Disabling Professions

Ivan Illich

• Editore: Marion Boyars
• Anno: 1977
• ISBN:
  9780714520803
• Argomento: Sciences sociales
• Categoria: Sociologie

In this fascinating and controversial collection of essays Ivan Illich, Irving K Zola, John McKnight, Jonathan Caplan and Harley Shaiken challenge the power and mystery of professions. Why do we put so much resource into medicine, education and the law with so little apparent result? Why do we hold the professions in awe and allow them to set up what are in effect monopolies? By analyzing these questions and putting forward radical answers, the authors make an invaluable contribution to the public debate on the power of professions.

IRVING KENNETH ZOLA

Healthism and Disabling Medicalization

My theme is that medicine is becoming a major institution of social control incorporating the more traditional institutions of religion and law. It is becoming the new repository of truth, the place where absolute and often final judgements are made by supposedly morally neutral and objective experts. And these judgements are no longer made in the name of virtue or legitimacy but in the name of health. Moreover this is not occurring through any increase in the political power of physicians. It is instead an insidious and often undramatic phenomenon, accomplished by ‘medicalizing’ much of daily living, by making medicine and the labels “healthy” and “ill” relevant to an ever increasing part of human existence.

A SPECULATIVE HISTORY

Concern with medical influence is not new. Over a hundred years ago Goethe feared that the modern world might turn into one giant medical institution. Philip Rieff updated this concern when he noted that ‘the hospital is succeeding the church and the parliament as the archetypal institution of Western culture.’1 This shift, one that is far from complete has spanned centuries. To understand this phenomenon we must be aware of two rather important characteristics of professions. Their control of their work and their tendency to generalize their expertise beyond technical matters. Everett Hughes stated these characteristics rather concisely:

Not merely do the practitioners, by by virtue of gaining admission to the charmed circle of colleagues, individually exercise the license to do things others do not, but collectively they presume to tell society what is good and right for the individual and for society at large in some aspect of life. Indeed, they set the very terms in which people may think about this aspect of life.2

How a professional gains the exclusive right and licence to manage its work has been documented very well by others.1 For now I wish to dwell on the second aspect—what Bittner has stated as a profession’s desire to extend its limits beyond its technically and traditionally ascribed and assumed competence to wider more diffuse spheres.2 It is here that we enter our brief examination of religion, law and medicine.

The Christian ministry as the prototype of all professions is as good a place as any to start. Ever since Christianity achieved its European dominance in the early Middle Ages, its ministry wrestled with the conflicts between its limited and diffuse functions. The former involved the specific administration of the means of grace to individuals, while the latter involved the functions of prophecy—the direct application of the message of the gospel to the structure of the community. It is in the conveyance and elaboration of “this message” that the Christian ministry wove itself deeply into communal life. Thus, well into the Reformation one could claim that all communities were in a real sense religious ones, all leaders religiously committed, and the meaning and values of all relationships derived from a religious framework.

But during the seventeenth and eighteenth centuries the influence of religious teachings on community life faded. In England, some date this to the 1640’s, the Age of Cromwell, when the common law was becoming the law of the land. Though it is perhaps impossible to pinpoint a single cause, the culmination may be seen in what Hobsbaum called the dual revolution1 — the Industrial Revolution itself, not a single event but one spanning literally centuries as well as the French Revolution and its concomitants. As the Industrial Revolution drastically altered the relationship within and between communities, families and people, a new basis to explain as well as define (and perhaps to control) these relationships was sought. The old order faded and a new codifier was needed. The seeding had been going on for a long time. Tracts were being written about the nature of man based on a less transcendental framework. They embodied the concept of the social contract. Their terms were legalistic and their espousers, Hobbes, Rousseau, Mills, Locke, were of varying persuasion. The American and French Constitutions perhaps enthroned the tools and transformation of this thinking. They spoke of human affairs without religious reference but rather in secular terms such as justice, right, duty, franchise, liberty, contract. And as once it had been in religious teaching, so now the search for the meaning and understanding of human life was sought in the law. In America it was a sentiment well expressed in the coloquialism ‘there ought to be a law’. And this law was a more earthly task-master. Where once we sought truth in delineating the wisdom of God, now we sought answers in deciphering the nature of man. And when we found such truth we reified it, at least in rhetoric, saying ‘that no man was above the law’.

