9>?&A, chap; &, pp; &:4J?;
xxx "otnote sl&tt xxx
((,/9))
conventional %isdom that a"te! a ce!tain oint in its exansion, the school s(stem inevita'l(
!e!od&ces a me!itoc!atic class societ( and neatl( a!!an*es eole acco!din* to levels o"
hi*hl( seciali=ed to!o! "o! %hich the( a!e t!ained in *!aded, a*e8seci"ic, cometitive, and
com&lso!( !it&als. -!&st!ation o" an exensive d!eam had led man( eole to *!as that no
amo&nt o" com&lso!( lea!nin* co&ld eA&ita'l( !ea!e the (o&n* "o! ind&st!ial hie!a!chies,
and that all e""ective !ea!ation o" child!en "o! an inh&man socio8economic s(stem
constit&ted s(stematic a**!ession a*ainst thei! e!sons. 5t this oint a ne% vision o" !ealit(
co&ld have *!o%n into a !adical !evolt a*ainst a caital8intensive s(stem o" !od&ction and the
'elie"s that 'olste! it. )&t instead o" 'lamin* the h&'!is o" eda*o*&es, the &'lic conceded to
eda*o*&es mo!e o%e! to do !ecisel( as the( leased. 7is*!&ntled teache!s "oc&sed
c!iticism on thei! ee!s, the methods, the o!*ani=ation o" schoolin*, and the "inancin* o"
instit&tions, all o" %hich %e!e de"ined as o'stacles to e""ective ed&cation.
<chool8'aitin* ena'led li'e!al schoolmaste!s to m&tate into a ne% '!eed o" ad&lt ed&cato!s.
<chool8'aitin* not onl( saved '&tDmomenta!il(D&*!aded the sala!( and !esti*e o" the
teache!. $he!eas 'e"o!e the c!isis oint the schoolmaste! had 'een !est!icted in his
eda*o*ical a**!ession to an a*e8seci"ic *!o& 'elo% sixteen (ea!s o" a*e, %hich %as
exosed to him d&!in* class ho&!s in the school '&ildin* to 'e initiated into a limited n&m'e!
o" s&':ects, the ne% +no%led*e8me!chant no% conside!s the %o!ld his class!oom. $hile the
c&!!ic&la! teache! co&ld disA&ali"( onl( those nonst&dents %ho da!ed to lea!n a c&!!ic&la!
matte! on thei! o%n, the ne% mana*e! o" li"elon* and !ec&!!ent Ged&cation,G
Gconscienti=ation,G Gsensitivit( t!ainin*,G o! Golitici=ationG !es&mes to de*!ade in the e(es
o" the &'lic an( 'ehavio!al atte!ns that he has not a!oved. The school8'aitin* o" the
sixties
((,5>))
co&ld easil( set the atte!n "o! the comin* medical %a!. -ollo%in* the lead o" the teache!s
%ho decla!e that the %o!ld is thei! class!oom, some chic c!&sadin* h(sicians ;, no% :&m
onto the 'and%a*on o" medicine8'aitin* and channel &'lic "!&st!ation and an*e! at c&!ative
medicine into a call "o! a ne% elite o" scienti"ic *&a!dians %ho %o&ld cont!ol the %o!ld as
thei! %a!d. ;.
,he Scientific ;rg<ni2ation=of 3ife
)elie" in medicine as an alied science *ene!ates a "o&!th +ind o" co&nte!meas&!e to
iat!o*enesis %hich inevita'l( inc!eases the i!!esonsi'le o%e! o" the health
xxx "otnote sta!t xxx
;, #o%a!d <. )ec+e!, 'utsiders= <t&dies in the Sociology of Deviance (Ne% No!+: -!ee
1!ess, 196.), . 177, oints o&t that the most o'vio&s conseA&ence o" a s&ccess"&l c!&sade
a*ainst some evil is the c!eation o" a set o" ne% !&les and esta'lished o""icials to en"o!ce
them. GI&st as !adical olitical movements t&!n into o!*ani=ed olitical a!ties and l&st(
evan*elical sects 'ecome staid !eli*io&s denominations,G so, I a!*&e he!e, eole %ho have
sta!ted o&t to mate!iali=e d!eams o" health delive!( t&!n into a !o"ession o" %a!dens.
;. ?icente Nava!!o, G<ocial 1olic( Iss&es: 5n Exlanation o" the 0omosition, Nat&!e, and
-&nctions o" the 1!esent #ealth <ecto! o" the 9nited <tates,G Iohns #o+ins 9nive!sit(, ae!
'ased on a !esentation at the 5nn&al 0on"e!ence o" the Ne% No!+ 5cadem( o" Medicine,
5!il ,58,6, 197/. Nava!!o a!*&es that the !evailin* val&es in the health secto! a!e indeed
shaed '( the health esta'lishment, '&t a!e s(mtomatic o" the dist!i'&tion o" economic and
olitical o%e! %ithin societ(. The o%e! to shae health val&es *ives the !o"essionals
%ithin the health secto! a dominant in"l&ence on the st!&ct&!e o" the health se!vices, '&t
act&all( no cont!ol. This cont!ol is exe!cised th!o&*h the o%ne!shi o" the means o"
!od&ction, !e!od&ction, and le*itimation held '( the caitalist elite. Nava!!o does not seem
to !eali=e that I do a*!ee %ith him on this oint '&t am less naivel( otimistic as to the
olitical indi""e!ence o" each and eve!( technique &sed in the !ovision o" health ca!e. I a!*&e
that dial(sis, t!anslants, and intensive ca!e "o! most ch!onic diseases, '&t also :&st the *ene!al
intensit( o" o&! medical endeavo!, inevita'l( imose exloitation on an( societ( that %ants to
&se them in the !ee!to!( o" its medical8ca!e s(stem. <ee ?icente Nava!!o, GThe
Ind&st!iali=ation o" -etishism o! the -etishism o" Ind&st!iali=ation: 5 0!itiA&e o" Ivan Illich,G
Iohns #o+ins 9nive!sit(, Ian&a!( 1975. -o! the a!*&ment that medical ideolo*ies shae a
ca!e s(stem that the( do not cont!ol, see also Massimo Oa*lio, *edicina e profitto= Tesi di
discussione per operai, studenti e tecnici (Milan: <ae!e Edito!e, 1971), and 5loisi et al., -a
medicina e la societf contemporanea, 5tti del 0onve*no !omoso dall6Instit&to O!amsci,
3oma, ,;8.> *i&*no 1967. (3ome: Edito!i 3i&niti, 196;).
xxx "otnote sl&tt xxx
((,51))
!o"essionDand the!e'( the dama*e medicine does. The !oonents o" hi*he! scienti"ic
standa!ds in medical !e8sea!ch and social o!*ani=ation a!*&e that atho*enic medicine is d&e
to the ove!%helmin* n&m'e! o" 'ad docto!s let loose on societ(. -e%e! decision8ma+e!s,
mo!e ca!e"&ll( sc!eened, 'ette! t!ained, mo!e ti*htl( s&e!vised '( thei! ee!s, and mo!e
e""ectivel( in command ove! %hat is done "o! %hom and ho%, %o&ld ens&!e that the o%e!"&l
!eso&!ces no% availa'le to medical scientists %o&ld 'e alied "o! the 'ene"it o" the eole.
;/ <&ch idolat!( o" science ove!loo+s the "act that !esea!ch cond&cted as i" medicine %e!e an
o!dina!( science, dia*nosis cond&cted as i" atients %e!e seci"ic cases and not a&tonomo&s
e!sons, and the!a( cond&cted '( h(*ienic en*inee!s a!e the th!ee a!oaches %hich
coalesce into the !esent endemic health8denial.
5s a science, medicine lies on a 'o!de!line. <cienti"ic method !ovides "o! exe!iments
cond&cted on models. Medicine, ho%eve!, exe!iments not on models '&t on the s&':ects
themselves. )&t medicine tells &s as m&ch a'o&t the meanin*"&l e!"o!mance o" healin*,
s&""e!in*, and d(in* as chemical anal(sis tells &s a'o&t the aesthetic val&e o" otte!(. ;5
In the &!s&it o" alied science the medical !o"ession has la!*el( ceased to st!ive to%a!ds
the *oals o" an association o" a!tisans %ho &se t!adition, exe!ience, lea!nin*, and int&ition,
and has come to la( a !ole
xxx "otnote sta!t xxx
;/ 1hili <el'(, G#ealth in 19;>8199>: 5 1!edictive <t&d( )ased on an Inte!national
InA&i!(,G +erspediaes in *edicine, vol. 6 (197/). -o!ecast, 'ased on a 7elhi scena!io,
desc!i'in* a &toia that "its the desi!es o" the six do=en health '&!ea&c!ats inte!vie%ed.
;5 B%in* to this "act, the innocence o" scienti"ic !esea!ch is a'sent "!om medicine. #ans
Ionas, G1hilosohical 3e"lections on Exe!imentin* %ith #&man <&':ects,G in 1a&l 5.
-!e&nd, ed., Exe!imentation with Pwnan Sub5sctc (Ne% No!+: )!a=ille!, 1969), . 18,;.
5ltho&*h this a!ticle deals !ima!il( %ith ext!eme "o!ms o" exe!imentation, it !ovides a
l&cid int!od&ction to the !elationshi 'et%een exe!iment and se!vice.
xxx "otnote sl&tt xxx
((,5,))
!ese!ved to ministe!s o" !eli*ion, &sin* scienti"ic !inciles as its theolo*( and technolo*ists
as acol(tes. ;6 5s an ente!!ise, medicine is no% conce!ned less %ith the emi!ical a!t o"
healin* the c&!a'le and m&ch mo!e %ith the !ational a!oach to the salvation o" man+ind
"!om attac+ '( illness, "!om the shac+les o" imai!ment, and even "!om the necessit( o" death.
;7 )( t&!nin* "!om a!t to science, the 'od( o" h(sicians has lost the t!aits o" a *&ild o"
c!a"tsmen al(in* !&les esta'lished to *&ide the maste!s o" a !actical a!t "o! the 'ene"it o"
act&al sic+ e!sons. It has 'ecome an o!thodox aa!at&s o" '&!ea&c!atic administ!ato!s %ho
al( scienti"ic !inciles and methods to %hole cate*o!ies o" medical cases. In othe! %o!ds,
the clinic has t&!ned into a la'o!ato!(. )( claimin* !edicta'le o&tcomes %itho&t conside!in*
the h&man e!"o!mance o" the healin* e!son and his inte*!ation in his o%n social *!o&, the
mode!n h(sician has ass&med the t!aditional ost&!e o" the A&ac+.
5s a mem'e! o" the medical !o"ession the individ&al h(sician is an inext!ica'le a!t o" a
scienti"ic team. Exe!iment is the method o" science, and the !eco!ds he +eesDi" he li+es it
o! notDa!e a!t o" the data "o! a scienti"ic ente!!ise. Each t!eatment is one mo!e !eetition o"
an exe!iment %ith a statisticall( +no%n !o'a'ilit( o" s&ccess. 5s in an( oe!ation that
constit&tes a *en&ine alication o" science, "ail&!e is said to 'e d&e to some so!t o"
i*no!ance: ins&""icient +no%led*e o" the la%s that al(
xxx "otnote sta!t xxx
;6 #a!!is L. 0o&lte!, Divided -egacy, A %istory of the Schism in *edical Thought, vol. 9,
The +atterns Emerge= %ippocrates to +aracelsusM vol; &, +rogress and egress= f; ,; 6an
%elmont to Claude ,ernardM vol; 0, Science and Ethics in American *edici== 9CBB49>9J
2"ashington, D;C;= *c$rath, 9>:0A; A vast and well4documented recent attempt to paint the
history of empirical medicine in constant tension with the rationalist tradition;
;7 #en!( E. <i*e!ist, G1!o'leme de! medi=inischen #isto!io*!ahie,G SudhQf fs Archiv &J
29>09A= 181;. The histo!( o" medicine can 'e %!itten as a histo!( o" disease atte!ns, medical
ideolo*ies, o! medical activities. The "i!st t%o a!oaches a!e o"ten ne*lected.
xxx "otnote sl&tt xxx
((,5.))
in the a!tic&la! exe!imental sit&ation, a lac+ o" e!sonal cometence in the alication o"
method and !inciles on the a!t o" the exe!imente!, o! else his ina'ilit( to cont!ol that
el&sive va!ia'le %hich is the atient himsel". B'vio&sl(, the 'ette! the atient can 'e
cont!olled, the mo!e !edicta'le %ill 'e the o&tcome in this +ind o" medical endeavo!. 5nd the
mo!e !edicta'le the o&tcome on a6o&lation 'asis, the mo!e e""ective %ill the o!*ani=ation
aea! to 'e. The technoc!ats o" medicine tend to !omote the inte!ests o" science !athe! than
the needs o" societ(. ;; The !actitione!s co!o!atel( constit&te a !e8sea!ch '&!ea&c!ac(.
Thei! !ima!( !esonsi'ilit( is to science in the a'st!act o!, in a ne'&lo&s %a(, to thei!
!o"ession. ;9 Thei! e!sonal !esonsi'ilit( "o! the a!tic&la! client has 'een !eso!'ed into a
va*&e sense o" o%e! extendin* ove! all tas+s and clients o" all collea*&es. Medical science
alied '( medical scientists !ovides the co!!ect t!eatment, !e*a!dless o" %hethe! it !es&lts in
a c&!e, o! death sets in, o! the!e is no !eaction on the a!t o" the atient. It is le*itimi=ed '(
statistical ta'les, %hich !edict all th!ee o&tcomes %ith a ce!tain "!eA&enc(. The individ&al
h(sician in a conc!ete case ma( still !emem'e! that he o%es nat&!e and the atient as m&ch
*!atit&de as the atient o%es him i" he has 'een s&ccess"&l in the &se o" his a!t. )&t onl( a
hi*h level o" tole!ance "o! co*nitive dissonance %ill allo% him to ca!!( on in the dive!*ent
!oles o" heale! and scientist.9>
xxx "otnote sta!t xxx
;; The a!*&ment is st!on*l( "o!m&lated '( Oe!ald Leach, The *arais= Imlications of
*edical +rogress 2.ew <or#= *c$raw4%ill, 9>:BM rev; ed;, ,altimore= +enguin, 9>:&A;
;9 Taleott 1a!sons, G3esea!ch %ith #&man <&':ects and the J1!o"essional comlex,6 G in
-!e&nd, E/perimentation with #&man Sub5ects, . 116 i". 1anons distin*&ishes %ithin the
medical8!o"essional comlex (1) !esea!ch, conce!ned %ith the c!eation o" ne% +no%led*eR
(,) se!vice, %hich &tili=es +no%led*e "o! !actical h&man inte!estsR and (.) teachin*, %hich
t!ansmits +no%led*e. #e a!*&es that the lait( needs "o!mal !eco*nition o" the !i*ht to
minimi=e in:&!ies !es&ltin* "!om &n!esolved tensions in this comlex.
9> 5"te! the atient has 'een dama*ed o! has died, the h(sician %ill t!( to "!ee=e the decision
that led to this !es&lt '( !ed&cin* co*nitive dissonance. The
xxx "otnote "o!tsette! E neste side xxx
((,5/))
The !oosals that see+ to co&nte! iat!o*enesis '( eliminatin* the last vesti*es o" emi!icism
"!om the enco&nte! 'et%een the atient and the medical s(stem a!e latte!8da( c!&sade!s o" an
inA&isito!ial +ind 91 The( &se the !eli*ion o" scientism to deval&e olitical :&d*ment. $hile
oe!ational ve!i"ication in the la'o!ato!( is the meas&!e o" science, the contest o" adve!sa!ies
aealin* to a :&!( that alies ast exe!ience to a !esent iss&e, as this iss&e is exe!ienced
'( act&al e!sons, constit&tes the meas&!e o" olitics. )( den(in* &'lic !eco*nition to
entities that cannot 'e meas&!ed '( science, the call "o! &!e, o!thodox, con"i!med medical
!actice shields this !actice "!om all olitical eval&ation.
The !eli*io&s !e"e!ence *iven to scienti"ic lan*&a*e ove! the lan*&a*e o" the la(man is one
o" the ma:o! '&l%a!+s o" !o"essional !ivile*e. The imosition o" this seciali=ed lan*&a*e
&on olitical disco&!se a'o&t medicine easil( voids it o" e""ectiveness.
The de!o"essionali=ation o" medicine does not iml( the !osc!ition o" technical lan*&a*e
an( mo!e than it calls "o! the excl&sion o" *en&ine cometence, no! does it oose &'lic
sc!&tin( and exos&!e o" mal!actice. )&t it
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
a!*&ment in "avo! o" the alte!native he has chosen aea!s eve! st!on*e! as he !e!esses the
a!*&ments in "avo! o" the &nchosen alte!native. #e is actin* li+e a ho&se%i"e: 'e"o!e she *oes
o&t to sho, the mo!e exensive the "ood, the less li+el( it is to *et to the "amil( ta'leR a"te!
he! visit to the s&e!ma!+et and he! decision to '&(, the hi*he! the cost, the mo!e li+el( the
"ood is to 'e &sed. <ee Leon -estin*e!, Conflict, Decision, and Dissonance, <tan"o!d <t&dies
in 1s(cholo*( no. . (<tan"o!d, 0ali".: <tan"o!d 9niv. 1!ess, 196/). Bn the !ole con"lict
'et%een the h(sician as advise! and the h(sician as scientist see Eliot -!eidson,
+rofessional Dominance= The Social <t!&ct&!e of *edical Cars (0hica*o: 5ldine, 197,).
91 5llan #o""man and 7avid 3ittenho&se In*lis, G3adiation and In"ants,G !evie% o" -ow4
-evel 3adiation, '( E!nest I. <te!n*lass, ,ulletin of the Atomic Scientists, 7ecem'e! 197,, .
/585,. The !evie%e!s "o!esee an imminent antiscienti"ic 'ac+lash "!om the *ene!al &'lic
%hen the evidence !ovided '( <te!n*lass 'ecomes *ene!all( +no%n. The &'lic %ill come to
"eel it has 'een l&lled into a sense o" sec&!it( '( the &n"o&nded otimism o" the so+esmen
"o! scienti"ic instit&tions !e*a!din* the th!eat constit&ted '( lo%8level !adiation. The !evie%e!s
a!*&e "o! olic( !esea!ch to !event s&ch a 'ac+lash and to !otect the scienti"ic comm&nit(
"!om its conseA&ences.
xxx "otnote sl&tt xxx
((,55))
does iml( a 'ias a*ainst the m(sti"ication o" the &'lic, a*ainst the m&t&al acc!editation o"
sel"8aointed heale!s, a*ainst the &'lic s&o!t o" a medical *&ild and o" its instit&tions, and
a*ainst the le*al disc!imination '(, and on 'ehal" o", eole %hom individ&als o!
comm&nities choose and aoint as thei! heale!s. The de!o"essionali=ation o" medicine does
not mean denial o" &'lic "&nds "o! c&!ative &!oses, '&t8it does mean a 'ias a*ainst the
dis'&!sement o" an( s&ch "&nds &nde! the !esc!ition o! cont!ol o" *&ild mem'e!s. It does
not mean the a'olition o" mode!n medicine. It means that no !o"essional shall have the
o%e! to lavish on an( one o" his atients a ac+a*e o" c&!ative !eso&!ces la!*e! than that
%hich an( othe! co&ld claim "o! his o%n. -inall(, it does not mean dis!e*a!d "o! the secial
needs that eole mani"est at secial moments in thei! lives: %hen the( a!e 'o!n, '!ea+ a le*,
'ecome c!iled, o! "ace death. The !oosal that docto!s not 'e licensed '( an in8*!o& does
not mean that thei! se!vices shall not 'e eval&ated, '&t !athe! that this eval&ation can 'e done
mo!e e""ectivel( '( in"o!med clients than '( thei! o%n ee!s. 3e"&sal o" di!ect "&ndin* to the
mo!e costl( technical devices o" medical ma*ic does not mean that the state shall not !otect
individ&al eole a*ainst exloitation '( ministe!s o" medical c&ltsR it means onl( that tax
"&nds shall not 'e &sed to esta'lish an( s&ch !it&als. 7e!o"essionali=ation o" medicine means
the &nmas+in* o" the m(th acco!din* to %hich technical !o*!ess demands the sol&tion o"
h&man !o'lems '( the alication o" scienti"ic !inciles, the m(th o" 'ene"it th!o&*h an
inc!ease in the seciali=ation o" la'o!, th!o&*h m&ltilication o" a!cane mani&lations, and the
m(th that inc!easin* deendence o" eole on the !i*ht o" access to ime!sonal instit&tions is
'ette! than t!&st in one anothe!.
