[Paleopsych] Foucault: The Crisis of Medicine or the Crisis of Antimedicine?

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The Crisis of Medicine or the Crisis of Antimedicine?
Michel Foucault
Foucault Studies, No 1, pp. 5-19, December 2004

[This is worth reading in its entirety. It is amazingly prescient and 
could have been written in 2004, not 1974.]

Translated by Edgar C. Knowlton, Jr. (Professor Emeritus, University of
Hawai'i), William J. King (University of Hawai'i) and Clare O'Farrell
(Queensland University of Technology)1 
1  [Ed.] Clare O'Farrell made very extensive changes working from the
French version while preserving some of the variations that exist in the
Spanish version. Editorial changes were also made by Stuart Elden and
Morris Rabinowitz. 
2  [Ed.] Ivan Illich, Medical Nemesis: the Expropriation of Health,
London, Calder and Boyars, 1975.


NOTE: This was the first of three lectures given by Michel Foucault on
social medicine in October 1974 at the Institute of Social Medicine,
Biomedical Center, of the State University of Rio de Janeiro, Brazil. It
was originally published in Portuguese translation as "Crisis de un
modelo en la medicina?", Revista centroamericana de Ciencas de la Salud,
No 3, January-April 1976, pp. 197-209; and in Spanish as "La crisis de
la medicina o la crisis de la antimedicina", Educacion Medica y Salud,
Vol 10 No 2, 1976, pp. 152-70. The version in Dits et écrits, (Paris:
Gallimard), vol III, pp. 40-58, is a retranslation of the Portuguese
back into French. We have translated this article from Spanish and thank
PAHO Publications for their permission to publish it. We have also
compared it to the French translation by Dominique Reynié.


I would like to open this lecture by drawing attention to a question
which is beginning to be widely discussed: should we speak of a crisis
of medicine or a crisis of antimedicine? In this context I shall refer
to Ivan Illich's book Medical Nemesis: the Expropriation of Health,2
which, given the major impact it has had and will continue to have in
the coming months, focuses world public opinion on the problem of the
current functioning of the institutions of medical knowledge and power.

  But to analyze this phenomenon, I shall begin from at an earlier
period, the years between 1940 and 1945, or more exactly the year 1942,
when the famous Beveridge Plan was elaborated. This plan served as a
model for the organization of health after the Second World War in
England and in many other countries. The date of this Plan has a
symbolic value. In 1942 - at the height of the World War in which
40,000,000 people lost their lives - it was not the right to life that
was adopted as a principle, but a different and more substantial and
complex right: the right to health. At a time when the War was causing
large-scale destruction, society assumed the explicit task of ensuring
its members not only life, but also a healthy life.
   Apart from its symbolic value, this date is very important for several
reasons: 
1. The Beveridge Plan signals that the State was taking charge of
health. It might be argued that this was not new, since from the
eighteenth century onwards it has been one of the functions of the
State, not a fundamental one but still one of vital importance, to
guarantee the physical health of its citizens. Nonetheless, until middle
of the twentieth century, for the State guaranteeing health meant
essentially the preservation of national physical strength, the work
force and its capacity of production, and military force. Until then,
the goals of State medicine had been, principally, if not racial, then
at least nationalist. With the Beveridge plan, health was transformed
into an object of State concern, not for the benefit of the State, but
for the benefit of individuals. Man's right to maintain his body in good
health became an object of State action. As a consequence, the terms of
the problem were reversed: the concept of the healthy individual in the
service of the State was replaced by that of the State in the service of
the healthy individual. 
2. It is not only a question of a reversal of rights, but also of what
might be called a morality of the body. In the nineteenth century an
abundant literature on health, on the obligation of individuals to
secure their health and that of their family, etc. made its appearance
in every country in the world. The concept of cleanliness, of hygiene,
occupied a central place in all these moral exhortations concerning
health. Numerous publications insisted on cleanliness as an
indispensable prerequisite for good health. Health would allow people to
work so that children could survive and ensure social labour and
production in their turn. Cleanliness ensured good health for the
individual and those surrounding him. In the second half of the
twentieth century another concept arose. It was no longer a question of
an obligation to practise cleanliness and hygiene in order to enjoy good
health, but of the right to be sick as one wishes and as is necessary.
The right to stop work began to take shape and became more important
than the former obligation to practise cleanliness that had
characterized the moral relation of individuals with their bodies. 
