Lecture in Hannover: "Health As One's Own Responsibility," given on Friday, the 14th of September, 1990.

Ivan Illich

Health as one's own Responsibility: No Thank You!

I am convinced that health and responsibility belong to a lost past and that, since I am neither a romantic, a visionary, nor a drop-out, must renounce both of them. But only if I succeed in unequivocally articulating this renunciation of health and responsiblity can I escape the reproach that I appear here as a rhetorical critic.

This presentation forms part of a larger joint project for the "recovery of askesis in higher education." My preparation included a close collaboration with Dirk von Boetticher. We discussed every sentence with a group of young friends. When, in what follows, I say "we," then I mean only this group.

We are preoccupied with a reflection on contemporary certainties and their history, that is, on assumptions which seem so commonplace that they escape critical testing. Over and over we find that the renunciation of these very certainties offers the only possibility to take up a critical position regarding that which Jaques Ellul calls la technique. And we want to free ourselves from it, not just run away. For that reason, my reaction to "taking responsibility for one's own health" is an emphatic "no."

But there is a risk here. Our "No, thank you!" in response to a suggestion for a new hygienic anatomy can be interpreted and used in five different ways to do exactly the opposite of what we intend:

1. First of all, the "no" can be understood as a necessity for tutelage. Health, so it is claimed, is too valuable, too sacred, to leave to the discretion of lay people. I will have nothing to do with this arrogant disempowerment. For thirty years I have publicly defended the total decriminalization of self-abuse. And I continue to insist on the complete elimination of all legal statutes which regulate the consumption of drugs, and unconventional and/or irregular healing. Following Paul Goodman, I build my argument on the respect we owe the dignity of the weakest.

2. Secondly, my fundamental "no" has nothing to do with the presumed scarcity of healing agents. Today, people are dying of hunger, not from a lack of medicine or surgical interventions. And the poorer people are, the more helplessly they become victims of ever cheaper medicine. For two decades I have defended the position that the consumption of medicine, as of liquor, tobacco and lotteries, ought to be subject to taxation as luxuries. Through taxation of dialysis, bypasses, and CAT scans, simple medical procedures such as appendectomy could be financed for everyone.

3. I do not speak my "no" as a global thinker seeking an unobstructed channel for ecological dictatorship. I can imagine no complex of controls capable of saving us from the flood of poisons, radiations, goods and services which sicken humans and animals more than ever before. There is no way out of this world. I live in a manufactured reality ever further removed from creation. I know today what that signifies, what horror threatens each of us. A few decades ago, I did not yet know it. At that time, it seemed possible that I could share the responsibility for the re-making of this manufactured world. Today, I finally know what powerlessness is. "Responsibility" is now an illusion. In such a world, "being healthy" is reduced to a combination of the enjoyment of techniques, protection of the environment, and adaptation to the consequences of techniques, all three of which are, inevitably, privileges. In the Mexican valley I know, the blue corn, under whose planting calendar the village still names its cyclical feasts, was wiped out fifteen years ago. And there is no money for the destructive techniques needed to grow hybrids. There is no protection against the poisonous clouds blowing over from the agribusiness plantation. But new places of employment are opened for the pedagogy of health, with sops thrown to the barefoot green enthusiasts in the process. Therefore, my "No!" is certainly not a "yes" for the pedagogy of health which entails the management of poisonous systems.

4. And I particularly don't say my "No!" to a new ethics of responsibility for health because I believe that modern sickness and dying are occasions for finding oneself. The suggestion that we ought to accept the unavoidable epidemics of the post-industrial age as a higher kind of health is an impudence currently fashionable among pedagogues. But such instruction in suffering and dying is shameful. Care through bereavement counselling, education for dying, and the making of health plans aim directly at the destruction of the traditional art of suffering and dying, practices developed over hundreds of years.

What sickens us today is something altogether new. What determines the epoch since the Kristallnacht is the growing matter-of-fact acceptance of a bottomless evil which Hitler and Stalin did not reach, but which today is the theme for elevated discussions on the atom, the gene, poison, health and growth. These are evils and crimes which render us speechless. Unlike death, pestilence and devils, these evils are without meaning. They belong to a non-human order. They force us into impotence, helplessness, powerlessness, ahimsa. We can suffer such evil, we can be broken by it, but we cannot make sense of it. Only he who finds joy in his friends can bear up under it. Our "No!" is thus a universe apart from every "yes" to the secondary accompaniments of progress.