((,56))
'ngineering for a Plastic >omb
<o "a! I have dealt %ith "o&! cate*o!ies o" c!iticism di!ected at the instit&tional st!&ct&!e o" the
medical8ind&st!ial comlex. Each *ives !ise to a seci"ic +ind o" olitical demand, and all o"
them 'ecome !ein"o!cements "o! the deendence o" eole on medical '&!ea&c!acies 'eca&se
the( deal %ith health ca!e as a "o!m o" the!ae&tic lannin* and en*inee!in*. 9, The( indicate
st!ate*ies "o! s&!*ical, chemical, and 'ehavio!al inte!vention in the lives o" sic+ eole o!
eole th!eatened %ith sic+ness. 5 "i"th cate*o!( o" c!iticism !e:ects these o':ectives. $itho&t
!elinA&ishin* the vie% o" medicine as an en*inee!in* endeavo!, these c!itics asse!t that
medical st!ate*ies "ail 'eca&se the( concent!ate too m&ch e""o!t on sic+ness and too little on
chan*in* the envi!onment that ma+es eole sic#;
Most !esea!ch on alte!natives to clinical inte!vention is di!ected to%a!ds !o*!am en*inee!in*
"o! the !o"essional s(stems o" man6s social, s(cholo*ical, and h(sical envi!onment. GNon8
health8se!vice health dete!minantsG a!e la!*el( conce!ned %ith lanned inte!vention in the
milie&. 9. The!ae&tic en*inee!s shi"t the th!&st o" thei! inte!8
xxx "otnote sta!t xxx
9, Thomas M. 7&na(e, G#ealth 1lannin*: 5 )i'lio*!ah( o" )asic 3eadin*s,G 0o&ncil o"
1lannin* Li'!a!ians, Exchan*e )i'lio*!ah(, mimeo*!ahed (Monticello, Ill., 196;), sa(s:
G<o extensive is the lite!at&!e o" so&!ce mate!ials on the s&':ect o" health lannin* that to
!ovide a comlete 'i'lio*!ah( has 'ecome an elehantine !o'lem. This di""ic&lt( has 'een
a!tiall( ove!come '( the a s s e m ' l ( o " s e a ! a t e 'i'lio*!ahies ... man( o" %hich a!e
incl&ded (in thisb &ni"ied 'od( o" 'asic !eadin*s &se"&l to the . . . ne%come! to the "ield.G <ee
also National Li'!a!( o" Medicine, Selected eferences on Environmental 2&alit( as )t
elates to %ealth Since 9>:9, National Li'!a!( o" Medicine, ;6>> 3oc+ville 1i+e, )ethesda,
Md.R National Instit&te o" Envi!onmental #ealth <cience, T!ian*le 1a!+, London,
Environmental %ealth, e!iodical since 1971R National Li'!a!( o" Medicine, Environmental
,iology and *edicine, e!iodical since 1971R Current ,ibliography of Epidemiology,
5me!ican 1&'lic #ealth 5ssociation, 17/> )!oad8%a(, N.N. 1>>19.
9. 5s an examle o" this a!oach, see Mon!oe Le!ne! et al., GThe Non8#ealth <e!vices6
7ete!minants o" #ealth Levels: 0oncet&ali=ation and 1&'lic 1olic( Imlications,G !eo!t o" a
s&'committee &nde! the 0a!ne*ie O!ant
xxx "otnote "o!tsette! neste side xxx
((,57))
ventions "!om the otential o! act&al atient to%a!ds the la!*e! s(stem o" %hich he is
ima*ined to 'e a a!t. Instead o" mani&latin* the sic+, the( !edesi*n the envi!onment to
ens&!e a healthie! o&lation. 9/
#ealth ca!e as envi!onmental h(*ienic en*inee!in* %o!+s %ithin cate*o!ies di""e!ent "!om
those o" the clinical scientist. Its "oc&s is s&!vival !athe! than health in its oosition to
diseaseR the imact o" st!ess on o&lations and individ&als !athe! than the e!"o!mance o"
seci"ic e!sonsR the !elationshi o" a niche in the cosmos to the h&man secies %ith %hich it
has evolved !athe! than the !elationshi 'et%een the aims o" act&al eole and thei! a'ilit( to
achieve them. 95
xxx "otnote "o!tsette! "!a "o!!i*e side xxx
to the Medical <ociolo*( <ection, 5me!ican <ociolo*ical 5ssociation, 5&*&st ,9, 197.,
mimeo*!ahed. This d!a"t !ovides a !ationale "o! the extension o" the health '&!ea&c!acies6
mandate to all those matte!s %hich t!aditionall( lie 'e(ond its cometence '( a!*&in* that
the( lie %ithin its inhe!ent o%e!s. -aced %ith the need to identi"( the limits o" its "ield, the
committee decided: (1) it %ill deal %ith "acto!s a""ectin* health levels, o! e!ceived as doin*
so, not %ith concets, meas&!ements o" health levels, o! exte!nalities o" health "o! im!ove8
ment o" socioc&lt&!al levelsR (,) it %ill deal selectivel( %ith "acto!s that a""ect o&lations at
!is+R (.) it %ill deal %ith !evention, maintenance, and adatation !elatin* to ch!onic illness
and disa'ilit(, '&t onl( so lon* as these a!e not e!ceived as Ghealth se!vicesGR (/) it %ill deal
%ith the &nintended ill8health ca&sed '( contact %ith the s(stem "o! the delive!( o" e!sonal
health. <ee also The Sources of %ealth= An Annotated ,ibliography of Current esearch
egarding the .on4thenspeutic Determinants of %ealth, 0ente! "o! 9!'an 5""ai!s,
No!th%este!n 9nive!sit( (Evanston, Ill., 197.).
9/ #&*h lids, Bne Lo&c+s, and 1ete! 5nd!e%s, G0!ite!ia "o! an Btim&m #&man
Envi!onment,G ,ulletin of the Atomic Scientists, Ian&a!( 197>, . ,86. Oeo!*e L. En*el, G5
9ni"ied 0oncet o" #ealth and 7isease,G +erspectives in ,iolooJ and *edicine 0 (s&mme!
196>): /598;5.
95 -o! a theo!etical anal(sis o" the health levels seci"ied in these te!ms, see 5a!on
5ntonovs+(, G)!ea+do%n: 5 Needed -o&!th <te in the 0oncet&al 5!mamenta!i&m o"
Mode!n Medicine,G <ocial <cience and *edicine 6 (Bcto'e! 197,): 5.78//G #e calls "o! a
"o&!th cate*o!( in the concet&al tools o" mode!n medicine: the !eco*nition o" '!ea+do%n. <o
"a! medicine has develoed th!ee ma:o! concets "o! the cont!ol o" disease. -i!st it %as
discove!ed that disease co&ld 'e !evented '( envi!onmental &'lic health meas&!es,
eseciall( '( exe!tin* cont!ol ove! s&lies o" "ood and %ate!. The second '!ea+th!o&*h came
%ith the concet o" imm&ni=ation, !ea!in* the individ&al "o! !esistance. )oth these
a!oaches a!e 'ased on the ima*e o" the dan*e!o&s a*ent. 5 thi!d '!ea+th!o&*h came %ith
the !eco*nition o" m&ltile ca&sation: one s&cc&m's to
xxx "otnote "o!tsette! E neste side xxx
((,5;))
In *ene!al, eole a!e mo!e the !od&ct o" thei! envi!onment than o" thei! *enetic endo%ment.
This envi!onment is 'ein* !aidl( disto!ted '( ind&st!iali=ation. 5ltho&*h man has so "a!
sho%n an ext!ao!dina!( caacit( "o! adatation, he has s&!vived %ith ve!( hi*h levels o"
s&'lethal '!ea+do%n. 7&'os 96 "ea!s that man+ind %ill 'e a'le to adat to the st!esses o" the
second ind&st!ial !evol&tion and ove!o&lation :&st as it s&!vived "amines, la*&es, and %a!s
in the ast. #e sea+s o" this +ind o" s&!vival %ith "ea! 'eca&se adata'ilit(, %hich is an asset
"o! s&!vival, is also a heav( handica: the most common ca&ses o" disease a!e exactin*
adative demands. The health8ca!e s(stem, %itho&t an( conce!n "o! the "eelin*s o" eole and
"o! thei! health, siml( concent!ates on the en*inee!in* o" s(stems that minimi=e '!ea+do%ns.
T%o "o!eseea'le and siniste! conseA&ences o" a shi"t
xxx "otnote sta!t xxx
a *iven disease %hen a *iven a*ent inte!acts %ith a *iven host in a *iven envi!onmentR the
tas+ o" medicine is to !eco*ni=e and cont!ol these *ivens. 5cco!din* to 5ntonovs+(, even
7&'os does not go exlicitl( 'e(ond this concet o" m&ltile ca&sation, even tho&*h 'e
st!esses the need to enhance man6s caacit( to adat to the st!ess th!eatenin* in seci"ic
diseases. 5ntonovs+( s&**ests the &lte!io! concet o" '!ea+do%n, and a de"inition that
e!mits this *lo'al concet to 'e made oe!ational. -o! this &!ose he !ooses
seci"ications "o! "o&! "acto!s common to all disease: (1) ain ma( 'e a'sent, mild, mode!ate,
o! seve!eR (,) handica ma( 'e a'sent, dist!actin*, mode!ate, o! seve!eR (.) ac&te o! ch!onic
cha!acte! can 'e assessed in six %a(s: no ac&te o! ch!onic condition, mild8ch!onic '&t not
de*ene!ative, ac&te '&t not li"e8th!eCtenin*, se!io&s8ch!onic '&t not de*ene!ative, se!io&s8
ch!onic8de*ene!ative, o! ac&te and li"e8th!eatenin*R and "inall( (/) disease can 'e !eco*ni=ed
'( the medical !o"ession as !eA&i!in* no hel, %atchin*, o! the!a(. Th&s ,;; ossi'le
'!ea+do%n t(es have 'een esta'lished. -o! the a&tho!, Ga !adicall( ne% A&estion a!ises: %hat
is the aetiolo*( o" '!ea+do%n4 Is the!e some ne% constellation o" "acto!s %hich is a o%e!"&l
!edicto! o" '!ea+do%n4G
96 3enT 7&'os, *a/ and %is Envi!onment ,iomedical Enowrladp and Social Action, 1an8
5me!ican #ealth B!*ani=ation Scientific 1&'lication no. 1.1 ($ashin*ton, 7.0., 1966).
5lexande! Mitsche!lich, G1s(chosomatische 5nass&n*s*e"iih!d&n*en,G in Das beschidigte
-eben= Diagnose wad T erapie in ever "elt wsabsehbarer 6nZadenanganM Ein <(mosi&m
geleitet %ed henussgeben von Ale/ander *itsche ieh (M&nich: 1ie!, 1969), . .58/6. 5t
%hich oint does the h(sician t&!n into the &nethical accomlice o" a dest!&ctive
envi!on!hent4 <. ?. )o(den, ed., $heal 5datation to ,iological *almo The )mpact of
avantU on the ,Ology of *an (0an'e!!a: 5&st!alian National !niv; 1!ess, 197>).
xxx "otnote sl&tt xxx
((,59))
"!om atient8o!iented to milie&8o!iented medicine a!e the loss o" the sense o" 'o&nda!ies
'et%een distinct cate*o!ies o" deviance, and a ne% le*itimac( "o! total t!eatment. 97 Medical
ca!e, ind&st!ial sa"et(, health ed&cation, and s(chic !econditionin* a!e all di""e!ent names "o!
the h&man en*inee!in* needed to "it o&lations into en*inee!in* s(stems. 5s the health8
delive!( s(stem contin&all( "ails to meet the demands made &on it, conditions no% classi"ied
as illness ma( soon develo into asects o" c!iminal deviance and asocial 'ehavio!. The
'ehavio!al the!a( &sed on convicts in the 9nited <tates 9; and the <oviet 9nion6s
inca!ce!ation o" olitical adve!sa!ies in mental hositals99 indicate the di!ection in %hich the
inte*!ation o" the!ae&tic !o"essions mi*ht lead: an inc!eased 'l&!!in* o" 'o&nda!ies 'et%een
the!aies ad8ministe!ed %ith a medical, ed&cational, o! ideolo*ical !ationale. 1>>
The time has come not onl( "o! &'lic assessment o" medicine '&t also "o! &'lic
disenchantment %ith those monste!s *ene!ated '( the d!eam o" envi!onmental en*inee!in*. I"
contemo!a!( medicine aims at ma+in* it &nnecessa!( "o! eole to "eel o! to heal, eco8
medicine !omises to meet thei! alienated desi!e "o! a lastic %om'.
xxx "otnote sta!t xxx
97 -o! !e"e!ence see 3o'e!t #a!!is, %ealth and Crime Abstracts 9>?B49>:9, #o&ston 1!o:ect
"o! the Ea!l( 1!evention o" Individ&al ?iolence (#o&ston: 9niv. o" Texas <chool o" 1&'lic
#ealth, 197,). $illiam Mo!!o% et al., ,ehavior Therapy ,ibliography 9>@949>?>, Annotated
and Indexed, 9nive!sit( o" Misso&!i <t&dies no. 5/ (0ol&m'ia: 9niv. o" Misso&!i 1!ess,
1971).
9; 7avid I. 3othman et al., G5n #isto!ical Bve!vie%: )ehavio! Modi"ication in Total
Instit&tions,G %astings Center 3eo!t 5 (-e'!&a!( 1975): 178,/. 3o( O. <ece, I!.,
G0onditionin* and Bthe! Technolo*ies 9sed to JT!eat46, 63eha'ilitate46, 67emolish46 1!isone!s
and Mental 1atients,G Southern California -aw eview /5, no. , (197,): 6168;/. 5 s&!ve( o"
the le*al stat&s in the 9.). o" the!aies that aim at the alte!ation o" 'ehavio!.
99 -o! a a!tic&la!l( sensitive a&to'io*!ahical !eo!t ci!c&lated in the <ami=dat and
&'lished in the o!i*inal in O!an, no. 79, 1971, see O. M. <himano"", G<o&veni!s de la Maison
3o&*e,G Esprit > (<etem'e! 197,): .,>86,.
1>> 7. 5. )e*elman, GThe Ethics o" )ehavio!al 0ont!ol and a Ne% M(tholo*(,G
+sychotherapy C, no. , (1971): 16589.
xxx "otnote sl&tt xxx
((,6>))
?. ,he %eco$ery of Health
M&ch s&""e!in* has 'een man8made. The histo!( of man is one lon* catalo*&e o" enslavement
and exloitation, &s&all( told in the eics o" conA&e!o!s o! s&n* in the ele*ies o" thei! victims.
$a! is at the hea!t o" this tale, %a! and the illa*e, "amine, and estilence that came in its
%a+e. )&t it %as not &ntil mode!n times that the &n%anted h(sical, social, and s(cholo*ical
side8e""ects o" so8called eace"&l ente!!ises 'e*an to comete %ith %a! in dest!&ctive o%e!.
Man is the onl( animal %hose evol&tion has 'een conditioned '( adatation on mo!e than one
"!ont. I" he did not s&cc&m' to !edato!s and "o!ces o" nat&!e, he had to coe %ith &se and
a'&se '( othe!s o" his o%n +ind. In his st!&**le %ith the elements and %ith his nei*h'o!, his
cha!acte! and c&lt&!e %e!e "o!med, his instincts %ithe!ed, and his te!!ito!( %as t&!ned into a
home;
5nimals adat th!o&*h evol&tion in !esonse to chan*es in thei! nat&!al envi!onment. Bnl( in
man does challen*e 'ecome conscio&s and the !esonse to di""ic&lt and th!eatenin* sit&ations
ta+e the "o!m o" !ational action and o" conscio&s ha'it. Man can desi*n his !elations to nat&!e
and nei*h'o!, and he is a'le to s&!vive even %hen his ente!!ise has a!tl( "ailed. #e is the
animal that can end&!e t!ials %ith atience and lea!n '( &nde!standin* them. #e is the sole
'ein* %ho can and m&st !esi*n
((,61))
himsel" to limits %hen he 'ecomes a%a!e o" them. 5 conscio&s !esonse to 8 ain"&l
sensations, to imai!ment, and to event&al death is a!t o" man6s coin* a'ilit(. The caacit(
"o! !evolt and "o! e!seve!ance, "o! st&''o!n !esistance and "o! !esi*nation, a!e inte*!al a!ts
o" h&man li"e and health.
)&t nat&!e and nei*h'o! a!e onl( t%o o" the th!ee "!ontie!s on %hich man m&st coe. 5 thi!d
"!ont %he!e doom can th!eaten has al%a(s 'een !eco*ni=ed. To !emain via'le, man m&st also
s&!vive the d!eams %hich so "a! m(th has 'oth shaed and cont!olled. No% societ( m&st
develo !o*!ams to coe %ith the i!!ational desi!es o" its most *i"ted mem'e!s. To date,
m(th has "&l"illed the "&nction o" settin* limits to the mate!iali=ation o" *!eed(, envio&s,
m&!de!o&s d!eams. M(th ass&!ed the common man o" his sa"et( on this thi!d "!ontie! i" he
+et %ithin its 'o&nds. M(th *&a!anteed disaste! to those "e% %ho t!ied to o&t%it the *ods.
The common man e!ished "!om in"i!mit( o! "!om violenceR onl( the !e'el a*ainst the h&man
condition "ell !e( to Nemesis, the env( o" the *ods.
Industriali2ed Nemesis
1!omethe&s %as he!o, not Eve!(man. 7!iven '( !adical *!eed 2p#one/iaA, he t!esassed
'e(ond the limits o" man (aitia and mesotesA and in &n'o&nded !es&mtion 2hubrisA stole "i!e
"!om heaven.1 #e th&s inevita'l( '!o&*ht Nemesis on himsel". #e %as &t into i!ons and
chained to
xxx "otnote sta!t xxx
1 Bn the olitical &se o" divine env(, see <vend 3an&l", The Iealo&s( of d& $ods and
0!iminal La% in 5thens, t!ans. 5nnie I. -a&s'pll, , vols. (0oenha*en: Levin V
M&n+s*aa!d, 19..8./). Bn h&'!is callin* "o!th nemesis, see 7avid Oene, $ree# 1olitical
Theo!(: The )mage of *an in Thas(dides and 1lato (0hica*o: 9niv. o" 0hica*o 1!at, 1hoenix
)oo+s, 1965R o!i*. Man in #is 1!ide)R and E. 3. 7odds, The $ree#s and the )rrational
()e!+ele(: 9niv. o" 0ali"o!nia 1!eis, 1951), eseciall( cha. ,.
xxx "otnote sl&tt xxx
((,6,))
a 0a&casian !oc+. 5n ea*le !e(ed all da( on his live!, and hea!tlessl( healin* *ods +et him
alive '( !e*!a"tin* his live! each ni*ht. Nemesis in"licted on him a +ind o" ain meant "o!
demi*ods, not "o! men. #is hoeless and &nendin* s&""e!in* t&!ned the he!o into an immo!tal
!eminde! o" inescaa'le cosmic !etaliation.