3. With the Beveridge Plan health entered the field of macroeconomics.
The costs involved in health, from the loss of work days, to the
necessity of covering those risks stopped being phenomena that could be
resolved through the use of pension funds or with mostly private
insurance. From then on, health - or the absence of health - the
totality of conditions which allowed the health of individuals to be
insured, became an expense, which due to its size became one of the
major items of the State budget, regardless of what system of financing
was used. Health began to enter the calculations of the macro-economy.
Through the avenue of health, illnesses and the need to ensure the
necessities of health led to a certain economic redistribution. From the
beginning of the present century one of the functions of budgetary
policy in the many countries has been ensuring a certain equalization of
income, if not of property, through the tax system. This redistribution
did not, however, depend on taxes, but on the system of regulation and
economic coverage of health and illnesses. In ensuring for all the same
opportunities for receiving treatment, there was an attempt to correct
inequalities in income. Health, illness, and the body began to have
their social locations and, at the same time, were converted into a
means of individual socialization. 
4. Health became the object of an intense political struggle. At the end
of the Second World War and with the triumphant election of the Labour
party in England in 1945, there was no political party or political
campaign, in any developed country, that did not address the problem of
health and the way in which the State would ensure and finance this type
of expenditure. The British elections of 1945, as well as those relating
to the pension plans in France in 1947, which saw the victory of the
representatives of the Confédération générale du travail [General
Confederation of Workers], mark the importance of the political struggle
over health.
  Taking the Beveridge Plan as a point of symbolic reference, one can
observe over the ten years from 1940-1950 the formulation of a new
series of rights, a new morality, a new economics, a new politics of the
body. Historians have accustomed us to drawing a careful and meticulous
relation between what people say and what they think, the historical
development of their representations and theories and the history of the
human spirit. Nevertheless, it is curious to note that they have always
ignored that fundamental chapter that is the history of the human body.
In my opinion, the years 1940-1950 should be chosen as dates of
reference marking the birth of this new system of rights, this new
morality, this new politics and this new economy of the body in the
modern Western world. Since then, the body of the individual has become
one of the chief objectives of State intervention, one of the major
objects of which the State must take charge.
  In a humorous vein, we might make an historical comparison. When the
Roman Empire was crystallized in Constantine's era, the State, for the
first time in the history of the Mediterranean world, took on the task
of caring for souls. The Christian State not only had to fulfil the
traditional functions of the Empire, but also had to allow souls to
attain salvation, even if it had to force them to. Thus, the soul became
one of the objects of State intervention. All the great theocracies,
from Constantine to the mixed theocracies of eighteenth century Europe,
were political regimes in which the salvation of the soul was one of the
principal objectives.
  One could say that the present situation has actually been developing
since the eighteenth century not a theocracy, but a 'somatocracy'. We
live in a regime that sees the care of the body, corporal health, the
relation between illness and health, etc. as appropriate areas of State
intervention. It is precisely the birth of this somatocracy, in crisis
since its origins, that I am proposing to analyze.
  At the moment medicine assumed its modern functions, by means of a
characteristic process of nationalization, medical technology was
experiencing one of its rare but extremely significant advances. The
discovery of antibiotics and with them the possibility of effectively
fighting for the first time against infectious diseases, was in fact
contemporary with the birth of the major systems of social security. It
was a dazzling technological advance, at the very moment a great
political, economic, social, and legal mutation of medicine was taking
place.
  The crisis became apparent from this moment on, with the simultaneous
manifestation of two phenomena: on the one hand, technological progress
signalling an essential advance in the fight against disease; on the
other hand, the new economic and political functioning of medicine.
These two phenomena did not lead to the improvement of health that had
been hoped for, but rather to a curious stagnation in the benefits that
could have arisen from medicine and public health. This is one of the
earlier aspects of the crisis I am trying to analyze. I will be
referring to some of its effects to show that that the recent
development of medicine, including its nationalization and socialization
- of which the Beveridge Plan gives a general vision - is of earlier
origin.
  Actually, one must not think that medicine up until now has remained an
individual or contractual type of activity that takes place between
patient and doctor, and which has only recently taken social tasks on
board. On the contrary, I shall try to demonstrate that medicine has
been a social activity since the eighteenth century. In a certain sense,
'social medicine' does not exist because all medicine is already social.
Medicine has always been a social practice. What does not exist is
non-social medicine, clinical individualizing medicine, medicine of the
singular relation. All this is a myth that defended and justified a
certain form of social practice of medicine: private professional
practice. Thus, if in reality medicine is social, at least since its
great rise in the eighteenth century, the present crisis is not really
new, and its historical roots must be sought in the social practice of
medicine.