5. And, finally, it would be either stupid or malevolent to label the "no" of which I speak as cynical indifference. Quite the contrary! At the forefront of our thoughts stand the many--the innumerable--people for whom four decades of development destroyed the cultural, technical and architectural space in which the inherited arts of suffering and dying were formerly nurtured. Today, the vast majority is poor, and becomes poorer. When we say "No!" to implanting health, at home or abroad, we first of all speak of something for me unthinkable: four billions in new wretchedness. Only if we ourselves start with "No, thank you!" can we attempt to be there with them.

The ground of our ethical "no" therefore does not place us in the service of these five: professional paternalism, the ideology of scarcity, systems thinking, liberation psychology or the new "commonsense" which asserts that in the fourth world no grass has grown over the consequences of development. But it grows, that grass: it is called self-limitation. And self-limitation stands in opposition to the fashionable self-help, self-management or even responsibility for oneself, all three of which produce an interiorization of global systems into the self, in the manner of a categorical imperative. Renunciation of health seems to us to be a starting point for conduct ethically, aesthetically and eudemonically fitting today. And I refuse to define self-limitation as responsibility for myself. With Orwell, I would rather speak of decency.

The concept of health in European modernity represents a break with the Galenic-Hippocratic tradition familiar to the historian. For Greek philosophers, "healthy" was a concept for harmonious mingling, balanced order, a rational interplay of the basic elements. He was healthy who integrated himself into the harmony of the totality of his world according to the time and place he had come into the world. For Plato, health was a somatic virtue, and spiritual health, too, a virtue. In "healthy human understanding" the German language--despite critiques by Kant, Hamann, Hegel and Nietzsche--preserved something of this cosmotropic qualification. But since the 17th century, the attempt to master nature displaced the ideal of the health of a people, who by this time were no longer a microcosm. This inversion gives the a-cosmic health created in this way the appearance of being engineerable. Under this hypothesis of engineerability, "health as possession" has gained acceptance since the last quarter of the 18th century. In the course of the 19th century, it became commonsense to speak of "my body" and "my health." In the American Declaration of Independence, the right to happiness is affirmed. The right to health materialized in a parallel way. In the same way as this happiness, modern-day health is the fruit of possessive individualism. There could have been no more brutal and, at the same time, more convincing way to legitimize a society based on self-serving greed. In a similarly parallel way, the concept of responsibility of the individual gained acceptance in formally democratic societies. Responsibility then took on the semblance of ethical power over ever more distant regions of society and ever more specialized forms of "happiness-bringing" service deliveries.

In the 19th and early 20th century, then, health and responsibility were still believable ideals. Today they are elements of a lost past to which there is no return. Health and responsibility are normative concepts which no longer give any direction. When I try to structure my life according to such irrecoverable ideals, they become harmful--I make myself sick. In order to live decently today, I must decisively renounce health and responsibility. Renounce, I say, not ignore--I do not use the word to denote indifference. I must accept powerlessness, mourn that which is gone, renounce the irrecoverable. I must bear the powerlessness which, as Marianne Gronemeyer tends to emphasize, can perhaps rob me of my awareness, my senses.

I firmly believe in the possibility of renunciation. Renunciation signifies and demands more than sorrow over the irrecoverable. It can free one from powerlessness, and has nothing to do with resignation, impotence, or even repression. Renunciation is not a familiar concept today. We no longer have a word for courageous, disciplined, self-critical renunciation accomplished in community--but that is what I am talking about. I will call it askesis. I would have preferred another word, for askesis today brings to mind Flaubert and Saint Antony in the desert--turning away from wine, women and fragrance. But the renunciation of which I speak has very little to do with this.

