1 Judith P. Swazey and Renée Fox, "The Clinical Moratorium: A Case Study of Mitral Valve Surgery," in Paul A. Freund, ed., Experimentation with Human Subjects (New York: Braziller, 1970), pp. 315-57.

   2 Francisco Goya, in Los Caprichos, the series of etchings of 1786, shows a man asleep at his desk with his head on his crossed arms, while monsters surround him. The inscription on the desk reads, "El sueno de la razon produce monstruos." Rene Dubos uses this picture as frontispiece of his book The Mirage of Health (see above, note 3, p. 13). It encapsulates his thesis, on which I try to elaborate in the present book.

   3 Morton Mintz, The Pill: An Alarming Report (Boston: Beacon Press, 1970). Model for a study of medicine by a newspaper reporter who knows how to combine studies in medicine with information that is significant but has been overlooked, repressed, or veiled in medical literature.

   4 Francis D. Moore, "The Therapeutic Innovation: Ethical Boundaries in the Initial Clinical Trials of New Drugs and Surgical Procedures," in Freund, ed., Experimentation with Human Subjects, pp. 358-78.

   5 One example of the need for such outside control over professional progress might be useful. Peter R. Breggin, "The Return of Lobotomy and Psychosurgery," Congressional Record 118 (February 24, 1972): 5567-77, presents a truly shocking review of the vast literature on the current resurgence of lobotomy in the U.S. and around the world. The first wave was aimed mostly (2/3) at female state hospital patients, and claimed 50,000 persons in the U.S. alone before 1964. New methods are available to destroy parts of the brain by ultrasonic waves, electric coagulation, and implantation of radium seeds. The technique is promoted for the sedation of the elderly, to render their institutionalization less expensive; for the control of hyperactive children; and to reduce erotic fantasies and the tendency to gamble.

   6 Each society has its characteristic "nosology," or classification of diseases. Both the extent of conditions classified as disease and the number and kinds of diseases listed change with history. The official or medical nosology recognized in a society can be to a very high degree out of gear with the perception of the disease shared by one or several of the society's classes. See Michel Foucault, The Birth of the Clinic, trans. A. M. Sheridan Smith (New York: Pantheon, 1973). In our society nosology is almost totally medicalized; ill-health that is not labeled by the physician is written off either as malingering or as illusion. As long as iatrogenic disease is treated as one small category within the established nosology, its contribution to the total volume of recognized diseases will not be appreciated.

   7I use the term "intensity" to designate an increase that can be marked by numbers but not measured directly. Paralyzing fear is by no means superior to a lesser fear that drives to flight. Fernand Renoitre, Éleménts de critique des sciences et de cosmologie, course published by the Institut Superieur de Philosophic, Louvain, 1947, pp. 129-30.

   8 For a more systematic analysis of the term "radical monopoly" as applied to professional institutions, see Ivan Illich, Tools for Conviviality (New York: Harper & Row, 1973), chap. 3, sec. 2, pp. 51-7.

   9 An example: Until about 1969, penicillin G tablets were available in Mexican pharmacies under their generic name at a very low price. They have since disappeared from the market. The Farmacopea Mexicana does not list any oral penicillin G even in trademark preparations. Only considerably more expensive preparations are available.

   10 John Blake, ed., Safeguarding the Public: Historical Aspects of Medical Drug Control, Papers from a Conference Sponsored by the National Library of Medicine (Baltimore: Johns Hopkins, 1970). On the process by which the medical profession developed its self-image of benevolent caretaker, see L. Edelstein, The Hippocratic Oath (Baltimore: Johns Hopkins, 1943).

   11 For the classic distinction between exchange-value and use-value consult Karl Marx, Capital (Chicago: Kerr, 1912), vol. 1, chap. 1, especially sec. 4.

   12 Michel Bosquet, "Quand la médecine rend malade: La Terrible Accusation d'un groupe d'experts," Le Nouvel Observateur, no. 519 (1974), pp. 84-118, and no. 520 (1974), pp. 90-130. This article shows how social iatrogenesis is fundamentally the result of the alibi function played by the professional monopoly of the sick-role.

   13 Paul Ramsey, Fabricated Man: The Ethics of Genetic Control (New Haven, Conn.: Yale Univ. Press, 1970), argues that there are things we can do which ought not to be done. To exclude these things is a necessary condition for safeguarding man from total abasement by technical control. Ramsey reaches this conclusion about specific kinds of medical techniques. I make the same argument, but about the global intensity of the medical endeavor.

   14 P. M. Brunetti, "Health in Ecological Perspective," Acta Psychiatrica Scandinavica 49, fasc. 4 (1973): 393-404. Brunetti argues that the concentration of power and the dependence on extrametabolic energy can make the vital milieu uninhabitable for beings whose integration depends on the exercise of their autonomy. Medicine is used to rationalize this transfer.

   15 Renée Fox, "Illness," in International Encyclopedia of the Social Sciences (1968), 7: 90-6. An excellent introduction to the evolution of this concept.

   l6 Talcott Parsons, The Social System (New York: Free Press, 1951), pp. 428 ff., contains the classic formulation of the sick-role. Miriam Siegler and Humphrey Osmond, Models of Madness, Models of Medicine (New York: Macmillan, forthcoming) compare several models for disabling deviance and plead, for political reasons, for the relative expansion of the Parsonian sick role on the grounds that it alone creates a claim to therapy. For the contrary plea see Niels Christie's still untitled forthcoming book on the counterproductivity of therapy. (For manuscript, write to Niels Christie, Faculty of Law and Jurisprudence, University of Oslo.)

   l7 Forrest E. Clements, "Primitive Concepts of Disease," University of California Publications in American Archaeology and Ethnology 32, no. 2 (1932): 185-252. Common etiologies fall into four main categories: (1) sorcery, (2) breach of taboo, (3) intrusion of foreign object, (4) loss of soul.

   18 Eliot Freidson, "Disability as Deviance," in M. B. Sussman, ed., Sociology and Rehabilitation (Washington: American Sociological Association, 1966), pp. 71-99. Professional diagnosis tends merely to give validity to lay perceptions of the value attributed to certain individuals.

   19 Harold Garfinkel, "Conditions of Successful Degradation Ceremonies," American Journal of Sociology 61 (March 1956): 420-44. In our society public degradation ceremonies outside the courts are rather rare. But medicine even today puts public evaluation on characteristics considered as essential as self-control or sexuality.

   20 Louis Lewin, The Untoward Effects of Drugs, trans. W. T. Alexandre (Detroit: Davis, 1883). Notwithstanding its early date, this remains a fascinating book to read, full of historical footnotes. It lists victims of medicine from Nero's guard captain (Spanish fly) to Otto II (aloes), and Avicenna (pepper enema).

   21 On the double meaning of this term from archaic texts to the Hippocratic corpus, see Walter Artelt, Studien zur Geschichte der Begriffe "Heilmittel" und "Gift": Urzeit-Homer-Corpus Hippocraticum (Darmstadt: Wissenschaftliche Buchgesell-schaft, 1968). John D. Gimlette, Malay Poisons and Charm Cures (Kuala Lumpur: Oxford Univ. Press, 1971); John D. Gimlette and H. W. Thompson, A Dictionary of Malayan Medicine (Kuala Lumpur: Oxford Univ. Press, 1971): both volumes form a fascinating introduction to the same ambiguity in an entirely different world.

   22 Judith Lorber, "Deviance as Performance: The Case of Illness," in Eliot Freidson and Judith Lorber, eds., Medical Men and Their Work (Chicago: Aldine, 1972), pp. 414-23. Discusses the attempts of the deviant person to convey the impression which he hopes will lead to the imposition of a certain label rather than another.

   23 Thomas S. Szasz, "The Psychology of Persistent Pain: A Portrait of l'Homme Douloureux," in A. Soulairac, J. Cahn, and J. Charpentier, eds. Pain, Proceedings of the International Symposium Organized by the Laboratory of Psychophysiology, Faculty of Sciences, Paris, April 11-13, 1967 (New York: Academic Press, 1968), pp. 93-113.

   24 Mark G. Field, "Structured Strain in the Role of the Soviet Physician," American Journal of Sociology, 58 (1953): 493-502. Describes a situation in which the government rationed sick passes, which were in great demand by overstrained workers. Physicians were forced to readjust the definition of sickness to balance the interest of the workers against the demands of the production process. Thomas S. Szasz, "Malingering: Diagnosis or Social Condemnation?" in Freidson, and Lorber, eds., Medical Mm and Their Work, pp. 353-68.

   25 Edwin S. Shneidman, "Orientations Towards Death: A Vital Aspect of the Study of Lives," in Robert W. White, ed., The Study of Lives: Essays on Personality in Honor of A. Murray (New York: Atherton, 1963). For the classification of death by intention and legitimacy and further literature on the subject, see Gregory Zilboorg, "Suicide Among Civilized and Primitive Races," American Journal of Psychiatry 92 (May 1936): 1347-69.

   26 Pharmacists, for instance, will not be condemned for poisoning their clients. See Earl R. Quinney, "Occupational Structure and Criminal Behavior: Prescription Violation by Retail Pharmacists," Social Problems 11 (1963): 179-85.

   27 Howard S. Becker, Outsiders: Studies in the Sociology of Deviance (New York: Free Press, 1963). Clarifies the connection between the therapeutic orientation of an occupation or profession and "entrepreneur-ship."

   28 Joseph R. Gusfield, "Social Structure and Moral Reform: A Study of the Woman's Christian Temperance Union," American Journal of Sociology 61 (November 1955): 221-32. Moral crusaders are always obsessed with improving those whom they set out to benefit.

   29 Frank Tannenbaum, Crime and the Community (New York: Columbia Univ. Press, 1938).

   30 Wilbert Moore and Gerald W. Rosenblum, The Professions: Roles and Rules (New York: Russell Sage, 1970). See especially chap. 3 of this comprehensive guide to the literature, "The Professionalization of Occupations."

   31 William J. Goode, "Encroachment, Charlatanism, and the Emerging Professions: Psychology, Medicine, and Sociology," American Sociological Review 25 (December 1960): 902-14.

   32 See Miriam Siegler and Humphrey Osmond, "Aesculapian Authority," Hastings Center Studies 1, no. 2 (1973): 41-52.

   33 Eliot Freidson, Profession of Medicine: A Study of the Sociology of Applied Knowledge (New York: Dodd, Mead, 1971), pp. 208 ff.

   34 June Goodfield, "Reflections on the Hippocratic Oaths," Hastings Center Studies 1, no. 2 (1973): 79-92.

   35 The law has had little experience with the problem of selecting one individual to live and thereby dooming others to die. Seamen have been convicted of manslaughter for having helped to throw 14 of 41 passengers out of a leaking lifeboat into the sea (U.S. vs. Holmes, 1842). So far the silence of the U.S. judiciary, combined with the silence of the legislature, seems to imply a preference for leaving decisions involving selection for survival to processes not subject to legal analysis. But increasing demands are made to create a rule of law to protect individuals seeking so-called life-prolonging treatment against the prejudices and arbitrariness of professional men. See below, note 204, p. 102.

   36 Seymour E. Harris, The Economics of American Medicine (New York: Macmil-lan, 1964). A detailed survey of the cost of services, drugs, various levels of manpower, and hospitals; of historical value for the period between 1946 and 1961, during which health-care costs rose by 380%.