The social nat&!e o" nemesis has no% chan*ed. $ith the ind&st!iali=ation o" desi!e and the
en*inee!in* o" co!!esondin* !it&al !esonses,. h&'!is has s!ead. 9n'o&nded mate!ial
!o*!ess has 'ecome Eve!(man6s *oal. Ind&st!ial h&'!is has dest!o(ed the m(thical
"!ame%o!+ o" limits to i!!ational "antasies, has made technical ans%e!s to mad d!eams seem
!ational, and has t&!ned the &!s&it o" dest!&ctive val&es into a consi!ac( 'et%een &!ve(o!
and client. Nemesis "o! the masses is no% the inescaa'le 'ac+lash o" ind&st!ial !o*!ess.
Mode!n nemesis is the mate!ial monste! 'o!n "!om the Bve!a!chin* ind&st!ial d!eam. It has
s!ead as "a! and as %ide as &nive!sal schoolin*, mass t!anso!tation, ind&st!ial %a*e la'o!,
and the medicali=ation o" health.
Inhe!ited m(ths have ceased to !ovide limits "o! action. I" the secies is to s&!vive the loss o"
its t!aditional m(ths, it m&st lea!n to coe !ationall( and oliticall( %ith its envio&s, *!eed(,
and la=( d!eams. M(th alone can do the :o' no mo!e. 1oliticall( esta'lished limits to
ind&st!ial *!o%th %ill have to ta+e the lace o" m(tholo*ical 'o&nda!ies. 1olitical exlo!ation
and !eco*nition o" the necessa!( mate!ial conditions "o! s&!vival, eA&it(, and e""ectiveness
%ill have to set limits to the ind&st!ial mode o" !od&ction.
Nemesis has 'ecome st!&ct&!al and endemic. Inc!easin*l(, man8made mise!( is the '(8
!od&ct o" ente!!ises that %e!e s&osed to !otect o!dina!( eole in thei! st!&**le %ith the
inclemenc( o" the envi!onment and a*ainst the %anton in:&stice in"licted on them '( the elite.
((,6.))
The main so&!ce o" ain, o" disa'ilit(, and o" death is no% en*inee!ed, al'eit nonintentional,
ha!assment. B&! !evailin* ailments, hellessness, and in:&stice a!e la!*el( the side8e""ects o"
st!ate*ies "o! mo!e and 'ette! ed&cation, 'ette! ho&sin*, a 'ette! diet, and 'ette! health.
5 societ( that val&es lanned teachin* a'ove a&tonomo&s lea!nin* cannot '&t teach man to
+ee his en*inee!ed lace. 5 societ( that !elies "o! locomotion on mana*ed t!anso!t m&st do
the same. )e(ond a ce!tain level, ene!*( &sed "o! t!anso!tation immo'ili=es and enslaves the
ma:o!it( o" nameless assen*e!s and !ovides advanta*es onl( "o! the elite. No ne% "&el,
technolo*(, o! &'lic cont!ols can +ee the !isin* mo'ili=ation and accele!ation o" societ(
"!om !od&cin* !isin* h&!!iedness, !o*!ammed a!al(sis, and ineA&alit(. The same is t!&e "o!
a*!ic&lt&!e. )e(ond a ce!tain level o" caital invest8ment in the *!o%in* and !ocessin* o"
"ood, maln&t!ition %ill 'ecome e!vasive. The !es&lts o" the O!een 3evol&tion %ill then !ac+
the live!s o" cons&me!s mo!eo tho!o&*hl( than Qe&s6s ea*le. No 'iolo*ical en*inee!in* can
!event &nde!no&!ishment and "ood oisonin* 'e(ond this oint. $hat is haenin* in the
s&'8<aha!an <ahel is onl( a d!ess8!ehea!sal."o! enc!oachin* %o!ld "amine. This is '&t the
alication o" a *ene!al la%: $hen mo!e than a ce!tain !oo!tion o" val&e is !od&ced '( the
ind&st!ial mode, s&'sistence activities a!e a!al(=ed, eA&it( declines, and total satis"action
diminishes. It %ill not 'e the so!adic "amine that "o!me!l( came %ith d!o&*ht and %a!, o! the
occasional "ood sho!ta*e that co&ld 'e !emedied '( *ood %ill and eme!*enc( shiments. The
comin* h&n*e! is a '(8!od&ct o" the inevita'le concent!ation o" ind&st!iali=ed a*!ic&lt&!e in
!ich co&nt!ies and in the "e!tile !e*ions o" oo! co&nt!ies. 1a!adoxicall(, the attemt to
co&nte! "amine '( "&!the! inc!eases in ind&st!iall( e""icient a*!ic&lt&!e onl( %idens the scoe
o" the
((,6/))
catast!ohe '( de!essin* the &se o" ma!*inal lands. -amine %ill inc!ease &ntil the t!end
to%a!ds caital8intensive "ood !od&ction '( the oo! "o! the !ich has 'een !elaced '( a ne%
+ind o" la'o!8intensive, !e*ional, !&!al a&tonom(. )e(ond a ce!tain level o" ind&st!ial h&'!is,
nemesis must set in, 'eca&se !o*!ess, li+e the '!oom o" the so!ce!e!6s a!entice, can no
lon*e! 'e t&!ned o"".
7e"ende!s o" ind&st!ial !o*!ess a!e eithe! 'lind o! co!!&t i" the( !etend that the( can
calc&late the !ice o" !o*!ess. The to!ts !es&ltin* "!om nemesis cannot 'e comensated,
calc&lated, o! liA&idated. The do%n8a(ment "o! ind&st!ial develoment mi*ht seem
!easona'le, '&t the como&nd8inte!est installments on exandin* !od&ction no% acc!&e in
s&""e!in* 'e(ond an( meas&!e o! !ice. $hen mem'e!s o" a societ( a!e !e*&la!l( as+ed to a(
an even hi*he! !ice "o! ind&st!iall( de"ined necessitiesDin site o" evidence that the( a!e
&!chasin* mo!e s&""e!in* %ith each &nit %omo economicus, d!iven '( the &!s&it o"
ma!*inal 'ene"its, t&!ns into %omo religiosusM sac!i"icin* himsel" to ind&st!ial ideolo*(. 5t
this oint, social 'ehavio! 'e*ins to !esem'le that o" the d!&* addict. Exectations 'ecome
i!!ational and ni*htma!ish. The sel"8in"licted o!tion o" s&""e!in* o&t%ei*hs the dama*e done
'( nat&!e and all the to!ts in"licted '( nei*h'o!s. #&'!is motivates sel"8dest!&ctive mass
'ehavio!. 0lassical nemesis %as the &nishment "o! the !ash a'&se o" !ivile*e. Ind&st!ial
nemesis is the !et!i'&tion "o! d&ti"&l a!ticiation in the technical &!s&it o" d!eams
&nchec+ed '( t!aditional m(tholo*( o! !ational sel"8!est!aint.
$a! and h&n*e!, estilence and nat&!al catast!ohes, to!t&!e and madness !emain man6s
comanions, '&t the( a!e no% shaed into a ne% $estalt '( the nemesis that ove!ta+es them.
The *!eate! the economic !o*!ess o" an( comm&nit(, the *!eate! the a!t la(ed '( ind&st!ial
nemesis in ain, imai!ment, disc!imination, and death.
((,65))
The mo!e intense the !eliance on techniA&es ma+in* "o! deendence, the hi*he! the !ate o"
%aste, de*!adation, and atho*enesis %hich m&st 'e co&nte!ed '( (et othe! techniA&es and
the la!*e! the %o!+ "o!ce active in the !emoval o" *a!'a*e, in the mana*ement o" %aste, and in
the t!eatment o" eole made lite!all( !ed&ndant '( !o*!ess.
3eactions to imendin* disaste! still ta+e the "o!m o" 'ette! ed&cational c&!!ic&la, mo!e
health8maintenance se!vices, o! mo!e e""icient and less oll&tin* ene!*( t!ans"o!me!s, and
sol&tions a!e still so&*ht in 'ette! en*inee!in* o" ind&st!ial s(stems. The s(nd!ome
co!!esondin* to nemesis is !eco*ni=ed, '&t its etiolo*( is still so&*ht in 'ad en*inee!in*
como&nded '( sel"8se!vin* mana*ement, %hethe! &nde! the cont!ol o" $all <t!eet o! o" The
1a!t(. Nemesis is not (et !eco*ni=ed as the mate!iali=ation o"8 a social ans%e! to a !o"o&ndl(
mis8ta+en ideolo*(, no! is it (et &nde!stood as a !amant del&sion "oste!ed '( the
nontechnical, !it&al st!&ct&!e o" o&! ma:o! ind&st!ial instit&tions. I&st as Oalileo6s
contemo!a!ies !e"&sed to loo+ th!o&*h the telescoe at I&ite!6s moons 'eca&se the( "ea!ed
that thei! *eocent!ic %o!ld` vie% %o&ld 'e sha+en, so d&! contemo!a!ies !e"&se to "ace
nemesis 'eca&se the( "eel incaa'le o" &ttin* the a&tonomo&s !athe! than the ind&st!ial mode
o" !od&ction at the cente! o" thei! socioolitical const!&cts.
From Inherited &yth to %espectful Procedure
1!imitive eole have al%a(s !eco*ni=ed the o%e! o" a s(m'olic dimensionR the( have seen
themselves as th!eatened '( the t!emendo&s, the a%esome, the &ncann(. This dimension set
'o&nda!ies not onl( to the o%e! o" the +in*
((,66))
and the ma*ician, '&t also to that o" the a!tisan and the technician. Malino%s+i claims that
onl( ind&st!ial societ( has allo%ed the &se o" availa'le tools to thei! &tmost e""icienc(R in all
othe! societies, !eco*ni=in* sac!ed limits to the &se o" s%o!d and o" lo% %as a necessa!(
"o&ndation "o! ethics. No%, a"te! seve!al *ene!ations o" licentio&s technolo*(, the "initeness
o" nat&!e int!&des a*ain &on o&! conscio&sness. The limits o" the &nive!se a!e s&':ect to
oe!ational !o'in*s. Net at this moment o" c!isis it %o&ld 'e "oolish to "o&nd the limits o"
h&man actions on some s&'stantive ecolo*ical ideolo*( %hich %o&ld mode!ni=e the m(thic
sac!edness o" nat&!e. The en*inee!in* o" an Peco8!eli*ion %o&ld 'e a ca!icat&!e o" t!aditional
h&'!is. Bnl( a %ides!ead a*!eement on the !oced&!es th!o&*h %hich the a&tonom( o"
ostind&st!ial man can 'e eA&ita'l( *&a!anteed %ill lead to the !eco*nition o" the necessa!(
limits to h&man action.
0ommon to all ethics is the ass&mtion that the h&man act is e!"o!med %ithin the h&man
condition. <ince the va!io&s ethical s(stems ass&med, tacitl( o! exlicitl(, that this h&man
condition %as mo!e o! less *iven, once and "o! all, the !an*e o" h&man action %as na!!o%l(
ci!c&msc!i'ed.
In o&! ind&st!iali=ed eoch, ho%eve!, not onl( the o':ect '&t also the ve!( nat&!e o" h&man
action is ne%., Instead o" "acin* *ods %e con"!ont the 'lind "o!ces o" nat&!e, and instead o"
"acin* the d(namic limits o" a &nive!se %e have no% come to +no%, %e act as i" these limits
did not t!anslate into c!itical th!esholds "o! h&man action. T!aditionall( the cate*o!ical
ime!ative co&ld ci!c&msc!i'e and validate action as 'ein* t!&l( h&man. 7i!ectl( en:oinin*
limits to one6s actions, it demanded
xxx "otnote sta!t xxx
, I have ta+en this a!*&ment, in a!t, ve!'atim "!om #ans Ionas, GTechnolo*( and
3esonsi'ilit(: 3e"lections on the Ne% Tas+ o" Ethics,G <ocial aaa n# JB (197,): .185/.
xxx "otnote sl&tt xxx
((,67))
!esect "o! the eA&al "!eedom o" othe!s. The loss o" a no!mative Gh&man conditionG int!od&ces
a ne%ness not onl( into the h&man act '&t also into the h&man attit&de to%a!ds the "!ame%o!+
in %hich a e!son acts. I" this action is to !emain h&man a"te! the "!ame%o!+ has 'een
de!ived o" its sac!ed cha!acte!, it needs a !eco*ni=ed ethical "o&ndation %ithin a ne%
ime!ative. This ime!ative can 'e s&mmed & onl( as "ollo%s: G5ct so that the e""ect o" (o&!
action is comati'le %ith the e!manence o"
genuine h&man li"e.G ?e!( conc!etel( alied, this co&ld mean: G7o not !aise !adiation levels
&nless (o& +no% that this action %ill not 'e visited &on (o&! *!andchild.G <&ch an ime!ative
o'vio&sl( cannot 'e "o!m&lated as lon* as G*en&ine h&man li"eG is conside!ed an in"initel(
elastic concet.
Is it ossi'le, %itho&t !esto!in* the cate*o!( o" the sac!ed, to attain the ethics that alone %o&ld
ena'le man+ind to accet the !i*o!o&s disciline o" this ne% ime!ative4 I" not,
!ationali=ations co&ld 'e c!eated "o! G an( at!ocit(: G$h( sho&ld 'ac+*!o&nd !adiation not 'e
!aised4 B&! *!andchild!en %ill *et &sed to itjG In some instances, "ea! mi*ht hel !ese!ve
minimal sanit(, '&t onl( %hen conseA&ences %e!e "ai!l( imminent. )!eede! !eacto!s mi*ht
not 'e made oe!ational "o! "ea! that the( %o&ld se!ve the Ma"ia "o! next (ea!6s exto!tions o!
ca&se cance! 'e"o!e the oe!ato! died. )&t onl( the a%e o" the sac!ed, %ith its &nA&ali"ied
veto, has so "a! !oved in8deendent o" the com&tations o" m&ndane sel"8inte!est and the
solace o" &nce!taint( a'o&t !emote conseA&ences. This6 co&ld 'e !einvo+ed as an ime!ative
that *en&ine h&man li"e dese!ves !esect 'oth no% and in the "&t&!e. This !eco&!se to the
sac!ed, ho%eve!, has 'een 'loc+ed in o&! !esent c!isis. 3eco&!se to "aith !ovides an escae
"o! those %ho 'elieve, '&t it cannot 'e the "o&ndation "o! an ethical ime!ative, 'eca&se "aith
is eithe! the!e o! not
((,6;))
the!eR i" it is a'sent, the "aith"&l cannot 'lame the in"idel. 3ecent histo!( has sho%n that the
ta'oos o" t!aditional c&lt&!es a!e i!!elevant in com'attin* an ove!extension o" ind&st!ial
!od&ction. The ta'oos %e!e tied to the val&es o" a a!tic&la! societ( and its mode o"
!od&ction, and it is !ecisel( those that %e!e i!!evoca'l( lost in the !ocess o"
ind&st!iali=ation.
It is not necessa!(, !o'a'l( not "easi'le, and ce!tainl( not desi!a'le to 'ase the limitation o"
ind&st!ial societies on a sha!ed s(stem o" s&'stantive 'elie"s aimin* at the common *ood and
en"o!ced '( the o%e! o" the olice. It is ossi'le to "ind the needed 'asis "o! ethical h&man
action %itho&t deendin* on the sha!ed !eco*nition o" an( ecolo*ical do*matism no% in
vo*&e. This alte!native to a ne% ecolo*ical !eli*ion o! ideolo*( is 'ased on an a*!ee8ment
a'o&t 'asic val&es and on !oced&!al !&les.
It can 'e demonst!ated that 'e(ond a ce!tain oint in the exansion o" ind&st!ial !od&ction in
an( ma:o! "ield o" val&e, ma!*inal &tilities cease to 'e eA&ita'l( dist!i'&ted and ove!8all
e""ectiveness 'e*ins, sim&ltaneo&sl(, to decline. I" the ind&st!ial mode o" !od&ction exands
'e(ond a ce!tain sta*e and continues to imin*e on the a&tonomo&s mode, inc!eased e!sonal
s&""e!in* and social dissol&tion set in. In the inte!imD'et%een the oint o" otimal s(ne!*(
'et%een ind&st!ial and a&tonomo&s !od&ction and the oint o" maxim&m tole!a'le ind&st!ial
he*emon(Dolitical and :&!idical !oced&!es 'ecome necessa!( to !eve!se ind&st!ial
exansion. I" these !oced&!es a!e cond&cted in a si!it o" enli*htened sel"8inte!est and a
desi!e "o! s&!vival, and %ith eA&ita'le dist!i'&tion o" social o&t&ts and eA&ita'le access to
social cont!ol, the o&tcome o&*ht to 'e a !eco*nition o" the ca!!(in* caacit( o" the
envi!onment and o" the otimal ind&st!ial comlement to a&tonomo&s action needed "o! the
e""ective &!s&it o" e!sonal *oals. 1olitical !oced&!es o!iented to the
((,69))
val&e o" s&!vival in dist!i'&tive and a!ticiato!( eA&it( a!e the onl( ossi'le !ational ans%e!
to inc!easin* total mana*ement in the name o" ecolo*(.
The !ecove!( o" e!sonal a&tonom( %ill th&s 'e the !es&lt o" olitical action !ein"o!cin* an
ethical a%a+enin*. 1eole %ill %ant to limit t!anso!tation 'eca&se the( %ant to move
e""icientl(, "!eel(, and %ith eA&it(R the( %ill limit schoolin* 'eca&se the( %ant to sha!e
eA&all( the oo!t&nit(, time, and motivation to lea!n in !athe! than about the %o!ldR eole
%ill limit medical the!aies 'eca&se the( %ant to conse!ve thei! oo!t&nit( and o%e! to
heal. The( %ill !eco*ni=e that onl( the discilined limitation o" o%e! can !ovide eA&ita'l(
sha!ed satis"action.
The !ecove!( o" a&tonomo&s action %ill deend, not on ne% seci"ic *oals eole sha!e, '&t
on thei! &se o" le*al and olitical !oced&!es that e!mit individ&als and *!o&s to !esolve
con"licts a!isin* "!om thei! &!s&it o" di""e!ent *oals. )ette! mo'ilit( %ill deend, not on some
ne% +ind o" t!anso!tation s(stem, '&t on conditions that ma+e e!sonal mo'ilit( &nde!
e!sonal cont!ol mo!e val&a'le. )ette! lea!nin* oo!t&nities %ill deend, not on mo!e
in"o!mation a'o&t the %o!ld 'ette! dist!i'&ted, '&t on the limitation o" caital8intensive
!od&ction "o! the sa+e o" inte!estin* %o!+in* conditions. )ette! health ca!e %ill deend, not
on some ne% the!ae&tic standa!d, '&t on the level o" %illin*ness and cometence to en*a*e
in sel"8ca!e. The !ecove!( o" this o%e! deends on the !eco*nition o" o&! !esent del&sions.