  As a consequence, I shall not be posing the problem in the terms used
by Illich and his disciples: medicine or antimedicine, should we save
medicine or not? The problem is not whether to have individual or social
medicine, but whether to question the model of the development of
medicine beginning in the eighteenth century, that is, from when what we
might describe as the 'take off' of medicine occurred. This 'take off'
of health in the developed world was accompanied by a technical and
epistemological removal of important obstacles in medicine and in a
series of social practices. And it is precisely these specific forms of
'take off' that have produced the current crisis. The problem can be
posed in the following terms: (1) what was that model of development?
(2) to what extent can it be corrected? (3) to what extent can it be
used today in societies or populations that have not experienced the
European and American model of economic and political development? To
sum up, what is this model of development? Can it be corrected and
applied in other places? I would now like to expose some hidden aspects
of this current crisis.

Scientificity and Efficacy of Medicine

In the first place, I would like to refer to the separation or
distortion that exists between the scientificity of medicine and the
positive nature of its effects, or between the scientificity and the
efficacy of medicine. It was not necessary to wait for Illich or the
disciples of anti-medicine to know that one of the capabilities of
medicine is killing. Medicine kills, it has always killed, and it has
always been aware of this. What is important, is that until recent times
the negative effects of medicine remained inscribed within the register
of medical ignorance. Medicine killed through the doctor's ignorance or
because medicine itself was ignorant. It was not a true science, but
rather a rhapsody of ill-founded, poorly established and unverified sets
of knowledge. The harmfulness of medicine was judged in proportion to
its non-scientificity.
  But what emerged at the beginning of the twentieth century, was the
fact that medicine could be dangerous, not through its ignorance and
falseness, but through its knowledge, precisely because it was a
science. Illich and those who are inspired by him uncovered a series of
data around this theme, but I am not sure how well elaborated they are.
One must set aside different spectacular results designed for the
consumption of journalists. I shall not dwell therefore on the
considerable decrease in mortality during a doctors strike in Israel;
nor shall I mention well-recorded facts whose statistical elaboration
does not allow the definition or discovery of what is being dealt with.
This is the case in relation to the investigation by the National
Institutes of Health (USA) according to which in 1970, 1,500,000 persons
were hospitalized due to the consumption of medications. These
statistics are upsetting but do not afford convincing proof, as they do
not indicate the manner in which these medications were administered, or
who consumed them, etc. Neither shall I analyze the famous investigation
of Robert Talley, who demonstrated that in 1967, 3,000 North Americans
died in hospitals from the side effects of medications. All that taken
as a whole does not have great significance nor is it based on a valid
analysis.3 There are other factors that need to be known. For example,
one needs to know the how these medications were administered, if the
problems were a result of an error by the doctor, the hospital staff or
the patient himself, etc. Nor shall I dwell on the statistics concerning
surgical operations, particularly in relation to certain studies of
hysterectomies in California that indicate that out of 5,500 cases, 14%
of the operations failed, 25% of the patients died young, and that in
only 40% of the cases was the operation necessary. All these facts, made
notorious by Illich, relate to the ability or ignorance of the doctors,
without casting doubt on medicine itself in its scientificity.
  On the other hand what appears to me to be much more interesting and
which poses the real problem is what one might call positive
iatrogenicity, rather than iatrogenicity4: the harmful effects of
medication due not to errors of diagnosis or the accidental ingestion of
those substances, but to the action of medical practice itself, in so
far as it has a rational basis. At present, the instruments that doctors
and medicine in general have at their disposal cause certain effects,
precisely because of their efficacy. Some of these effects are purely
harmful and others are unable to be controlled, which leads the human
species into a perilous area of history, into a field of probabilities
and risks, the magnitude of which cannot be precisely measured. 
3  [Ed.] Letters in relation to this study can be found in Robert B.
Talley, Marc F. Laventurier, and C. Joseph Stetler, 'Letters: Drug
Induced Illness.' Journal of the American Medical Association 229, no. 8
(1974) pp. 1043-44.
  It is known, for example, that anti-infectious treatment, the highly
successful struggle carried out against infectious agents, led to a
general decrease of the threshold of the organism's sensitivity to
hostile agents. This means that to the extent that the organism can
defend itself better, it protects itself, naturally, but on the other
hand, it is more fragile and more exposed if one restricts contact with
the stimuli which provoke defences.