   37 Robert W. Hetherington, Carl E. Hopkins, and Milton I. Roemer, Health Insurance Plans: Promise and Performance (New York: Wiley 1975). The U.S. is dominated by a galaxy of autonomous and often competing health plans that are sometimes commercial, sometimes provider-sponsored, and sometimes organized along the lines of group practice. For most citizens all this is supplemented by some coverage through national health insurance. This evaluation of clients' reactions to different choices shows how little they really differ.

   38 Martin S. Feldstein, The Rising Cost of Hospital Care (Washington, D.C.: Information Resources, 1971). Hospital costs have outstripped by far the rise in physicians' fees. The over-all cost of medical care has gone up faster than the average cost of all goods and services in the consumer price index. Prescription and drug costs have risen the least. Over-the-counter drug prices have actually fallen, but the drop is more than made up for by prescription costs.

   39 CREDOC (Centre de recherches et de documentation sur la consommation), Évolution de la structure des soins médicaux, 1959-1972 (Paris, 1973).

   40 "Krankheitskosten: 'Die bombe tickt'; Das westdeutsche Gesundheitswesen," 1. "Der Kampf um die Kassen-Milliarden"; 2. "Die Phalanx der niedergelassenen Ärzte," Der Spiegel, no. 19 (1975), pp. 54-66; no. 20 (1975), pp. 126-42.

   41 An excellent general introduction to the cost explosion in health care is R. Maxwell, Health Care: The Proving Dilemma; Needs vs. Resources in Western Europe, the U.S., and the U.S.S.R. (New York: McKinsey & Co., 1974). lan Douglas-Wilson and Gordon McLachlan, eds., Health Service Projects: An International Survey (Boston: Little, Brown, 1973). This international comparison shows "the extreme heterogeneity in organization and ideology" of different systems. Everywhere "the rationalization is motivated, not by politics of the left or the right, but by the sheer necessity to secure more effective use of scarce and expensive resources." No country can indefinitely sustain unchecked increases in funds allocated for the treatment of illness.

   42 Louise Russell et al., Federal Health Spending, 1969-74 (Washington, D.C.: Center for Health Policy Studies, National Planning Association, 1974). For comparison check B. Able Smith, An International Study of Health Expenditures and Its Relevance for Health Planning, Public Health Paper no. 32 (Geneva: World Health Organization, 1967). Based on a questionnaire to ministries, this supersedes the author's earlier Paying for Health Services and provides data for the study of trends. Herbert E. Klarman, The Economics of Health (New York: Columbia Univ. Press, 1965), gives a qualitative analysis of demand, supply, and organization in the U.S., with ample bibliographical guidance.

   43John Bryant, Health and the Developing World (Ithaca, N.Y.: Cornell Univ. Press, 1969). A picture of health care in countries receiving international aid.

   44 For documentation assembled by professional administrators, see Bruce Balfe et al., Resource Materials on the Socio-economic and Business Aspects of Medicine (Chicago: Center for Health Services R & D., American Medical Association, 1971). For orientation on current, mostly U.S., materials on medical economics ranging from research reports to articles in Time magazine, see American Medical Association, Medical Socioeconomic Research Sources, 12 issues per year since 1970.

   45 Feldstein, Rising Cost of Hospital Care.

   46 John H. Knowles, "The Hospital," Scientific American 229 (September 1973): 128-37. Contains charts and graphs on the evolution of hospital expenditures.

   47 Martin S. Feldstein, "Hospital Cost Inflation: Study of Nonprofit Price Dynamics," American Economic Review 61 (December 1971): 853-76. For a complementary prediction of a further increase in capital-intensive medicine see Dale L. Hiestand, "Research into Manpower for Health Services," Milbank Memorial Fund Quarterly 44 (October 1966): 146-81.

   48 Robert Rushmer, Medical Engineering: Projections for Health Care Delivery (New York: Academic Press, 1972), p. 115.

   49 Victor R. Fuchs, Who Shall Live? Health, Economics and Social Choice (New York: Basic Books, 1974), p. 15.

   50 W. H. Forbes, "Longevity and Medical Costs," New England Journal of Medicine 277 (1967): 71-8. Longevity is measured as "average remaining lifetime" (ARL). It has remained nearly constant for 1947-1965, but the U.S. rate compared with other industrialized countries has fallen sharply for men and slightly for women. "There is no longer any significant relationship [in 30 countries studied] between the money spent on health and the longevity of the population." See also P. Longone, "Mortalité et morbidité," Population et Société, no. 43 (January 1972).

   51 Victor Cohen, "More Hospitals To Fill: Abuses Grow," Technology Review, October-November 1973, pp. 14-16.

   52 Robert F. Rushmer, Medical Engineering: Projections for Health Care Delivery (New York: Academic Press, 1972), expresses the hope that the forthcoming increase in federal funding will create a new market for spare parts, from breast-enhancers to artificial hearts.

   53 Feldstein, Rising Cost of Hospital Care.

   54 William A. Glaser, Paying the Doctor: Systems of Remuneration and Their Effects (Baltimore: Johns Hopkins, 1970). Consult this cross-national comparative analysis for the impact of different methods of payment on the costliness of the physician.

   55 John and Sylvia Jewkes, Value for Money in Medicine (Oxford: Blackwell, 1963), pp. 30-7, argue: "It may be that, as electorates become more sophisticated, they will recognize they have in fact to pay (or free services"; also that relatively cheap prevention through more healthy everyday habits is more effective than purchase of repairs.

   56 Fuchs, in Who Shall Live?, chap. 3, argues for institutional licensing as a substitute for the licensing of individuals. Under such a system, medical-care institutions would be licensed by the state and would then be free to hire and use personnel as each saw fit. This system would deploy resources more efficiently and provide more upward job mobility. But the physician's control over care produced and delivered by others would be weakened.

   57 For a bibliography on socialized medicine in Britain, consult Freidson, Profession of Medicine, p. 34, n. 9.

   58 Michael H. Cooper, Rationing Health Care (London: Halsted Press, 1975). A sober, critical, and lively attempt at an over-all economic review of the nature and problems of the first 26 years of the British National Health Service.

   59 Y. Lisitsin, Health Protection in the USSR (Moscow: Progress Publishers, 1972).

   60 Mark G. Field, Soviet Socialized Medicine: An Introduction (New York: Free Press, 1967). A standard introduction (now 12 years out of date) to the Soviet medical system. Pp. ix-xii provide a critical orientation to German, English, and French literature, and chap. 5, references to the return from social to curative priorities.

   61 See below, note 64.

   62 John Frey, Medicine in Three Societies (MTP, Aylesbury, England, 1974).

   63 Mark G. Field, "Soviet and American Approaches to Mental Illness: A Comparative Perspective," Review of Soviet Medical Sciences 1 (1964): 1-36.

   64 Joachim Israel, "Humanisierung oder Bürokratisierung der Medizin?" Neue Gesellschaft 21 (1974): 397-404. Provides an inventory of 15 strong tendencies towards the bureaucratization of life, which takes specifically health-related forms in medicine and menaces people equally in the Federal Republic of Germany and in the U.S.S.R.

   65 Odin W. Anderson, Health Care: Can There Be Equity? The United States, Sweden, and England (New York: Wiley, 1972). All three systems grow towards the same kind of bureaucracy, at comparable costs, but equity in access is much lower in the U.S.A.

   66 International Bank for Reconstruction and Development, Health Sector Policy Paper, Washington, D.C., March 1975.

   67 It must not be overlooked that medical schools in poor countries constitute one of the most effective means for the net transfer of money to the rich countries. O. Ozlak and D. Caputo, "The Migration of Medical Personnel from Latin America to the U.S.: Towards an Alternative Interpretation," paper presented at the Pan-American Conference on Health and Manpower Planning, Ottawa, Canada, September 10-14, 1973. The authors estimate that the annual net loss for the whole of Latin America due to the flow of physicians to the U.S. is $200 million, a figure equal to the total medical aid given by the U.S. to Latin America during the first development decade, i.e., the period that started with the "Alliance for Progress." Hossain A. Ronaghy, Kathleen Cahill, and Timothy D. Baker, "Physician Migration to the United States: One Country's Transfusion Is Another Country's Hemorrhage," Journal of the American Medical Association 227 (1974): 538-42, provides information on outmigration of Iranian students by the university from which they graduated. Oscar Gish, ed., Doctor Migration and World Health, Occasional Papers on Social Administration no. 43, Social Administration Research Trust (London: Bell, 1971). Stephen S. Mick, "The Foreign Medical Graduate," Scientific American 232 (February 1975): 14-22. There are 58,000 imported physicians now practicing in the U.S.; fully licensed practitioners have quadrupled. In the Middle Atlantic, North Central, and New England regions, they outnumber native physicians. India, the Philippines, Italy, and Canada each paid for the full education of more than 3,000 of these; Argentina, South Korea, and Thailand, among others, for more than 1,000 each. N.B.: The training of a Peruvian physician costs about six thousand times as much as the education of a typical Peruvian peasant.

   68 In Ghana, the Central Hospital absorbed 149 of the 298 physicians available to the official health services, yet only about 1% of the patients had been officially referred by medical personnel outside the hospital. M. J. Sharpston, "Uneven Geographical Distribution of Medical Care, a Ghanaian Case Study," Journal of Development Studies 8 (January 1972): 205-22.

   69 For a useful survey of social science research on health in Latin America, see Arthur Rubel, "The Role of Social Science Research in Recent Health Programs in Latin America," Latin American Research Review 2 (1966): 37-56. Dieber Zschock, "Health Planning in Latin America: Review and Evaluation," Latin American Research Review 5 (1970): 35-56.

   70 Victor R. Fuchs, "The Contribution of Health Services to the American Economy," Milbank Memorial Fund Quarterly 44 (October 1966): 65-103. Fuchs drives this point home.

   71 For orientation see Joshua Horn, Away with All Pests: An English Surgeon in People's China, 1954-1969 (New York: Monthly Review Press, 1971). Victor W. and Ruth Sidel, "Medicine in China: Individual and Society," Hastings Center Studies 2, no. 3 (1974): 23-36. Victor Sidel, "The Barefoot Doctors of the People's Republic of China," New England Journal of Medicine 286 (1972): 1292-1300. A. J. Smith, "Medicine in China" (5 articles), British Medical Journal, 1974, 2:367-70, and the following four issues. Carl Djerassi, "The Chinese Achievement in Fertility Control," Bulletin of the Atomic Scientists, June 1974, pp. 17-24. Paul T. K. Lin, "Medicine in China," Center Magazine (Santa Barbara, Calif), May-June, 1974. M. H. Liang et al., "Chinese Health Care: Determinants of the System," American Journal of Public Health 63 (February 1973): 102-10. Horn's is still the best first-person report. Sidel's and Smith's are reports from traveling colleagues to the profession. Djerassi gives valuable insights into the status of contraception. Lin calls attention to the new challenges created by the recent prevalence of degenerative disease. See also Ralph C. Croizier, Traditional Medicine in Modem China: Science, Nationalism, and the Tension of Cultural CJiange (Cambridge: Harvard Univ. Press, 1968).

   72 David Lampton, Health, Conflict, and the Chinese Political System, Michigan Papers in Chinese Studies no. 18 (Ann Arbor: Univ. of Michigan, Center for Chinese Studies, 1974). Since 1971 competing interest groups, each trying to maximize realization of its values, have helped to re-establish the pre-1968 bureaucratic model in medicine.

