Ivan Illich’s criticism of professional medicine can be summed up with an old adage about the life cycle of institutions. First comes an idea—a vision, a fresh perspective on things. The idea then becomes an ideology, with an official doctrine and worldview. The ideology becomes a movement, which people join to realize that doctrine. The movement coalesces into an institution to carry out the doctrine, which is also attached to a bureaucracy that focuses on consolidating power and expanding its reach. The bureaucracy eventually turns into a racket that abandons the mission set forth in the original idea, although the old rhetoric is sometimes used to give cover to the racket. In my own variation I have added a sixth and final position: the scam. Although a racket may monopolize an industry, it still offers reasonably good products or services; the scam doesn’t offer even those. 

In Medical Nemesis, which was first published in 1975 but resonates to this day, Illich argued that the medical profession in the West hovers somewhere between the bureaucracy and the racket, while occasionally revealing the qualities of a scam. Doctoring, he said, began as a noble idea, but somehow the medical profession lost its way and became a monopoly that serves the interests of doctors over patients. Indeed, the first line of his introduction reads, “The medical establishment has become a major threat to health.” That threat, he argued, comes from two directions. First, doctors often damage people’s health through their treatments, a phenomenon called iatrogenesis. Second, they encourage dependency among patients, tying them to the system by medicalizing their problems. Insofar as it is a bureaucracy, medicine has become incapable of reforming itself from within; insofar as it is a racket, it snares patients while pretending to help them; and insofar as it is an outright scam, it actually hurts patients with bad products. 

Although it’s a bit eccentric, Illich’s book was not ignored upon release. Some major medical journals even reviewed it, and a few were even impressed. But soon fell silence. When I trained in medicine during the 1980s, first as a medical student and then as a resident, I heard Illich’s name mentioned only once, by a physician and professor of health policy who scorned the book. 

I heard Illich’s name mentioned far more as a graduate student in political science during the 1990s. Radical political theorists saw in Illich another weapon with which to bludgeon Western institutions. For them, the medical profession’s crimes and its veneer of justifications were part of an overall pattern of abuse rooted in capitalism, liberalism, religion, and race-neutral meritocracy. Most of the West’s major institutions, they believed, passed back and forth between soulless bureaucracies, rackets, and scams. The medical profession was just one example of the rot.  

Illich’s popularity among political scientists and muted reception in medicine makes sense. He was not a physician, nor did he work in health care. He studied philosophy, theology, and medieval history, and became a Catholic priest and a social activist. He pushed various causes, including birth control, nuclear disarmament, and economic justice, in various places, including Puerto Rico, Mexico, South Africa, and the United States, stirring up trouble here and there. In his own estimation, he was a kind of wandering philosopher—an “errant pilgrim.” He also applied his intellectual paradigm to other institutions, including in his 1971 book Deschooling Society. There, he condemned an education establishment that, he argued, had grown rigid and bureaucratic and encouraged people’s dependency on “experts,” rendering them psychologically impotent. Moreover, the main product of education itself—the certificate earned in an institution demanding conformity and obedience—paled in comparison to what self-motivated students can learn organically through free databases and collaborative work with their peers.

Illich’s tendency to create intellectual paradigms for universal application places him in a long line of political theorists. With no experience in any particular economic sector or trade—and therefore unaware of the local conditions—those theorists can run into trouble when they apply their pet theory anywhere and always (see, for example, the histories of the French Revolution and communism).

Still, Illich deserves credit. For sources, Medical Nemesis drew not just from philosophy, but from articles published in the established medical journals, such as the Journal of the American Medical Association and The New England Journal of Medicine. Also, he worked his position as the outsider-looking-in to his advantage. While he lacked a medical background, he spotted trends in medicine and realized their significance when most doctors, immersed in daily practice and unable to see the forest for the trees, did not.



Let’s start with the book’s bad parts. Simply put, Illich often overstated his case. For example, he said environmental improvements, such as clean water and sanitation, had a far greater effect on bettering people’s health and improving longevity than any medical treatments developed by doctors. He was right, but only to a degree, and he overlooked the important role doctors played in environmental improvements. 

