On Health and Health Care (Illich's Manifesto with my commentary)

Hygienic Autonomy: A Manifesto {from the essay Brave New Biocracy}

By Ivan Illich

Many persons are confused today about something called "health." Experts prate knowingly about "health care systems." Some persons believe that without access to sophisticated and expensive treatments, people will be sick. Everyone worries about increasing costs. One even hears talk of a "health care crisis." I would like to say something about these matters.

First, I believe it necessary to assert the truth of the human condition: I suffer pain; I am afflicted with certain impairments; I will certainly die. Some undergo greater pain, some more debilitating disorders, but we all equally face death.

Looking around me, I see that we -- as people in other times and places -- have a great capacity to care for one another, especially in the moments of birthing, accidents and dying. Unless unbalanced by historical novelties, our households, in close cooperation with their surrounding communities, have been wonderfully hospitable, that is, generally adequate to care for the real needs of living, celebrating and dying.

In opposition to this experience, some of us today have come to believe that we desperately need packages, commodities, all under the label of "health," all designed and delivered by a system of professionalized services. Some try to convince us that an infant is born, not only helpless -- needing the loving care of household -- but also sick, requiring specialized treatment by self-certified experts. Others believe that adults routinely require various drugs and interventions in order to become old, while the dying need medical treatment.

Many have forgotten -- or are no longer able to enjoy -- those common-sense ways of living that contribute to one's well-being and ability to recover from illness. Many have allowed themselves to become dependent on a self-aggrandizing technological myth, against which they nevertheless complain, because of the impersonal ways in which it impoverishes many while enriching a few.

Sadly, I recognize that many of us are infected with a strange illusion: a person has a "right" to something called health care. Thus, one states a claim to receive the latest assortment of technological therapies, based on some professional's diagnosis, to enable one to survive longer in a situation which often ugly, injurious, or depressing or just boring.

I believe it is time to state clearly that specific situations and circumstances are "sickening," rather than that people themselves are sick. The symptoms which modern medicine attempts to treat often have little to do with the condition of our bodies; they are, rather, signals pointing to the disorders and presumptions of modern ways of working, playing and living.

Nevertheless. many of us are mesmerized by the glitter of high-tech "solutions, " we pathetically believe in"fix-it" drugs, we mistakenly think all pain is an evil to be suppressed, we seek to postpone death at almost any cost.

I appeal to the actual experience of people, to the sensibleness of the ordinary person, in direct opposition to professional diagnosis and judgment. I appeal to people's memories, in opposition to the illusions of progress. Let us look at the conditions of our households and communities, not at the quality of "health care" delivery; health is not a deliverable commodity and care does not come out of a system.

I demand certain liberties for those who would celebrate living rather than preserve "life":

* the liberty to declare myself sick;

* the liberty to refuse any and all medical treatment at any time;

* the liberty to take any drug or treatment of my own choosing;

* the liberty to be treated by the person of my choice, that is, by anyone in the community who feels called to the practice of healing, whether that person be an acupuncturist, a homeopathic physician, a neurosurgeon, an astrologer, a witch doctor or someone else;

* the liberty to die without diagnosis.

I do not believe that countries need a national "health" policy, something given to their citizens.
Rather, the latter need the courageous virtue to face certain truths:


* we will never eliminate pain;

* we will not cure all disorders;

* we will certainly die.

Therefore, as sensible creatures, we must face the fact that the pursuit of health may be a sickening disorder. There are no scientific, technological solutions. There is the daily task of accepting the fragility and contingency of the human situation. There are reasonable limits which must be placed on conventional "health" care. We urgently need to define anew what duties belong to us as persons, what pertains to our communities, what we relinquish to the state.

Yes, we suffer pain, we become ill, we die. But we also hope, laugh, celebrate; we know the joy of caring for one another; often we are healed and we recover by many means. We do not have to pursue the path of the flattening out of human experience.

I invite all to shift their gaze, their thoughts, from worrying about health care to cultivating the art of living. And, today, with equal importance, to the art of suffering, the art of dying.

IVAN ILLICH The philosopher and theologically trained historian Ivan Illich published his seminal and highly controversial study op health care, medical nemesis: The Expropriation of Health, in 1976.