   73 Instruments for the further study of contemporary Chinese health care: Joseph Quinn, Medicine and Public Health in the People's Republic of China, U.S. Department of Health, Education, and Welfare no. NIH 73-67. Fogarty International Center, A Bibliography of Chinese Sources on Medicine and Public Health in the People's Republic of China: 1960-1970, Department of Health, Education, and Welfare publication no. NIH 73-439. American Journal of Chinese Medicine, P.O. Box 555, Garden City, N.Y. 11530.

   74 Vicente Navarro, "The Underdevelopment of Health or the Health of Underdevelopment: An Analysis of the Distribution of Human Health Resources in Latin America," International Journal of Health Services 4, no. 1 (1974): 5-27. Scarcity of health care is consistent with the general scarcity of industrial outputs that favors an urban, entrepreneurial lumpen-bourgeoisie dependent on its foreign counterparts. This paper is based on a presentation at the Pan-American Conference on Health and Manpower Planning in Ottawa, Canada, September 10-14, 1973. A modified version appears in the spring 1974 issue of Politics and Society.

   75 B. Shenkin, "Politics and Medical Care in Sweden: The Seven Crowns Reform," New England Journal of Medicine 288 (1973): 555-59. For background consult Ronald Huntford, The New Totalitarians (New York: Stein & Day, 1972).

   76 Roy A. and Zhores Medvedev, A Question of Madness (New York: Knopf, 1972), complain that the nature of society is such that at least two professions, medicine and law, are not part of the state system. The totalitarian centralization of medical services, while it has introduced the progressive principle of free health care for all, has also made it possible to use medicine as a means of government control and political regulation.

   77 David R. Hyde et al., "The American Medical Association: Power, Purpose, and Politics in Organized Medicine," Yale Law Journal 63 (May 1954): 938-1022. Hyde is an early, dated, but still valuable critic. Richard Harris, A Sacred Trust (Baltimore: Penguin, 1969). A history of the American Medical Association's clever and costly battle against public health legislation in the sixties. Elton Rayack, Professional Power and American Medicine: The Economics of the American Medical Association (Cleveland: World Pub., 1967), describes blackmail and conspiracy by the American Medical Association lobby to maintain tight control over licensing and the setting of standards for every product that physicians perceive as health-related. This control removes all limits from their power.

   78 On the reasons that foreshadow the unionization of doctors, see S. Kelman, "Towards a Political Economy of Medical Care," Inquiry 8, no. 3 (1971): 30-8; also note 79, p. 248.

   79 Lewis Mumford, The Pentagon of Power, vol. 2, The Myth of the Machine (New York: Harcourt Brace, 1970), elaborates on the concept of society as megamachine.

   80 Beyond a certain point of intensity, consumption produces a scarcity of time: Staffan B. Linder, Harried Leisure Class (New York: Columbia Univ. Press, 1970); acceleration produces a penury of space: Jean Robert, "Essai sur 1'accélération des dons," L'Arc (Aix-en-Provence), fall 1975; and planning destroys the possibilities for choice: Herbert Marcuse, Eros and Civilization (Boston: Beacon Press, 1955).

   81 René Dubos, Man and His Environment: Biomedical Knowledge and Social Action, Pan-American Health Organization, Scientific Publication no. 131 (Washington, D.C., March 1966). "The kind of health that men desire most is ... the condition best suited to reach goals that each individual formulates for himself." See also Heinz von Foerster, Molecular Ethology: An Immodest Proposal (New York: Plenum Press, 1970), for a demonstration from theoretical biology that nontrivial "life" can be extinguished by overprogramming.

   82 Victor Fuchs, "Some Economic Aspects of Mortality in Developed Countries," paper presented at the Conference on the Economy of Health and Medical Care, Tokyo, 1973, mimeographed. Fuchs assumes that "life is primarily produced by nonmarket activities, and that the female tends to specialize in such activities." The attempt to replace rather than to complement these "nonmarket activities" with commodities is literally unhealthy. See Alan Berg, The Nutrition Factor: Its Role in National Development (Washington, D.C.: Brookings Institution, 1973), app. C, p. 229, on the sickening effects of the substitution of various formulas for breast milk.

   83 The medicalization of the budget is a measure of the professional disseizin of health and of the acquiescence of people in their own disendowment by therapeutic caretakers. Disseizin: "the wrongful putting out of him from that which is actually seized as a freehold": P. G. Osborn, Concise Law Dictionary (London: Sweet & Maxwell, 1964).

   84 For a first orientation: Alfred M. Ajami, Jr., Drugs: An Annotated Bibliography and Guide to the Literature (Boston: Hall, 1973). Ajami selects and annotates more than 500 references on psychopharmacology for an interdisciplinary course on the U.S. "scene" of the late sixties. U.S. National Clearing House for Mental Health, Bibliography of Drug Dependence and Abuse 1928-1966 (Chevy Chase, Md., J969). Indispensable for historical research. Alice L. Brunn, How to Find Out in Pharmacy: A Guide to Sources of Pharmaceutical Information (Oxford: Pergamon Press, 1969). A simple reference guide. R. H. Blum et al., Society and Drugs, 2 vols. (Berkeley, Calif.: Jossey-Bass, 1970). A portable library on society and drugs.

   85 G. E. Vaillant, "The Natural History of Narcotic Drug Addiction," in Seminars in Psychiatry 2 (November 1970): 486-98. Drugs depend both for their desirability and their effect on the milieu in which they are taken. The choice of the drug is a function of the culture, but the abuse of the drug is a function of the man. The ritualization of drug-taking creates its subculture: thus the history of drug addiction as that of society must be rewritten every few years. Samuel Proger, ed., The Medicated Society (New York: Macmillan, 1968), provides documents showing the kind of drug culture that prevailed in the U.S. long before LSD.

   The extent to which addicts are forced into a ghetto of their own depends upon the community that rejects them. For instance, Puerto Ricans in New York do not reject their addicts in the way middle-class Americans do: J. P. Fitzpatrick, "Puerto Rican Addicts and Nonaddicts: A Comparison," unpublished report, Institute for Social Research, Fordham University, 1975.

   86 Hans Wiswe, Kulturgeschichte der Kochkunst: Kochbücher und Rezepte aus zwei Jahrtausenden (Munich: Moos, 1970). Most societies cannot distinguish clearly between their pharmacopeia and their diet. This survey of cookbooks shows that many were written by physicians, with a frequent insistence that the best medicine comes from the kitchen and not from the pharmacy. Most contain "recipes" for the care of the sick.

   87 For the present information available on drug action, see Louis S. Goodman and Alfred Gilman, The Pharmacological Basis of Therapeutics, 4th ed. (New York: Macmillan, 1970). On prescribing patterns, see Karen Dunnell and Ann Cartwright, Medicine Takers, Prescribers and Hoarders (London: Routledge, 1972). Who takes which sort of medicines for what types of conditions and symptoms? How do doctors encourage or discourage this pattern? What kinds of medicines are kept in the home and for how long? Detailed information about England. Also see John P. Morgan and Michael Weintraub, "A Course on the Social Functions of Prescription Drugs: Seminar Syllabus and Bibliography," Annals of Internal Medicine 77 (August 1972): 217-22; Paul Stolley and Louis Lasagna, "Prescribing Patterns of Physicians," Journal of Chronic Diseases 22 (December 1969): 395-405.

   88 Business in Thailand, special issue on the pharmaceutical industry, August 1974.

   89 The American physician can easily gain access to this information from such sources as Medical Letter on Drugs and Therapeutics, Medical Library Association, 919 N. Michigan Avenue, Chicago, 111. This is an unbiased source of drug information mailed fortnightly. Nothing comparable is available in French, German, or Spanish. Also see Richard Burack, The New Handbook of Prescription Drugs: Official Names, Prices, and Sources for Patient and Doctor, rev. ed. (New York: Pantheon, 1970). (See below, note 99, p. 67, for description of this book.)

   90 Arturo Aldama, "Establecimiento de un laboratorio farmacéutico nacional," Higiene: Organo oficial de la Sociedad Mexicana de Higiene 11 (January-February 1959). This sounded the alarm.

   91 The information on Cloromycetin is taken from U.S. Senate, Select Committee on Small Business, Subcommittee on Monopoly, Competitive Problems in the Drug Industry, 90th Congress, 1st and 2nd Sessions, 1967-68, pt. 2, p. 565.

   92 On the mechanisms that turn self-regulation into license for performance of the maximum publically tolerated abuse, see Eliot Freidson and Buford Rhea, "Process of Control in a Company of Equals," Social Problems 9 (1963): 119-131. They show that, though much abuse goes unobserved, even if observed it is not communicated to colleagues, and even if communicated it is treated by "talking to the offender" and remains uncontrolled. Self-regulation principally protects the profession by eliminating the incompetent butcher and the brazen moral leper. William J. Goode, "The Protection of the Inept," American Sociological Review 32 (February 1967): 5-19. Goode describes how self-regulation consists to a large degree in the protection of the inept within the group and the protection of the group's self-interest from the excesses of the inept. Modernization consists in the more efficient utilization of the inept in the self-interest of the group. Eliot Freidson and Buford Rhea, "Knowledge and Judgment in Professional Evaluations," Administrative Science Quarterly 10 (June 1965): 107-24.

   93 Memory is no guide to which drugs have been prescribed or consumed in the past. A search in the national registry of prescriptions in England and Wales shows that 8 out of 10 women who had borne a defective child after taking thalidomide on prescription denied that they had taken the drug, and that their physicians denied having ordered it. See A. L. Speirs, "Thalidomide and Congenital Abnormalities," Lancet, 1962, 1:303.

   94 Henri Pradal, Guide des médicaments les plus courants (Paris: Seuil, 1974). In November 1973 my French publisher, Seuil, brought out a paperback original of this book by a physician with many years' experience as a toxicologist. It is a list of the 100 best-selling pharmaceuticals, including prescription drugs, explaining what each one is, what it is indicated for, how it tends to be used or prescribed, and with what consequences. On publication day 57 drug firms started separate legal actions to have the book withdrawn and sued for reimbursement for probable damages.

   95 A. del Favero and G. Loiacono, Farmaci, salute e profitti in Italia (Milan: Feltrinelli, 1974), describe the dependence and servility of the Italian physician in his relations with the drug industry, and the exploitative integration of the Italian drug firms among transnational companies. Full of documentation and detail.

   96 James H. Young, Medical Messiahs: A Social History of Health Quackery in Twentieth-Century America (Princeton, N.J.: Princeton Univ. Press, 1967). Historical background for the cavalier confidence of U.S. organized medicine based on its protection of the public against free-lance healers and self-medication. For the earlier history see James H. Young, The Toadstool Millionaires: A Social History of Patent Medicines in America Before Federal Regulation (Princeton, N.J.: Princeton Univ. Press, 1961).

   97 Robert S. McCleery, One Life—One Physician: An Inquiry into the Medical Profession's Performance in Self-Regulation, A Report to the Center for the Study of Responsive Law (Washington, D.C.: Public Affairs Press, 1971). This report to a study group initiated by Ralph Nader concludes that there is a total lack of internal quality control within the medical profession.

   98 Morton Mintz, By Prescription Only: A Report on the Roles of the United States Food and Drug Administration, the American Medical Association, Pharmaceutical Manufacturers and Others in Connection with the Irrational and Massive Use of Prescription Drugs that May Be Worthless, Injurious, or Even Lethal, 2nd ed. (Boston: Beacon Press, 1967). Originally published as The Therapeutic Nightmare (Boston: Houghton Mifflin, 1965), this masterpiece of investigative journalism by a staff reporter of the Washington Post has done more than any other book to change the focus of the U.S. discussion of medicine. For ten years a benevolent minority had worried about the damage done by capitalist medicine to the poor. Now the pill-swallowing majority became aware of what it was doing to them.