For example, John Snow, a nineteenth-century English physician, used data sets to pinpoint the cause of a London cholera epidemic, tracing the outbreak to a water pump. His work laid the foundation for modern epidemiology. In another example, Ignaz Semmelweis, a nineteenth-century Hungarian physician, discovered that routine handwashing could prevent the spread of infection, particularly among women giving birth. Those discoveries saved millions of lives. True, the medical establishment at the time resisted the new ideas—Semmelweis was ostracized from the medical community—but paradigm shifts typically encounter pushback at first in any science, something observed by Thomas Kuhn in The Structure of Scientific Revolutions. Pushback doesn’t invalidate the role scientists play in those paradigm shifts. And while sanitation reforms are not medical “treatments” per se—they do not take the form of pills, surgery, or radiation—doctors spearheaded many of them. To say otherwise is disingenuous. 

Illich used another sleight of hand to play down the value of medical treatments. He wrote that many of those treatments, such as for childhood infectious diseases, have had little effect on life expectancy: “In contrast to environmental improvements and nonprofessional health measures, the specifically medical treatment of people is never significantly related to a decline in the compound disease burden or a rise in life expectancy.” Again, he was right, but he misrepresented the situation. Illich defined “specifically medical treatment” as those treatments that require full medical training to implement. If laypeople can implement them, Illich doesn’t count them as medical treatments, although doctors were the ones who invented them. In this way, Illich eliminated vaccination, immunization, and the widespread use of antimicrobials, such as antimalaria drugs, from the list of medical treatments. In his book, doctors got no credit for helping children survive diseases such as malaria, typhoid, and pneumonia. 

The sleight of hand continued when Illich said treatment of childhood diseases fails to have a statistically significant impact on the life expectancy of the population as a whole. But since most children in Western societies do not get malaria, typhoid, or pneumonia, one would not expect their treatment to affect the life expectancy of the population as a whole. Instead of asking, “Does treatment of childhood pneumonia raise the life expectancy of the population as a whole?” he should have asked, “Does medical intervention for this condition help the small number of people who develop pneumonia in childhood?” When Illich argued the former, he was right—but only in an inhumane, technical sense that neglects the benefits for those people affected. 

For another example of such twisted reasoning, take testicular cancer, which is rare, making up only 0.5 percent of all new cancer cases. But before the 1970s, when Illich was writing, it was almost a death sentence. Since then, new treatments have made it practically curable. Because so few people get testicular cancer, curing the condition would not be expected to show up in improved health statistics for the total population. Yet those suffering from the condition are elated; for them, medical progress is literally a lifesaver. 

Then there is the problem of measuring life expectancy to begin with. Child mortality was once quite high, but when children did survive (now more than ever, thanks to modern medicine) they often enjoyed the life expectancy for adults of their era. Helping them become adults dramatically improved average life expectancy—high infant and childhood mortality a century ago skewed the averages downward—but did not significantly improve maximum lifespan. People in Western societies do live a few years longer than they did a century ago. Sometimes their quality of life during those few extra years, as the wards of doctors, can be pretty unpleasant, subjected as they are to medicines with bad side effects and painful procedures. Illich was right to raise this point. But by overlooking or dismissing solid medical achievements that can honestly be credited to doctors, Illich unnecessarily weakened his case.

Illich stood on firmer ground when attacking the problem of clinical iatrogenesis. Treatment inflicting new problems on patients remains a serious problem to this day. But the fact that it has taken different forms over time shows that the medical profession can change its spots; it can reform itself and fix a problem, even as another one stands ready to arrive on scene. For example, more than a century ago, many medicines were unsafe and ineffective. The founding of the Food and Drug Administration (FDA) and its mission to ensure the safety and efficacy of medicines dramatically improved matters. The so-called “father of the FDA,” Harvey Wiley, was a physician and a chemist. 

Medical research helped ease another major iatrogenic problem. Many medicines used in the early twentieth century had what is called a “low therapeutic index,” meaning the difference between the therapeutic dose and the toxic dose was small. New medicines emerged over the years with the same therapeutic purpose but with a much higher index. In anesthesiology (my specialty), many of the older anesthetic gases, muscle relaxants, and sedatives were replaced with safer versions. More recently, the major problem in clinical iatrogenesis has been something different: physician error. But reforms such as checklists and “time outs,” again originating from within the medical profession, have helped matters considerably. Medical practice will always include the risk of iatrogenesis. The only way to avoid such risk is to do nothing at all—a dangerous proposition in its own right.