In his first major essay on this subject in the nearly 20 years since Medical Nemesis Illich argues here that the modern social construction of "a life" into an abstract, disembodied and dis-integrated entity -- a "fetish" -- prepares the way for depersonalized manipulation and management of our existence from womb to tomb.

Going beyond his argument in 1976 that the medical establishment itself had become a threat to health through doctor-induced suffering, Illich here renounces as an indecent demand the very idea of "responsibility" for one's health in a sickening environment. Instead, he takes a radical leap and calls for the only "decent" alternative: hygienic autonomy from any system of health care.

COMMENTARY:

I posted the above snippet from Illich's essay here because it seemed at the time to be a good summary of my own views on the matter of Health as it relates to Health Care. After rereading though, I am not really satisfied.  What I miss most in Illich's manifesto is the assertion of a positive, progressive conception of health, sickness, and of "health care.  I think that such a positive though tentative formulation, is possible and that, just because it would gesture at responsibilities as well as rights, is necessary, if the needs of what I call the "Inner Adult" are to be respected.

I certainly agree that "health is not a commodity and care does not come out of a system" but to leave it at that frustrates the part of me that really cares about how to move toward real health in a way that includes the collective dimension. Illich hints at the possibility of some form of this in that p (see footnote) seems to be implicitly, almost explicitly, asking for a general (collective) dialog on the proper limits of professionalized health care, and perhaps on the meaning of health itself. Here I want to both bring out and emphasize that implied request and also try to help that dialog  happen by contributing my part to it. In doing so I'll make explicit the view of health behind my own critique of the status quo and I'll also be showing another path than the one I think Illich took (Illich was an ordained Catholic Priest, while I am coming from the assumptions of what I call Healthy Culture) to reach the same (or at least a similar) clearing in what seems otherwise the dense thicket of confusion  of our current conceptions of health and health care.

What follows is adapted from an essay in my other blog at integralscience.motime.com.

Medicine and Individual-Personal Health

--I-P Odori

The difference between Individual-Personal Health and the view of health implied in such conceptions as "Health Care", "Fitness", "Wellness", and various other products of mainstream and so-called Alternative medicine, is as extreme as the difference between healthy culture and sick culture generally. In a culture of apart-ness and dissociation, the vary concept of health and of wholeness--and so of "medicine", must necessarily be distorted and fragmented out of all recognition if it is to have anything but the most tenuous viability within that dominant culture. After all, any conception of health that was at all integrated would have political and economic dimensions that would inherently challenge the status quo of any society in which the alienated Individual, rather than the Individual-Person is understood as the unit.

By saying this I don't mean to single out capitalist or libertarian views as especially distorting of the concept of health or even as especially pathological manifestations of sick culture. A healthy, Individual-Personal, view of Health would be equally unwelcome in a more "socialist" or a more "traditional" society that downplayed Individualism in favor of one or another (or even all four) of the four roles that constitute the nexus of relationship and responsibility that I call "Personhood". In other words the concept of "familial health", or "local health" or "civic health" or even "religious or psychological health" would be just as dissociated oxymoronic, pernicious and pathological as that of "Individual health" if such terms are pursued in reductive isolation and understood from the dissociated point of view of sick culture.

Since, however, the dominant manifestation of sick culture in this society is more in the capitalist vain of Individual-focused dissociation (of the dissociation of the individual from the whole social nexus of that individuals' Personhood), most of the following essay will primarily address the misrepresentations of Health and Health Care  that derive from this particular form of unhealthy view of health.

Firstly, from the point of view of Healthy Culture, the phrase "individual health" is an oxymoron, since it already falsely assumes our primary identity as relatively isolated, dissociated "individuals" without the inherent relationships and responsibilities of Personhood as any inherent part of the reality of who we are. Starting from such a false view, any kind of "health care", whether it came from a system or not, could not do anything but treat some obscenely diminished version of who we are; usually not even our whole selves as individuals, but only our bodies as viewed through the filter of mechanized and reductionist assumptions. The best that could be hoped for regarding any such "treatment" would be a mere prolonging of the fear and existential pain of inner and outer alienation and unconsciousness.

