Medical Nemesis

8

The Recovery of Health

 

   Much suffering has been man-made. The history of man is one long catalogue of enslavement and exploitation, usually told in the epics of conquerors or sung in the elegies of their victims. War is at the heart of this tale, war and the pillage, famine, and pestilence that came in its wake. But it was not until modern times that the unwanted physical, social, and psychological side-effects of so-called peaceful enterprises began to compete with war in destructive power.

   Man is the only animal whose evolution has been conditioned by adaptation on more than one front. If he did not succumb to predators and forces of nature, he had to cope with use and abuse by others of his own kind. In his struggle with the elements and with his neighbor, his character and culture were formed, his instincts withered, and his territory was turned into a home.

   Animals adapt through evolution in response to changes in their natural environment. Only in man does challenge become conscious and the response to difficult and threatening situations take the form of rational action and of conscious habit. Man can design his relations to nature and neighbor, and he is able to survive even when his enterprise has partly failed. He is the animal that can endure trials with patience and learn by understanding them. He is the sole being who can and must resign himself to limits when he becomes aware of them. A conscious response to painful sensations, to impairment, and to eventual death is part of man's coping ability. The capacity for revolt and for perseverance, for stubborn resistance and for resignation, are integral parts of human life and health.

   But nature and neighbor are only two of the three frontiers on which man must cope. A third front where doom can threaten has always been recognized. To remain viable, man must also survive the dreams which so far myth has both shaped and controlled. Now society must develop programs to cope with the irrational desires of its most gifted members. To date, myth has fulfilled the function of setting limits to the materialization of greedy, envious, murderous dreams. Myth assured the common man of his safety on this third frontier if he kept within its bounds. Myth guaranteed disaster to those few who tried to outwit the gods. The common man perished from infirmity or from violence; only the rebel against the human condition fell prey to Nemesis, the envy of the gods.


Industrialized Nemesis

   Prometheus was hero, not Everyman. Driven by radical greed (pleonexia), he trespassed beyond the limits of man (aitia and mesotes) and in unbounded presumption (hubris) stole fire from heaven.1 He thus inevitably brought Nemesis on himself. He was put into irons and chained to a Caucasian rock. An eagle preyed all day on his liver, and heartlessly healing gods kept him alive by regrafting his liver each night. Nemesis inflicted on him a kind of pain meant for demigods, not for men. His hopeless and unending suffering turned the hero into an immortal reminder of inescapable cosmic retaliation.

   The social nature of nemesis has now changed. With the industrialization of desire and the engineering of corresponding ritual responses, hubris has spread. Unbounded material progress has become Everyman's goal. Industrial hubris has destroyed the mythical framework of limits to irrational fantasies, has made technical answers to mad dreams seem rational, and has turned the pursuit of destructive values into a conspiracy between purveyor and client. Nemesis for the masses is now the inescapable backlash of industrial progress. Modern nemesis is the material monster born from the overarching industrial dream. It has spread as far and as wide as universal schooling, mass transportation, industrial wage labor, and the medicalization of health.

   Inherited myths have ceased to provide limits for action. If the species is to survive the loss of its traditional myths, it must learn to cope rationally and politically with its envious, greedy, and lazy dreams. Myth alone can do the job no more. Politically established limits to industrial growth will have to take the place of mythological boundaries. Political exploration and recognition of the necessary material conditions for survival, equity, and effectiveness will have to set limits to the industrial mode of production.

   Nemesis has become structural and endemic. Increasingly, man-made misery is the by-product of enterprises that were supposed to protect ordinary people in their struggle with the inclemency of the environment and against the wanton injustice inflicted on them by the elite.

   The main source of pain, of disability, and of death is now engineered, albeit nonintentional, harassment. Our prevailing ailments, helplessness, and injustice are largely the side-effects of strategies for more and better education, better housing, a better diet, and better health.