   99 Richard Burack, M.D., The New Handbook of Prescription Drugs: Official Names, Prices and Sources for Patient and Doctor (New York: Pantheon, 1970). Published at a time when judicial evidence for the undue bias of regulatory commissions, conspiracy for the dissemination of misleading information on poisonous drugs, and the venality of not a few professors of medicine was still difficult to obtain this book provides information and evaluation of the efficiency, usefulness, side-effects, and application of the 200 most prescribed drugs, comments on brand-name prices in comparison with generic equivalents (for which suppliers are listed with addresses), and adds spicy anecdotes on many trademarked nostrums.

   100 James L. Goddard, "The Drug Establishment," Esquire, March 1969. A readable and well-researched report.

   101 Edwin Sutherland, While-Collar Crime (New York: Holt, 1961), uses this term to designate a wide variety of serious offenses involving recognized social harm that either are not prosecuted or are confined to civil courts. The medical variety has epidemic consequences and might be called "white-coat crime."

   102 Herbert Schreier and Lawrence Berger, "On Medical Imperialism: A Letter," Lancet, 1974, 1:1161: "Under pressure from the US Food and Drug Administration, Parke-Davis inserted strict warnings of hazards and cautionary statements about indications for the use of the drug in the USA. The warning did not extend to the same drug abroad." Also see John F. Hellegers, "Chloramphenicol in Japan: Let It Bleed," Bulletin of Concerned Asia Scholars 5 (July 1973): 37-45. The expansion of federal controls over the export of drugs would only partially remedy this form of imperialism. Federal authority, which now does cover the $6 billion pharmaceutical drug industry, does not yet extenc over the $3 billion medical device industry. It cannot, for example, stop the A. H. Robins company from supplying foreign companies with a model of a contraceptive shield which has been withdrawn from the U.S. market because of its high infection rate; see Hastings Center Studies 5, no. 3 (1975): 2.

   103 On medicine in Chile under Allende consult Howard Waitzkin and Hilary Modell, "Medicine, Socialism, and Totalitarianism: Lesson from Chile," New England Journal of Medicine 291 (1974): 171-7; Vicente Navarro, "What Does Chile Mean? An Analysis of Events in the Health Sector Before, During, and After Allende's Administration," Milbank Memorial Fund Quarterly 52 (spring 1974): 93-130. This article is based on a paper presented at the International Health Seminar at Harvard University, February 1974. For an eyewitness report, see Ursula Bernauer and Elisabeth Freitag, Poder popular in Chile am Beispiel Gesundtieit: Dokumente ata Elendsvierteln (Stein/Nuremberg: Laetere/Imba, 1974).

   104 Albert Jonsen et al., "Doctors in Politics: A Lesson from Chile," New England Journal of Medicine 291 (1974): 471-2. Describes the particular violence with which physicians were persecuted by the junta.

   105John M. Firestone, Trends in Prescription Drug Prices (Washington, D.C.: Enterprise Institute for Public Policy Research, 1970). Drug expenditures account for only about 10% of health expenditures. The moderate rise in the cost of each prescription during the last years is due mainly to an increase in the size of the average prescription.

   106 Edward M. Brecher and Consumer Reports Editors, Licit and Illicit Drugs: The Consumers Union Report on Narcotics, Stimulants, Depressants, Inhalants, Hallucinogens and Marijuana—Including Caffeine, Nicotine and Alcohol (Boston: Little, Brown, 1973).

   107 D. M. Dunlop, "The Use and Abuse of Psychotropic Drugs," in Proceedings of the Royal Society of Medicine 63 (1970): 1279. G. L. Klerman, "Social Values and the Consumption of Psychotropic Medicine," in Proceedings of the First World Congress on Environmental Medicine and Biology (Haarlem: North-Holland, 1974). For a particularly pernicious form of medically prescribed drug addiction see Dorothy Nelkin, Methadone Maintenance: A Technological Fix (New York: Braziller, 1973).

   108 James L. Goddard, "The Medical Business," Scientific American 229 (September 1973): 161-6. Contains graphs and charts showing U.S. sales of prescription and nonprescription drugs by category, 1962-71; breakdown by sales dollar estimated in 1968 for 17 leading pharmaceutical houses; introduction of new drugs, combinations, and dosage forms, 1958-72. Also identifies 8 classes of prescription drugs. Within the category "nervous system drugs" alone, sales aggregate more than $1 billion per year. This compares with three other categories each aggregating about $500 million, and the rest, each less than $350 million. For a breakdown, by age, sex, and type, of medicines prescribed to nonhospitalized patients in the course of one year in the U.S., see B. S. H. Harris and J. B. Hallan, "The Number and Cost of Prescribed Medicines: Selected Diseases," Inquiry 7 (1970): 38-50.

   109 Drug Use in America: Problem in Perspective, Second Report of the National Commission on Marihuana and Drug Abuse, 1972, 1973, 1974, 4 vols. (Washington, D.C.: Government Printing Office; stock no. 5266-0003). National Commission for the Study of Nursing and Nursing Education, An Abstract for Action (New York: McGraw-Hill, 1970).

   110 Mitchell Baiter et al., "Cross-national Study of the Extent of Anti-Anxiety/Sedative Drug Use," New England Journal of Medicine 290 (1974): 769-74.

   111 Michael Balint, Treatment or Diagnosis: A Study of Repeat Prescriptions in General Practice, Mind and Medicine Monographs (Philadelphia: Lippincott, 1970). Prescription provides luster and seeming rationality to the belief that progress consists in buying one's way out of everything, including reality itself. Balint points out that in two-thirds of cases in which drugs were repeatedly prescribed without any technical justification, the physician himself took the initiative to offer the drug. Harry Dowling, "How Do Practicing Physicians Use New Drugs?" Journal of the American Medical Association 185 (1963): 233-36. Out of fear of "doing nothing" the practitioner is led to prescribe more than is indicated by instructions on the package. On the pattern according to which prescription abuses spread, see Leighton E. duff et al., "Studies in the Epidemiology of Adverse Drug Reactions," Journal of the American Medical Association 188 (1964): 976-83.

   l12Philippe de Felice, Poisons sacrés: Ivresses divines; Essai sur quelques formes inferieures de la mystique (Paris: Albin, 1936; reprinted 1970). The traditional, usually religious setting and goal for drug consumption are contrasted with present-day laicized use of mind-altering substances.

   113 Charles Levinson, Valium zum Beispiel: Die multinational Konzeme der pharmazeutischen Industrie (Hamburg: Rowohlt, 1974). The prices charged in India by Glaxo, Pfizer, Hoechst, CIBA-Geigy, and Hofftnann-LaRoche are on the average 357% higher than those listed in the Western countries where these firms have their home offices.

   114 See also Burack, New Handbook of Prescription Drugs.

   115 In most countries, most information on drugs for the physician comes from industry-sponsored manuals such as Physicians' Desk Reference to Pharmaceutical Specialities and Biologicals, published since 1946 by Medical Economics, Rutherford, NJ. This annual publication, known as PDR, is supported by the pharmaceutical industry. The drug descriptions are written by the companies themselves, which pay $115 per column-inch for the space; see John Pekkanen, The American Connection: Profiteering and Politicking in the "Ethical" Drug Industry (Chicago: Follett, 1973), p. 106. The French Vidal contains descriptions which suppress the warnings that are obligatory in the leaflet that comes with the drug. In contrast to these, the U.S. has two semiofficial pharmacological compendia, the Pharmacopeia of the United States of America (USP) and the National Formulary (NF). The USP has consistently given consideration to therapeutic worth and toxicity. These compendia are not written for the guidance of physicians, but to provide drug manufacturers with technical standards that preparations must meet to be marketed legally in interstate commerce in the U.S.

   116 For an idea of the number of physicians at the service of a single manufacturer in the decision to promote just one product consult Librium: Worldwide Bibliography, published yearly since 1959 by Roche Laboratories. The first four years contain 832 entries. See also Science 180 (1973): 1038, for a report of a study conducted by the Federal Drug Administration on the ethics of physicians who conduct field research with new drugs. One-fifth of those investigated had invented the data they sent to the drug companies, and pocketed the fees.

   117 Selig Greenberg, The Quality of Mercy: A Report on the Critical Condition of Hospital and Medical Care in America (New York: Atheneum, 1971).

   118 H. Friebel, "Arzneimittelverbrauchs-Studien," in H. J. Dengler and W. Wirth, eds., Seminar für Klinische Pharmakologie auf Schloss Reisenberg bei Günzburg/ Donau, vom 25-29. Oktober, 1971, Uberreicht von der Medizinisch-Pharmazeu-tischen Studiengesellschaft E.V., Frankfurt am Main, pp. 228-40. Short, valuable statement on the lack of useful measurements, which makes such a broad statement the best that can be responsibly offered. The author is a director of the Drug Efficacy and Safety Division of the World Health Organization.

   119 World Health Organization, Regional Office for Europe, Consumption of Drugs: Report on a Symposium, Oslo, November 3-7, 1969. Limited edition, available only to persons with official professional standing through the WHO regional office in Copenhagen. This study is the first of its kind. It compares 22 countries, noting significant differences in drug-consumption patterns but enormous difficulties in establishing precise comparisons. Therapeutic categories, cost evaluations, and measurements for pharmacological units differ. From the information it is legitimate to deduce that total consumption of medicine is largely independent of cost or of the kind of practice that is prevalent, i.e., private or socialized. The consumption in a given country of those drugs that require a prescription is positively related to the density of prescribing physicians.

   120 Alfred M. Freedman, "Drugs and Society: An Ecological Approach," Comprehensive Psychiatry 13 (September-October 1972): 411-20.

   121 Alvin Moscow, Merchants of Heroin (New York: Dial Press, 1968). This can serve as an introduction to one branch of underworld business.

   122 For the history of the conscious use of the placebo effect, see Arthur K. Shapiro, "A Contribution to a History of the Placebo Effect," Behavioral Science 5 (April 1960): 109-35; Gerhard Kienle, Arzneimittelsicherheit und Gesellschaft: Eine kritische Untersuchung (Stuttgart: Schattauer, 1974). The ability of the placebo to provoke symptoms of a specific kind, even when given in a double-blind situation, is discussed by Kienle in chap. 7. A mine of international literature on drug safety.

   123 See the statements by Henry Simmons, director of the Food and Drug Administration's Bureau of Drugs, in Nicholas Wade, "Drug Regulation: Food and Drug Administration Replies to Charges by Economists and Industry," Science 179 (1973): 775-7.

   124 Ibid.

   125 Fuchs, Who Shall Live?

   126 William M Wardell, "British Usage and American Awareness of Some New Therapeutic Drugs," Clinical Pharmacology and Therapeutics 14 (November-December 1973): 1022-34. Studies new drugs which became available in England and were widely discussed in the literature to which U.S. doctors subscribe. Wardell finds that the American specialist is not aware of the existence of these drugs unless they are marketed in the U.S. and that he is therefore subject to enlightment by detail men.