  More generally, one can say that through the very effect of medications
- positive and therapeutic effects - there occurs a disturbance, even
destruction, of the ecosystem, not only at the individual level, but
also at the level of the human species itself. Bacterial and viral
protection, which represent both a risk and a protection for the
organism, with which it has functioned until then, undergoes a change as
a result of the therapeutic intervention, thus becoming exposed to
attacks against which the organism had previously been protected.
  Nobody knows where the genetic manipulation of the genetic potential of
living cells in bacteria or in viruses will lead. It has become
technically possible to develop agents that attack the human body
against which there are no means of defence. One could forge an absolute
biological weapon against man and the human species without the means of
defence against this absolute weapon being developed at the same time.
This has led American laboratories to call for the prohibition of some
genetic manipulations that are at present technically possible. 
We thus enter a new dimension of what we might call medical risk.
Medical risk, that is the inextricable link between the positive and
negative effects of medicine, is not new: it dates from the moment when
the positive effects of medicine were accompanied by various negative
and harmful consequences. With regards to this there are numerous
examples that signpost the history of modern medicine dating from the
eighteenth century. In that century, for the first time, medicine
acquired sufficient power to allow certain patients to become healthy
enough to leave a hospital. Until the middle of the eighteenth century
people generally did not survive a stay in a hospital. People entered
this institution to die. The medical technique of the eighteenth century
did not allow the hospitalized individual to leave the institution
alive. The hospital was a cloister where one went to breathe one's last;
it was a true 'mortuary'. 
4  [Ed.] Caused by a doctor, from iatros, physician.
  Another example of a significant medical advance accompanied by a great
increase in mortality was the discovery of anaesthetics and the
technique of general anaesthesia in the years from 1844 to 1847. As soon
as a person could be put to sleep surgical operations could be
performed, and the surgeons of the time devoted themselves to this work
with great enthusiasm. But at the time they did not have access to
sterilized instruments. Sterile surgical technique was not introduced
into medical practice until 1870. After the Franco-Prussian war and the
relative success of German doctors, it became a current practice in many
countries.
  As soon as individuals could be anaesthetized, the pain barrier - the
natural protection of the organism - disappeared and one could proceed
with any operation whatsoever. In the absence of sterile surgical
technique, there was no doubt that every operation was not only risky,
but led to almost certain death. For example, during the war of 1870, a
famous French surgeon, Guérin, performed amputations on several wounded
men, but only succeeded in saving one; the others died. This is a
typical example of the way medicine has always functioned, on the basis
of its own failures and the risks it has taken. There has been no major
medical advance that has not paid the price in various negative
consequences.
  This characteristic phenomenon of the history of modern medicine has
acquired a new dimension today in so far as that, until the most recent
decades, medical risk concerned only the individual under care. At most,
one could adversely affect the individual's direct descendants, that is,
the power of a possible negative action limited itself to a family or
its descendants. Nowadays, with the techniques at the disposal of
medicine, the possibility for modifying the genetic cell structure not
only affects the individual or his descendants but the entire human
race. Every aspect of life now becomes the subject of medical
intervention. We do no know yet whether man is capable of fabricating a
living being which will make it possible to modify the entire history of
life and the future of life.
  A new dimension of medical possibilities arises that I shall call
bio-history. The doctor and the biologist are no longer working at the
level of the individual and his descendants, but are beginning to work
at the level of life itself and its fundamental events. This is a very
important element in bio-history. 
It has been known since Darwin that life evolved, that the evolution of
living species is determined, to a certain degree, by accidents which
might be of a historical nature. Darwin knew, for example, that
enclosure in England, a purely economic and legal practice, had modified
the English fauna and flora. The general laws of life, therefore, were
then linked to that historical occurrence. In our days something new is
in the process of being discovered; the history of man and life are
profoundly intertwined. The history of man does not simply continue
life, nor is simply content to reproduce it, but to a certain extent
renews it, and can exercise a certain number of fundamental effects on
its processes. This is one of the great risks of contemporary medicine
and one of the reasons for the uneasiness communicated from doctors to
patients, from technicians to the general population, with regards to
the effects of medical action.
  A series of phenomena, like the radical and bucolic rejection of
medicine in favour of a non-technical reconciliation with nature, themes
of millenarianism and the fear of an apocalyptic end of the species,
represent the vague echo in public awareness of this technical
uneasiness that biologists and doctors are beginning to feel with
regards to the effects of their own practice and their own knowledge.
