What it does
Diagnoses and treats illness, mostly through hospitals and clinics run by licensed professionals and paid for by insurers or the state.
Where it stops
It doesn’t, and that is the problem. Illich argued that past about 1955 medicine put more effort into prolonging unhealthy life and managing people as patients than into keeping them well, and that the institution had become a source of harm itself.
How easily you can stop using it
Hard. Treatment, drugs, and sick notes are gated by licensed professionals, and few people can diagnose or treat themselves safely. Leaving the system entirely means doing without help that can be effective.
What is scored
- The unit: Hospital and clinic medicine as an institution: licensed professionals, paid for by insurers or the state, since the mid-1950s. Left out: public health, and what people do to look after themselves.
- The job it is tested against: Diagnosing and treating illness. It does this for many conditions, and is scored as doing its job; “often” is as far as this record’s evidence goes.
- Where and when: Rich countries, on Illich’s argument of 1975. None of the scores has been checked against current evidence. Five of the six balances are assessed.
Illich’s clearest case of a tool past its second watershed. It is here as a bad example, and also because it is not a case for abandoning medicine: the same tool was past its first watershed and doing real good.
What Illich saw
In Medical Nemesis (1975) he argued that the medical establishment had become a major threat to health. In Tools for Conviviality (chapter I, “Two Watersheds,” pp. 9–14) he dates the second watershed to the “mid-fifties,” after which, he writes, preserving the sick life of medically dependent people in an unhealthy environment became “the principal business of the medical profession.” Holbrook’s summary frames the same turn as resources going more to extending unhealthy life than to keeping people healthy.
The six balances
Scored as set out in How to evaluate tools. Hospital medicine often does its job, so the scoring starts from the six balances. These scores follow Illich’s argument. They are not yet checked against current evidence.
- Biological degradation: 0. Not yet assessed.
- Radical monopoly: 2. Treatment, drugs, and sick notes are gated by licensed professionals.
- Overprogramming: 2. Illich’s argument in Medical Nemesis: medical care displaces people’s own ability to deal with pain, illness, and dying.
- Polarization: 1. Costly treatment for a few takes resources from basic care for many. Not yet checked against current evidence.
- Obsolescence: 1. New drugs, machines, and procedures arrive constantly, and practice has to follow them.
- Frustration: 2. Illich’s central claim: past the second watershed, medicine itself becomes a cause of illness.
Where the threshold falls
Past the second watershed, at 90. Three balances score 2, and any balance at 2 puts a tool past the limit: 70, plus 2.5 for each of the eight points in its total.
This record puts hospital medicine well past the second watershed, but the placement is an interpretation of Illich’s 1970s argument, not a reading of current evidence. Medicine has changed since, and some of the changes (patient advocacy, evidence-based practice, self-managed care) cut against his claim.
Open questions
- What do the best-supported arguments for and against Illich’s claim look like fifty years on? The record needs a response from health-services research, not just Illich.
- Which parts of medicine are past the second watershed, and which are still convivial? Public vaccination and a family doctor you can reach are different tools from a specialist ward.
- Illich says it is “not strictly necessary” to accept 1913 and 1955 as the exact years. How much does the second-watershed placement depend on the date?
Sources
- Holbrook, J. Britt. “Two Watersheds for Open Access?” 2013. https://jbrittholbrook.com/2013/09/06/two-watersheds-for-open-access/.
- Illich, Ivan. Medical Nemesis: The Expropriation of Health. London: Calder & Boyars, 1975. Free copy is the Pantheon edition (1976). https://ratical.org/ratville/AoS/MedicalNemesis.pdf.
- Illich, Ivan. Tools for Conviviality. New York: Harper & Row, 1973. https://archive.org/details/illich-conviviality.