   127 Medizinisch-Pharmazeutischen Studiengesellschaft E.V., Bioverfügbarkeit van Arzneistoffen, Schriftenreihe der Medizinisch-Pharmazeutischen Studiengesellschaft E.V., vol. 6 (Frankfurt: Umschau, 1974). Joint public-relations campaigns conducted by otherwise competing firms deserve special attention. At present, they focus on extolling the superiority of trademarked products over generic equivalents—e.g., of Bayer Aspirin over the generic drug aspirin—on the grounds of "bio-availability," a higher and more controlled biological availability of the drug once it is incorporated into the organism. For any unprejudiced mind, ten years' research has proved that with the one exception of a generic preparation of chloramphenicol (see Burack, A New Handbook of Prescription Drugs, p. 85), generic drugs are in no way inferior to those produced under trade names. This conclusion has been incorporated into U.S. federal policy-making. Nevertheless, for the last 5 years the drug companies have sponsored several hundred "research papers" per year on differences in "bio-availability," spending on the author of each paper an average of $6,000 in honoraria, expenses, and costs of attending professional conferences. Many of these authors are department heads of major universities. The conclusions of most papers show no medically significant difference. But the total impact of this phantom research is the mystification of the prescribing general practitioner, who will often recommend the drug advertised for its high "bio-availability," irrespective of its cost.

   128 J. P. Dupuy and A. Letourmy, Déterminants et coûts sociaux de I'innovation en matière de santé, report by the OCDE, 1974. The authors support this thesis. The refinement of those criteria by which a specialist measures the effectiveness of his specialized intervention, after a certain threshold, will ensure the appearance of generically predictable unwanted side-effects. If, in their turn, the specific diagnosis and treatment of these side-effects were attempted, this further medical intervention would only reinforce iatrogenesis.

   129 On the certification of prostitutes, see William W. Sanger, The History of Prostitution (New York: American Medical Press, 1858).

   130 For history of medical death certificates, see U.S. National Office of Vital Statistics, First Things and Last: The Story of Birth and Death Certificates, U.S. Public Health Service Publication no. 724 (Washington, D.C., I960).

   131 Office of Health Economics, Off Sick, January 1971, p. 17. It is estimated that between 15 and 30% of all visits to the doctor have no other purpose than obtaining a certificate. In 58% of the cases, the final day of incapacity noted on certificates justifying sick leave is Saturday.

   132 The encroachment of expertise on the rule against hearsay is of course not limited to medicine. It is a common feature of secularization and of the rise of the professions. Inside and outside the courtroom, it whittles away confidence in what the common man sees and hears, and thus undermines both the judicial and the political process. On the author's view of professional expropriation of language, science, and legal procedures, see Ivan Illich, Tools for Conviviality (New York: Harper & Row, 1973), pp. 85-99.

   133 Franz Boll, "Die Lebensalter: Ein Beitrag zur antiken Ethologie und zur Geschichte der Zahlen," Neue Jahrbucher für das klassische Altertum, Geschichte und deutsche Literatur 16, no. 31 (1913): 89-145.

   134 See E. E. Evans-Pritchard, Witchcraft, Oracles, and Magic Among the Azande (New York: Oxford Univ. Press, 1937), for the distinction of the sorcerer from the witch. This distinction is refined and applied to Western culture by Jeffrey B. Russell, Witchcraft in the Middle Ages (Ithaca, N.Y.: Cornell Univ. Press, 1972). The demonological element that transforms the sorceress into a heretic is usually grafted on at the level of the courts.

   135 Victor W. Turner, "Betwixt and Between: The Liminal Period in Rites de Passage," in American Ethnological Society, Symposium on New Approaches to the Study of Religion: Proceedings, 1964 (Seattle: Univ. of Washington Press, 1965), pp. 4-20. By medicalization of life, what appeared to be "liminal" in past societies has been made the everyday situation of administered man.

   136 Arnold van Gennep, The Rites of Passage (London: Routledge, 1960 [French original, 1909]). The recent critique of the author by Levy-Strauss has not called into question his basic idea that periods of initiation affirm and symbolize the continuing health-maintaining function of culture.

   137 For literature on the subtle penetration of the hospital into the interstices of the modern city consult Gerald F. Pyle. "The Geography of Health Care," in John Melton Hunter, The Geography of Health and Disease, Studies in Geography no. 6 (Chapel Hill, N.C.: Univ. of North Carolina Press, 1974), a spatial analysis at the service of health planners. For a book-length treatment of the architectonic impact of hospitals on our society, see Roslyn Lindheim, The Hospitalization of Space (London: Calder & Boyars, 1976). Lindheim demonstrates how the reorganization of spatial patterns at the service of physicians has impoverished the nonmedical, health-supporting, and healing aspects of the social and physical environment for modern man.

   138 For orientation on the social science literature on the old and aging, see James E. Birren, Yonina Talmon and Earl F. Cheit, "Aging: 1. Psychological Aspects; 2. Social Aspects; 3. Economic Aspects," International Encyclopedia of the Social Sciences (1968), 1:176-202. For orientation on German literature, see Volkmar Boehlau, ed., Wege zur Erforschung des Alterns, Wege der Forschung, vol. 189 (Darmstadt: Wissenschaftliche Buchgesellschaft, 1973), an anthology. On French contemporary aging, Michel Philibert, L'Echelle des âges (Paris: Seuil, 1968).

   139John H. Dingle, "The Ills of Man," Scientific American 229 (September 1973): 77-82. The study that comes to this "conclusion" is broadly based. It distinguishes four perspectives on "ailment": (1) people, (2) physicians, (3) patients, (4) compilers of vital statistics. From all four points of view this conclusion seems to hold.

   140 Max Neuburger, The Doctrine of the Healing Power of Nature Throughout the Course of Time, trans. L. J. Boyd (New York: privately printed, 1932). For more recent referencees, Joseph Schumacher, Antike Medizin: Die naturphilosophischm Grundlagen der Medizin in der griechischen Antike (Berlin: Gruyter, 1963).

   141 J. F. Partridge and J. S. Geddes, "A Mobile Intensive-Care Unit in the Management of Myocardial Infarction," Lancet, 1967, 2:271.

   142 Simone de Beauvoir, The Coming of Age: The Study of the Aging Process, trans. Patrick O'Brian (New York: Putnam, 1972). A monumental treatment of old age throughout history in the perspective of contemporary aging. See also Jean Amery, Über das Alter: Revolte und Resignation (Stuttgart: Klette, 1968), an exceptionally sensitive contemporary phenomenology of aging.

   143 World Health Statistics Report 27, September 1974. An international comparison of 27 industrialized countries shows that for the age group 15-44 years old, accidents were the leading cause of death in 1971 (except for England and Wales). In half of these countries they accounted for more than 30% of all deaths.

   144 David Jutman, "The Hunger of Old Men," Trans-Action, November 12, 1971, pp. 55-66.

   145 A. N. Exton-Smith, "Terminal Illness in the Aged," Lancet, 1961, 2:305-8. Most pain and suffering are associated with processes that lead indirectly to death. Although the use of antibiotics may avert or delay complications such as bronchopneumonia, which would otherwise be fatal, this often adds little time and much pain to a life.

   146 Rick Carlson, in The End of Medicine (New York: Wiley Interscience, 1975), develops this whole point very well. See also H. Harmsen, "Die sozialmedizin-ische Bedeutung der Erhöhung der Lebenserwartung und der Zunahme des Anteils der Bejahrten bis 1980," Physikalische Medizin und Rehabilitation 9, no. 5 (1968): 119-21.

   147 Robert A. Scott, The Making of Blind Mm (New York: Russell Sage, 1969). Being accepted among the blind and behaving like a blind person are to a great extent independent of the degree of optical impairment. For most of the "blind," it is above all the result of their successful client relationship to an agency concerned with "blindness."

   148 Roslyn Lindheim, "Environments for the Elderly: Future-Oriented Design for Living?" February 20, 1974, mimeographed. Describes the way the old experience space.

   149 On the social elimination of the old the main source remains John Koty, Die Behandlung der Alien und Kranken bei dm Naturvölkem (Stuttgart: Hirschfeld, 1934). I have not seen Fritz Paudler, Die Alien- und Krankentötung als Situ bei dm indogermanischen Völkern (Heidelberg, 1936). Complete reference to the literature in Will-Eich Peuckert, ed., "Altentotung," in Handwörterbuch der Sage (Gottingen: Vandenhoeck & Ruprecht, 1961).

   150 A. Jores and H. G. Puchta, "Der Pensionierungstod: Untersuchungen an Hamburger Beamten," Medizinische Klinik 54, no. 25 (1959): 1158-64.

   151 David Bakan, Disease, Pain and Sacrifice: Toward a Psychology of Suffering (Boston: Beacon Press, 1971). These diseases include asthma, cancer, congestive heart failure, diabetes mellitus, disseminated lupus, functional uterine bleeding, Raynaud's disease, rheumatoid arthritis, thyrotoxicosis, tuberculosis and ulcerative colitis. See ibid, for literature on each.

   152 Elisabeth Markson, "A Hiding Place To Die," Trans-Action, November 12, 1972, pp. 48-54. A pathetic and sensitive report. See also Jutman, "The Hunger of Old Men." The old have always obliged by dying on request: David Lester, "Voodoo Death: Some New Thoughts on an Old Phenomenon," American Anthropologist 74 (June 1972): 386-90; Walter B. Cannon, "Voodoo Death," American Anthropologist 44 (April-June 1942): 169-81. There were always ways of driving them to suicide: J. Wisse, Selbstmord und Todesfarcht bei den Naturvölkern (Zutphen: Thieme, 1933).

   153 Peter Townsend, The Last Refuge: A Survey of Residential Institutions and Homes for the Aged in England and Wales (London: Routledge, 1962). Complements previous work done by the author. Evaluates residential accommodations as provided under the British National Assistance Act of 1948 and points to the lack of equity in treatment. Anne-Marie Guillemard, La Retraite, one mart sociale: Sociologie des conduites en situation de retraite (Paris: Mouton, 1972). A socio-economic study which shows that class discrimination is strongly accentuated in French retirement.

   154 A. Eardley and J. Wakefield, What Patients Think About the Christie Hospital, University Hospital of South Manchester, 1974. From year to year the demands made by people at a certain age above 70 become more specific and costly.

   155 The "baby" is a rather recently developed social category: the first stage in the development of man-the-consumer. On the process by which the suckling was slowly turned into a baby and the assistance that medicine provided in this process, see Luc Boltanski, "Prime education et morale de classe," Cahiers du Centre de sociologie européenne (The Hague/Paris: Mouton, 1969).

   156 The culture of childhood as that characteristic for an age group distinct from the adult and the infant is of social origin, like that of the "baby." See Philippe Aries, Centuries of Childhood: A Social History of Family Life (New York: Knopf, 1962), especially on the profound change the attitude towards the death of a child underwent between the 17th and the 19th centuries.

   157 John Bryant, M.D., Health and the Developing World (Ithaca, N.Y.: Cornell Univ. Press, 1969).

   158 About the relatively much higher resistance to malaria, infections, and deficiency diseases of breast-fed babies, see "Milk and Malaria," British Medical Journal, 1952, 2:1405, and 1953, 2:1210. O. Mellander and B. Vahlquiest, "Breast Feeding and Artificial Feeding," Acta Paediatrica 2, suppl. (1958): 101. For a survey of literature, the editorial "Breast Feeding and Polio Susceptibility," Nutrition Review, May 1965, pp. 131-3. Leonardo J. Mata and Richard Wyatt, "Host Resistance to Infection," American Journal of Clinical Nutrition 24 (August 1971): 976-86.