Not knowing stops being dangerous when the danger feared is knowledge
itself. Knowledge is dangerous, not only because of its immediate
consequences for individuals or groups of individuals, but also at the
level of history itself. This is one of the fundamental characteristics
of the present crisis.

Undefined Medicalization

The second characteristic is what I am going to call the phenomenon of
undefined 'medicalization'. It is often argued that in the twentieth
century medicine began to function outside its traditional field as
defined by the wishes of the patient, his pain, his symptoms, his
malaise. This area defined medical treatment and circumscribed its field
of activity, which was determined by a domain of objects called
illnesses and which gave medical status to the patient's demands. It was
thus that the domain specific to medicine was defined.
  There is no doubt that if this is its specific domain, contemporary
medicine has gone considerably beyond it for several reasons. In the
first place, medicine responds to another theme which is not defined by
the wishes of the patient, wishes which now exist only in limited cases.
More frequently, medicine is imposed on the individual, ill or not, as
an act of authority. One can cite several examples in this instance.
Today, nobody is employed without a report from a doctor who has the
authority to examine the individual. There is a systematic and
compulsory policy of 'screening', of tracking down disease in the
population, a process which does not answer any patient demand. In some
countries, a person accused of having committed a crime, that is, an
infringement considered as sufficiently serious to be judged by the
courts, must submit to compulsory examination by a psychiatric expert.
In France, it is compulsory for every individual coming under the
purview of the legal system, even if it is a correctional court. These
are examples of a type of a familiar medical intervention that does not
derive from the patient's wishes.
  In the second place, the objects that make up the area of medical
treatment are not just restricted to diseases. I offer two examples.
Since the beginning of the twentieth century, sexuality, sexual
behaviour, sexual deviations or anomalies have been linked to medical
treatment, without a doctor's saying, unless he is naive, that a sexual
anomaly is a disease. The systematic treatment by medical therapists of
homosexuals in Eastern European countries is characteristic of the
'medicalization' of something that is not a disease, either from the
point of view of the person under treatment or the doctor.
  More generally, it might be argued that health has been transformed
into an object of medical treatment. Everything that ensures the health
of the individual; whether it be the purification of water, housing
conditions or urban life styles, is today a field for medical
intervention that is no longer linked exclusively to diseases. Actually,
the authoritarian intervention of medicine in an ever widening field of
individual or collective existence is an absolutely characteristic fact.
Today medicine is endowed with an authoritarian power with normalizing
functions that go beyond the existence of diseases and the wishes of the
patient.
  If the jurists of the seventeenth and eighteenth centuries are
considered to have invented a social system that had to be governed by a
system of codified laws, it might be argued that in the twentieth
century doctors are in the process of inventing a society, not of law,
but of the norm. What governs society are not legal codes but the
perpetual distinction between normal and abnormal, a perpetual
enterprise of restoring the system of normality. This is one of the
characteristics of contemporary medicine, although it may easily be
demonstrated that it is a question of an old phenomenon, linked to the
medical 'take off'. Since the eighteenth century, medicine has
continually involved itself in what is not its business, that is, in
matters other than patients and diseases. It was precisely in this
manner that epistemological obstacles were able to be removed at the end
of the eighteenth century.
  Until sometime between 1720 to 1750, the activities of doctors focused
on the demands of patients and their diseases. Thus has it been since
the Middle Ages, with arguably non-existent scientific and therapeutic
results. Eighteenth century medicine freed itself from the scientific
and therapeutic stagnation in which it had been mired beginning in the
medieval period. From this moment on, medicine began to consider fields
other than ill people and became interested in aspects other than
diseases, changing from being essentially clinical to being social.
  The four major processes which characterize medicine in the eighteenth
century, are as follows: 
1. Appearance of a medical authority, which is not restricted to the
authority of knowledge, or of the erudite person who knows how to refer
to the right authors. Medical authority is a social authority that can
make decisions concerning a town, a district, an institution, or a
regulation. It is the manifestation of what the Germans called
Staatsmedizin, medicine of the State. 
2. Appearance of a medical field of intervention distinct from diseases:
air, water, construction, terrains, sewerage, etc. In the eighteenth
century all this became the object of medicine. 
3. Introduction of an site of collective medicalization: namely, the
hospital. Before the eighteenth century, the hospital was not an
institution of medicalization, but of aid to the poor awaiting death. 
4. Introduction of mechanisms of medical administration: recording of
data, collection and comparison of statistics, etc.