   A society that values planned teaching above autonomous learning cannot but teach man to keep his engineered place. A society that relies for locomotion on managed transport must do the same. Beyond a certain level, energy used for transportation immobilizes and enslaves the majority of nameless passengers and provides advantages only for the elite. No new fuel, technology, or public controls can keep the rising mobilization and acceleration of society from producing rising harriedness, programmed paralysis, and inequality. The same is true for agriculture. Beyond a certain level of capital investment in the growing and processing of food, malnutrition will become pervasive. The results of the Green Revolution will then rack the livers of consumers more thoroughly than Zeus's eagle. No biological engineering can prevent undernourishment and food poisoning beyond this point. What is happening in the sub-Saharan Sahel is only a dress rehearsal for encroaching world famine. This is but the application of a general law: When more than a certain proportion of value is produced by the industrial mode, subsistence activities are paralyzed, equity declines, and total satisfaction diminishes. It will not be the sporadic famine that formerly came with drought and war, or the occasional food shortage that could be remedied by good will and emergency shipments. The coming hunger is a by-product of the inevitable concentration of industrialized agriculture in rich countries and in the fertile regions of poor countries. Paradoxically, the attempt to counter famine by further increases in industrially efficient agriculture only widens the scope of the catastrophe by depressing the use of marginal lands. Famine will increase until the trend towards capital-intensive food production by the poor for the rich has been replaced by a new kind of labor-intensive, regional, rural autonomy. Beyond a certain level of industrial hubris, nemesis must set in, because progress, like the broom of the sorcerer's apprentice, can no longer be turned off.

   Defenders of industrial progress are either blind or corrupt if they pretend that they can calculate the price of progress. The torts resulting from nemesis cannot be compensated, calculated, or liquidated. The down-payment for industrial development might seem reasonable, but the compound-interest installments on expanding production now accrue in suffering beyond any measure or price. When members of a society are regularly asked to pay an even higher price for industrially defined necessities—in spite of evidence that they are purchasing more suffering with each unit—Homo economicus, driven by the pursuit of marginal benefits, turns into Homo religiosus, sacrificing himself to industrial ideology. At this point, social behavior begins to resemble that of the drug addict. Expectations become irrational and nightmarish. The self-inflicted portion of suffering outweighs the damage done by nature and all the torts inflicted by neighbors. Hubris motivates self-destructive mass behavior. Classical nemesis was the punishment for the rash abuse of privilege. Industrial nemesis is the retribution for dutiful participation in the technical pursuit of dreams unchecked by traditional mythology or rational self-restraint.

   War and hunger, pestilence and natural catastrophes, torture and madness remain man's companions, but they are now shaped into a new Gestalt by the nemesis that overtakes them. The greater the economic progress of any community, the greater the part played by industrial nemesis in pain, impairment, discrimination, and death.

   The more intense the reliance on techniques making for dependence, the higher the rate of waste, degradation, and pathogenesis which must be countered by yet other techniques and the larger the work force active in the removal of garbage, in the management of waste, and in the treatment of people made literally redundant by progress.

   Reactions to impending disaster still take the form of better educational curricula, more health-maintenance services, or more efficient and less polluting energy transformers, and solutions are still sought in better engineering of industrial systems. The syndrome corresponding to nemesis is recognized, but its etiology is still sought in bad engineering compounded by self-serving management, whether under the control of Wall Street or of The Party. Nemesis is not yet recognized as the materialization of a social answer to a profoundly mistaken ideology, nor is it yet understood as a rampant delusion fostered by the nontechnical, ritual structure of our major industrial institutions. Just as Galileo's contemporaries refused to look through the telescope at Jupiter's moons because they feared that their geocentric world-view would be shaken, so our contemporaries refuse to face nemesis because they feel incapable of putting the autonomous rather than the industrial mode of production at the center of their sociopolitical constructs.