Illich proved more prescient—and relevant—in his accusation that the medical profession was “medicalizing life.” He saw the phenomenon as a variation on iatrogenesis: what he called “social iatrogenesis” and “cultural iatrogenesis.” In social iatrogenesis,

the medical bureaucracy creates ill-health by increasing stress, by multiplying disabling dependence, by generating new painful needs, by lowering the levels of tolerance for discomfort or pain, by reducing the leeway that people are wont to concede to an individual when he suffers, and by abolishing even the right to self-care.

“Cultural iatrogenesis,” he wrote, pertains to a “prolific bureaucratic program based on the denial of each man’s need to deal with pain, sickness, and death…. It represents an endeavor to do for people what their genetic and cultural heritage formerly equipped them to do for themselves.” The passage of time has proved Illich right, with the problem he described growing worse. 

To cite just one example among many, Illich observed that everyday unhappiness had become medicalized, as evidenced by the mass use of minor tranquilizers during the 1950s and benzodiazepines during the 1970s. The trend would later pass through other iterations, including the SSRI antidepressant craze starting in the 1990s and today’s ketamine craze. Analogous trends can be observed in the treatment of anxiety, pain, and impotence. 

Illich went beyond simple conspiracy theories to explain these events. It was more than just doctors or pharmaceutical companies pushing medicines to make money, he said, although that was part of it. More important, he suggested, was an iron triangle of support for the new approach: a public that wanted the quickest and surest route to happiness (“unrealistic expectations on the part of patient majorities”), doctors aspiring to manage everyday unhappiness scientifically—as if unhappiness were an engineering problem—and pharmaceutical companies eager to meet the new demand while putting their fingers on the scale when regulators tested their products. 

Since the publication of Medical Nemesis, the problem has intensified in ways that Illich might have predicted: for example, the pharmaceutical industry’s direct marketing of psychoactive medications to the public starting in the 1990s and the rise of the care industry, with its legions of therapists, counselors, and life coaches who manage people’s everyday unhappiness. The care industry exemplifies what Illich described as “patient dumping.” “Medical lords” (i.e., doctors) divest themselves of low-prestige care (in this case, talk therapy) and award the duty to lesser-credentialed professionals who build “a derivative medical fiefdom.” The racket (or scam) grows.

Still, Illich was not inventing the wheel here. Although he fails to discuss Karl Marx in his text (though he does refer to him several times in the footnotes), his intellectual paradigm is decidedly Marxist—and especially indebted to the early Marx, often known as the “psychological Marx.” Marx said capitalism exists to meet people’s needs, but that the satisfaction of those needs inevitably leads to new needs, which also demand satisfaction. This causes people to grow increasingly dependent on those who service their multiplying needs. The phenomenon he described was dialectical and brings to mind the image of an infinitely winding staircase. 

Here is one application of Marx’s ideas to contemporary American health that follows Illich’s approach. A growing population needs more food. The market produces mass quantities of cheap, highly processed food to satisfy the need. This leads to more cases of obesity, type 2 diabetes, and high cholesterol. The market invents diabetes and high-cholesterol medications to meet these new needs, tying patients closer to medicine. Persistent obesity also leads to low self-esteem and depression among the population. To meet these needs the market invents diet food and regimens, as well as therapists and counselors to attack the problem of low self-esteem directly. But crash diets and diet food often make people hungrier and cause even more weight gain. Meanwhile, therapists and counselors—whose services allow people to shed friends and family as confidants—can be expensive. Inevitably, more new needs arise. The market addresses the need for more urgent weight loss through Ozempic-like medications; for cheaper self-esteem through antidepressants; for cheaper companionship and counseling through telehealth and chatbots. Patients are tied even more closely to market solutions and professional medicine. Yet these solutions, of course, create new problems, such as “Ozempic face” stemming from rapid fat loss, and therefore new needs. The market comes to the rescue with new plastic surgeries for repair, including new dermal fillers to return volume to people’s faces—and the dialectical cycle goes on and on. Illich deserves credit for applying early Marxian ideas to the medical profession. He didn’t invent the intellectual paradigm, but he applied it in an original and insightful way to diagnose new problems.