  With a base in the hospital and in all these social controls, medicine
was able to gain momentum, and clinical medicine acquired totally new
dimensions. To the extent that medicine became a social practice instead
of an individual one, opportunities were opened up for anatomical
pathology, for hospital medicine and the advances symbolized by the
names of Bichat, Laënnec, Bayle, et al. As a consequence, medicine
dedicated itself to areas other than diseases, areas not governed by the
wishes of the sick person. This is an old phenomenon that forms one of
the fundamental characteristics of modern medicine. But what more
particularly characterizes the present phase in this general tendency is
that in recent decades, medicine in acting beyond its traditional
boundaries of ill people and diseases is taking over other areas. 
If in the eighteenth century, medicine had in fact gone beyond its
classic limits there were still things that remained outside medicine
and did not seem to be 'medicalizable'. There were fields outside
medicine and one could conceive of the existence of a bodily practice, a
hygiene, a sexual morality etc., that was not controlled or codified by
medicine. The French Revolution, for example, conceived of a series of
projects concerning a morality of the body, a hygiene of the body, that
were not in any way under the control of doctors. A kind of happy
political order was imagined, in which the management of the human body,
hygiene, diet and the control of sexuality corresponded to a collective
and spontaneous consciousness. This ideal of a non-medical regulation of
the body and of human conduct can be found throughout the nineteenth
century in the work of Raspail for example.5 
What is diabolical about the present situation is that whenever we want
to refer to a realm outside medicine we find that it has already been
medicalized. And when one wishes to object to medicine's deficiencies,
its drawbacks and its harmful effects, this is done in the name of a
more complete, more refined and widespread medical knowledge.
  I should like to mention an example in this regard: Illich and his
followers point out that therapeutic medicine, which responds to a
symptomatology and blocks the apparent symptoms of diseases, is bad
medicine. They propose in its stead a demedicalized art of health made
up of hygiene, diet, lifestyle, work and housing conditions etc. But
what is hygiene at present except a series of rules set in place and
codified by biological and medical knowledge, when it is not medical
authority itself that has elaborated it? Anti-medicine can only oppose
medicine with facts or projects that have been already set up by a
certain type of medicine.
  I am going to cite another example taken from the field of psychiatry.
It might be argued that the first form of antipsychiatry was
psychoanalysis. At the end of the nineteenth psychoanalysis was aimed at
the demedicalization of various phenomena that the major psychiatric
symptomatology of that same century had classified as illnesses. This
antipsychiatry is a psychoanalysis, not only of hysteria and neurosis,
which Freud tried to take away from psychiatrists, but also of the daily
conduct which now forms the object of psychoanalytic activity. Even if
psychoanalysis is now opposed by antipsychiatry and antipsychoanalysis,
it is still a matter of a type of activity and discourse based on a
medical perspective and knowledge. One cannot get away from
medicalization, and every effort towards this end ends up referring to
medical knowledge. 
5  [Ed.] François Vincent Raspail, Histoire naturelle de la santé et de
la maladie, suivie du formulaire pour une nouvelle méthode de traitement
hygiénique et curatif, Paris: A. Levavasseur, 2 Volumes, 1843.
  Finally, I would like to take an example from the field of criminality
and criminal psychiatry. The question posed by the penal codes of the
nineteenth century consisted in determining whether an individual was
mentally ill or delinquent. According to the French Code of 1810, one
could not be both delinquent and insane. If you were mad, you were not
delinquent, and the act committed was a symptom, not a crime, and as a
result you could not be sentenced.
  Today an individual considered as delinquent has to submit to
examination as though he were mad before being sentenced. In a certain
way, at the end of the day, he is always condemned as insane. In France
at least, a psychiatric expert is not summoned to give an opinion as to
whether the individual was responsible for the crime. The examination is
limited to finding out whether the individual is dangerous or not.
  What does this concept of dangerous mean? One of two things: either the
psychiatrist responds that the person under treatment is not dangerous,
that is, that he is not ill and is not manifesting any pathology, and
that since he is not dangerous there is no reason to sentence him. (His
non-pathologization allows sentence not to be passed). Or else the
doctor says that the subject is dangerous because he had a frustrated
childhood, because his superego is weak, because he has no notion of
reality, that he has a paranoid constitution, etc. In this case the
individual has been 'pathologized' and may be imprisoned, but he will be
imprisoned because he has been identified as ill. So then, the old
dichotomy in the Civil Code, which defined the subject as being either
delinquent or mad, is eliminated. As a result there remain two
possibilities, being slightly sick and really delinquent, or being
somewhat delinquent but really sick. The delinquent is unable to escape
his pathology. Recently in France, an ex-inmate wrote a book to make
people understand that he stole not because his mother weaned him too
soon or because his superego was weak or that he suffered from paranoia,
but because he was born to steal and be a thief.6 
Pathology has become a general form of social regulation. There is no
longer anything outside medicine. Fichte spoke of the 'closed commercial
State' to describe the situation of Prussia in 1810.7 One might argue in
relation to modern society that we live in the 'open medical States' in
which medicalization is without limits. Certain popular resistances to
medicalization are due precisely to this perpetual and constant
predomination. 
