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medically managed setting is an option they would rather reject.
Outside of the heroic efforts by the hospice and palliative care
movement to enable a ‘good death’, one which is pain free and digniﬁed
(Ellershaw et al., 2003), the use of medical technology aimed at
preserving life, however futile, continues, as evidenced by a recent
quality of death index. This ranked 40 countries (Economist Intelligence
Unit, 2010) according to their End of Life Care (EoLC) provision and
highlighted that in most developed countries the focus is still on
preventing death rather than helping people achieve this without
suffering, pain, discomfort or stress. It should be noted that the UK was
ranked ﬁrst because of its network of hospices and statutory
involvement in EoLC, whilst the USA was ranked ninth because of the
ﬁnancial burden it imposes at the end of life. China, Mexico and Brazil
ranked at the bottom because, as this report noted, their commitment to
stronghospital programmes and the power of medicinemeans that they
see little value in hospices. This is a shame and perhaps only identiﬁes
the need for today's medical establishment to acquaint themselves with
Illich's medical nemesis to understand that minimal medical interven-
tion is more likely to result in a ‘good death’ than the current and futile
overload of technological wizardry at the end of life stage. ‘Less not
more’ in terms of medical interventions is prescribed by Illich
throughout his polemic as necessary for a full and healthy life. As he
‘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 than enhances the
conscious acceptance of limits to population,of ageing, of incomplete
recovery and ever-imminent death. Healthy people need minimal
bureaucratic interference to mate, give birth, share the human
condition, and die’ (Illich, 1973, 275).
I hope that this paper has highlighted some of Illich's big ideas, and
will entice a new generation of nurses to explore what I believe to be a
masterpiece and help them consider and reﬂect upon the limits of
medicine and its effects upon the human condition. Illich's polemic is
not an easy read, some of his arguments are convoluted, and there are
strands of philosophy, as well as factual information, which may
discombobulate the reader. Illich was a troublesome priest in the best
Thomas à Beckett tradition and this comes across in some of his
provocative statements. Having heard him speak and defend his
position at a conference during the 1990s I can attest that he was as
provocative in person as he is on paper. It is also worth noting that,
when published, Medical Nemesis earned criticisms from the political
left and right for its lack of discussion about the role of capitalism in
relation to medicine. This may seem odd given that the driving force
behind medical hegemony is capitalism (Scott-Samuel, 2003) but this
omission does not detract from its overall power and ability to make
one question the status quo. Medical Nemesis has stood the test of time
and continues to give us a real insight into the limits of medicine; it is
incisive and insightful and bound together with a real understanding
and concern for the human condition.
Barnet, R.J., 2003. Ivan Illich and the nemesis of medicine. Medicine, Health Care and
Philosophy 6, 273–286.
Chadwick, E., 1842. Report of the Poor Law Commissioners to the Secretary of State, on
an Inquiry into the Sanitary Condition of the Labouring Population of Great Britain,
19, p. 1.
Clark, D., 2002. Between hope and acceptance: the medicalisation of dying. British
Medical Journal 905–907.
Economist Intelligence Unit, 2010. The Quality of Death: Rating End of Life Care across
the World. Economic Intelligence Unit. http://www.eiu.com/site_info.a.
Ellershaw, J., Ward, C., Neuberger, J., 2003. Care of the dying patients: the last hour or
days of life. British Medical Journal 326, 30–34.
Illich, I., 1970. Deschooling Society. Harper and Row, New York.
Illich, I., 1973. Tools for Conviviality. Harper and Row, New York.
McKeown, T., Record, R.G., 1962. Reason for the decline in mortality in England and
Wales during the nineteenth century. Population Studies 15, 94–122.
OECD Health Data, 2011. How Does the United States Compare? http://www.oecd.org/
Scott-Samuel, A., 2003. Less medicine, more health: a memoir of Ivan Illich. Journal of
Epidemiology and Community Health 57 (12), 955.
Todd, A., La Cecla, F., 2002. Ivan Illich Obituary The Guardian 9th December 2002.
Vincent, C., Neale, G., Woloshyndwych, M., 2000. Adverse events in British Hospitals:
preliminary retrospective record reviews. British Medical Journal 322, 517–519.
Wall, R., 2005. A Turbulent Priest in the Global Village: Ivan Illich 1926–2002. http://
Weiner, J.P., Kfur, T., Chan, K., Fowles, J.B., 2007. ‘E-Iatrogenesis’: the most critical
unintended consequence of CPOE and other HIT. Journal of the American Medical
Association 14, 387–388.
College of Human and Health Science, Swansea University, United Kingdom
Tel.: +44 1792 602253.
E-mail address: R.E.Davies@swansea.ac.uk.
6 Big Ideas