   159 For more data on the impact of the bottle on world nutrition, see Alan Berg, The Nutrition Factor: Its Role in National Development (Washington, D.C.: Brookings Institution, 1973). A child nursed through the first two years of its life receives the nutritional equivalent of 461 quarts of cow's milk, which costs the equivalent of the average yearly income of an Indian.

   160 The pattern of worldwide modern malnutrition is reflected in the two forms that infant malnutrition takes. The switch from the breast to the bottle introduces Chilean babies to a life of endemic undernourishment; the same switch initiates British babies into a life of sickening, addictive overalimentation: see R. K. Gates, "Infant Feeding Practices," British Medical Journal, 1973, 2:762-4.

   161 On life as a constant training for survival in the megamachine, see Lewis Mumford, The Pentagon of Power: The Myth of the Machine, Volume 2 (New York: Harcourt Brace, 1970).

   162 Thomas J. Scheff, Being Mentally III: A Sociological Theory (Chicago: Aldine, 1966). Though he deals primarily with psychiatric issues, Scheff does stress the analytic difference between mental illness that is part of the social system and the corresponding behavior.

   163 Freidson, Profession of Medicine, p. 223.

   164 Erving Goffman, Stigma: Notes on the Management of Spoiled Identity (Engle-wood Cliffs, N.J.: Spectrum 1963). See also Richard Sennett, "Two on the Aisle," New York Review of Books, November 1, 1973, who underlines that for Goffman the central task is a description of the consciousness induced by living in a modern city. Contemporary life inevitably stigmatizes; on the mechanisms see H. P. Dreitzel, Die gesellschaftlichen Leiden und das Leiden an der Gesellschaft: Vorstudien zu einer Pathologic des Rollenverhaltens (Stuttgart: Enke, 1972).

   165 Wilhelm Aubert and Sheldon Messinger, "The Criminal and the Sick," Inquiry 1 (1958): 137-60. Discusses the different forms social control can take, depending on the special way in which stigma impinges on moral identity.

   166 Fred Davis, Passage Through Crisis: Polio Victims and Their Families (Indianapolis: Bobbs-Merrill, 1963). Davis relates transitoriness not only to seriousness but also to social class. The poor will be diagnosed as "permanently impaired" much sooner than the rich.

   167 C. M. Wylie, "Participation in a Multiple Screening Clinic with Five-Year Follow-up," Public Health Reports 76 (July 1961): 596-602. Report indicates disappointing results.

   168 G. S. Siegel, "The Uselessness of Periodic Examination," Archives of Environmental Health 13 (September 1966): 292-5. "Periodic health examination of adults, as originally conceived and currently practiced, remains, after 50 years of vigorous American promotion, a scientifically unproven medical procedure. We do not have conclusive evidence that a population receiving such care lives longer, better, healthier, or happier because of it, nor do we have evidence to the contrary."

   169 Paul D. Clote, "Automated Multiphasic Health Testing: An Evaluation," independent study with John McKnight, Northwestern University, 1973; reproduced in Antologia A8 (Cuernavaca: CIDOC, 1974). Reviews the available literature.

   170 J. Schwartz and G. L. Baum, "The History of Histoplasmosis," New England Journal of Medicine 256 (1957): 253-8. Describes the costly discovery of an incurable "disease" that neither kills nor impairs and seems to be endemic wherever people come in contact with chickens, cattle, cats, or dogs.

   171 Freidson, Profession of Medicine, pp. 73 ff., makes the distinction I here apply. As a scholarly professional, the medical scientist need contend only with his colleagues and their acceptance of his "invention" of a new disease. As a consulting professional, the practicing physician depends on an educated public that accepts his exclusive right to diagnose.

   172 Parsons, The Social System, pp. 466 ff. The author makes this point commenting on Pareto.

   173 Thomas J. Scheff, "Decision Rules, Types of Error, and Their Consequences in Medical Diagnosis," Behavioral Science 8 (1963): 97-107.

   174 American Child Health Association, Physical Defects: The Pathway to Correction (New York, 1934), chap. 8, pp. 80-96.

   175 Harry Bakwin, "Pseudodoxia Pediatrica," New England Journal of Medicine 232 (1945): 691-97.

   176 For references and further bibliography see L. H. Garland, "Studies on the Accuracy of Diagnostic Procedures," American Journal of Rontgenology, Radium Therapy, and Nuclear Medicine 82 (July 1959): 25-38. See also A. L. Cochrane and L. H. Garland, "Observer Error in the Interpretation of Chest Films: An International Comparison," Lancet 263 (1952): 505-9. Suggests that American diagnosticians might have a stronger penchant for positive findings than their British counterparts. A. L. Cochrane, P. J. Chapman, and P. D. Oldham, "Observers' Errors in Taking Medical Histories," Lancet 260 (1951): 1007-9.

   177 Osier Peterson, Ernest M. Barsamian, and Murray Eden, "A Study of Diagnostic Performance: A Preliminary Report," Journal of Medical Education 41 (August 1966): 797-803.

   178 Maurice Pappworth, Human Guinea Pigs: Experimentation on Man (Boston: Beacon Press, 1968). In 1967 Dr. Pappworth published a report on experimental diagnostic procedures that involved high risks of permanent damage or death, which had recently been described in the most respectable medical journals and were often performed on nonpatients, infants, pregnant women, mental defectives, and the old. He has been attacked for rendering a disservice to his profession, for undermining the trust lay people have in doctors, and for publishing in a paperback what could "ethically" be told only in literature written for doctors. Perhaps most surprising in these reports is the relentless repetition of identical high-risk procedures for the sole purpose of earning academic promotions.

   179 "Such a procedure is as informative as recording a patient's blood pressure once in a lifetime, or examining his urine once every 20 years. This practice is ridiculous, absurd and unnecessary . . . and of absolutely no value in diagnosis or treatment." Maurice Pappworth, "Dangerous Head That May Rule the Heart," Perspective, pp. 67-70.

   180 Minimal brain damage in children is as often as not a creation of Ritalin; it is a diagnosis determined by the treatment. See Roger D. Freeman, "Review of Medicine in Special Education: Medical-Behavioral Pseudorelationships," Journal of Special Education 5 (winter-spring 1971): 93-99.

   181 Alexander R. Lucas and Morris Weiss, "Methylphenidate Hallucinosis," Journal of the American Medical Association 217 (1971): 1079-81. Ritalin is used for the control of minimal brain dysfunction in schoolchildren. The author questions the ethics of using a powerful agent with serious side-effects, some well defined and others suspected, for mass therapy of a condition that is ill-defined. See^lso Barbara Fish, "The One-Child-One-Drug Myth of Stimulants in Hyperkinesis," Archives of General Psychiatry 25 (September 1971): 193-203. Considerable permanent damage has probably been done to hyperactive children treated with amphetamines for a condition possibly due to biochemical stress from lead poisoning: D. Bryce-Smith and H. A. Waldron, "Lead, Behavior, and Criminality," Ecologist 4, no. 10 (1975).

   182 Barbara Blackwell, The Literature of Delay in Seeking Medical Care for Chronic Illnesses, Health Education Monograph no. 16 (San Francisco: Society for Public Health Education, 1963).

   183 Philip Rieff, Triumph of the Therapeutic: Uses of Faith after Freud (New York: Harper Torchbook, 1968), argues that the hospital has succeeded the church and the parliament as the archetypical institution of Western culture.

   184 Like policemen in pursuit of crime prevention, doctors are now given the benefit of the doubt if they harm the patient. William A. Westley, "Violence and the Police," American Journal of Sociology 59 (July 1953): 34-41, found that one-third of all people in a small industrial city, asked, "When do you think a policeman is justified in roughing up a man?" said they believed it was legitimate to use violence just to coerce respect for the police.

   185 Joseph Cooper, "A Non-Physician Looks at Medical Utopia," Journal of the American Medical Association 197 (1966): 697-9.

   186 Orville Brim et al., eds., The Dying Patient (New York: Russell Sage, 1960). An anthology with a bibliography for each contribution. First deals with the spectrum of technical analysis and decision-making in which health professionals engage when they are faced with the task of determining the circumstances "under which an individual's death should occur." Provides a series of recommendations about what might be done to make this engineering process "somewhat less graceless and less distasteful for the patient, his family and, most of all, the attending personnel."

   187 Though the cost of intensive terminal care has easily doubled just in the last 4 years, it is still useful to consult Robert J. Glaser, "Innovation and Heroic Acts in Prolonging Life," in Brim et al., The Dying Patient, chap. 6, pp. 102-28.

   188 Richard A. Kalish, "Death and Dying: A Briefly Annotated Bibliography," in Brim et al., The Dying Patient, pp. 327-80. An annotated bibliographic survey of English-language literature on dying, limited mainly to items which deal with contemporary professional activity, decision-making, and technology in the hospital. This is an extract from a much larger list by the same author. For complementing items see Austin H. Kutscher, Jr., and Austin H. Kutscher, A Bibliography of Books on Death, Bereavement, Loss and Grief, 1953-68 (New York: Health Sciences Publishing Corp., 1969).

   189 Increase in medical expenditures can add no more to the average life expectancy of entire populations in rich countries, from the U.S. to China. It can add significantly only to the life-span of the very young in most of the poorer countries. This has been dealt with in the first chapter. The ability of medicine to affect the survival rates of small groups of people selected by medical diagnosis is something else. Antibiotics have enormously increased the chances of surviving pneumonia; oral rehydration, the probability of surviving dysentery or cholera. Such effective interventions are overwhelmingly of the cheap and simple kind. Their administration under the control of a professional physician may have become a cultural must for Americans, but it is not yet so for Mexicans. A third issue is the ability of medical treatment to increase the chances for survival among an even smaller proportion of people: those affected by acute conditions that can be cured thanks to speedy and complex hospital care, and those affected by degenerative conditions in which complex technology can obtain remissions. For this group the rule applies: the more expensive the treatment, the less its value in terms of added life expectancy. A fourth group are the terminally ill: money tends to prolong dying only by starting it earlier.

   190 For the language with which Americans referred to the corpse just before physicians intruded into the mortician's business, see Jessica Mitford, The American Way of Death (New York: Simon & Schuster, 1963).

   191 Under new names the "zombie" has become an important subject in medicolegal disputations, to judge from the inflation of literature on conflicting claims of death and life over the body. Institute of Society, Ethics, and the Life Sciences, Research Group on Ethical, Social, and Legal Issues in Genetic Counseling and Genetic Engineering, "Ethical and Social Issues in Screening for Genetic Disease," New England Journal of Medicine 286 (1972): 1129-32. A good summary of current opinions on the criteria for determining that death has occurred. The authors carefully separate this issue from any attempt to define death. Alexandre Capron and Leon R. Kass, "A Statutory Definition of the Standards for Determining Human Death: An Appraisal and a Proposal," University of Pennsylvania Law Review 121 (November 1972): 87-118. An introduction to the legal aspects of the physician's intrusion into the gravedigger's domain.

   192 This spread of legitimacy for the institutional management of crisis has enormous political potential because it prepares for irreversible crisis government. Just as Weber could argue that Puritan wealth was an unintended consequence of the anxiety aroused by the doctrine of predestination, so a moralist historian of Tawney's fiber might argue that readiness for technofascism is the unintended consequence of a society that voted for terminal care to be paid for by national insurance.