From Inherited Myth to Respectful Procedure

   Primitive people have always recognized the power of a symbolic dimension; they have seen themselves as threatened by the tremendous, the awesome, the uncanny. This dimension set boundaries not only to the power of the king and the magician, but also to that of the artisan and the technician. Malinowski claims that only industrial society has allowed the use of available tools to their utmost efficiency; in all other societies, recognizing sacred limits to the use of sword and of plow was a necessary foundation for ethics. Now, after several generations of licentious technology, the finiteness of nature intrudes again upon our consciousness. The limits of the universe are subject to operational probings. Yet at this moment of crisis it would be foolish to found the limits of human actions on some substantive ecological ideology which would modernize the mythic sacredness of nature. The engineering of an eco-religion would be a caricature of traditional hubris. Only a widespread agreement on the procedures through which the autonomy of postindustrial man can be equitably guaranteed will lead to the recognition of the necessary limits to human action.

   Common to all ethics is the assumption that the human act is performed within the human condition. Since the various ethical systems assumed, tacitly or explicitly, that this human condition was more or less given, once and for all, the range of human action was narrowly circumscribed.

   In our industrialized epoch, however, not only the object but also the very nature of human action is new.2 Instead of facing gods we confront the blind forces of nature, and instead of facing the dynamic limits of a universe we have now come to know, we act as if these limits did not translate into critical thresholds for human action. Traditionally the categorical imperative could circumscribe and validate action as being truly human. Directly enjoining limits to one's actions, it demanded respect for the equal freedom of others. The loss of a normative "human condition" introduces a newness not only into the human act but also into the human attitude towards the framework in which a person acts. If this action is to remain human after the framework has been deprived of its sacred character, it needs a recognized ethical foundation within a new imperative. This imperative can be summed up only as follows: "Act so that the effect of your action is compatible with the permanence of genuine human life." Very concretely applied, this could mean: "Do not raise radiation levels unless you know that this action will not be visited upon your grandchild." Such an imperative obviously cannot be formulated as long as "genuine human life" is considered an infinitely elastic concept.

   Is it possible, without restoring the category of the sacred, to attain the ethics that alone would enable mankind to accept the rigorous discipline of this new imperative? If not, rationalizations could be created for any atrocity: "Why should background radiation not be raised? Our grandchildren will get used to it!" In some instances, fear might help preserve minimal sanity, but only when consequences were fairly imminent. Breeder reactors might not be made operational for fear that they would serve the Mafia for next year's extortions or cause cancer before the operator died. But only the awe of the sacred, with its unqualified veto, has so far proved independent of the computations of mundane self-interest and the solace of uncertainty about remote consequences. This could be reinvoked as an imperative that genuine human life deserves respect both now and in the future. This recourse to the sacred, however, has been blocked in our present crisis. Recourse to faith provides an escape for those who believe, but it cannot be the foundation for an ethical imperative, because faith is either there or not there; if it is absent, the faithful cannot blame the infidel. Recent history has shown that the taboos of traditional cultures are irrelevant in combatting an overextension of industrial production. The taboos were tied to the values of a particular society and its mode of production, and it is precisely those that were irrevocably lost in the process of industrialization.

   It is not necessary, probably not feasible, and certainly not desirable to base the limitation of industrial societies on a shared system of substantive beliefs aiming at the common good and enforced by the power of the police. It is possible to find the needed basis for ethical human action without depending on the shared recognition of any ecological dogmatism now in vogue. This alternative to a new ecological religion or ideology is based on an agreement about basic values and on procedural rules.

   It can be demonstrated that beyond a certain point in the expansion of industrial production in any major field of value, marginal utilities cease to be equitably distributed and over-all effectiveness begins, simultaneously, to decline. If the industrial mode of production expands beyond a certain stage and continues to impinge on the autonomous mode, increased personal suffering and social dissolution set in. In the interim—between the point of optimal synergy between industrial and autonomous production and the point of maximum tolerable industrial hegemony—political and juridical procedures become necessary to reverse industrial expansion. If these procedures are conducted in a spirit of enlightened self-interest and a desire for survival, and with equitable distribution of social outputs and equitable access to social control, the outcome ought to be a recognition of the carrying capacity of the environment and of the optimal industrial complement to autonomous action needed for the effective pursuit of personal goals. Political procedures oriented to the value of survival in distributive and participatory equity are the only possible rational answer to increasing total management in the name of ecology.