,he %ight to Health
Inc!easin* and i!!ea!a'le dama*e accomanies !esent ind&st!ial exansion in all secto!s. In
medicine this dama*e aea!s as iat!o*enesis. lat!o*enesis is clinical %hen ain, sic+ness, and
death !es&lt "!om medical ca!eR it
((,7>))
is social %hen health olicies !ein"o!ce an ind&st!ial o!*ani=ation that *ene!ates ill8healthR it is
c&lt&!al and s(m'olic %hen medicall( sonso!ed 'ehavio! and del&sions !est!ict the vital
a&tonom( o" eole '( &nde!minin* thei! cometence in *!o%in* &, ca!in* "o! each othe!,
and a*in*, o! %hen medical inte!vention c!iles e!sonal !esonses to ain, disa'ilit(,
imai!ment, an*&ish, and death.
Most o" the !emedies no% !oosed '( the social en*inee!s and economists to !ed&ce
iat!o*enesis incl&de a "&!the! inc!ease o" medical cont!ols. These so8called !emedies *ene!ate
second8o!de! iat!o*enic ills on each o" the th!ee c!itical levels: the( !ende! clinical, social, and
c&lt&!al iat!o*enesis sel"8!ein"o!cin*.
The most !o"o&nd iat!o*enic e""ects o" the medical technost!&ct&!e a!e a !es&lt o" those
nontechnical "&nctions %hich s&o!t the inc!easin* instit&tionali=ation o" val&es. The
technical and the nontechnical conseA&ences o" instit&tional medicine coalesce and *ene!ate a
ne% +ind o" s&""e!in*: anestheti=ed, imotent, and solita!( s&!vival in a %o!ld t&!ned into a
hosital %a!d. Medical nemesis is the exe!ience o" eole %ho a!e la!*el( de!ived o" an(
a&tonomo&s a'ilit( to coe %ith nat&!e, nei*h'o!s, and d!eams, and %ho a!e technicall(
maintained %ithin envi!onmental, social, and s(m'olic s(stems. Medical nemesis cannot 'e
meas&!ed, '&t its exe!ience can 'e sha!ed. The intensit( %ith %hich it is exe!ienced %ill
deend on the indeendence, vitalit(, and !elatedness o" each individ&al.
The e!cetion o" nemesis leads to a choice. Eithe! the nat&!al 'o&nda!ies o" h&man endeavo!
a!e estimated, !eco*ni=ed, and t!anslated into oliticall( dete!mined limits, o! com&lso!(
s&!vival in a lanned and en*inee!ed hell is acceted as the alte!native to extinction. 9ntil
!ecentl( the choice 'et%een the olitics o" vol&nta!(
((,71))
i
ove!t( and the hell o" the s(stems en*inee! did not "it into the lan*&a*e o" scientists o!
oliticians. B&! inc!easin* con"!ontation %ith medical nemesis no% lends ne% si*ni"icance to
the alte!native: eithe! societ( m&st choose the same st!in*ent limits on the +ind o" *oods
!od&ced %ithin %hich all its mem'e!s ma( "ind a *&a!antee "o! eA&al "!eedom, o! societ(
m&st accet &n!ecedented hie!a!chical cont!ols. to !ovide "o! each mem'e! %hat %el"a!e
'&!ea&c!acies dia*nose as his o! he! needs.
In seve!al nations the &'lic is no% !ead( "o! a !evie% o" its health8ca!e s(stem. 5ltho&*h
the!e is a se!io&s dan*e! that the "o!thcomin* de'ate %ill !ein"o!ce the !esent "!&st!atin*
medicali=ation o" li"e, the de'ate co&ld still 'ecome "!&it"&l i" attention %e!e "oc&sed on
medical nemesis, i" the !ecove!( o" e!sonal !esonsi'ilit( "o! health ca!e %e!e made the
cent!al iss&e, and i" limitations on !o"essional monoolies %e!e made the ma:o! *oal o"
le*islation. Instead o" limitin* the !eso&!ces o" docto!s and o" the instit&tions that emlo(
them, s&ch le*islation %o&ld tax medical technolo*( and !o"essional activit( &ntil those
means that can 'e handled '( la(men %e!e t!&l( availa'le to an(one %antin* access to them.
Instead o" m&ltil(in* the secialists %ho can *!ant an( one o" a va!iet( o" sic+8!oles to
eole made ill '( thei! %o!+ and thei! li"e, the ne% le*islation %o&ld *&a!antee the !i*ht o"
eole to d!o o&t and to o!*ani=e "o! a less dest!&ctive %a( o" li"e in %hich the( have mo!e
cont!ol o" thei! envi!onment. Instead o" !est!ictin* access to addictive, dan*e!o&s, o! &seless
d!&*s and !oced&!es, s&ch le*islation %o&ld shi"t the "&ll '&!den o" thei! !esonsi'le &se
onto the sic+ e!son and his next o" +in. Instead o"
xxx "otnote sta!t xxx
. The #ono!a'le Iames Mc3&e!, 'ntario ogwl 0ommission )nquiry into 0ivil ights
(To!onto: 2&een6s 1!inte!, 196;, 1969, 1971). Bn sel"8*ove!nin* !o"essions and occ&ations,
see cha. 79. The *!antin* o" sel"8*ove!nment is a dele*ation o" le*islative and :&dicial
"&nctions that can 'e :&sti"ied onl( as a sa"e*&a!d to &'lic inte!ests.
xxx "otnote sl&tt xxx
((,7,))
s&'mittin* the h(sical and mental inte*!it( o" citi=ens to mo!e and mo!e %a!dens, s&ch
le*islation %o&ld !eco*ni=e each man6s !i*ht to de"ine his o%n healthDs&':ect onl( to
limitations imosed '( !esect "o! his nei*h'o!6s !i*hts. Instead o" st!en*thenin* the licensin*
o%e! o" seciali=ed ee!s and *ove!nment a*encies, ne% le*islation %o&ld *ive the &'lic a
voice in the election o" heale!s to tax8s&o!ted health :o's. Instead o" s&'mittin* thei!
e!"o!mance to !o"essional !evie% o!*ani=ations, ne% le*islation %o&ld have them eval&ated
'( the comm&nit( the( se!ve.
Health as a 4irtue
#ealth desi*nates a !ocess o" adatation. It is not the !es&lt o" instinct, '&t o" an a&tonomo&s
(et c&lt&!all( shaed !eaction to sociall( c!eated !ealit(. It desi*nates the a'ilit( to adat to
chan*in* envi!onments, to *!o%in* & and to a*in*, to healin* %hen dama*ed, to s&""e!in*,
and to the eace"&l exectation o" death. #ealth em'!aces the "&t&!e as %ell, and the!e"o!e
incl&des an*&ish and the inne! !eso&!ces to live %ith it.
#ealth desi*nates a !ocess '( %hich each e!son is !esonsi'le, '&t onl( in a!t !esonsi'le
to othe!s. To 'e !esonsi'le ma( mean t%o thin*s. 5 man is !esonsi'le "o! %hat he has done,
and !esonsi'le to anothe! e!son o! *!o&. Bnl( %hen he "eels s&':ectivel( !esonsi'le o!
ans%e!a'le to anothe! e!son %ill the conseA&ences o" his "ail&!e 'e not c!iticism, cens&!e, o!
&nishment '&t !e*!et, !emo!se, and t!&e !eentance. / The conseA&ent states o" *!ie" and
dist!ess a!e ma!+s o" !ecove!( and healin*, and a!e henomenolo*icall( somethin* enti!el(
di""e!ent "!om *&ilt "eelin*s. #ealth is a tas+, and as s&ch is not
xxx "otnote sta!t xxx
/ 5l"!ed <ch&t=, G<ome EA&ivocations in the Notion o" 3esonsi'ilit(,G in Collected +apers,
vol. &, <t&dies in Social 4leoc( (The #a*&e: Ni:ho", 196/), . ,7/86.
xxx "otnote sl&tt xxx
((,7.))
coma!a'le to the h(siolo*ical 'alance o" 'easts. <&ccess in this e!sonal tas+ is in la!*e a!t
the !es&lt o" the sel"8a%a!eness, sel"8disciline, and inne! !eso&!ces '( %hich each e!son
!e*&lates his o%n dail( !h(thm and actions, his diet, and his sex&al activit(. @no%led*e
encomassin* desi!a'le activities, cometent e!"o!mance, the commitment to enhance health
in othe!sDthese a!e all lea!ned "!om the examle o" ee!s o! elde!s. These e!sonal activities
a!e shaed and conditioned '( the c&lt&!e in %hich the individ&al *!o%s &: atte!ns o" %o!+
and leis&!e, o" cele'!ation and slee, o" !od&ction and !ea!ation o" "ood and d!in+, o"
"amil( !elations and olitics. Lon*8tested health atte!ns that "it a *eo*!ahic a!ea and a
ce!tain technical sit&ation deend to a la!*e extent on lon*8lastin* olitical a&tonom(. The(
deend on the s!ead o" !esonsi'ilit( "o! health( ha'its and "o! the socio'iolo*ical
envi!onment. That is, the( deend on the d(namic sta'ilit( o" a c&lt&!e.
The level o" &'lic health co!!esonds to the de*!ee to %hich the means and !esonsi'ilit( "o!
coin* %ith illness a!e dist!i'&ted amon* the total o&lation. This a'ilit( to coe can 'e
enhanced '&t neve! !elaced '( medical inte!vention o! '( the h(*ienic cha!acte!istics o" the
envi!onment. That societ( %hich can !ed&ce !o"essional inte!vention to the minim&m %ill
!ovide the 'est conditions "o! health. The *!eate! the otential "o! a&tonomo&s adatation to
sel", to othe!s, and to the envi!onment, the less mana*ement o" adatation %ill 'e needed o!
tole!ated.
5 %o!ld o" otimal and %ides!ead health is o'vio&sl( a %o!ld o" minimCl and onl(
occasional medical inte!vention. #ealth( eole a!e those %ho live in health( homes on a
health( diet in an envi!onment eA&all( "it "o! 'i!th, *!o%th, %o!+, healin*, and d(in*R the( a!e
s&stained '( a c&lt&!e that enhances the conscio&s accetance o" limits to
((,7/))
o&lation, o" a*in*, o" incomlete !ecove!( and eve!8imminent death. #ealth( eole need
minimal '&!ea&c!atic inte!"e!ence to mate, *ive 'i!th, sha!e the h&man condition, and die.
Man6s conscio&sl( lived "!a*ilit(, individ&alit(, and !elatedness ma+e the exe!ience o" ain,
o" sic+ness, and o" death an inte*!al a!t o" his li"e. The a'ilit( to coe %ith this t!io
a&tonomo&sl( is "&ndamental to his health. 5s he 'ecomes deendent on the mana*ement o"
his intimac(, he !eno&nces his a&tonom( and his health must decline. The t!&e mi!acle o"
mode!n. medicine is dia'olical. It consists in ma+in* not onl( individ&als '&t %hole
o&lations s&!vive on inh&manl( lo% levels o" e!sonal health. Medical nemesis is the
ne*ative "eed'ac+ o" a so\ial o!*ani=ation that set o&t to im!ove and eA&ali=e the oo!t&nit(
"o! each man to coe in a&tonom( and ended '( dest!o(in* it.
((,75))
((,76))
Sub0ect Inde@
2see also )nde/ of .amesA
adve!tisin* and !omotion, ha!mace&tical, 6/85, 718,, 75
a*ed: diseases o", 1., ;18.R emlo(ment o", and Ind&st!ial 3evol&tion, 191R exendit&!e "o!
ca!e, ;,R health ca!e, demand "o!, ;18,,19,8/, 197R instit&tionali=ation, ;.8/R medicali=ation
o" lives o", 798;1R e!cetion o" need '(, and de!ivation, ,19R o&lation *!o%th, ;,R social
val&e o", develoment o", 19,8/
a*in*, nat&!al, t!eated as disease, 7;8;/
5lliance "o! 1!o*!ess, ,,.
5me!ican 0ance! <ociet(, 1/ n., ,/
5me!ican Medical 5ssociation, 6>81, ,/6
5me!ican 1ha!mace&tical 5ssociation, 6>81
anemia, alastic, as side8e""ect, 65 anti'iotics, 9; n.R disease atte!ns, chan*es in, and, 1.816,
,,
5!a's: death, attit&des to%a!d, 179,
1;6R hositals, ea!l(, 156R side
e""ects o" d!&*s st&died '(, ,7 n. 5!*entina, 57 n;
a!th!itis, 17, ;,
asi!in, 67, 7,
a&tho!it( and a&tonom(, medical, /687R sic+8!oles and, 1,>8, a&tonom(, e!sonal, !ecove!(
o", ,7>
)el*i&m, 5185,'ilha!=iasis, ,,.
'i!th cont!ol, 198,> n.R *enetic
co&nselin*, 91
'lac+ ma*ic, medical inte!vention
as, 11/816
)lac+ 1anthe!s, 156 )olivia, ,.9
)o!neo, ,> n;
)!a=il, 6/
'!onchitis, 17
0anada, 1. n., 5,, 75R emi*!ation o" docto!s to 9. <., 57 n.
cance!, 1/ n., 17, ,/85, ;,R !adiation and, .>81 n.R !esea!ch 'oom, 1>6 n.R te!minal ca!e, 1>/
ca!diovasc&la! diso!de!s, ,586, ,9, ;,R dia*nosis e!!o!, 9.. See also hea!t diso!de!s
0ent!al 5me!ica, 6;. See also Latin 5me!icaR co&nt!ies
chemothe!a(: nonin"ectio&s diseases and, ,/86R in"ectio&s diseases and, ,,8.R side8e""ects o",
,789. See also medicines and the!ae&tic aids
child!en: '!ain dama*e, minimal, 95 n.R deaths, accidental, .1R deaths, "!om dia!!heal diseases,
1>5R diseases, in"ectio&s, 16, ,.R h(e!active, dia*nosis o", 95R la'elin* as health !is+, 91R li"e
exectanc(, ;1R medicali=ation o" lives o", ;5R nondiseases, disa'lin* t!eatment o", ,9R
tonsillectomies
((,77))
o", and dia*nostic 'ias, 9.. See also in"ants
0hile, 5;, 6;89, ;78;R '!east8"eedin* o" 'a'ies in, ;687
0hina, 5ncient, 1/7
0hina, 0omm&nist, 5;86>,156, 16; chlo!amhenicol, a'&se and side8e""ects o", 6586
chole!a, 16, 1>/
0h!istianit(: death, attit&des to%a!d, 175, 1768;7, ,>586 n.R hositals, ea!l(, 156R ain,
attit&des to%a!d, 1/789
clinical iat!o*enesis, ,78.5
0olom'ia, /985>, ;5
0on*!ess o" ?ienna, 159, 19,
cons&me! movement, ,,6, ,,9
0&'a, ,. n.
c&lt&!al iat!o*enesis, ..8/R death, handlin* o", 17/8,>7R ain, alte!ed attit&des to%a!d, 1..85/R
olitici=ation o" disease and health, 155869R s&""e!in*, !esonse to, 1,78.,
c&lt&!es: health, $estalt o", and accetance o" !ealit(, 1,;8.>R medicines and. 6.85R ain,
accetance and tole!ance o", 1,;8.>, 1..87R e!cetion o" disease and, //8;, 55,11;819R
!eli*io&s medicine and ma*ic, 1>7816
death. See d(in* and death
de"ectives: la'elin* o", 9>81R s&!vival o", ..
7enma!+, 66
dental health, ,/
dee!sonali=ation: o" dia*nosis and the!a(, .>, ,1/R o" val&es, victims o", ,1781;
de!ivation, lea!ned needs and, ,198,>
de!o"essionalitation: o" medicine, ,5586R o" !ima!( ca!e, and national health, ,,7
deviance: c&lt&!al e!cetion o", //8;, 55, 117819R d&min* o" deviants on nonmedical
mana*e!s, 116817R hositals. ea!l(, and, 15687R la'elin* o", /586, 9>81, 96, 11681;R mental,
17, 9>R Gmental,G and Gdisease,G 1668;R !od&ctivit( and, 1,.8/R social iat!o*enesis and, /.
dia'etes, 17,,/
dia*nosis: 'ias in "avo! o" disease, 9,8/R deviance, esta'lishment o", 9>81, 96R e!!o! !ate, 9.8/R
in:&!ies ca&sed '( testin* !oced&!es, 9/86R li"e exectanc( and, 97R !esea!ch and, 9,, 96
dia!!heal diseases, 16, 7/, 1>5
dihthe!ia, 1., 16, ,.
disease (s) : a*in*, nat&!al, t!eated as, 7;8;/R availa'ilit( o" medical ca!e and, ,,,8.R
classi"ication and !eco*nition, /> n., 16987>R c&lt&!al e!cetion o", //8;, 55, 11;819R
develoment, histo!ical, 16>8.R dia*nostic 'ias in "avo! o", 9,8/R dia*nosis o" 2see also
dia*nosis) , 16>8.
disease: ecolo*ical 'alance and, ,> n.R as entities, !eco*nition o", 15986.R envi!onment and,
178,1, 169R and health8testin*, m&lti8hasic, 918,R h&nts "o!, 91,96R ideolo*( and, 166R o"
in"ants, 6, n., ;78;R in"ectio&s, decline o", 15816, ,,8.R lan*&a*e o", 17>8,R maln&t!itional, 16,
,>, 6, n., ;78;R maste!( o", and s(m'olic "&nctions o" medicine, 111816R mechanistic theo!(
and, 16>: nonexistent, disa'lin* t!eatment o", ,;89R nonin"ectio&s, medical inte!vention and,
,/86R n&t!itional, ,,/85, ,,6 n.R o" old a*e, 1., ;18.R atholo*(, st&d( o", 16., 175R
olitici=ation o", 15589, 16;89R !evalence, chan*es in, 1.8,6R G!ealG vs. G&n!ealG o! Gmental,G
1668;R side8e""ects o" medication, 6586R social o!*ani=ation and classi"ication o", 16987>R
toxonom( o", 16>
dist!&st, *!o%in*, o" medical !o"ession, ,,58.>
docto!s: 'ias, dia*nostic, 9,8/R dee!sonali=ation o" atient 8 !elationshis, .>R dist!&st o",
*!o%th o", ,,58.>R d!&* !esea!ch
((,7;))
and, 7, n., 76 n.R "ees, 51, 5.R mal!actice, ,;8.., ./5R as medical !iesthood, 1>7816R
mi*!ation to 9.<., 5687 n.R ee!s, eval&ation o", ,,;R !e:&dices and o!i*ins, class8seci"ic,
,,7R !atio, and o&lation, ,18,R !esc!ition o" d!&*s 2see also medicines and the!ae&tic
aids) , 658;R as !ole and stat&s classi"ie!s, 7689,.,/9R sel"8!e*&lation, "ail&!e o", 6687R and
te!minall( ill 2see also d(in* and death) , 9;81>7, 116R &nioni=ation, 61
d!&* addiction and a'&se, 69 n., 7>
d!&*s. <ee medicines and
the!ae&tic aids
d(in* and death, ./R in atomic a*e, ,>,8.R )a!oA&e concets o", 1;9, ,>>: 'o&!*eois attit&des,
1;989/R ca&ses o" death, 1., 15816, ,., .1, ;1, 19;89R 0h!istianit( and,
1768;7, ,>586 n.R clinical attit&des to%a!d, 19586, ,>>R &nde! com&lso!( ca!e, 19;89, ,>>R
costs o", 97,1>1,1>5,1>6: c!isis mana*ement, medical, 9;81>7R 7anse Maca'!e, 1;>8,, 199R
Gdance o" the dead,G 17689, 199R de"inition o", 9; n.R desi!a'ilit( o", dete!mination o", 97 n.R
dissection o" co!ses, 1;;89R e&thanasia iss&e, 1>.8/ n. "ol+8!actices, 1;5R *!o& solida!it(
and, ,>.R health and accetance o", 1,;, 1.>, 1.,R at home. 1>/R hositali=ed, /,, 97, 1>>81,
1>/87, ,>/85R h&manism and, 1;/85, 1;;R individ&alit(, sense o", and attit&de to%a!d, 1;.8/R
ind&st!ial ethos and, 19;, ,>/87R instit&tionali=ation o" a*ed, and mo!talit( !ate, ;.8/R in
intensive8ca!e &nits, 1>687R le*al standin* o" co!se, 1;7R ma*ical !it&al and, 116R medieval
attit&des to%a!d, 1768;/, 1;6, 1;;,1;989> n., 199R monool(, medical, and, /,R Gnat&!al
death,G evol&tion o" ima*e o", 1758,>;R G!imitive
death,G 176 n.R !olon*ation o" li"e, 9;,1>>,1>,8.,1>5P86,1;6, 19>R 3enaissance attit&des
to%a!d, 1;/85, 1;;89R social !o*!ess concets and, 1978;R s&icide, /5,1>5,199R and ta'oo,
,>, n.R t!ade &nionism and old8a*e ca!e, 197R &ntended medicall(, ille*alit( o", 19;
ecolo*(, technolo*( and, ,> n., ,.. ,,.86
ed&cation: medical a&tho!it( and, /7R costs, 5687R develoment o". 16,8/,.196R mi*!ation o"
docto!s to 9.<., 5687 n.R ha!mace&tical ind&st!( and, 7,
em'(sema, 17
En*land, 75, 115, ,.1R 'lood t!ans"&sions, e""ectiveness o", 11> n.R dissection e!mitted in,
1;;R d!&* cons&mtion, 69R eidemics. 16R health8ca!e s(stem, 5.8/, ;>, ,,18.R hosital
e!sonnel, immi*!ant, ,/;R thalidomide &se, 66 n.