The epoch in which we live is abstract and disembodied. The certainties on which it rests are largely sense-less. And their worldwide acceptance gives them a semblance of independence from history and culture. What I want to call epistemological askesis opens the path toward renouncing those axiomatic certainties on which the contemporary world view rests. I speak of convivial and critically practiced discipline. The so-called values of health and responsibility belong to these certainties. Examined in depth, one sees them as deeply sickening, disorienting phenomena. That is why I regard a call to take responsiblity for my health as senseless, misleading, indecent, and in a very particular way, blasphemous.

--It is senseless today, to speak of health.

Health and responsibility have been made largely impossible from a technical point of view. This was not yet clear to me when I wrote Medical Nemesis, and perhaps it was not yet the case at that time. In hindsight, it was a mistake to understand health as the quality of "survival," and as the "intensity of coping behavior." Adaptation and conditioning to the misanthropic genetic, climatic, chemical and cultural consequences of growth is now described as health. Neither the Galenic-Hippocratic representations of a humoral balance, nor the Enlightenment utopia of a right to "health and happiness," nor any Vedic or Chinese concepts of well-being, have anything to so with survival in a technical system.

"Health" as function, process, mode of communication, health as an orienting behaviour which requires management--these belong with those post-industrial conjuring formulas which suggestively connote much, but denote nothing that can be grasped. As soon as health is addressed, it has already turned into a sense-destroying pathogen, a member of a word family which Uwe Poerksen calls plastic words, word husks which one can wave around, making oneself important, but which can say or do nothing.

--Political deception.

The situation is similar with responsibility, although to demonstrate this is much more difficult. In a world which which worships an ontology of systems, ethical responsibility is reduced to a legitimizing formality. The poisoning of the world, to which I contribute with my flight from New York to Frankfurt, is not the result of an irresponsible decision, but rather of my presence in an unjustifiable web of inter-connections. It would be politically naive, after health and responsibility have been made technically impossible, to somehow resurrect them through inclusion into a personal project. Some kind of resistance is demanded.

Instead of brutal self-enforcement maxims, the new health requires the smooth integration of my immune system into a socio-economic world system. Being asked to take responsibility for myself is, when seen more clearly, a demand for the destruction of sense and self. And this proposed self-assignment to a system that cannot be experienced stands in stark contrast to suicide. It demands self-extinction in a world hostile to death. Precisely because I also seek tolerance to suicide in a society which has become a-mortal, I must publicly expose the idealization of healthy self-integration. One cannot feel healthy; one can only enjoy her own functioning in the same way as one enjoys the use of her computer.

To demand that our children feel well in the world which we leave them is an insult to their dignity. Then to impose on them responsibility for this insult is a base act.

--Indecent demands

In many respects, biological, demographic and medical research of the last decade, focusing on health showed that medical achievements only contributed in an insignificant way to the medically defined level of health of the population. Secondly, studies have found that even preventive medicine is of secondary importance in this respect. Further, we now see that a majority of these medical achievements are deceptive misnomers, actually prolonging the suffering of madmen, cripples, old fools and monsters. Therefore, I find it reprehensible that the self-appointed health experts now emerge as caring monitors who, with their slogans, put the responsibility of suffering onto the sick themselves. In the last fifteen years, propaganda in favour of hypochondria has certainly led to a reduction in smoking and the butter consumption of the rich, and to an increase in their jogging. It has also led to the fact that the USA now exports more tobacco, butter, and jogging shoes.

But throughout the world, propaganda for medically defined health coincided with an increase in misery for the many. This is how one can summarize the argument of Banerji. He demonstrates how the importation of western thought undermined the hygienic customs of the majority and solidified advancement of elites in India. Twenty years ago, Hakin Mohamed Said, the leader of the Pakistan Unani, spoke about medical sickening through the imposition of a western concept of health. What concerned him was the corruption of the praxis of traditional Galenic physicians, not by western pharmacopeia so much as by a western concept of health which sees death as the enemy. This hostility to death [sic!]--which is to be internalized along with personal responsibility for health--is why I regard the slogan as indecent.

--Life as blasphemy.