   The recovery of personal autonomy will thus be the result of political action reinforcing an ethical awakening. People will want to limit transportation because they want to move efficiently, freely, and with equity; they will limit schooling because they want to share equally the opportunity, time, and motivation to learn in rather than about the world; people will limit medical therapies because they want to conserve their opportunity and power to heal. They will recognize that only the disciplined limitation of power can provide equitably shared satisfaction.

   The recovery of autonomous action will depend, not on new specific goals people share, but on their use of legal and political procedures that permit individuals and groups to resolve conflicts arising from their pursuit of different goals. Better mobility will depend, not on some new kind of transportation system, but on conditions that make personal mobility under personal control more valuable. Better learning opportunities will depend, not on more information about the world better distributed, but on the limitation of capital-intensive production for the sake of interesting working conditions. Better health care will depend, not on some new therapeutic standard, but on the level of willingness and competence to engage in self-care. The recovery of this power depends on the recognition of our present delusions.


The Right to Health

   Increasing and irreparable damage accompanies present industrial expansion in all sectors. In medicine this damage appears as iatrogenesis. Iatrogenesis is clinical when pain, sickness, and death result from medical care; it is social when health policies reinforce an industrial organization that generates ill-health; it is cultural and symbolic when medically sponsored behavior and delusions restrict the vital autonomy of people by undermining their competence in growing up, caring for each other, and aging, or when medical intervention cripples personal responses to pain, disability, impairment, anguish, and death.

   Most of the remedies now proposed by the social engineers and economists to reduce iatrogenesis include a further increase of medical controls. These so-called remedies generate second-order iatrogenic ills on each of the three critical levels: they render clinical, social, and cultural iatrogenesis self-reinforcing.

   The most profound iatrogenic effects of the medical technostructure are a result of those nontechnical functions which support the increasing institutionalization of values. The technical and the nontechnical consequences of institutional medicine coalesce and generate a new kind of suffering: anesthetized, impotent, and solitary survival in a world turned into a hospital ward. Medical nemesis is the experience of people who are largely deprived of any autonomous ability to cope with nature, neighbors, and dreams, and who are technically maintained within environmental, social, and symbolic systems. Medical nemesis cannot be measured, but its experience can be shared. The intensity with which it is experienced will depend on the independence, vitality, and relatedness of each individual.

   The perception of nemesis leads to a choice. Either the natural boundaries of human endeavor are estimated, recognized, and translated into politically determined limits, or compulsory survival in a planned and engineered hell is accepted as the alternative to extinction. Until recently the choice between the politics of voluntary poverty and the hell of the systems engineer did not fit into the language of scientists or politicians. Our increasing confrontation with medical nemesis now lends new significance to the alternative: either society must choose the same stringent limits on the kind of goods produced within which all its members may find a guarantee for equal freedom, or society must accept unprecedented hierarchical controls3 to provide for each member what welfare bureaucracies diagnose as his or her needs.

   In several nations the public is now ready for a review of its health-care system. Although there is a serious danger that the forthcoming debate will reinforce the present frustrating medicalization of life, the debate could still become fruitful if attention were focused on medical nemesis, if the recovery of personal responsibility for health care were made the central issue, and if limitations on professional monopolies were made the major goal of legislation. Instead of limiting the resources of doctors and of the institutions that employ them, such legislation would tax medical technology and professional activity until those means that can be handled by laymen were truly available to anyone wanting access to them. Instead of multiplying the specialists who can grant any one of a variety of sick-roles to people made ill by their work and their life, the new legislation would guarantee the right of people to drop out and to organize for a less destructive way of life in which they have more control of their environment. Instead of restricting access to addictive, dangerous, or useless drugs and procedures, such legislation would shift the full burden of their responsible use onto the sick person and his next of kin. Instead of submitting the physical and mental integrity of citizens to more and more wardens, such legislation would recognize each man's right to define his own health—subject only to limitations imposed by respect for his neighbor's rights. Instead of strengthening the licensing power of specialized peers and government agencies, new legislation would give the public a voice in the election of healers to tax-supported health jobs. Instead of submitting their performance to professional review organizations, new legislation would have them evaluated by the community they serve.