6  [Ed.] Foucault is probably referring to Serge Livrozet, De la prison
à la révolte. Paris: Mercure de France, 1973. Foucault's preface to this
book also appears in Dits et écrits. Paris: Gallimard, 1994, vol II, pp.
394-416. 
7  [Ed.] Johann Gottlieb Fichte, Der geschlossne Handelsstaat, Tübingen:
Coota, 1800. There is no complete translation into English, but for
selections, see Hans Reiss (ed.), The Political Thought of the German
Romantics, 1793-1815, Oxford: Basil Blackwell, 1955, pp. 86-102.

The Political Economy of Medicine

Finally I should like to speak of another characteristic of modern
medicine, namely, what might be called the political economy of
medicine. Here again, it is not a question of a recent phenomenon, since
beginning in the eighteenth century medicine and health have been
presented as an economic problem. Medicine developed at the end of the
eighteenth century in response to economic conditions. One must not
forget that the first major epidemic studied in France in the eighteenth
century and which led to a national data gathering was not really an
epidemic but an epizootic. It was the catastrophic loss of life of herds
of cattle in the south of France that contributed to the origin of the
Royal Society of Medicine. The Academy of Medicine in France was born
from an epizootic, not from an epidemic, which demonstrates that
economic problems were what motivated the beginning of the organization
of this medicine.
  It might also be argued that the great neurology of Duchenne de
Boulogne, Charcot, et al., was born in the wake of the railroad
accidents and work accidents that occurred around 1860, at the same time
that the problems of insurance, work incapacity and the civil
responsibility of employers and transporters, etc. were being posed. The
economic question is certainly present in the history of medicine. 
But what turns out to be peculiar to the present situation is that
medicine is linked to major economic problems in a different way from
the traditional links. Previously, medicine was expected to provide
society with strong individuals who were capable of working, of ensuring
the constancy, improvement and reproduction of the work force. Medicine
was called on as an instrument for the maintenance and reproduction of
the work force essential to the functioning of modern society.
  At present, medicine connects with the economy by another route. Not
simply in so far as it is capable of reproducing the work force, but
also in that it can directly produce wealth in that health is a need for
some and a luxury for others. Health becomes a consumer object, which
can be produced by pharmaceutical laboratories, doctors, etc., and
consumed by both potential and actual patients. As such, it has acquired
economic and market value.
  Thus the human body has been brought twice over into the market: first
by people selling their capacity to work, and second, through the
intermediary of health. Consequently, the human body once again enters
an economic market as soon as it is susceptible to diseases and health,
to well being or to malaise, to joy or to pain, and to the extent that
it is the object of sensations, desires, etc. As soon as the human body
enters the market, through health consumption, various phenomena appear
which lead to dysfunctions in the contemporary system of health and
medicine.
  Contrary to what one might expect, the introduction of the human body
and of health into the system of consumption and the market did not
correlatively and proportionally raise the standard of health. The
introduction of health into an economic system that could be calculated
and measured showed that the standard of health did not have the same
social effects as the standard of living. The standard of living is
defined by the consumer index. If the growth of consumption leads to an
increase in the standard of living, in contrast, the growth of medical
consumption does not proportionally improve the level of health. Health
economists have made various studies demonstrating this. For example,
Charles Levinson, in a 1964 study of the production of health, showed
that an increase of 1% in the consumption of medical services led to a
decrease in the level of mortality by 0.1%. This deviation might be
considered as normal but only occurs as a purely fictitious model. When
medical consumption is placed in a real setting, it can be observed that
environmental variables, in particular food consumption, education and
family income, are factors that have more influence than medical
consumption on the rate of mortality. Thus, an increased income may
exercise a negative effect on mortality that is twice as effective as
the consumption of medication. That is, if incomes increase only in the
same proportion as the consumption of medical services, the benefits of
the increase in medical consumption will be cancelled out by the small
increase in income. Likewise, education is two and one-half times more
important for the standard of living than medical consumption. It
follows that, in order to live longer, a higher level of education is
preferable to the consumption of medicine.