The art of the historian consists in the interpretation of traces and texts of those long dead. In the course of my life as a medieval historian something has fundamentally changed in this task. Before a recent radical transformation--roughly, in actio and passio--it was possible for the exegete to relate substantives and verbs to activities and things which lie within the circumference of his own sensed experience. After this transformation, that capacity is lost. This watershed, separating the historian from his object, becomes particularly clear when the experienced body is the subject of historical writing. Dr. Barbara Duden presents this convincingly in reference to body history of the experience of pregnancy. I myself am made dizzy. How deeply the ways of speaking and of experiencing have been altered in the last two decades!

In a very short time, the representation of the substantive concept, "life," has prominently emerged. During the Vietnam war, there was still a bodycount of the enemy; only the lives of Americans were saved. But soon thereafter it was taken for granted that something called "a life" begins and then ends. Around 1969, the quality of life was suddenly before us. Immediately, the physician was required to take responsibility for life. Biomedicine discovered its competence over "life."

Studying the history of well-being, the history of health, it is obvious that with the arrival of life and its quality--which was also called health--the thread which linked that which is called health today with health in the past, was broken. Health has become a scale on which one measures an immune system's fitness for living. The reduction of a person to an immune system corresponds to the deceptive reduction of creation to a global system, Lovelock's Gaia. And in this perspective, responsibility ends up being understood as the self-steering of an immune system. As much as I would like to rescue for future use the word, "responsible"--a word that, as a philosophical concept, only appeared around 1920--to characterize my actions and omissions, I cannot do it. And this is true, not primarily because through this slogan favoring self-regulation of one's own "quality of life" sense is extinguished, management transfigured as beneficial, and politics reduced to feedback, but because God is thus blasphemed.

I would ask you to pay careful attention to my form of expression. I am a Christian, yet when I speak here about blaspheming God, I would like to be understood as a historian, not as a theologian. I can only claim solidity for an argument constructed by a historian. I hope to do this respectfully, but I cannot mince words.

I have outlined my thinking. Longing for that which health and responsibility might have been in the recently arrived modernity I leave to romantics and drop-outs. I consider it a perversion to use the names of high-sounding illusions which cannot fit in the world of computer and media for the internalization and embodiment of systems and information theory. Further, I consider the renouncing of these fictions a real possibility. And I call the practice of this renunciation an epistemic askesis. I believe that an art of suffering appropriate to contemporary life can grow out of this askesis.

What is important for the argument is to understand that all the central concepts I discuss here are of profoundly western origin: health and responsibility, life and askesis ... and God. They were put into the world and became powerful through beliefs that took hundreds of years to come into being. Only if one understands the history of health and life in their historical interconnection is there a basis for the passion with which I can call for the renunciation of "life." I completely agree with Dirk von Boetticher when he quotes T.S.Eliot:

Where is the Life we have lost in living?

Where is the wisdom we have lost in knowledge?

Where is the knowledge we have lost in information?

The cycles of Heaven in twenty centuries

Bring us farther from God and nearer to the Dust.

Eliot here inquires about life pertaining to God, about the life of which Christ says in John 11.25: "I am the life." Aristotle did not know about this. Aristotle knew living beings which were different from all other things because they had a "psyche." He did not know "life." As an appearance in the world, only in the 18th century did life acquire that dominant and exclusive significance which gave it the character of its own answer, not from God, but from the world. Lamarck and Treviranus, who founded (1801) biology as the "science of life" in a conscious turning away from the classifications of natural history, were quite aware of the fundamental newness of their object. This life, which owes its origin and definitions to the world is, however, profoundly determined by western Christianity, and can only be understood as a perversion of the tradition in which the God become flesh describes himself as life, and calls everyone to this life.

That is mystery. And every person who occupies himself seriously with almost two thousand years of history must admit that not only individual mystics but great cultures between Novgorot and Santiago de Compostella, between Upsalla and Monreale, have honored this mystery. That is simply historical reality, even for an historian who has no concept and no sense of what it means. And just as plain and unquestionable is the derivation of the biological concept of life from the Christian mystery. When seen in this way, the concept of a life which can be reduced to a survival phase of the immune system is not only a caricature, not only an idol, but a blasphemy. And seen in this way, the desire for responsibility for the quality of this life is not only stupid or impertinent, it is a sin.