   193 By "ritualization" crisis is transformed from an urgent occasion for personal integration (Erikson) into a stress situation (Robinson, for some discussion) in which a bureaucratic apparatus is forced into action in pursuit of a goal for which, by its very nature, it cannot be organized. Under such circumstances, the institution's make-believe functions will take the upper hand. This must happen when medicine pursues a "dying policy." The confusion is enhanced by the use of a word such as "dying" or "decision," which designates action that springs from intimacy in a context devoid of it. Erik Erikson, "Psychoanalysis and Ongoing History: Problems of Identity, Hatred, and Nonviolence," American Journal of Psychiatry 122 (September 1965): 241-53. James Robinson, The Concept of Crisis in Decision-Making, Symposi Studies Series no. 11 (Washington, D.C.: National Institute of Social and Behavioral Science, 1962).

   194 Leonard Lewin, Triage (New York: Dial Press, 1972), raises the issue of society committed to dying policy in a novel which, unfortunately, does not compare with his previous Report from Iron Mountain.

   195 Valentina Borremans and Ivan Illich, "Dying Policy," manuscript prepared for Encyclopedia of Bio-Ethics, Kennedy Institute, Washington, D.C., to be published in 1976. The authors have agreed to contribute the entry under the title proposed by the editors of the encyclopedia precisely to highlight the fact that the combination of the intransitive verb "to die" and the bureaucratic term "policy" constitutes the supreme attack on language and reason.

   196 He who successfully claims power in an emergency suspends and can destroy rational evaluation. The insistence of the physician on his exclusive capacity to evaluate and solve individual crises moves him symbolically into the neighborhood of the White House.

   197 For the author's view on the distinction between hope and expectation as two opposed future-oriented attitudes, see Ivan Illich, "The Dawn of Epithimethean Man," paper prepared for a symposium in honor of Erich Fromm. Expectation is an optimistic or pessimistic reliance on institutionalized technical means; hope, a trusting readiness to be surprised by another person.

   198 "Crisis" thus becomes the red herring used by the executive to heighten his power in inverse proportion to the services he renders. It also becomes, in ever new combinations (energy crisis, authority crisis, East-West crisis), an inexhaustible subject for well-financed research by scientists paid to give to "crisis" the scholarly content that justifies the grantor. See Renzo Tomatis, La ricerca illimitaia (Milan: Feltrinelli, 1975).

   199 The term "hospital death" is used here to designate all deaths that happen in a hospital, and not only that 10% of the total which are "associated with a diagnostic or therapeutic procedure which is considered a contributing, precipitating or primary cause of obitus." Elihu Schimmel, "The Hazards of Hospitalization," Annals of Internal Medicine 60 (January 1964): 100-16.

   200 Monroe Lerner, "When, Why, and Where People Die," in Brim et al., The Dying Patient, pp. 5-29. Gives breakdowns of this evolution between 1955 and 1967 by cause of death, color, and region of the U.S.

   201 Erwin H. Ackerknecht, "Death in the History of Medicine," Bulletin of the History of Medicine 42 (1968): 19-23. For the elites of the Enlightenment, death became different and far more frightening than it had been for earlier generations. Apparent death became a kind of secularized hell and a major medical concern. "Live tests" by trumpet-blowing (Professor Hufeland) and electric shock (Creve) were introduced. Bichat's Recherches physiologiques sur la vie et la mart (1800) ended the anti-apparent-death movement in medicine as suddenly as Lancisi's work had started it in 1707.

   202 All societies seem to have distinguished stages by which the living pass into the grave. I will deal with these in chapter 9, and show how the renewed concern with the taxonomy of decay is consistent with other contemporary regressions to primitive fascinations.

   203 Margot Augener, "Scheintod als medizinisches Problem im 18. Jahrhundert," Mitteilungen zur Geschichte der Medizin und der Naturwissenschafien, nos. 6-7 (1967). The secularized fear of hell on the part of the enlightened rich focused on the horror of being buried alive. It also led to the creation of philanthropic foundations dedicated to the succor of the drowning or the burning.

   204 "Scarce Medical Resources," editorial, Columbia Law Review 69 (April 1969): 690-2. A review article based on interviews with several dozen U.S. experts. Describes and evaluates the current policies of exclusion and selection from a legal point of view. Uncritically accepts the probable effectiveness of the techniques supposed to be in extreme demand.

   205 Shannon Sollito and Robert M. Veatch, Bibliography of Society, Ethics and the Life Sciences, a Hastings Center Publication (Hastings-on-Hudson, N.Y., 1974). J. R. Elkinton, "The Literature of Ethical Problems in Medicine," pts. 1, 2, 3, Annals of Internal Medicine 73 (September 1970): 495-8; (October 1970): 662-6; (November 1970): 863-70. These are mutually complementary introductions to the ethical literature.

   206 Hermann Feifel, "Physicians Consider Death," in Proceedings of the American Psychological Association Convention (Washington, D.C.: the Association, 1967), pp. 201-2. Physicians seem significantly more afraid of death than either the physically sick or the normal healthy individual. The argument could lead to the thesis that physicians are now carriers of infectious fright.

   207 Euthanasia: An Annotated Bibliography, Euthanasia Educational Fund, 250 West 57th Street, New York, N.Y. 10019.

   208 The right to heal as an intransitive activity that must be exercised by the patient can enter into conflict with the assertion of the physician's right to heal, a transitive activity. For the origins of a medical right to heal, which would correspond to a professional duty, see Ludwig Edelstein, "The Professional Ethics of the Greek Physician," Bulletin of the History of Medicine 30 (September-October 1956): 391-419. Walter Reich raises the contemporary issue about the substance in the physician-patient contract when the disease turns from curable to terminal and therefore a "healer contract" comes to an end. Walter Reich, "The Physician's 'Duty' to Preserve Life," Hastings Center Report 5 (April 1975): 14-15.

   209 The recognition of the facies hippocratica, the signs of approaching death that indicated to the physician the point at which curative efforts had to be abandoned, was part of medical curricula until the end of the 19th century. On this subject, see chapter 8.

   210 Fred Davis, "Uncertainty in Medical Prognosis, Clinical and Functional," American Journal of Sociology 66 (July 1960): 41-7. Davis examines the doctor's behavior when an unfavorable prognosis of impairment or death becomes certain, and finds widespread cultivation of uncertainty by dissimulation or evasion. Dissimulation feeds Dr. Slop or Dr. Knock, who proffers clinically unsubstantiated diagnoses to curry favorable opinion by selling unwarranted placebos. Evasion, or the failure to communicate a clinically substantiated prognosis, keeps the patient and his family in the dark, lets them find out "in a natural sort of way," allows the doctor to avoid loss of his time—and scenes, and permits the doctor to pursue treatments the patient would have rejected had he known they cannot cure. Uncertainty is often cultivated as a conspiracy between doctor and patient to avoid acceptance of the irreversible, a category which does not fit their ethos.

   211 Sissela Bok et al., "The Dilemmas of Euthanasia," Bioscience 23 (August 1973): 461-78. It is often overlooked that euthanasia, or the medical termination of human life, could not have been an important issue before terminal care was medicalized. At present, most legal and ethical literature dealing with the legitimacy and the moral status of such professional contributions to the acceleration of death is of very limited value, because it does not call in question the legal and ethical status of medicalization, which created the issue in the first place. H. L. Hart, Law, Liberty and Morality (Stanford, Calif.: Stanford Univ. Press, 1963). By arguing that the law ought to take a neutral position, Hart goes perhaps furthest in this discussion. On one side the travesty of ethics takes the form of forced sale of medical products at literally any cost. Freeman states that "the death of an unoperated patient is an unacceptable means of alleviating sufferings" not only for the patient but also for his family: John M. Freeman, "Whose Suffering?" and Robert E. Cooke, "Is There a Right To Die—Quickly?" Journal of Pediatrics 80 (May 1972): 904-8. On the other hand, even the spokesmen in favor of terminal self-medication with pain-killers proceed on the assumption that in this as in any other consumption of drugs, the patient must buy what another selects for him.

   212 John Hinton, Dying (Baltimore: Penguin Books, 1974).

   213 Institute of Medicine of Chicago, Terminal Care for Cancer Patients (Chicago: Central Service for the Chronically Ill, 1950).

   214 David Sudnow, Passing On: The Social Organization of Dying (Englewood Cliffs, N.J.: Prentice-Hall, 1967). Described in its introduction as "salutary reading for the layman whose contact with the terminal phase of human life is limited to occasional encounters," this book should cure one of any desire for professional assistance.

   215 Exton-Smith, "Terminal Illness in the Aged."

   216 For a summary of several studies, see International Bank for Reconstruction and Development, Health Sector Policy Paper (Washington, D.C., March 1975), p. 34.

   217 "Improvements in artificial kidneys are needed, as borne out by the fact that uremic patients often are subjectively worse for a period after dialysis even though their blood chemistry is apparently near normal. Possible explanations are the nonremoval of an unknow 'uremic factor' or more likely the unwanted removal of a needed factor from the blood, or perhaps some subtle injury to the blood by the kidney machine." Rushmer, Medical Engineering, p. 314.

   218 C. H. Calland, "Iatrogenic Problems in End-Stage Renal Failure," New England Journal of Medicine 287 (1972): 334-8. An autobiographical account of a medical doctor in such terminal treatment.

   219 Hans von Hentig, Vom Ursprung der Henkersmahlzeit (Tübingen: Mohr, 1958). The medicalization of death has enormously increased the percentage of people whose death happens under bureaucratic control. In his encyclopedic study of the breakfast offered a condemned man by his executioner, Hentig concludes that there exists a deep-felt need to lavish favors on persons who die in a publicly determined way. Usually this favor takes the form of a sumptuous meal. Even during World War I soldiers still exchanged cigarettes, and the firing-squad commander offered a last cigarette. Terminal treatment in war, prison, and hospital has now been depersonalized. Intensive care for the dying can also be seen as a funeral gift for the unburied.

   220 Stephen P. Strickland, Politics, Science and Dread Disease: A Short History of the United States Medical Research Policy, Commonwealth Fund Series (Cambridge: Harvard Univ. Press, 1972). Strickland describes how the U.S. government medical research policy got under way with the 1927 proposal by a senator to post a $5 million reward for the person who collared the worst killer, namely cancer. Gives the history of the boom in cancer research. The U.S. government now spends more than $500 million per year on it.

   221 H. G. Mather et al., "Acute Myocardial Infarction: Home and Hospital Treatment," British Medical Journal, 1971, 3:334-8.

   222 John Powles has made this argument; see "On the Limitations of Modern Medicine," in Science, Medicine and Man (London: Pergamon, 1973), 1:1-30. An increasingly large proportion of the contemporary disease burden is man-made; engineering intervention in sickness is not making much progress as a strategy. The continued insistence on this strategy can be explained only if it serves nontechnical purposes. Diminishing returns within medicine are a specific instance of a wider crisis in industrial man's relationship to his environment.

   223 M. Bartels, Die Medizin der Naturvölker (Leipzig: Grieben, 1893). A classic on the magical element in the medicine of primitive peoples.

   224 William J. Goode, "Religion and Magic," in Goode, ed, Religion Among the Primitives (New York: Free Press, 1951), pp. 50-4.

   225 On the history of medical studies of the placebo effect and the evolution of the term, see Arthur K. Shapiro, "A Contribution to a History of the Placebo Effect," Behavioral Science 5 (April 1960): 109-35.