Religion of course did not fade away but concentrated more on matters of the inner life leaving the secular sphere to law. And flourish it did with little challenge for over a century. But two world wars including “a war to end all wars” led to the questioning of such untoward confidence. And two legal events ironically chimed its death knell—a set of trials in Nuremburg and Jerusalem where men as their defence against charges of genocide evoked without success their obedience to law and authority. In addition, in the United States at least, despite the laws, the poor still seemed poorer, the minorities still exploited, the consumer cheated, until the idea of law itself began to be questioned. The symbol of justice as blindfold was being replaced by one with its eyes slightly open and with its hand slightly extended. In America, a relatively new concept emerged, one almost “unthinkable” a couple of decades previously, the concept of a “bad law”. An old tactic caught fire again—civil disobedience and with it debates arose as to the circumstances under which it was just to violate the law. Again the interpretative system of values was beginning to crumble.

There is another way of stating this historical situation. Bittner has said it most eloquently: ‘The utlimate ground of Christian influence, its charisma was The Truth. (This does not mean) that what was preached was true or not true but merely that it was with reference to its truth-value that the claims of Christian influence were asserted. In an equally fundamental sense, the idea of authority was the basis of the influence of jurisprudence … Obviously it cannot be said that Christianity did not claim authority; nor can it be maintained that the law neglected questions of truth. However, what in the former was the authority of truth became in the latter the truth of authority. The crisis of the ministry and of jurisprudence consists precisely in the fact that the former could not sustain its truth claims and that the latter was failing in its authority claims’.1

But again there was another group of codifiers waiting in the wings—new purveyors of both truth and authority. Medical Science was there to fill the vacuum.

WHY MEDICAL SCIENCE

First, there is a why of the where—why this phenomenon is reflected in the United States more clearly than elsewhere.

Perhaps it is necessary to state almost a truism, that modern medicine has never succeeded nor been accepted in any country just because it is better in some way than the existing method nor even if it can be shown to significantly reduce mortality or disability.2 Thus, we can more easily understand the acceptance of medical science in the United States by noting its fit with at least three central values, which have been dominant almost since the creation of that nation.1 The first of these can be labelled activism—a continual emphasis on mastering the environment, the struggle of man over nature rather than the effort to adjust or submit to it. In the United States there was no river that could not be dammed, no space that could not be bridged and ultimately no disease that could not be conquered. The idea of conquest is an appropriate one as the United States waged successive “wars” against polio, measles and now against heart disease, stroke, cancer. A second might be called worldliness which consists of a general preference for practical secular pursuits over more aesthetic, mystical, or theoretical ones. This phenomenon was no doubt aided by the absence of any state or institutionalized religion. As a result, medical science had no formidable institutionalized opponent as in other countries. Finally, there is the American valuation on instrumentalism—an emphasis on doing—on doing something, almost anything, when confronted with a problem. “Doing nothing in a difficult situation” was interestingly enough an item diagnostic of neuroticism on a popular American psychological test. Sometimes the emphasis on movement became so great that speed itself was emphasized—sometimes for no logical reason. Where else but in America could a selling point of a TV-set be that it goes on 30 seconds faster than its nearest competitor.

The second ‘why’ is the “why of when”—when medical science took hold. Again there is no single event.

With the bacteriological revolution and the Flexner report in the United States, medicine wedded itself not only to science but became the great incorporator of knowledge. Thus, long before it claimed to be the truth, it began to garner to its bosom any form of knowledge (admittedly some more grudgingly than others) that might be relevant to its ends. From biology to physics to economics to psychology to engineering to philosophy to ethics, all found a place in the medical curriculum. And once in, no piece of knowledge seemed ever to be dropped, and so the scope of medical training continued to expand and lengthen. While this apparently may be the source of much consternation to curriculum committees, it di...