Health as a Virtue

   Health designates a process of adaptation. It is not the result of instinct, but of an autonomous yet culturally shaped reaction to socially created reality. It designates the ability to adapt to changing environments, to growing up and to aging, to healing when damaged, to suffering, and to the peaceful expectation of death. Health embraces the future as well, and therefore includes anguish and the inner resources to live with it.

   Health designates a process by which each person is responsible, but only in part responsible to others. To be responsible may mean two things. A man is responsible for what he has done, and responsible to another person or group. Only when he feels subjectively responsible or answerable to another person will the consequences of his failure be not criticism, censure, or punishment but regret, remorse, and true repentance.4 The consequent states of grief and distress are marks of recovery and healing, and are phenomenologically something entirely different from guilt feelings. Health is a task, and as such is not comparable to the physiological balance of beasts. Success in this personal task is in large part the result of the self-awareness, self-discipline, and inner resources by which each person regulates his own daily rhythm and actions, his diet, and his sexual activity. Knowledge encompassing desirable activities, competent performance, the commitment to enhance health in others—these are all learned from the example of peers or elders. These personal activities are shaped and conditioned by the culture in which the individual grows up: patterns of work and leisure, of celebration and sleep, of production and preparation of food and drink, of family relations and politics. Long-tested health patterns that fit a geographic area and a certain technical situation depend to a large extent on long-lasting political autonomy. They depend on the spread of responsibility for healthy habits and for the sociobiological environment. That is, they depend on the dynamic stability of a culture.

   The level of public health corresponds to the degree to which the means and responsibility for coping with illness are distributed among the total population. This ability to cope can be enhanced but never replaced by medical intervention or by the hygienic characteristics of the environment. That society which can reduce professional intervention to the minimum will provide the best conditions for health. The greater the potential for autonomous adaptation to self, to others, and to the environment, the less management of adaptation will be needed or tolerated.

   A world of optimal and widespread health is obviously a world of minimal and only occasional medical intervention. Healthy people are those who live in healthy homes on a healthy diet in an environment equally fit for birth, growth, work, healing, and dying; they are sustained by a culture that enhances the conscious acceptance of limits to population, of aging, of incomplete recovery and ever-imminent death. Healthy people need minimal bureaucratic interference to mate, give birth, share the human condition, and die.

   Man's consciously lived fragility, individuality, and relatedness make the experience of pain, of sickness, and of death an integral part of his life. The ability to cope with this trio autonomously is fundamental to his health. As he becomes dependent on the management of his intimacy, he renounces his autonomy and his health must decline. The true miracle of modern medicine is diabolical. It consists in making not only individuals but whole populations survive on inhumanly low levels of personal health. Medical nemesis is the negative feedback of a social organization that set out to improve and equalize the opportunity for each man to cope in autonomy and ended by destroying it.
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   1 On the political use of divine envy, see Svend Ranulf, The Jealousy of the Gods and Criminal Law in Athens, trans. Annie J. Fausboll, 2 vols. (Copenhagen: Levin & Munksgaard, 1933-34). On hubris calling forth nemesis, see David Grene, Greek Political Theory: The Image of Man in Thucydides and Plato (Chicago: Univ. of Chicago Press, Phoenix Books, 1965; orig. Man in His Pride); and E. R. Dodds, The Greeks and the Irrational (Berkeley: Univ. of California Press, 1951), especially chap. 2.

   2I have taken this argument, in part, verbatim from Hans Jonas, "Technology and Responsibility: Reflections on the New Task of Ethics," Social Research 40 (1972): 31-54.

   3 The Honorable James McRuer, Ontario Royal Commission Inquiry into Civil Rights (Toronto: Queen's Printer, 1968, 1969, 1971). On self-governing professions and occupations, see chap. 79. The granting of self-government is a delegation of legislative and judicial functions that can be justified only as a safeguard to public interests.

   4 Alfred Schutz, "Some Equivocations in the Notion of Responsibility," in Collected Papers, vol. 2, Studies in Social Theory (The Hague: Nijhoff, 1964), pp. 274-6.