Editorials

Death undefeated

BMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7021.1652 (Published 23 December 1995) Cite this as: BMJ 1995;311:1652
  1. Ivan Illich
  1. D28 203 Bremen, Germany

    From medicine to medicalisation to systematisation

    Back in 1974, when I wrote Medical Nemesis, I could speak about the “medicalisation” of death.1 The western art of dying—an outcome of Europe's Christianisation—had ceded to guaranteed terminal care. I coined the term in reference to a medical establishment that had assumed the functions of a dominant church and whose symbolic effects included the shaping of people's beliefs and perceptions, needs and claims. What professionals saw as the ultimate therapeutic failure, laymen feared as limited financial coverage. It was then plausible to use the term “iatrogenesis” not just for symptomatic side effects suffered by individuals in their encounter with physicians, drugs, or hospitals, but also for the superstitious reshaping of society and culture through the internalisation of medicine's myths.

    Two decades later, I would have to write a very different book. Before, I used medicine to illustrate a general feature of major institutions at midcentury—their counterproductive action in making the goals for which they were designed impossible to attain for the majority of their clients. For example, schools impeded learning; transportation contrived to make feet redundant; communications warped conversation. I analysed the medical enterprise as a post-Christian liturgy that instilled a keen fear of pain, disability, and death in its devotees. Today, various institutions, especially those purporting to provide social services, have lost their identity; systems for education and medicine are interlocked with military, economic, and other systems.

    At midcentury, many people's most intense involvement with medical care began …

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