Enli*htenment, 19/
ent!ament in medicali=ation, .,86
envi!onment, health and, 178,1, ,> n., ,., ,,.5R ind&st!ial envi!onment, 169R the!ae&tic
en*inee!in* and, ,5786>
eidemics: ecolo*ical &sets and, ,> n., ,., ,,.86R evol&tion o" atte!ns o", 15817
ethics: scientism and, /78;R social o!*ani=ation o" medicine and, 1>;811R s&i vival o" h&man
li"e and a ne% a%a+enin*, ,6687>
e&thanasia iss&e, 1>.8/ n.
eval&ation o" health ca!e: non8!o"essional, necessit( o", />, ,56, ,7.R '( ee!s, ,,;, ,/687
exendit&!es "o! health ca!e: administ!ative costs, 5>81R "o! a*ed, ;,: '&d*ets, national, and,
/;85>, ;,: class st!&ct&!e and, 6>8,R develoin* and &nde!8develoed co&nt!ies. /985>, 558;R
"o! d!&*s, 69 n., 7> n., 71 n., 157R En*lish exe!ience, %ith national
((,79))
health se!vice, 5.8/R d(in* and death, 97, 1>1, 1>5, 1>6R "ees, docto!s6, 51, 5.R hosital costs,
5>81,157R ins&!ance cove!a*e and, 5>, 51, 5,R li"e exectanc( and, 518,, 5/R in <oviet 9nion,
5/85
"amil( lannin*, 198,> n;M *enetic co&nselin*, 91
"ood. See n&t!ition
-ood and 7!&* 5dminist!ation, 7/86
-!ance, 6/, 75, ,.1R a*in*, attit&des to%a!d, 19,R death, attit&des to%a!d, 197, 1;;, 19586,
197, ,>586 n.R dissection e!mitted in, 1;;R exendit&!es "o! health ca!e, /9, 5,R hosital
e!sonnel, ,/;R mo!talit( !ates, ,, n., 5,R olitici=ation o" health and disease, 15589R sel"8
!e*&lation, medical, 66
-!ench 3evol&tion, 5>, 15586, 16,, 19., 195
*enetic co&nselin*. 91
Oe!man(, 75, ,.1R docto!8atient contact, .> n.R exendit&!es "o! health ca!e, /9, 5,R hosital
e!sonnel, immi*!ant, ,/;R mo!talit( !ate, 518,R sel"8!e*&lation, medical, 66
Ohana, 57
O!eece, 5ncient, /5, 11>811, 1/687, 17>R ain, handlin* o", 1./ n., 1/687, 1/;
*nosis, contemo!a!(, and technolo*ical medicine, 1>9816
O!een 3evol&tion, ,,/, ,6/
health: accetance o" !ealit( and, 1,78.,, ,57R clinical standa!ds, develoment o", 16/86R
$estalt o", and c&lt&!e, 1,;8.,R !i*ht to, ,7>8.R as vi!t&e, ,7.85
health ca!e: a*in*, and demand "o!, ;18,, 19,8/, ,198,>R class8seci"ic, ,,687R demand "o!
claim to, 1,,8.R eval&ation '( comm&nit( and non!o"essionals, />, ,56, ,7.R eval&ation '(
ee!s, ,,;, ,/687R exendit&!es "o!, /;86,, 69 n;, 7> n;, ;,, 157R exo!t o" technolo*( to
develoin* co&nt!ies and, ,,.85R health8testin*, m&ltihasic, c&lt o", ;9897R medical nemesis
and, ./86R nationali=ation, En*lish exe!ience %ith, 5.8/, ;>, ,,18.R !ima!(,
de!o"essionali=ation o", and national health, ,,7R !e"o!m !oosals, anal(sis o", 2see also
!e"o!m !oosals, anal(sis o") , ,,986>R sel"8ca!e and A&alit( o", ,7>R social iat!o*enesis and,
/>81R %omen6s li'e!ation movement and, ,,6R as %o!ld !eli*ion, ,>586
#ealth, Ed&cation, and $el"a!e 7ea!tment, .1, 51, ,,;
health !o"essions: deendence on, ,198,>R licensin*, ,//85, ,/;, ,56, ,7.R sic+ !oles and,
117, 1,,R seciali=ation, ,/687. See also docto!sR health ca!e
hea!t diso!de!s, 17, ,586, ,9R dia*nosis e!!o!, 9.R intensive ca!e and, 1>687
hi*h 'lood !ess&!e, ,6
#olland, 66
hositals and hositali=ation: clinical standa!ds, develoment o", 16/86R costs, 5>8,, 157R
dee!sonali=ation, technolo*( and, .>R d(in*, cont!ol o", /,, 1>>881, 1>/87R in:&!ies and, .18,R
intensive ca!e, 1>687R o'solescence o", 166R ain8+ille!s, !est!iction o", 1>/R esthole:, ea!l(
hositals as, 15687R in oo!e! co&nt!ies, 568;R !esea!ch hositals, iat!o*enic disease and, .,R
seciali=ation, 156,,,.R teachin* and t!ainin* cente!s, ea!l(, 16,8/
h(e!tension, 17
India, 57 n.
Ind&st!ial 3evol&tion, 191R li"e exectanc( and, 191
ind&st!iali=ation, imact o", 1;8,> n.R co&nte!!od&ctivit( and medical ente!!ise, ,1.8,>R li"e
exectanc( and, 191R mano%e!
((,;>))
maintenance, !eventive medicine and, ;9R social costs, ,1, ind&st!iali=ed nemesis, ,6,86
in"ants: n&t!ition and health, 6, n;, ;68;R mo!talit( !ates, ;586, ,,7. <ee also child!en
in:&!ies: dia*nostic !oced&!es and, 9/86R docto!8in"licted, ,687R o" hositali=ed, .18,R side8
e""ects o" medication, ,78;, 6586, 6;, 76 n;, 95
innovation, !esistance to, ,>81
insecticides and esticides, ecolo*( and, ,> n;, ,., ,,., ,,6
ins&!ance: health costs and, 5>, 51,
5,R mal!actice, no8"a&lt, .5 n;
Islam, attit&des to%a!d death, 179
Ital(, 57 n;, 66R ha!mace&tical
ind&st!(, 66 n.
Iava, 1,9
Iamaica, ;6
Ie%s: death, attit&des to%a!d, 1;6R
ain, attit&des to%a!d, 1/78;
la'elin*, iat!o*enic, /586, 9>8,, 96, 11681;
lan*&a*e: medical, 17>8,, ,5586R ain8desc!itive, 1.9/>
Latin 5me!ica, 57, 6;89, ,.;8/>R mi*!ation o" docto!s to 9. <., 56 n. See also co&nt!ies
leishmaniasis, ,.
licensin* o" health !o"essionals, ,//85, ,/;, ,56, ,7.
li"e exectanc(: o" ad&lt males, 518,, 5/R o" a*ed, ;,R dia*nostic !oced&!es and, 9,R
Ind&st!ial 3evol&tion and, 19>R o" in"ants, ;586R medical inte!vention and, 15, ,>8,, 9; n;M
!eventive medicine and, 97R o" te!minall( ill, 9;, 1>>, 1>,8.,1>587R o" (o&n* ad&lts, ;1
li"e8st(le, medicali=ation o", 768;,R in a*ed, 798;/R in in"anc( and childhood, ;/8;
lo'otom(, /> n;
mala!ia, ,> n., ,,8., 7/, ,,. Mali, ,>/
maln&t!ition: hi*h8calo!ic, o" oo!, ,,/R in"ant health, and '!east8"eedin* vs. comme!cial
"oods, 6, n., ;68;R s(nd!omes, 16, ,>, ,6
mal!actice, medical, ,;8..R claims settlements, .1R ins&!ance, no8"a&lt, ./ n.
measles, 16, ,.
Medicaid costs, 51
medical nemesis, ./86
medicines and the!ae&tic aids: addiction, licit and illicit, 69 n., 7>, 7., 1>/R adve!tisin* and
!omotion, 6/85, 718,, 75R anti'iotics, 1., 16, ,,R cons&mtion o" d!&*s, ,;. 6987>, 7,8.R
co&nte!"eit, ,;R c&lt&!es and, 6.85R dosa*es, excessive, 7> n.R e""icac( o", 7/85R exendit&!es
"o!, 69 n., 7> n., 157R in"o!mation conce!nin*, availa'ilit( o", 6/85, :9 n;, :@ n;M monool(,
comme!cial, /,R ne!vo&s8s(stem a*ents, 6987>R ain8+ille!s, !est!iction o", 1>/R lace'os, 7/
n;, 1>;R !esc!ition, ill8in"o!med, o", 6586R 1!ices, 69 n;, 71R !oli"e!ation o" d!&*s, 7/85R
!e*&lation, *ove!n8ment, 6;89R sel"8&se, 65, 67 n;, 76, 17,8.R side8e""ects o", ,78;, 6/86, 6;,
76 n., 95R simlicit( o" most dis*&ised '( lan*&a*e, 17,8.
mental disease and diso!de!s, 17R la'elin* and, 9>R vs, Gh(sicalG disease, 1668;R seen as
olitical !o'lem, 16;
Mexico, /, n;, 6/85, 6;, ,>/85, ,.98/>
Middle 5*es: death, attit&des to%a!d, in, 1768;/, 1;6, 1;;,
1;989> n;, 199R hositals, 156
monool(, medical, /18.
mo!alit(, medicine and, //8;, 115816R sic+8!ole and, 11;8,1
m(th, "ail&!e o", ,6,86.
National #ealth <e!vice ()!itish) , 5.8/, ,,18.1
need, e!cetion o", and de!ivation, ,198,>
No!%a(, 66
n&t!ition. health and. 16. 1;,>:
((,;1))
"ood additives, ,,6: *lo'al, ,,.85R o" in"ants, 6, n., ;68;
o'esit(, 17
ove!medicali=ation, social, ..
ain: accetance and tole!ance, c&lt&!al s(stems and, 1,;8.>. 1..87R classical attit&des to%a!d
and !e:ection o" ain8+illin*, 1/689R comm&nication o" exe!ience o", 1/>81R in"licted on
othe!s, limits to, 1.5R lan*&a*e and desc!ition o", 1.98/>R mana*ement o", t!aditional
c&lt&!al, 1//85R mechanistic theo!( and, 15>R medicali=ation o", 1/586, 1518/R o':ectivi=ation
and A&anti"ication o",1.78;,1/,R e!cetion o" in anothe!, 1/18,R h(siolo*( and social
"acto!s, inte!action o", 1.687R !e"e!ential asects o", 1/18,R !elationshi to othe! ills, 1.; 9R as
social c&!se, 1.586: s&""e!in*, and c&lt&!al "!ame%o!+, 1/.89R t!eatment vs. healin*, 1/6R
&tilit( o", 15>81
ain8+ille!s, &se o": assivit( and, 1518,: !est!iction o", "o! te!minall( ill, 1>/R and sea!ch "o!
sensation, 15,8/
a!amedicals, &se o": in 0hina, 5;89R in health8testin*, 91
a!ents, and medicali=ation o" child!en,6;5
1eace 0o!s, ,,.
ella*!a, 66
e!sonal !esonsi'ilit(: "o! handlin* ain, 1./, 1/.89R "o! healin*, 1>;89, 11/, 1./R s&!!ende!
o", sic+8!ole and, 1,.
enicillin, /, n.
1e!&, 57 n;
ha!mace&tical ind&st!(, 6.876R adve!tisin* and !omotion, 6/85. 718,, 75R ed&cation,
medical, and, 7,R medical !o"ession and, 668;, 718,R !esea!ch, 7, n., 76 n.R !e*&lation,
*ove!nment, 6;89. See also medicines and the!ae&tic aids
1hiliines, 57 n.
lace'os, 7/ n., 1>;, 11.81/
ne&monia, 1., ,,
olio, 1., ,.
o&lation: a*ed, ;,R sta'ilit( o", 198,>
ove!t(, seciali=ation o", ,19
!eventive medicine: 'ias, dia*nostic, 9,8/R as !ole dete!minant, ;989,R sc!eenin* !oced&!es,
918,
s(chiat!(, oosition to, 1678;
!adiation: cance! and, .>81 n;M dia*nostic &se, 95
!ealit(, accetance o", and health, 1,;8.>. See also ainR s&""e!in*
3ed O&a!ds, 156
!e"o!m !oosals, anal(sis o": cate*o!ies o" !e"o!m, ,,98.>R cons&me! !otection "o! medical
addicts, ,.>.6R de!o"essionali=ation o" medicine, ,5586R eA&it( and eA&alit( o" access, ,.18
//R &'lic cont!ols ove! cometence and hie!a!chical o!*ani=ation, ,//851R scientism and
medical '&!ea&c!ac(, ,5185R the!ae&tic en*inee!in*, ,5786>
!eli*ion: ain, attit&des to%a!d, and, 1/75>R death, attit&des to%a!d, and, 175, 1768;7, ,>586
n.
!eli*io&s medicine. 1>7816R 'lac+ ma*ic, de*!adation into, 11/816R ce!emonialism, 1>78;R
ethics and, 11>R *nosis, contemo!a!(, and social o!*ani=ation o" medicine, 1>9R e!sonal
!esonsi'ilit( "o! healin*, 1>;89, 11/R s(m'olic, nontechnical !oles o" medical technicians,
11181/
3enaissance, attit&des to%a!d death, 1;/85,1;689
!esea!ch: cance!, 1>6 n.R dia*nostic !oced&!es and, 9,, 96R d!&*, 7, n;, 76 n.
!ic+ets, 16
!oles: medical dete!mination o", 768;;, 11681;, ,/9R !eventive medicine and, ;989,R side8
!ole, incl&sive exansion o", 1168,/
((,;,))
3ome, 5ncient, ,98.> n., 111
sanitation, 16 n., 17 n., ,>8.
sca!let "eve!, 16, ,.
scientism: '&!ea&c!ac(, medical,
and, ,5185R ethics and, /78;
sel"8ca!e: inc!easin* di""ic&lt( o", ,1/R A&alit( o" health ca!e and, ,7>R !eno&nced in "avo! o"
technolo*(, 1>5R !i*ht o", /1R o" te!minall( ill, 1>/R &nde!minin* o" and intole!ance o" dail(
!ealit(, ,,,
sel"8*ove!nment, ind&st!iall( !od&ced a!al(sis o", ,1.8,>
sel"8medication, 65, 67 n;, 76, 17,8.
sleein* sic+ness, ,., ,,.
smallox, 1618,
social costs o" ind&st!iali=ation, exte!nalities and, ,1,
social *oals, achievement o", and hete!onono&s modes o" !od&ction, ,15817
social iat!o*enesis, .., />81R cont!ol o" !ole and stat&s, 768;;,
1168,.R cost o" health ca!e, /;86,R dia*nosis and, 768;;R d(in* and death, !it&ali=ation o", 978
1>7R monool(, medical, /18.R ha!mace&ticals and, 6.876R !eventive medicine c&lt, ;9897R
sic+8!ole, incl&sive exansion o", 1168,.R s(m'olic and nontechnical "&nctions o" medicine,
1>7816
<o&th @o!ea, 57 n;
<oviet 9nion, 5/86>,16;, ,6>
<ain, dissection e!mitted in, 1;;
seciali=ation: o" health !o"es sionals and eval&ation o" cont!i'&tion, ,/687R o" hositals,
156, ,,.
s&""e!in*, ./, /1R c&lt&!al e!cetion o", 11>81,R ethics and, 11>811R ina'ilit( to coe %ith,
,198,>R isolation o" sic+ and mo!al de*!adation, 115816R mo!alit( and, /586R !ealit(,
accetance o", and, 1,78.,. See also d(in* and deathR ainR ain8+ille!s, &se o" s&icide,
/5,1>5,19;
s&!*e!(, ,5R dia*nostic 'ias and, 9.R dia*nostic, ha=a!ds vs. val&e o", 9/85R lo'otom(, /> n.R
&nnecessa!(, ,;
<%eden, 5185,, 6>, 75, ,.1
<%it=e!land, 5,
s(hilis, 1., ,,8.
technolo*(, exo!tin* o", ,,.85
tetan&s, ,.
Thailand, 57 n., 6/, ;6
thalidomide, 66 n.
the!aies, daim to, 1,,8.
tonsillectomies, dia*nostic 'ias and, 9.
t!anA&ili=e!s, 6987>
t&'e!c&losis, 1.,15816, ,.
t(hoid, 16, ,,, 6586, 6;
&lce!s, 16817
&nions: old8a*e medical ca!e and, 197R o%e! o", 61
9e! ?olta, ,>/
&se8val&es: ind&st!iali=ation o" %o!ld8vie% and, ,1/815R medical monool( and, /,
val&e s(stems: c&lt&!al e!cetion o" disease, //8;R medical monool( and, /,8.
vene!eal disease, 1., ,,8.
?ene=&ela, 6/, ,.9
$ales, 66 n., ;>, ;5
%ate! s&l(, 16 n., 17 n., 1; n., ,>8,
%hooin* co&*h, 16, ,.
%omen: '!east8"eedin* o" 'a'ies, 6, n., ;68;R cance! and, ,/85R li'e!ation movement, and
health ca!e, ,,6R s&!*e!( and, ,;89, /> n. $o!ld #ealth B!*ani=ation, ,,7
((,;.))