Still, the old paradigm also burdened him with old, unworkable solutions. Just as Marx was somewhat hazy about how communism might look after the revolution, Illich never adequately addressed the question of how to reform medicine. Indeed, both men’s ideas on these fronts could be rather silly. Soviet Communists pushing industrialization rolled their eyes when reading Marx’s description of communism, in which the worker of the future would hunt in the morning, fish in the afternoon, herd cattle in the evening, and be a theater critic after dinner, without ever having to work at any of these vocations full-time. In the same vein, Illich’s reformed medicine included: not allowing doctors to use modern technology until all the devices and means that laypeople could use on their own are exhausted, abolishing controls over addictive and dangerous drugs and letting patients decide themselves when to use them, and abandoning standards for doctors and letting people elect healers to government-supported jobs. Those reforms are not just silly but implausible and even dangerous. 

Christian notions also peep through Illich’s ideas for reform, although his emphasis on preserving individuality has deep roots in secular philosophy as well. Illich denied being an anarchist, but he did flirt with the kind of primitive, anti-institutional Christianity espoused by novelist Leo Tolstoy, as well as the “spiritualized” Christianity of early nineteenth-century Welsh reformer Robert Owen. Both Tolstoy and Owen believed it was only in small communities that the best in religion could flourish: people could truly love their neighbors, avoid becoming commodities in the production process, and be governed by the dictates of their consciences rather than controlled by government experts. In this spirit, Tolstoy, the borderline anarchist, proclaimed, “Government is organized violence!” When Illich suggested that people be allowed to leave the industrial mode of existence and live differently, and that each person be allowed to define his or her own health rather than let experts in state agencies do it for them, he was embracing a longstanding, albeit somewhat obscure, rebellious current within Christianity.

Later in his life, Illich had a lesser-known second act that in some ways was more interesting than his first. Rather than apply his intellectual paradigm to specific Western institutions, he worked at a higher level of generality while touching more on theology. 

Illich had always fit uneasily within the Church structure. He had begun his career as a missionary priest in Puerto Rico in the 1950s, but was forced out of his post due to a charge of insubordination. During the 1960s, having established a learning center for missionaries in Mexico, he ran afoul of the Church again for his flirtations with Marxism and liberation theology, especially for his criticism of the Church’s role in assisting what leftists called “American cultural imperialism.” The Gospel preached human freedom, not dependency on Western benefactors trying to reform poor countries along neoliberal lines, he argued, presaging his later critiques of the medical and education establishments. He resigned from active priesthood while continuing to identify as a priest. In 1976, he accused his own learning center of “institutionalization” and shut it down. He spent the 1980s and ’90s wandering, traveling, and teaching at various universities.

During that later period, he adopted a more pessimistic tone that comes out especially in his speeches and in interviews with the Canadian writer and broadcaster David Cayley. In his 1982 book Gender, rather than focus on a specific institution with an eye toward reform, he suggested the problems in society ran deeper, and that reform, while still necessary, might be elusive. He defended the everyday attitudes of average people, what he called “the vernacular,” against the dictates of experts—again, echoing Tolstoy’s defense of the cultural prejudices of uneducated Russian peasants against the commands of church and state elites. Included among those everyday attitudes was a simple dualistic ontology that made life comprehensible: life and death, sacred and profane, and, most important, male and female. He suggested returning to a version of what he called “vernacular gender,” with a clear demarcation line between the two genders. Society, especially the political left, was moving in the opposite direction on gender issues, and away from a world rooted in simple complementary differences. Illich, once hip and radical, now seemed more like a conservative, even a curmudgeon. 

It’s easy to dismiss elderly curmudgeons’ complaints, but they often have interesting things to say. Their historical experience makes their warnings worth pondering. At the turn of the twentieth century, Tolstoy, by then an old man, warned about the emerging union of modern science and modern government. He feared that when decisions are made by committee, through impersonal directives, or by “orders from above,” with responsibility for a decision’s results never falling on any one person individually, it would unleash a wave of brutality so great that the coming century would be the most murderous era in human history. He proved to be correct.