  If medical consumption is placed in the context of other variables that
have an effect on the rate of mortality, it will be observed that this
factor is the weakest of all. Statistics in 1970 indicate that, despite
a constant increase in medical consumption, the rate of mortality, which
is one of the most important indicators of health, did not decrease, and
remains greater for men than for women. Consequently, the level of
medical consumption and the level of health have no direct relation,
which reveals the economic paradox of an increase in consumption that is
not accompanied by any positive effect on health, morbidity and
mortality.
  Another paradox of the introduction of health into the political
economy is that the social changes that were expected to occur via the
systems of social security did not occur as expected. In reality, the
inequality of consumption of medical services remains just as
significant as before. The rich continue to make use of medical services
more than the poor. This is the case today in France. The result is that
the weakest consumers, who are also the poorest, fund the over
consumption of the rich. In addition, scientific research and the great
proportion of the most valuable and expensive hospital equipment are
financed by social security payments, whereas the private sectors are
the most profitable because they use relatively less complicated
technical equipment. What in France is called the hospital hotel
business, that is, a brief hospitalization for minor procedures, such as
a minor operation, is supported in this way by the collective and social
financing of diseases. 
Thus, we can see that the equalization of medical consumption that was
expected from social security was watered down in favour of a system
that tends more and more to reinforce the major inequalities in relation
to illness and death that characterized nineteenth century society.
Today, the right to equal health for all is caught in a mechanism which
transforms it into an inequality.
  Doctors are confronted with the following problem: who profits from the
social financing of medicine, the profits derived from health?
Apparently doctors, but this is not in fact the case. The remuneration
that doctors receive, however elevated it might be in certain countries,
represents only a minor proportion of the economic benefits derived from
illness and health. Those who make the biggest profits from health are
the major pharmaceutical companies. In fact, the pharmaceutical industry
is supported by the collective financing of health and illness through
social security payments from funds paid by people required to insure
their health. If health consumers - that is, those who are covered by
social security - are not yet fully aware of this situation, doctors are
perfectly well aware of it. These professionals are more and more aware
that they are being turned into almost mechanized intermediaries between
the pharmaceutical industry and client demand, that is, into simple
distributors of medicine and medication.
  We are living a situation in which certain phenomena have led to a
crisis. These phenomena have not fundamentally changed since the
eighteenth century, a period that marked the appearance of a political
economy of health with processes of generalized medicalization and
mechanisms of bio-history. The current so-called crisis in medicine is
only a series of exacerbated supplementary phenomena that modify some
aspects of the tendency, but did not create it. 
The present situation must not be considered in terms of medicine or
antimedicine, or whether or not medicine should be paid for, or whether
we should return to a type of natural hygiene or paramedical bucolicism.
These alternatives do not make sense. On the other hand what does make
sense - and it is in this context that certain historical studies may
turn out to be useful - is to try to understand the health and medical
'take off' in Western societies since the eighteenth century. It is
important to know which model was used and how it can be changed.
Finally, societies that were not exposed to this model of medical
development must be examined. These societies, because of their colonial
or semi-colonial status, had only a remote or secondary relation to
those medical structures and are now asking for medicalization. They
have a right to do so because infectious diseases affect millions of
people, and it would not be valid to use an argument, in the name of an
antimedical bucolicism, that if these countries do not suffer from these
infections they will later experience degenerative illnesses as in
Europe. It must be determined whether the eighteenth- and
nineteenth-century European model of medical development should be
reproduced as is, or modified and to what extent it can be effectively
applied to these societies without the negative consequences we already
know.
  Therefore, I believe that an examination of the history of medicine has
a certain utility. It is a matter of acquiring a better knowledge, not
so much of the present crisis in medicine, which is a false concept, but
of the model for the historical development of medicine since the
eighteenth century with a view to seeing how it is possible to change
it.
  This is the same problem that prompted modern economists to engage in
the study of the European economic 'take off' in the seventeenth and
eighteenth centuries with a view to seeing how this model of development
could be adapted to non-industrialized societies. One needs to adopt the
same modesty and pride as the economists in order to argue that medicine
should not be rejected or adopted as such; that medicine forms part of
an historical system. It is not a pure science, but is part of an
economic system and of a system of power. It is necessary to determine
what the links are between medicine, economics, power and society in
order to see to what extent the model might be rectified or applied.