Inde@ of Names
(see also <&':ect Index)
5'el8<mith, )!ian, 159 n.
5'!ams, M. #., 151 n.
5c+e!+necht, E!%in #., 1. n., 1; n; ,7 n., 1>1 n., 11> n., 115 n., 1,; n., 1.> n., 1., n., 19, n.
5dle!, 5l"!ed, 199 n.
5dle!8@a!hson, O&nna!, ,.9 n.
5do!no, Theodo! $., 19. n.
5:ami, 5l"!ed M., I!., 6. n;
5+e!s, 3onald, ,/5 n;
5ldama, 5!t&!o, ?@n;, ,,6 n.
5lexande!, -., 165 n.
5llende, 7!. <alvado!, 5;, 6;89
5l8Nadim, ,7 n;
5loisi, ,51 n.
5l83a=i, ,7 n.
5lston, I. #., ,. n.
5me!(, Iean, ;1 n;
5nde!son, Bdin $., 1. n., 55 n.
5nde!son, 3., ,/> n;
5nd!e%s, 1ete!, ,5; n.
5nd!iola, I., ,9 n.
5ntonovs+(, 5a!on, ,5;89 n.
5el, -!ancis 5., ,,; n;
5!iTs, 1hilie, ;6 n., 175 n.,
1;989> n., 191 n;
5!istotle, 1/7
5!telt, $alte!, /5 n., 155 n., 17, n.
5sh'&!n, 1e!c( M., 1., n.
5t+ins, #edle(, ,5 n.
5&'e!t, $ilhelm, 9> n.
5&d(, 3alh, .. n., ,,. n., ,./ n.
5&*ene!, Ma!*ot, 1>1 n., 19, n.
5&ste!, 3icha!d, ,/1 n.
5vicenna, ,7 n.
)ac+man, E. L., 17, n.
)acon, -!ancis, 19>
)a+an, 7avid, ;.8/ n;, 1/> n.
)a+e!, Timoth( 7., 56 n. )a+%in. #a!!(, 9. n.
)ald!(, #. 0., 1., n.
)al"e, )!&ce, 5> n.
)alint, Michael, 7> n;
)aloch, I., 177 n;
)aite!, Mitchell, 7> n.
)alt!&saitis, I&!*is, 1;, n.
)am'ec+, Man"!ed, 1;/ n.
)an+s, I. 5., ,> n.
)a!iet(, Ma&!ice, 1;; n.
)a!+in, 7avid, ,.9 n.
)a!na!d, 0h!istiaan, 11.
)a!samian, E!nest M., 9/ n.
)a!tels, M., 1>7 n.
)asa*lia, -!anco, 1,1 n., 1,.
)a&e!, #e!mann, 1;9 n.
)a&e!, ?eit #a!old, 16> n.
)a&m, O. L., 9, n.
)eall, Btho T., 16, n.
)eat(, #a!!( N., ,; n.
)ec+e!, #o%a!d <., /6 n., ,,7 n., ,/9 n., ,51 n.
)eeche!, #en!( @., 11, n., 11. n., 1.6 n., 1.7 n.
)e*elman, 7. 5., ,6> n.
)eh!man, <. I., 19 n.
)elo, Iane, 1.1 n.
)elt!Cn, Oon=alo 5*&i!!e, 1., n;
'en 7avid, Ioseh, ,.9 n.
)en=, E!nst, 17/85 n;
)enveniste, Emile, 161 n.
((,;/))
)e!*, 5lan, 1; n., 6, n;, C: n;, ,,/ n.
)e!*e!, )., 1,9 n.
)e!*e!, La%!ence, 6; n.
)e!*e!, 1ete!, 1,9 n., 1.. n;
)e!*e!, 1lacid&s, 1;/ n;
)e!*ho"", Eman&el, 16. n.
)e!*man, 5'!aham )., ,9 n.
)e!*man, 3o'e!t L., 1// n.
)e!lin*&e!, Oiovanni, ,,; n.
)e!mann, O!e*o!ia, 16;
)e!na!d, 0la&de, 16.
)e!na&e!, 9!s&la, 6; n.
)e!ta&d, lmile, 1,6 n;
)ichat, 1>1 n.
)il=, 3&dol", 1.5 n.
)inde!, -!ed, 1.> n;
)i!ch, #e!'e!t T., ,/1 n.
)i!!en. Iames E., 79 n.
)itte!, $ilhelm, 1/5 n.
)lac+%ell, )a!'a!a, 96 n., ,,7 n.
)la+e, Iohn, /, n.
)loch, Ma!c, 1; n., 115 n.
)loch, $e!ne!, .5 n., 19/ n., 199 n.
)lohm+e, Ma!ia, ,,; n.
)loomA&ist, E. 3., 1// n.
)l&m, 3. #., 6. n.
Ol&mme!, #&*o, 175 n.
)l(ed81!ieto, #., 1// n.
)l(th, Iames N., 157 n.
)oase, T. <. 3., 1;1 n.
)oehla&, ?ol+ma!, 79 n.
)oinet, -., 157 n.
)o+, <issela, 1>/ n.
)olin, T. 7., ,,/ n.
)oll, -!an=, 7; n.
)oltans+i, L&c, ;5 n., 17, n., ,,6 n.
)o!*st!om, Oeo!*e, ,,/ n.
)o!os, Ladisla&s, ,>6 n.
)o!!emans, ?alentina, 9981>> n., ,>1 n.
)osA&et, Michel, /. n.
)oss&at, 3o'e!t, 179 n;
)o&ldin*, @enneth, ,.; n.
)o(den, <. ?., ,59 n.
)!adsha%, Ionathan, ,.; n.
)!a&del, -e!nand, 1; n.
)!a&e!, E!nst #annes, 1./ n;
)!eche!, Ed%a!d M., 69 n.
)!e**in, 1ete! 3., /> n.
)!emne!, 3o'e!t, ,,5 n.
)!est, 5l'e!t N., ,5 n.
)!iesenmeiste!, 7iet!ich, 1;1 n;, 199 n.
)!illat8<ava!in, 5nthelme, ,>18; n.
)!im, B!ville, 97 n., ,>7 n.
)!oo+, 3o'e!t #., ,,; n.
)!oo+e, E., ,,, n.
)!o%n, 3. O. <., ,,, n.
)!&netti, 1. M., /. n.
)!&nn, 5lice L., 6. n.
)!&nne!, #ein!ich, 1;7 n.
)!(ant, Iohn, 5> n., ;6 n.
)!(ce8<mith, 7., 95 n.
)&chheit, Oe!t, 1;> n.
)&c+, 0a!l 7a!lin*, 1.9 n.
)&llo&*h, ?e!n L., 11> n.
)&!ac+, 3icha!d, 6/ n., 67 n., 71 n.
)&!dett, #en!(, 156 n.
)&!+e, 3icha!d M., 1/ n.
)&!ton, 3o'e!t, 1// n.
)&tte!%o!th, 0ha!les, .1 n.
)&(tendi:+, -. I. I., 1,7 n., 1,9 n., 1.. n.
)(a!, 7. 1., ,5 n.
0ahill, @athleen, 56 n.
0ahn, I., /5 n., 1.7 n., 1/. n.
0ain, #a!ve(, 7., ,6 n.
0alland, 0. #., 1>586
0am'ell, Ioseh, 1;, n;
0an*&ilhem, Oeo!*es, 16/ n.
0annon, $alte! )., ;/ n., 11/ n.
0a!on, 5lexand!e, 9; n.
0a&to, 7., 56 n.
0a!lson, 3ic+, 1/ n;, ;, n;
0a!l(le, Thomas, 1.18, n.
0a!!&the!s, I. 7., 1; n.
0a!son, 3ao&l, 171 n.
0a!stai!s, O. M., 1// n.
0a!t%!i*ht, 5nn, 6/ n., ,,, n.
0assel, E!ic I., ,>. n;
0assel, Iohn, 17 n.
0e!ma+, Ida, 1./ n. 0had%ic+, Ed%in, 17 n.
0hamisso, 5. ?., 16, n;
0haman, 1. I., 9/ n.
0ha!entie!, I., /5 n., 1.7 n., 1/. n.
0ha&ce!, Oeo""!e(, 17;
0heit, Ea!l -., 79 n.
0h!istie, Niels, // n., 1,18, n.
0la!+, Iames M., 1;>
0lements, -o!!est E., // n.
((,;5))
0li=e!, E. E., ,,6 n.
0ote, 1a&l 7., 9, n.
01&"", Lei*hton, 7> n;
0oale, 5nsle( I., 19 n.
0och!ane, 5. L., ,, n., ,/ n., 9/ n.
0ohen, @athleen, 17; n.
0ohen, ?icto!, 5, n.
0ohen, Neh&di 5., 1.> n.
0ohn8#a"t, Lo&is, 111 n.
0oleman, Emil( 3., 19 n., 19, n.
0omte, 5&*&ste, 16/
0ontena&, Oeo!*es, 171 n.
0oo+e, 3o'e!t E., 1>.8/ n.
0ooe!, Ioseh, 97 n;
0ooe!, Michael #., 5/ n., ,.1 n.
0o!eia, -e!nando da <ilva, 156 n.
0o&lte!, #a!!is L., ,5. n;
0o&t(, 0ha!les, 1;; n.
0!oi=ie!, 3alh 0., 59 n.
0!&e, )en:amin L., 1.7 n.
7an'lon, 1a&l, ,>586 n;
7anc+e!t, $e!ne!, 115 n., 177 n.
765!c(, 1. -m ,6 n.
da <ilva 0o!eia, -e!nando, 156 n.
7a&mie!, #ono!T, .5 n.
7avies, I. E., ,> n;
7avis, 5. E., ,,/ n.
7avis, 5delle, ,,5 n., ,,6 n.
7avis, -!ed, 91 n;, 1>. n.
de )ea&voi!, <imone, ;1 n.
de -Tlice, 1hilie, 7> n.
de @adt, Eman&el, 19 n., ,// n.
7eich&!an, $. )., ,,6 n.
de la To!!e, Iose"ina M&!iel, 157 n.
del -ave!o, 5l, 66 n.
7eloo=, 1ie!!e, ,>5 n;
de Mi*&el, Iesda, ,.; n.
7elit8Mo!ando, 17 n;
7esca!tes, 3enT, 15>, 16>
de <olla 1!ice, 7e!e+ I., 1/ n.
7es 1!es, Te!!ence, 15.
7essaive, Iean81a&l, 159 n.
7e%a!, Tom, ,.5 n.
7ic+83ead, O!antl(, 1.6 n.
7id!on, 5. N., 1;1 n.
7ie*en, 1., 16. n;
7in*le, Iohn #., 798;> n.
7ion(sios o" -o&!na, 1;1 n;
7:e!assi, 0a!l, 5; n;, @> n;
7odds, E. 3., ,6, n;
7oll, 1a&l I., 1;7
7o%lin*, #a!!(, 7> n.
7o(le, Iames 0., ,9 n.
7!eit=el, #. 1., 9> n., ,,> n.
7&'os, Iean, 15 n.
7&'os, 3enT, 1. n., 15 n;, .9 n;, 6, n;, 15;, ,59
7&'!&dc, Edel*a!d, 1;> n;
7&chesna(, $uy, &? a;
7&dle(, Ed%a!d, 15; n;
7&"", 3a(mond <., ,,7 n;
7&mont, 3enT, ,,/ n.
7&na(e, Thomas M., ,57 n.
7&nlo, 7. M., 69 n.
7&nn, -. L., 1,;89 n.
7&nnell, @a!en, 6/ n., ,,, n.
7&&(, Iean81ie!!e, 76,n., ,,; n.
7&!lin*, <heila, 17, n;
Ea!dle(, 5., ;/ n.
Eaton, Leona!d @., 159 n;
E'stein, E., 19/ n.
Echeve!!ia, IosT, 17/ n.
Edelstein, L&d%i*, /, n., 1>. n., 90B n;
Eden, M&!!a(, 9/ n.
Edm&ndson, $. -., ,> n;
E**e'e!t, -!ied!ich8$ilhelm, 1;9 n.
E*ils!&d, I. <., 17; n.
Eh!en!eich, )a!'a!a, ,.7 n.
Eh!en!eich, Iohn, ,.7 n;
Eh!lich, 5nne #., ,,6 n.
Eh!lich, 1a&l 3., ,,6 n;
Eissle!, 3. <., 11, n;
Elias, No!'e!t, 157 n., 166 n.
El+inton, I. 3., 1>, n.
Ell&l, IacA&es, 1,> n;
Elscsse!, OYnte!, 1.> n;
En*el, Oeo!*e L., ,5; n.
En*elha!dt, @., 17> n;
Ente!line, 1. E., ,,. n.
Ent!al*o, 1ed!o Lain, 16. n., 165 n.
Estein, <am&el, ,,6 n.
E!dmann, #ein!ich, 0B n;
E!i+son, E!i+, 99 n.
Este!son, 5., 167 n;
Et=ioni, 5mitai, ,/6 n.
E&lne!, #ans8#ein=, ,// n.
Evans, @. T., ,5 n;
Evans81!itcha!d, E. E., 7; n., 1,; n.
Exton8<mith, 5. N., ;, n., 1>/ n.
((,;6))
-a*nani, -., 17 n.
-alloi&s, 7!., 1;9
-a!va!, M. Ta*hi, ,. n., ,,. n., ,,/ n.
-e'v!e, L&cien, 1; n.
-eh!, #., 1;7 n.
-ei"el, #e!mann, 1>, n., 17/ n;
-ein, 3ashi, ,/1 n.
-eldstein, Ma!tin <., /9 n., 5> n., 51 n.,5,n.
-enne!, -!ied!ich, 1/; n;
-e!'e!, 0h!istian von, 17/ n.
-e!'e!, Liselotte von, ,,7 n.
-e!*&son, Iohn, 1/5 n.
-e!!e!o, 0., 19 n.
-e!!(81ie!!et, Ianine, 16/86 n;
-estin*e!, Leon, ,55 n;
-ield, Ma!+ O., /5 n., 5/85 n.
-i!estone, Iohn M., 69 n. -ische!, 1a&l, 1;7 n.
-ish, )a!'a!a, 95 n.
-ishe!, 5!ch'isho o" 0ante!'&!(, ,>6 n.
-it=at!ic+, I. 1., 6. n.
-land!in, I.8L.,19 n.
-letche!, Ioseh -., ,>6 n.
-linn, M. $., 17 n.
-oe!ste!, #ein= von, 6, n.
-o!'es, $. #., 5, n.
-o!ste!, Me!lin #., 1;5 n.
-osse(e&x, Ma!cel, 157 n.
-o&ca&lt, Michel, /> n., 1,>, 1,/ n.,
155 n., 157 n.,16/ n.
-ox, 3enTe, .9 n., // n., 1,> n.
-!a+e, 0ha!les B., 11; n.
-!an+, I. 1., 17 n;
-!an+l, ?icto! E., 15, n.
-!ase!, I. T., 1;, n;
-!a=e!, Iames Oeo!*e, 179 n.
-!ede!ic+, $illiam L., ,/5 n.
-!eedman, 5l"!ed M., 7. n.
-!eeman, #o%a!d, ,// n.
-!eeman, Iohn M., 1>.8/ n.
-!eeman, 3o*e! 7., 95 n.
-!eidson, Eliot, 1; n., // n., /5 n;, /7 n., 5. n., 66 n;, ;9 n.,9,n., 9?? n;, &JJ n., ,/9 n. -!eita*,
Elisa'eth, 6; n; -!en=en, $., 1.9 n.
-!e&d, <i*m&nd, 179 n.
-!e&nd, 1a&l 5., ,9 n., ,5, n., ,5/ n.
-!e(, Iohn, @@ n;
-!e('e, 5l'e!t, 17; n., 1;6 n.
-!e(e!, #ans, 165 n;
-!ie'el, #., 7, n.
-!omm, E!ich, 1>> n.
-&chs, ?icto! 3., 51 n;, @& n;, 5; n;, 6, n., 75 n., ,/; n.
-&chs, $e!ne!, 176 n., ,>, n.
-iilo8Mille!, 3enT, 165 n.
-&lton, 3o'e!t, 17/ n;
-&!tmYlle!, 0a!l, 199 n;
Oa'ald'n, 5!noldo, ,.9 n.
Oa*lio, Massimo, ,51 n;
Oalen,.161
Oa!', <olomon, ,; n;
Oa!dine!, Ed%a!d N., 1.> n;
Oa!"in+el, #a!old, // n. Oa!land, L. #., 9/ n.
Oa!na&d, -., 1./ n;
Oa!!ison, -ieldin* #., 17/ n.
Oe'sattel, ?icto! E. von, 1.687 n.
Oeddes, I. <., ;> n.
Oee!t=, 0li""o!d, 1,98.> n.
Oehlen, 5!nold, 1,9 n;
Oei*e!, 1a&l, 171 n., 1;6 n., 1;7 n.
Oeo!*oo&los, ). <., ,7 n.
Oe!son, Iean 0ha!lie! de, 1;;
Oe(e!, T., .> n.
Oi'e!t, -!an\ois, ,, n.
Oiedion, <ie*"!ied, 1; n;, 1;, n., 19; n.
Oil', 0o!inne Lath!o, ,/9 n.
Oil"illan, <., ,/1 n;
Oilman, 5l"!ed, 6.8/ n.
Oimlette, Iohn 7., /5 n.
Oish, Bsca!, 5687 n., ,/; n.
Olase!, 3o'e!t I., 97 n.
Olase!, $illiam 5., 5,8. n.
Olasse!, 3icha!d, 1;, n.
Ola=e!, Nathan, ,.7 n.
Olixelli, <te"an, 17; n.
Ol&c+man, Max, 1>9 n.
Oodda!d, Iames L., 67 n., 6987> n.
Oodin, 5nd!T, ,>586 n.
Oo""man, E!vin*, 9> n., 167
Oo""man, Iohn $., .> n.
Oolt=, 7ietlinde, 171 n.
Ooode, $illiam I., /6 n., 66 n., 1>; n;, ,/6 n;
Oood"ield, I&ne, /7 n.
((,;7))
Ooodman, Lo&is <., 6.8/ n;
Ooossens, N., ,6 n.
Oo!don, Iohn E., 16 n.
Oo!e!, Oeo""!e(, ,>, n;
OZ!!es, 5l'e!t, 1.5 n;, 169 n;
Oo!tva(, O., ,> n;
Oo&*a&d, L., 177 n;
Oo(a, -!ancisco, .9 n;
O!a'ne!, El"!iede, 1,9 n;
O!ao%, #e!mann, 171 n.
O!a(stone, 1ete!, 1/5 n.
O!een'e!*, 7aniel, 1/ n.
O!een'e!*, <eli*, 7, n.
O!ene, 7avid, ,6, n.
O!eve!&s, Ina8Ma!ia, 1,9 n.
O!i""in, I. 1., ,6 n.
O!me+, Mi!+o 7., 16.8/ n.
O!ossman, Michael, ,.. n;
O!&'e!, O. )., 16. n.
O&'se!, 5. $., 1.1 n;
O&e!!a, -!ancisco, 1., n;
O&illema!d, 5nne8Ma!ie, ;/ n.
O&s"ield, Ioseh 3., /6 n.
O&sso%, Ioan 7(e, ,/1 n;
#a'enstein, 3o'e!t $., ,>, n.
#a**e!t(, 3o'e!t I., ,.6 n.
#ahn, 5lois, 1;, n.
#allan, I. )., 7> n.
#a!d(, Iames 7., 1.7 n.