A self-professed admirer of George Orwell, Illich also believed society was moving in a dangerous direction, with life becoming an object of medical, professional, and administrative management, thereby paving the way for mass callous brutality. He began his analysis by citing the New Testament, where Jesus says, “I am life.” Jesus doesn’t say, “I am a life,” Illich observed. For the next two millennia, according to Illich, life was spoken of in this active sense, with “aliveness,” a quality intimately connected to the living creature. But in the mid-twentieth century, Illich said, the idea of “a life” began to replace the old idea of “life” in Western thinking as an expression of aliveness. “A life” became something disembodied, abstract, a value, a resource, and an idol. Life was being laundered through science, then returned to civilian discourse, where people began to speak of life as something disconnected from a person. We manage “quality of life”; we “administer life” in departments of human resources; we “produce life” in the lab; we “study life” as a series of self-organized systems; we “take charge” of life.

The new way of thinking had also crept into the Church, he argued. Churches today embrace “the cause of life.” God is supposedly “a friend of life.” The thinking even infiltrated the abortion debate. In the past, “life” meant a relationship with Jesus; today, Illich explained, we say an embryo is “a life.” Illich found it odd that Cardinal Ratzinger (later Pope Benedict XVI) took science’s definition of a life, in which a human embryo is technically “a life,” and transposed it into our ordinary situation for use in the argument against abortion. Doing so led to a distortion in Church thinking, Illich argued. Everyday people cannot recognize the embryo as “a life” in the vernacular sense of the word; it lacks “aliveness.” Still, Cardinal Ratzinger argued that we must deal with an embryo as we would deal with our weakest neighbor; the moment of conception now brings forth “a life,” a helpless life. For many religious Christians, said Illich, the statement lacked a commonsense correlate, given that the embryo seems nothing like an alive human being. 

For Illich, the shift in our understanding of life crystallized while he was staring at a poster on a wall with two circles on it: one a fertilized egg, the other the earth viewed from space; one brown circle, one blue circle. He realized that life had become an emblem, a symbol—an idol—and therefore also an object for manipulation. We are now responsible for life—rather than to life; being responsible for it means that we can recover it, we can save it, and we can make it. The two circles represent doorways, he said; they prod us to believe that we are in total control of the cosmos, which is construed as contingent on human beings. Life, not God, has become the ultimate purpose of history, and we are the protectors of life, our new idol and fetish. And for that we need new clergies—a managing clergy, a governing clergy, a dictatorial clergy—and new subjects. The average person was becoming more administrable than ever, declared Illich. All very Orwellian, all very dangerous. 

During his later life, too, Illich had a tendency to go over the top, especially when identifying particular words (what he calls “plastic words”) that have changed in definition, with life as just one example. The result is a curious mixture of eccentric modern-day scholasticism and apocalyptic eschatology. In one essay titled “H2O and the Waters of Forgetfulness” (1985), he explored how modern society, through modern science, has stripped water of its mythic and cultural meaning and transformed it from a life-giving symbol to a technical substance, analogous to what science did with life. He wrote, “H2O is a social creation of modern times, a resource that is scarce and that calls for technical management. It is an observed fluid that has lost the ability to mirror the water of dreams.” He continued, “The city child has no opportunity to come in touch with living water. Water can no more be observed; it can only be imagined, by reflecting on an occasional drop or a humble puddle.” These hyperbolic statements flowed out of, believe it or not, a debate over whether to build a lake in central Dallas! And it gets worse. Seven years later, Illich opined on that water debate, “By now, in 1992, I wonder if God might not have to redeem us by fire because we have done away with water.”  

Ivan Illich was a brilliant man whose thoughts floated about in the abstract. He did not tell stories, he preached. He was not a friend but a judge. Unlike a true realist, who can make life flow on paper, he lived on a higher, somewhat more sterile plane, which may account for both his insights and his oversights. Tellingly, in the course of reading Illich’s work, I never found Illich the man. On that level, he still remains a total mystery to me. Perhaps it’s what he wanted.