From any sane perspective, such a diminished view, such a diminished experience of who we are is itself a profound sickness and indeed the primary one to be "treated" for anyone with any understanding of what real health is. Since this unacknowledged sickness is usually shared equally by both the "cared for" and the "care-giver" (such labels are themselves part of the problem), what happens instead in most kinds of "health care", is that inner and outer alienation is not only not treated, but is actually reinforced in everyone involved through the alienated farce of mutual connivance and denial that constitutes the "care".

For one thing, such pseudo-care of our pseudo-selves, can only increase our fear and our  alienation and repress any latent sense of community and mutuality with the whole great world of living, suffering, celebrating, killing, eating, and dying beings; with the Tree of Life which brought us in to being, which fed us with the lives and deaths of countless other Indivdual-Persons, and the roots of which we ourselves are destined to feed in our turn with our own deaths.

 Of course the kind of care for ourselves and each other that  stems from such a realization of who we really are, the kind that would manifest as an expression of realization, contrition, affirmation, and growth during a time of physical suffering or mortal illness, would not be something that only began on the onset of such difficulties. I can't imagine that an entire life-time of the culture of apartness, denial, anesthesia, repression, and competition is likely to be completely counteracted even by the sanest kind of care in such times of acute crisis, though I think times of crisis are times of acute opportunity as well. Our capacity to care for ourselves and each other as individual-persons, to acknowledge and learn the lesson of equality and compassion from the experience of suffering and death, to acknowledge and take up the challenge to really Live that is the gift of forknowledge death,all of this is the proper part of eveyday life and everyday culture, everyday community.

For ultimately caring for the health of ourselves and each other as Individual-Persons, has to do, not with "surviving" in inner and outer apartness,  but with Living every day in a way the affirms and moves us toward the realization of ultimate inner and outer togetherness. In a sense, real living is such inner and outer care, real health is such care, and if our every day culture is not about such care, but is instead one of fear-based, technology-and-"substance"-assisted, (inner and outer) denial and apartness, then future death and suffering should really be the least of our worries. 


And of course we can care for our own and each others Health in this everyday sense, that is, as a matter of every day culture, but not in some unilateral and specialized way as "medical professionals", "care givers" or "patients" or "the sick". All of these roles diminish, isolate, and keep us in denial of our essential equality as beings who are going to die, as being that suffer inwardly and outwardly from sick culture in various forms, and as beings that also have within themselves the capacity to love and learn, laugh and heal. It is only when the denial and separation that these roles imply begins to dissolve that the healing balm of true inner and outer Friendship and Belonging in the light of healthy culture can begin to effect not only our physical, but our mental, social, political/economic and ecological health in a way that opens the door to real change for the better.

In short, only healthy culture and living friendship between individual-persons constitute real Health and real Health Care. Under the present circumstances such healing can only take the form of Lapses or breaks in the assumptions, identity-politics, rituals, and infrastructure of the dominant culture of apartness. In such moments our fear-and-image-based identities and assumptions in terms of profession, class, race, species or anything else, drop away and we can perceive ourselves and each other clearly and compassionately in our paradoxical mutuality as wounded and yet also whole Individual-Persons. At such times, the appropriate gesture--the appropriate care--can then flow out of that changed perception in all directions-though probably not without some cognitive dissonance in  superficially unaffected onlookers.

At any rate, without some way of understanding, talking about, and deliberately cultivating such moments of authenticity and wholeness--of true health--, they will be both few and brief; easily explained away or even perverted into the service of the sick culture that they would otherwise threaten to transform. The purpose of these blog entries, of Integral Science, of my life really, is to progressively further the creation of such moments both in myself and others, and to create and develop the situations, actions, concepts, understandings, and infrastructure, needed to both enable and sustain such moments.

As a practical answer then, to those who consider themselves in need of health Care in any way, (as well as to those who consider themselves needing to be healers in any way), I can only offer my own hospitality and equalitarian friendship in the co-creation of the kind of Healthy Culture in which, among many other things, the roles of "health care-giver and receiver, of healthy and sick, are not only unseperated but inseparable. For outside of such a culture of ego-and-faction-transcending wholeness and living compassion, I can honestly see no possibility true healing, either of ourselves, of each other, or of the world...


Welcome and Thanks,

--I-P