#a!msen, #., ;,
#a!!is, ). <. #., 7> n;
#a!!is, 3icha!d, 61 n;
#a!!is, 3o'e!t, ,6> n.
#a!!is, <e(mo&! E., /; n.
#a!t, #. L., 1>. n;
#a!tland, E. <., 179 n;
#a!tla&', O. -., 17; n;
#a!tman, 3o'e!t <., 1/> n.
#a!tmann, -!it=, 165 n.
#a&"", $., 16, n.
#a(te!, 5lethea, 151 n.
#eint=, 3., ,6 n;
#elle!*e!s, Iohn -., 6; n.
#ema!dinA&e!, I., ,,/ n;
#ende!son, La%!ence, 11;819
#enti*, #ans von, 1>6 n., 1;7 n.
#e!she(, Nathan, ,., n;, ,/; n.
#e!t=, 3o'e!t, 179 n. #e!=ha"t, O., 11/ n.
#e!=o*, Ed*a!, 179 n.
#ethe!in*ton, 3o'e!t $., /;89 n.
#e(e!8O!ote, L., 1.> n.
#iestand, 7ale L., 51 n.
#ill, #a!!is, 1.6 n.
#inton, Iohn, 1>/ n.
#ioc!ates, 1/687, 15986>
#i!sch, E!na, 1;> n.
#i!sh"ield, 7aniel <., ,,1 n.
#och, E. M., 1/5 n.
#o""man, 5llan, ,55 n;
#o""man, E. T. 5., 16, n;
#Zse!, Max, 171 n;
#ol'ein, #ans, the No&n*e!, 1;>8,, 1;9
#ollcnde!, E&*en, 16> n.
#ollin*shead, 5&*&st )., ,,7 n.
#olmes, Blive! $endell, 1/6
#olmstedt, )., 1// n.
#o+ins, 0a!l E., /;89 n.
#o!n, #., ,; n.
#o!n, Iosh&a, 5; n;
#o!n&n*, I. 1., 17; n.
#&e'schmann, #., 1,, n;
#&"eland, 0. $., 165 n.
#&*hes, 0ha!les 0., ,,. n.
#&i=in*a, Iohan, 177 n.
#&nte!, Iohn Melton, 1; n;, 79 n.,
,,. n;
#&nt"o!d, 3onald, 6> n.
#&ntle(, 3. 3., ., n;
#(de, 7avid 3., 6>81 n;
Illich, Ivan, /1 n., 77 n., 9981>> n.
Iltis, #&*h, ,5; n.
Im'e!t, Iean, 15687 n., 16. n.
In*lis, 7avid 3ittenho&se, ,55 n.
Is!ael, Ioachim, 55 n.
Is!ael, L., ., n;
Is!ael, <., ,,, n.
Iaco, E. Oa!tl(, 1/. n.
Iaco', $ol"*an*, .. n., 165 n.
Iae*e!, $e!ne!, 1.> n;
Ia+o'ovit=, Imman&el, 1/7 n.
Ian+elevitch, ?ladimi!, 17/ n.
Ia!vi+, M. E., 1.6 n.
Iette!, 7iete!, 156 n.
Ie%+es, Iohn, 5. n.
Ie%+es, <(lvia, 5. n.
Ionas, #ans, ,5, n., ,67 n.
Ionas, <tehen, ,,5 n.
((,;;))
Ionsen, 5l'e!t, 69 n.
Io!es, 5., ;. n.
I&tman, 7avid, ;, n.
@ad&shin, 0ha!les, ,,7 n;, ,.; n.
@alish, 3icha!d 5., 978; n.
@a!ie!, 0la!ence, 1,1 n.
@a!sent(, <e!*e, 16586 n.
@ass, Leon 3., 9; n.
@a&l"&ss87iesch, 17; n.
@eele, @enneth 7., 1.; n.
@ee!loo, Ioost 5. M., 1;, n.
@eith, Thomas, 1.7 n.
@ellne!, #., 1,9 n.
@elman, <., 61 n., ,/;8.9 n.
@elsen, #ans, 179 n.
@enned(, Ed%a!d M., ,,5 n.
@e(s, Thomas, 1.; n.
@hald&n, I'n, 111 n., 1.1 n.
@ie"e!, @a!l, 1./ n.
@ienle, Oe!ha!d, 7/ n., 11/ n.
@i!+e*aa!d, <Z!en, 15. n.
@in*, <. #., ,,7 n.
@isch, 5!nold I., ,,;89 n.
@ittel, Oe!ha!d, 1/7 n.
@la!man, #e!'e!t E., /9 n.
@lass, E'e!ha!d, 1;/ n.
@lein, L., 1;/ n.
@lein'ach, O., ,,7 n.
@le!man, O. L., 69 n.
@lin*e!, Max, ,>>
@l&c+hohn, 0l(de, 11;819 n.
@natte!&d, O. L., ,/ n.
@no%les, Iohn #., 51 n.
@och, @la&s, ,>, n.
@och, 3., 165 n.
@Zni*, @a!l, 1;7 n.
@o!sch, M. )., 17> n.
@osa, Iohn, ,/1 n;
@osa+(, <tehen 1., 1;>81 n.
@otle!, $ilton, 157 n;
@ot(, Iohn, ;. n;, 9>& n;
@o(!T, 5lexand!e, 16/ n.
@!ei*, Ma!*a!et, ,; n;
@!et=en'ache!, Leoold, 1;/85 n.
@!iss83etten'ec+, Len=, 1;586 n.
@!oll, I., ;, 175 n;
@&'le!83oss, Elisa'eth, ,>5 n.
@&dlien, -!idol",1.> n.
@Ymme!le, #. 1., ,6 n.
@&nstle, @a!l, 17; n., 1;1 n;
@&nstle!, O&stav, 1;/ and n.
@&!t=, L. 1., 1;> n.
@&tne!, 5nn O., ,5 n.
@&tsche!, 5&stin #., 9; n. 8
@&tsche!, 5&stin #., I!., 9; n.
La )a!!e, $., 1// n.
Lac!oix, Iean, 1/6 n.
Ladne!, Oe!ha!t, 177 n.
Laennec, 3enT T. #., 16,
Lain*, 3. 7., 167
Lalonde, Ma!c, 1. n.
Lamton, 7avid, 5986> n.
Lancisi, Oiovanni Ma!ia, 19, n.
Lands'e!*, 1a&l, 17/ n.
Lan*, 0osmo Oo!don, 5!ch'isho
o" 0ante!'&!(, ,>6 n.
La!son, $illiam 3., ,,5 n.
Lasa*na, Lo&is, 6/ n. La&e, #., 16>81 n.
Lave, Leste! )., 19 n.
Leach, Oe!ald, ,5/ n.
Le'!&n, -!an\ois, 1; n.
Le'v!e, L&cien, 1.> n.
Lecle!c, L&cien, 111 n.
Le*ato!, Ma!vin, ,,6 n.
Lie'nit=. Oott"!ied $ilhelm, 15>
Lei'o%it=, Iosh&a >., 1;6 n.
Lei'!and, $e!ne!, 165 n.
Lei"e!, 3onald, 167
Lenoi!, 3enT, ,,7 n.
Le!idon, M., 19 n.
Le!ne!, 7aniel, 161 n.
Le!ne!, Mon!oe, 1. n., 1>> n., ,578; n.
Lessa, $illiam 5., 115 n.
Leste!, 7avid, ;/ n., ,>5 n.
Leto&!m(, 5lain, ,, n., 76 n.
Levine, <ol, ,// n.
Levinson, 0ha!les, 71 n.
LTvi8<t!a&ss, 0la&de, 7; n., 179 n.
Le%in, Leona!d, 99 n.
Le%in, Lo&is, // n.
Le%is, 0ha!les E., ,9 n.
Le%ison, Ed%in -., ,5 n.
Lian*, M. #., 59 n.
Li"ton, 3o'e!t I., 15.
Lin, 1a&l T. @., 5;89 n.
Linde!, <ta""an )., 6, n.
Lindheim, 3osl(n, 79 n., ;. n.
Lindne!, #., 1;> n.
((,;9))
Lindsa(, Malcolm I., ,586 n.
Li!oss, Btto, 11. n.
Liton, <. 7.,11, n.
Lisitsin, N., 5/ n.
Lo*an, $. 1. 7., ,,, n.
Loiacono, O., 66 n.
Lon*one, 1., 5, n.
Lo!'e!, I&dith, /5 n.
Lo&c+s, B!ie, ,5; n.
Lo&is [I?, 19,
Lo%e, 0. 3., ,,; n.
Lo%!e(, Oeo!*e #., ., n.
L&cas, 5lexande! 3., 95 n.
L&cia, <alvato!e 1., 1.> n., 1// n.
L&the!, Ma!tin, 1;1, 1;, n., 1;.
Macco'(, Michel, ,,5 n;
Macdonald, 7&ncan )., 1/5 n.
Mac@inne(, Lo!en 0., 1;; n.
Ma*&i!e, 7aniel, ,>6 n.
Maitland, -!ede!ic $:. 191 n.
Male, Emile, 1;1 n.
Malino%s+i, )!onislav, ,>.
Ma!c&s, Iaco', 111 n;
Ma!c&se, #e!'e!t, 6, n.
Ma!ia The!esa, Em!ess, 77
Ma!ien, Michael, ,/5 n.
Ma!+son, Elisa'eth, ;/ n;
Ma!stall, <im+in, 157 n.
Ma!x, @a!l, /, n.,15. n.
Massman, #. -., 1;> n.
Mata, Leona!do, I., ;7 n.
Mathe!, 0otton, 16, Mathe!, #. O., ,6 n., 1>7 n.
Matthe%s, Mit"o!d M., 151 n.
Man=i, 3o'e!t, 151 n.
Max%ell, 3., /9 n.
Ma(, IacA&es M., 17 n., ,. n.
Ma(e!, I., .1 n.
Ma(e!o"", Milton, 1,> n.
Mc0lee!(, 3o'e!t <.R 67 n., ,.> n.
McOlashan, N. 7., 17 n.
Mc@eo%n, Thomas, 1.81/ n., 17 n., ,,; n.
Mc@innon, N. E., ,5 n.
Mc@ni*ht, Iohn, 9, n., ,>, n.
McLachlan, Oo!don, 1.81/ n., ,,; n., ,.; n.
McLam', I. T., ., n.
McLelland, 7onna, 17 n.
Mc3&e!, Iames, ,7, n.
Meado!, 0li"ton, ,9 n.
Mechanic, 7avid, 11; n., ,,7 n.
Medvedev, 3o( 5., 6> n.
Medvedev, Qho!es, 6> n.
Meine!t, 0. L., ,/ n.
Meiss, Milla!d, 1;; n.
Mellan'(, @eith, ,. n.
Mellande!, B., ;7 n.
Mel=ac+, 3., 1.6 n.
Me!lea&81ont(, M., 165 n.
Me!a+e(, #., 1.; n.
Messin*e!, <heldon, 9> n.
Me(le!, L., ,7 n.
Michaelson, Michael, ,,5 n.
Micha&lt, 1ie!!e, 17; n.
Michle!, M., 1.> n.
Mic+, <tehen <., 57 n.
Milleie!!es, -!an\ois, 159 n.
Milton, Iohn 1., ,. n., ,,. n., ,,/ n.
Mino*&e, @enneth, 151 n.
Mint=, Mo!ton, ,; n., .9 n., 67 n.
Mitchel, )!&ce, ,/ n.
Mit"o!d, Iessica, 9; n.
Mitsche!lich, 5lexande!, ,59 n.
Modell, #ila!(, 6; n.
Moehle, #., 1./ n.
Moll, Btto E., 171 n.
Montai*ne, Michel de, 19>
MontesA&ie&, 0ha!les de <econdat, )a!on de, .> n.
Moo!e, -!ancis 7., .9 n.
Moo!e, $il'e!t, /6 n., ,/6 n.
Mo!*an, Iohn 1., 6/ n.
Mo!in, Ed*a!, 17/ n., ,>/ n.
Mo!ison, 3o'e!t <., ,>5 n.
Mo!!o%, $illiam, ,6> n.
Mosco%, 5lvin, 7. n.
Mose!, 3o'e!t 5., ,6 n.
Moss, 3osalind, 179 n.
M&ehi, Max, 1., n.
M&hlmann, $. E., 1,9 n.
MYlle!, Btto, 1.7 n.
M&m"o!d, Le%is, 61 n., ;; n.
M&!i, $., 16> n.
M&!!a(, #en!(, 119 n.
M(e!o"", )a!'a!a, ,,5 n.
Nade!, 3alh, 67 n;, ,,586
Nava!!o, ?incente, 6> n;, 6; n., ,51 n.
((,9>))
Ne*!ete, ?. -., 17> n.
Nel+in, 7o!oth(, 69 n.
Nelson, #en!(, ,/9 n.
Ne&'&!*e!, Max, ;> n.
Ne%ell, @enneth $., ,,7 n.
Ne%man, Iohn -., ,/> n.
Ne%ton, M., ,,7 n.
Niet=sche, -!ied!ich, 15. n.
Nixon, 3icha!d M., ,./85
Noin, 7aniel, 17 n.
Noonan, Iohn Thomas, ,> n.
No!th, 0h!istohe! 3., 1/; n.
Nova+, Maximillian E., 15; n.
Bates, 3. @., ;; n.
B6)!ien, Ma!(8$in,,.>81 n.
Bcamo, 7o!a. ,>/ n.
B60onno!, Ma!( 0athe!ine, 1;/ n.
Bese!, #., ,/85 n.
Bhm, Thomas, 176 n.
Bldham, 1. 7., 9/ n.
Blson, 3o'e!t O., 17/ n.
Bnians, 3icha!d )., 1.> n.
Bit=, )., ,; n.
Bs'o!n, 1. 7., 6, n.
Bsmond, #&mh!e(, // n., /7 n.,1,1 n.
Bst!ande!, <heila, ,/5 n.
Bve!!ath, #ein=8OYnthe!, .> n.
B=la+, B., 56 n.
1addoc+, 1a&l, ,,/ n;
1addoc+, $illiam, ,,/ n.
1a*e, Ioseh, ,.>81 n.
1ae, #. B., 1,7 n.
1a%o!th, Ma&!ice, 9/ n., 95 n.
1a!acels&s, 1;687
1a!ish, #en!( I., ,. n.
1a!sons. Talcott, // n., 9, n., 11;819, ,5/ n;
1a!t!id*e, I. -., ;> n.
1atch, #o%a!d 3., 1;/ n;
1ate!son, T. T., 1,1 n.
1a==ini, 5dal'e!to, 111 n;
1ea!sall, Ma!ion, 1,9 n.
1ei*not, O., 191 n.
1e++anen, Iohn, 71 n., ,,5 n.
1ela*i&s.177 n.
1e!nede!. 5nd!eas, 15; n.
1ete!, Iean81ie!!e, 159 n.
1ete!ado!", 3o'e!t O., ,; n.
1ete!son, Bsie!, 9/ n.
1et!ie, 5senath, 1.6 n.
1ette!+o"e!, Max von, 17 n.
1e&c+e!t, $ill8Eich, ;. n., 19, n.
1itts, Iesse 3., 1,, n. 1i&s [II,
1oe, ,>6 n. 1lessne!, #elm&th, 1;, n.
1lini&s <ec&nd&s, ,9 n.
1lY*e, #e!'e!t, 1,9 n., 15> n.
1o**e, 3. 0., 11/ n.
1oit!inea&, 5., 1; n
1olac+, Iean80la&de, 1/ n.
1ol*a!, <teven, 1; n., 1,9 n.
1ollac+, -!ede!ic+, 191 n.
1ollac+, #e!'e!t, ,./ n.
1olla!d, <idne(, 1., n.
1o!te!, 3. 3., 16 n. 1o!tmann, 5dol", 1,; n.
1o%les, Iohn, 1/ n., 19 n., 1>7 n.
1o(nte!, -. N. L., 1.1 n., 157 n., ,.1 n.
1!adal, #en!i, 66 n.
1!e&ss, I&li&s, 1/7 n.
1!ice, 7e!e+ I. de <oils6, 1/ n.
1!o*e!, <am&el, 6. n.
1!os+a&e!, 0&!t, 17, n.
1&chta, #. O., ;. n.
2&e!ido, 5., ,, n.
2&inn, Iames )., ./ n.
2&inn, Ioseh, 6> n.
2&inne(, Ea!l 3., /6 n.
2&inne(. 3icha!d, ,/5 n.
3adenac, 17 n.
3adoms+i, I. L., ,,6 n.
3ahne!, @a!l, ,>6 n.
3ain%ate!, Lee, ,,7 n;
3amse(, 1a&l, /. n., ,>5 n.
3an&l", <vend, ,6, n.
3a(ac+, Elton, 61 n.
3eco!d, 3. O., 17 n.
3eede!, Leo O., ,,;89 n., ,// n.
3ehm, $alte!, 1;> n.
3eich. $alte!, 1>. n.
3ei"achneide!, #ilde*a!d, 1;/ n.
3enoit!e, -e!nand, /1 n.
3hea, )&"o!d, 66 n.
3hode, Iohann I., 166 n.
3ichet, 0ha!les, 151 n.
3ichelie&, 0a!dinal, 16/
((,91))
3ie"", 1hili, 96 n.
3iese, $althe!, 11; n.
3ile(, Iohn, I!., ,>, n.
3o'e!t, Iean, 6, n.
3o'inson, 7avid, 119 n;
3o'inson, Iames, 99 n;
3o'itsche!, Ionas )., ,>6 n.
3ochaix, Ma&!ice, 16. n.
3oden%aldt, E., 1; n.
3oeme!, Milton I., /;89 n.
3ollet, 0athe!ine, 1; n.
3ona*h(, #ossain, 5., 56 n.
3ondet, #en!i, 1;6 n.
3on=e, )e!na!d, 19; n.
3osen'e!*, 0ha!les E., 16 n.
3osen'l&m, Oe!ald $., /6 n;, ,/6 n;
3osen"eld, #ellm&t, 1;> n;
3osenan, 7. L., 16687 n.
3osie!, )e!na!d, ,,/ n.
3oth, I&li&s, 11, n.
3othman, 7avid I., 157 n., ,6> n;
3othsch&h, @a!l E., 1.; n., 1/9 n., 165 n.
3ot=le!, $ill(, 17; n;
3o&ssea&, Iean8IacA&es, 15;
3o%le(, #. #., 1/5 n.
3o%le(, #a!old, 1/; n.
3o(, $illiam 3., ,,5 n.
3&'el, 5!th&!, 57 n.
3&ch, 0., 1;6 n;
3&dol", Oe!ha!d, 15; n;
3&e**, $alte!, 17, n.
3&shme!, 3o'e!t -., 51 n., 5, n., 1>5 n.
3&ssell, Ie""!e( )., 7; n.
3&ssell, Lo&ise, /9 n;
<ahlins, Ma!shall, ,> n;, ,,/ n;
<alin, Ed*a!, 1./85 n.
<an*e!, $illiam $., 75 n;
<a!ano, IacA&es, 1.7 n;, 1/6 n.
<a!t%ell, 1. E., ,7 n;
<a&e!, @., 175 n.
<a&e!'!&ch, -e!dinand, 1.; n;
<a&*nie&x, I., 1;1 n.
<avona!ola, Oi!olamo, 1;.
<chade%aldt, #., 16. n;
<chae"e!, #ans, ,,; n.
<che"", Thomas I., ;9 n., 9. n;
<che!e!, $ilhelm, 1./ n;
<chimmel, 5., 17687 n;
<chimmel, Elih&, 1>> n.
<chie!*es, #ein!ich, 1/ n;, 111 n.,156 n.
<chmid, Ma*n&s, 1;6 n;
<chmidt, Iohanna, 1.> n.
<ch!eie!, #e!'e!t, 6; n;
<ch!oede!, L(nn, ,/5 n;
<ch&l=e8Mai=ie!, -!ied!ich, 1./ n;
<ch&mache!, 0ha!les -., ,,7 n;
<ch&t=, 5l"!ed, ,7. n. <ch%a!t=, I., 9, n.
<ch%a!=, #ein!ich, 17; n;
<cott, T. #., 1.6 n.
<cott, 3o'e!t 5., ;. n.
<c!imsha%, N. <., 16 n.
<ed*%ic+, 1ete!, 1,; n., 16; n;
<el'(, 1hili, ,5, n.
<emmel%eis, L, ,>8,1 n;
<ennett, 3icha!d, 9> n.
<es+in, E&*ene 1., 19 n.
<exa&, 3icha!d, 1;9 n.
<hai!o, 5!th&! @., 7/ n;, 1>; n., 11. n.
<ha!ston, M. I., 57 n.
<heldon, 7onald 3., ,./ n.
<hen+in, )., 6> n.
<hental, I. E., ,,. n.
<himano"", O. M., ,6> n;
<hneidman, Ed%in <.. /5 n;
<h!e%s'&!(, I. -. 7., 1; n;
<h!(oc+, 3icha!d, 161 n;, 16, n., 17, n;, 9>@ n;
<idel, 3&th, 5; n;, 59 n;
<idel, ?icto! $., 5; n., 59 n.
<ie*el, O. <., 91 n.
<ie*le!, Mi!iam, // n., /7 n., 1,1 n.
<i*e!ist, #en!(, 117 n., 1,; n., 1.> n., ,,1 n., ,/5 n., ,5. n.
<immons, #en!(, 7/ n;
<lac+, 1a&l, 1; n;
<mith, 5. I., 5; n;, 59 n;
<mith, ). 5'le, /9 n;
<mith, O. Teelin*, ,,, n;
<o"ol&%e, O. B., ,. n.
<ollito, <ha!mon, 1>, n;
<o&lai!ac, 5., /5 n;, 1.7 n;, 1/. n;
<o&A&es, 5., 1/7 n;
<o&!iac, 5*nXs, 1; n;
<ain, 7avid M., ,6 n;
<an+e. #., 177 n;
((,9,))
<ea!, -. O., 1.; n;
<ece, 3o( O., I!., ,6> n;
<ei!s, 5. L., 66 n.
<ie+e!man, 3alh E., ,5 n.
<oc+, )en:amin, ,,/ n;
<tallones, 3e&el 5., ,1 n;
<tamm. <tanle( I., ,9 n.
<tammle!, $ol"*an*, 17; n., 1;> n.
<tam, L. 7., 1; n.
<tein*iesse!, #ilde*a!d, 196 n.
<te!n*lass, E!nest I., ,,5 n.
<te&del, Iohannes, 171 n., 17, n.
<tevens, 3osema!(, ,// n.
<tevens, <. <., 161 n., 16, n.
<tevenson, 3o'e!t, I!., ,,; n.
<te%a!d, I&lian #a(nes, 1., n.
<te%a!d, @ilton, 1.1 n.
<te%a!t, 0ha!les T., I!., ,1 n.
<tolle(, 1a&l, 6/ n.
<to!e!81e!e=, 7anielle, 1.1 n.
<t!ic+land, <tehen 3., 1>6 n.
<&dho"", @a!l, 1;6 n.
<&dno%, 7avid, 1>/ n., ,>7 n.
<&the!land, Ed%in, 678; n.
<&the!land, 3o'e!t, ,5 n.
<%a=e(, I&dith 1., ,9 n.
<=as=, Thomas <., /5 n., 1.. n;, 1.7 n., 1/. n;, 167
Talmon, Nonina, 79 n;
Tam, )ill(. 1/5 n.
Tam, Mi!iam, 1/5 n.
Tamlin, 5!th&! 3., .> n;
Tannen'a&m, -!an+, /6 n.
Ta%ne(, 3. #., 99 n;
Ta(lo!, 0. E., 16 n.
Ta(lo!, Ie!em(, 1;.8/
Tem+in, 0. Lilian, 1.> n.
Tem+in, B%sei, 1; n., 1.> n.
Tenenti, 5l'e!to, 1;> n.
Tenon, IacA&es83enT, 15; n;
Te&te'e!*, #ans I., 1; n.
Thomson, #. $., /5 n;
Thomson, Mo!ton, ,1 n.
Thomson, $. M., 1;9 n=
Thomson, Eli=a'eth, 19. n.
Th&illie!, O&(, 1; n., 19 n;
Titm&ss, 3icha!d M., 11> n., ,.18,, ,.; n.
Toellne!, 3icha!d, 1.; n., 165 n.
Tolsto(, Leo, 1;9 n.
Tomatis, 3en=o, 1>> n.
To%nsend, 1ete!, ;/ n;
To(n'ee, Iocel(n M. 0., 175 n.
T!oels8L&nd, T. -., 11; n;
T&!n'&ll, -!an+, ,,. n.
T&!ne!, Iames S;, ,,6 n.
T&!ne!, ?icto! $., 7; n.
9llmann, Man"!ed, 111 n.
9!'an ?III, 1oe, 1;7
9x+&ll, Th&!e, .> n.
9x+&ll, $ol"*an*, .> n.
?ahlA&iest, )., ;7 n.
?aillant, O. E., 6. n.
?allin, I., 1781; n.
van )!oc+, Nadia, 171 n.
van Oenne, 5!nold, 7; n;, 1;5 n.
?an O&li+, 3o'e!t #., 1.> n.
van Qi:l, $. I., 16 n.
?a(da, E&*ene, ,;89 n.
?eatch, 3o'e!t M., 1>, n.
?e!nic+, Ioel I., ,>, n.
?esali&s, 1;9
?ien, N*&(en @hac, ,. n.
?ilain, 17 n.
?illon, -!an\ois, 17;
?i!cho%, 3., 165 n;
?oe*lin, E!ic, 1>9
?o*t, Evon Q., 115 n.
?o*t, #elm&t, 16> n;; 9:& n;
von. See at!on(m, von
?o(elle, O., 1;/ n.
Novelle, M., 1;/ n;
$ade, Nicholas, ,; n;, 7/ n., 75 n;
$ait=+in, #o%a!d, 6; n. $a+e"ield, 3;, ;/ n.
$ald!on, #. 5., 95 n;
$alton, 5lice, 17/ n.
$a!dell, $illiam M., 75 n.
$a!thin, 5l"!ed <cott, 19/ n;
$asson, 3. O., 1// n.
$alt, $. Mont*ome!(, 1/5 n.
$e'e!, Max, 99 n;
$e'e!, 5l"!ed, 17, n., 199 n.
$eine!man, 3icha!d E., ,,; n.
$eine!man, <hi!le(, ,,; n.
$ein!e', -!ied!ich, 1/78; n;
$eint!a&', Michael, 6/ n.
$est"e!t, I. N., 15
22&>0AA
$eiss, Mo!!is, 95 n.
$eis= c+e!, ?i+to! von, 1,; n., 1.. n., 1./85 n.
$elch, 0la&de, ,.5 n.
$elle!, Thomas #., ,9 n.
$elt"o!d, #a!!ison, ,,6 n.
$e*+e, #ans, 1.; n;
$estle(, $illiam 5., 97 n.
$heele!, $alte! <., ,/; n.
$hite, Eli=ah L., ,/> n.
$hite, @e!! L.. ,.; n.
$hite, 3o'e!t $., /5 n.
$ho!", ). L., 17> n;
$ie*elman, Oante!, 1; n.
$ilens+(, #a!old, ,/6 n.
$illett, 7avid E., ,.5 n.
$illiams, @athleen N., ,..8/ g., ,./85 n.
$in+elstein, $a!!en, I!., 17 n;
$inslo%, 0ha!les E. 5., ,,1 n. $isse, I., ;/ n;, 19, n;
$is%e, #ans, 6. n., 1.> n.
$itt, -!it=, 17, n. $itt*enstein, L&d%i*, 1/1
$ol", <., 11/ n;
$ol"", ). )., 1.6 n;
$ol"", #a!old O., 1.7 n. $ol"", <te%a!t, 1.7 n.
$ol"!am, 3icha!d, 177 n;
$olton, 7ominiA&e, 117 n.
$ool", #a!!(, 161 n.
$!i*ht, La%!ence, 19 n., 157 n
$(att, 3icha!d, ;7 n.
$(lie, 0. M., 91 n;
Nance(, $. L., ,,7 n.
No&n*, Iames #., 67 n.
Qald, M. N., ,7 n;
Qae!t, Oeo!*, 1.9 n;
Q'o!o%s+i, Ma!+, 1/. n.
Qil'oo!*, O!e*o!(, /5 n.
Qoltan, I., ,> n.
Qschoc+, 7iete!, 57 n.
((,9/))
AA)nnonserBB
$o!+s '( Ivan Illich availa'le "!om
Ma!ion )o(a!s 1&'lishe!s
CE-E,AT)'. '( A"AE.ESS
This, his "i!st 'oo+, esta'lished Ivan Illich as a "o!mida'le and assionate c!itic o" the. social
m(ths and che!ished instit&tions o" mode!n ind&st!ial societ(. 0ommitted to a !adical
h&manism he set himsel" the ta!*et o" '!ea+in* do%n the ideolo*ies %hich alienate men "!om
men as %ell as "!om thei! t!aditional so&!ces o" h&man di*nit( and :o(. The a&tho! challen*es
ne%e! o!thodoxies and c&!!ent ideas o" social vi!t&e '( his !o"o&nd A&estionin* o" 'o&!*eois
and li'e!al ass&mtions. #e &!*es &s to a ne% cele'!ation o" a%a!eness so that %e can escae
the existin* deh&mani=in* s(stems '( o&! &n%illin*ness to 'e const!ained and o&! %illin*ness
to accet !esonsi'ilit( "o! the "&t&!e.
DESC%''-).$ S'C)ET<
Ivan Illich !esents a sta!tlin* vie% o" schoolin*: schoolin* (as oosed to ed&cation) has
'ecome o&! mode!n do*ma, a sac!ed co% %hich all m&st %o!shi, se!ve, and s&'mit to, (et
"!om %hich little t!&e no&!ishment is de!ived. <chools have "ailed o&! individ&al needs,
s&o!tin* "allacio&s notions o" J!o*!ess6 and develoment that "ollo% "!om the 'elie" that
eve!8inc!easin* !od&ction, cons&mtion and !o"it a!e !oe! (a!dstic+s "o! meas&!in* the
A&alit( o" h&man li"e. B&! schools have 'ecome !ec!&ite!s o" e!sonnel "o! the cons&me!
societ(, ce!ti"(in* citi=ens "o! se!vice, %hile at the
22&>@AA
same time disosin* o" those ad:&d*ed &n"it "o! the cometitive !ace. The a&tho! o""e!s
!adical s&**estions "o! !e"o!m.
T''-S (' C'.6)6)A-)T<
5 %o!+ o" seminal imo!tance, this 'oo+ !esents the a&tho!6s enet!atin* anal(sis o" the
ind&st!ial mode o" !od&ction %he!e ente!!ises, !an*in* "!om health se!vices to national
de"ense, a!e Jeach !od&cin* a se!vice commodit(, each o!*ani=ed as a &'lic &tilit( and each
de"inin* its o&t&t as a 'asic necessit(6, and event&all( imosin* thei! &ses on the cons&me!.
Illich chooses Jconvivialit(6 to mean the oosite: individ&al "!eedom !eali=ed in e!sonal
inte!8deendence and, as s&ch, an int!insic ethical val&e6. The ove!all o':ective is to s&!vive
%ith :&stice, avoidin* the 'lea+ !osects o" totall( lanned *oals and desi!es and total loss o"
individ&al !ivac(.
E.E$< A.D EW!)T<
In this essa(, '( means o" a detailed s&!ve( o" the %a( eole t!avel, Ivan Illich develos his
a!*&ments a*ainst ind&st!ial societ(. #e a!*&es that seed is a so&!ce and tool o" olitical
mani&lative o%e! in !ich as %ell as oo! co&nt!ies. The ideolo*( o" contin&al *!o%th o"
'oth socialist and caitalist s(stems imoses intole!a'le social ineA&alities. The
ove!cons&mtion o" ene!*( not onl( dest!o(s the h(sical envi!on8ment th!o&*h oll&tion '&t
ca&ses the disinte*!ation o" societ( itsel". Illich advocates a !adical olitical decision to
ne&t!ali=e the ene!*( c!isis '( the limitin* o" t!a""ic, %hich he a!*&es co!!&ts and enslaves,
and !es&lts in a "&!the! decline o" eA&it(, leis&!e and a&tonom( "o! all.
((,96))
-)*)TS T' *ED)C).E
*edical .emesis \ The E/propriation of %ealth;
JThe medical esta'lishment has 'ecome a ma:o! th!eat to health6. This is the oenin*
statement and 'asic contention o" Ivan Illich6s sea!in* social c!itiA&e. 7ecimatin* the m(th o"
the ma*ic o" contemo!a!( medicine and !&thlessl( examinin* the !it&als cond&cted '( the
medical !o"ession and its ad:&ncts, he demonst!ates ho% the "&l"ilment o" *en&ine h&man
needs, s&ch as the maintenance o" *ood health, has 'een t&!ned '( ove!8!o"essionali=ation
into a ni*htma!ish si!it&al and h(sical a*ent o" dest!&ction: t!eatment c!eates illness. In
!esonse Illich calls "o! a halt to the ex!o!iation o" man6s coin* a'ilit( and !esents an
alte!native to the inevita'le Medical Nemesis that %ill set in &nless the a&tonom( o" the
individ&al is !e8esta'lished.
D)SA,-).$ +'(ESS)'.S
Ivan Illich, I!vin* @enneth Qola, Iohn Mc@ni*ht, Ionathan 0alan, #a!le( <hai+en
$h( do %e send so m&ch on health se!vices, and levels o" t!eatment do not im!ove4 $h(
do %e send so m&ch on ed&cation and o&! child!en seem to lea!n less4 $h( is so m&ch sent
on la% en"o!cement and c!iminal :&stice s(stems and o&! societ( seems less sec&!e and less
:&st4 This "ascinatin* and cont!ove!sial collection o" essa(s A&estions the o%e! o" the
!o"essional ove! an aathetic citi=en!(.
T%E )$%T T' !SE(!- !.E*+-'<*E.T
A.D )TS +'(ESS)'.A- E.E*)ES
#e!e Ivan Illich, ossi'l( at his most cont!ove!sial, calls "o! the !i*ht to useful &nemlo(ment:
a ositive, const!&ctive, and even otimistic concet dealin* %ith that activit( '( %hich
eole a!e &se"&l to themselves and othe!s outside the !od&ction o" commodities "o! the
ma!+et. 9n"ette!ed '(
((,97))
mana*in* !o"essionals, &nmeas&!ed and &nmeas&!a'le '( economists, these activities t!&l(
*ene!ate satis"action, c!eativit( and "!eedom.
S%AD'" "'E
This ma:o! histo!ical and sociolo*ical anal(sis o" mode!n man6s economic existence t!aces
and anal(=es otions %hich s&!ass the conventional olitical J!i*ht8le"t6 and the technolo*ical
Jso"t8ha!d6 alte!natives and !esents the concet o" the Jve!nac&la!6 domain: Jthe !ea!ation o"
"ood and the shain* o" lan*&a*e, child'i!th and !ec!eation.6 Illich deals !ovocativel( %ith
the cont!ollin* &ses o" lan*&a*e and science and the val&ation o" %omen and %o!+.
$E.DE
Ivan Illich insists that %e s&!ve( attit&des to male and "emale in 'oth ind&st!ial societ( and its
antecedents in o!de! to !ecove! a lost Ja!t o" livin*6. In !e8ind&st!ial comm&nities the!e %as
Jve!nac&la! *ende!6: the sexes acceted thei! di""e!ences %hich %e!e ex!essed in seech8
idioms and ao!tioned tas+s. The inc!easin*l( o%e!"&l "o!ces o" o!*ani=ed !eli*ion, and the
!ise o" a comme!cial c&lt&!e, c!eated ima*es o" the sexes %hich acA&i!ed sel"8e!et&atin*
o%e!. B&! !esent ind&st!ial societ( has de'ased Jve!nac&la! *en8de!6 into Jeconomic sex6 D
less sec&!e and mo!e sava*el( c!ilin*. Illich a!*&es that onl( a !adical sc!&tin( o" sca!cit(
can !event an intensi"ication o" this *!im !edicament.
%&' A.D T%E "ATES '( ('$ET(!-.ESS
J$ate! th!o&*ho&t histo!( has 'een e!ceived as the st&"" %hich !adiates &!it(: #,B is the
ne% st&"", on %hose &!i"ication h&man s&!vival no% deends. #,B and %ate! have 'ecome
oosites: #,B is a social c!eation o" mode!n
22&>CAA
times, a !eso&!ce that is sca!ce and that calls "o! technical mana*ement. It is an o'se!ved "l&id
that has lost the a'ilit( to mi!!o! the %ate! o" d!eams6. T!acin* the histo!( o" the &se and a'&se
o" #,B as a so&!ce o" commodit( in t%entieth cent&!( li"e %ith its A&est "o! odo!less h(*iene,
Ivan Illich cont!asts these matte!s %ith an examination o" the histo!( o" ideas, m(tholo*ies
and visions associated %ith %ate!.
A,C= T%E A-+%A,ET)]AT)'. '( T%E +'+!-A *).D
(%ith )a!!( <ande!s)
Ivan Illich and )a!!( <ande!s (medieval schola! and lite!a!( c!itic) have !od&ced an o!i*inal
and !ovocative st&d( o" the advent, s!ead and !esent decline o" lite!ac(. The( exlo!e the
imact o" the alha'et on "&ndamental tho&*ht !ocesses and attit&des and c&lminate thei!
!esea!ch in an examination o" the !esent e!osion o" lite!ac( in the ne% technolo*ical
lan*&a*es o" Jne%sea+6 and J&niA&ac+6R and the( oint o&t ho% ne% attit&des to lan*&a*e a!e
alte!in* o&! %o!ldvie%, o&! sense o" sel" and o" comm&nit(.
). T%E *)' '( T%E +AST;
-ectures and Addresses 9>:CX9>>B
7&!in* the 19<>s, Ivan Illich added a ne% dimension to his tho&*ht th!o&*h the st&d( o"
Medieval histo!(. In this collection o" %!itin*s, he aims to demonst!ate the extent to %hich the
*!o&nd%o!+ "o! the instit&tions that cha!acte!i=e o&! %o!ld toda( %as laid in the t%elth
cent&!(. These insi*ht"&l olemics A&estion societ(6s most !eve!ed intellect&al instit&tions D
lan*&a*e, &!it(, in"o!mation technolo*( and the economics o" eace D and a!*&e that, to
live c!eativel(, man m&st !easse!t his a&tonom( and ta+e cont!ol o" his envi!onment. Illich
!eveals that he has lost none o" his o%e! to !ovo+e and challen*e. The toics %hich
contin&e to en*a*e him, s&ch as health, ho&sin*, lite!ac(, schoolin* and ethics, a!e the ones
%hich have !oved him to 'e !ohetic. #e !emains '!illiant at dis8mantlin* the "alse ima*es
o" o&! a*e.
22&>>AA

You might also like