   226 The distinction between the magical elimination, religious interpretation, or ethical socialization of suffering and its technical manipulation and legal control deserves much more detailed analysis. I introduce these distinctions only to clarify that (1) medical technique does have nontechnical effects (2) some of which cannot be considered economic or social externalities (3) because they specifically influence health levels. (4) These health-related latent functions do have a complex, multilayered structure and (5) more often than not spoil health.

   227 By myths I here mean set behavior patterns which have the ability to generate among the participants a blindness to or tolerance for the divergence between the rationalization reinforced by the celebration of the ritual and the social consequences produced by this same celebration, which are in direct contradiction to the myth. For an analysis see Max Gluckman, Order and Rebellion in Tribal Africa (New York: Free Press, 1963).

   228 Eric Voeglin, Science, Politics and Gnosticism, trans. William Fitzpatrick (Chicago: Regnery, 1968).

   229 The social ordering of compassion, nurture, and celebration has been the most effective aspect of primitive medicine; see Erwin H. Ackerknecht, "Natural Diseases and Rational Treatment in Primitive Medicine," Bulletin of the History of Medicine 19 (May 1946): 467-97.

   230 Richard M. Titmuss, The Gift Relationship (New York: Pantheon, 1971), compares the market for human blood under U.S. commercial and British socialized medical systems, shows the immense superiority of British blood transfusions, and argues that the greater effectiveness of the British approach is due to the lower level of commercialization.

   231 Only in Chaucer's time did a common name for all healers appear: Vern L. Bullough, "Medical Study at Medieval Oxford," Speculum 36 (1961): 600-12.

   232 "The Term 'Doctor,' " Journal of the History of Medicine and Allied Sciences 18 (1963): 284-7.

   233 Louis Conn-Haft, The Public Physician of Ancient Greece (Northampton, Mass.: Smith College, 1956).

   234Adalberto Pazzini, Storia delta medidna, 2 vols. (Milan: Societa editrice libraria, 1947).

   235 For Arab medicine in general, consult Lucien Leclerc, Histoire de la médicine arabe: Exposé complet des traductions du grec: Les Sciences en Orient, leur transmission à I'Occident par les traductions latines, 2 vols. (1876; reprint ed., New York: Franklin, 1971); Manfred Ullmann, Die Medizin im Islam (Leiden: Brill, 1970), an exhaustive guide. But see also the judgment of Ibn Khaldun, The Muqaddimak: An Introduction to History, trans. Franz Rosenthal, Bollingen Series XLIII, 3 vols. (Princeton, N.J.: Princeton Univ. Press, 1967). For a critical review of Arabic contributions to the Western image of the doctor, see Heinrich Schipperges, "Ideologic und Historiographie des Arabismus," Sudhoffs Archiv, suppl. 1, 1961.

   236 Jacob Marcus, Communal Sick-Care in the German Ghetto (Cincinnati: Hebrew Union College Press, 1947). This book provides reasons for bad conscience for relying on outsiders.

   237 S. D. Lipton, "On Psychology of Childhood Tonsillectomy," in R. S. Eissler et al., eds., Psychoanalytic Study of the Child (New York: International Univs. Press, 1962), 17:363-417; reprinted in Anthología A8 (Cuernavaca: CIDOC, 1974).

   238 Julius A. Roth, "Ritual and Magic in the Control of Contagion," American Sociological Review 22 (June 1957): 310-14. Describes how doctors come to believe in magic. Belief in the danger of contagion from tuberculosis patients leads to ritualized procedures and irrational practices. For instance, the rules compelling patients to wear protective masks are strictly enforced when they go to X-ray services but not when they go to movies or socials.

   239 Arthur K. Shapiro, "Factors Contributing to the Placebo Effect: Their Implications for Psychotherapy," American Journal of Psychotherapy 18, suppl. 1 (March 1964): 73-88.

   240 Otto Lippross, Logik und Magie in der Medizin (Munich: Lehmann, 1969), pp. 198-218. Lippross argues, and documents his belief, that most effective healing depends on the physician's choice of the method that most suits his personality. For bibliography, see pp. 196-218.

   241 Henry K. Beecher, "Surgery as Placebo: A Quantitative Study of Bias," Journal of the American Medical Association 176 (1961): 1102-7. It has been long known that surgery can have placebo effects on the patient. I argue here that similar effects can be sociopolitically transmitted by highly visible interventions.

   242 Gerhard Kienle, Arzneimittelsicherheit and Gesellschaft: Eine kritische Untersuchung (Stuttgart: Schattauer, 1974), makes this point but deals only with the pharmacology-related sector of medical technology.

   243 Henry K. Beecher, "Nonspecific Forces Surrounding Disease and the Treatment of Disease," Journal of the American Medical Association 179 (1962): 437-40. "Any fear can kill, but fearful diagnosis can almost guarantee death from diagnosis." Walter B. Cannon, "Voodoo Death," American Anthropologist 44 (April-June 1942): 169-81. Victims of Haitian magic have ominous and persistent fears, which cause intense action of the sympatico-adrenal system and a sudden fall of blood pressure resulting in death.

   244 R. C. Pogge, "The Toxic Placebo," Medical Times 91 (August 1963): 778-81. S. Wolf, "Effects of Suggestion and Conditioning on the Action of Chemical Agents in Human Subjects: The Pharmacology of P\a.cebos," Journal of Clinical Investigation 29 (January 1950): 100-9. G. Herzhaft, "L'Effet nocebo," Encéphale 58 (November-December 1969): 486-503.

   245 Erwin Ackerknecht, "Problems of Primitive Medicine," in William A. Lessa and Evon Z. Vogt, Reader in Comparative Religion (New York: Harper & Row, 1965), chap. 8, pp. 394-402. Ackerknecht offers an important corrective to the Parsonian prejudice that all societies incorporate a specific kind of power in the healer. He shows that medicine man and modern physician are antagonists rather than colleagues: both take care of disease, but in all other ways they are different.

   246 Marc Bloch, The Royal Touch: Sacred Monarchy and Scrofula in England and France, trans. J. E. Anderson (Montreal: McGill-Queens Univ. Press, 1973).

   247Werner Danckert, Unehrliche Leute: Die verfemten Berufe (Bern: Francke, 1963). Deals with the healing powers traditionally attributed to outcastes and marginals such as executioners, gravediggers, prostitutes, and millers.

   248 Dominique Wolton, Le Nouvel Ordre sexuel (Paris: Seuil, 1974), describes the outcome of the French sexual revolution: a new "sexocracy" made up of physicians, militants, educators, and pharmacists has secularized and schooled French sexuality and "by subjecting body awareness to orthopedic management has reproduced the welfare receiver even in this intimate domain."

   249 Henry E. Sigerist, Civilization and Disease (Chicago: Univ. of Chicago Press, 1970).

   250 For complementary references, refer to notes 15-18, p. 44 above.

   251 T. F. Troels-Lund, Gesundheit and Krankheit in der Ansctumung alter Zeiten (Leipzig, 1901), is an early study of the shifting frontiers of sickness in different cultures. Walther Riese, The Conception of Disease: Its History, Its Versions and Its Nature (New York: Philosophical Library, 1953), attempts a philosophical epistemology. For orientation on the evolution of recent discussion see David Mechanic, Medical Sociology: A Selective View (New York: Free Press, 1968), especially pp. 33 ff.

   252 As just one example of a society without the Aesculapian role, see Charles O. Frake, "The Diagnosis of Disease Among the Subanun of Mindanao," American Anthropologist 63 (1961): 113-32. In the sphere of making decisions about disease, differences in individual skill and knowledge receive recognition, but there is no formal status of diagnostician or even, by Subanun conception, of curer.

   253 Lawrence J. Henderson, "Physician and Patient as a Social System," New England Journal of Medicine 212 (1935): 819-23, was perhaps the first to suggest that the physician exonerates the sick from moral accountability for their illness. For the classical formulation of the modern, almost morality-free sick-role, see Talcott Parsons, "Illness and the Role of the Physician" (orig. 1948), in Clyde Kluckhohn and Henry Murray, eds., Personality in Nature, Society and Culture, rev. ed. (New York: Knopf, 1953).

   254 David Robinson, The Process of Becoming Ill (London: Routledge, 1971), discovers a fundamental weakness in most studies done so far on the sick-role: they are based on people who finally did become patients, and deal with the person who feels ill but does not see the doctor as somebody who delays. He rejects the notion that illness starts with the presentation of symptoms to a professional. Most people are not patients most of the time they feel ill. Robinson studies empirically the sick behavior of nonpatients.

   255 The distinction between the intransitive healing by the patfent and the transitive healing provided for him must be further refined. The latter, a service to the patient, can be provided in two profoundly distinct ways. It can be the output of an institution and its functionaries executing policies, or it can be the result of personal, spontaneous interaction within a cultural setting. The distinction has been elaborated by Jacques Ellul, The Technological Society (New York: Random House, 1964). Ellul's concept of "institutionalized values" has been subjected to the analysis of a symposium: Katallagete [Be Reconciled]: Journal of the Committee of Southern Churchmen 2 (winter-spring 1970): 1-65. The phenomenology of personal care has been developed by Milton Mayeroff, On Caring (New York: Harper & Row, 1971).

   256 Renée Fox, Experiment Perilous: Physicians and Patients Facing the Unknown (Glencoe, Ill.: Free Press, 1959), studies terminal patients who have consented to be used as subjects for medical experiment. Notwithstanding the prevailing logical and rational explanations for their sickness, they too grapple with it in religious, cosmic, and especially moral terms.

   257 Sickness becomes associated with high living standards and high expectations. In the first six months of 1970, 5 million working days were lost in Britain owing to industrial disputes. This has been exceeded in only 2 years since the general strike in 1926. In comparison, over 300 million working days were lost through absence due to certified sickness. Office of Health Economics, Off Sick (London, 1971).

   258 Clarence Karier, "Testing for Order and Control in the Corporate Liberal State," Educational Theory 22 (spring 1972), shows the role the Carnegie Foundation played in developing educational testing materials that can be used for social control in situations where the ability of schools to perform this task has broken down. According to Karier, tests given outside the schools are a more powerful device for discrimination than tests given within a pedagogical situation. In the same way, it can be argued that medical testing becomes an increasingly powerful means for classification and discrimination, as the number of test results accumulate for which no significant treatment is feasible. Once the patient role becomes universal, medical labeling turns into a tool for total social control.

   259 Siegler and Osmond, "Aesculapian Authority." According to the authors, Aesculapian authority was first mentioned in T. T. Paterson, "Notes on Aesculapian Authority," unpublished manuscript, 1957. It comprises three roles: sapiential authority to advise, instruct, and direct; moral authority, which makes medical actions the right thing and not just something good; and charismatic authority, by which the doctor can appeal to some supreme power and which often outranks the patient's conscience and the ration d'etat. Pedagogues, psychologists, movement leaders, and nonconventional healers tend increasingly to appeal to this three-tiered authority in the name of their peculiar technique, thus joining the ranks of the scientific doctors and contributing to a cancerous expansion of the Aesculapian role.

   260 Franco Basaglia, La maggioranza deviante: L'ideologia del contralto sociale totale, Nuovo Politecnico no. 43 (Turin: Einaudi, 1971). Since the sixties a citizen without a medically recognized status has come to constitute an exception. A fundamental condition of contemporary political control is the conditioning of people to believe they need such a status for the sake not only of their own but of other people's health.

   261 Nils Christie, "Law and Medicine: The Case Against Role Blurring," Law and Society Review 5 (February 1971): 357-66. A case study by a criminologist of the conflict between two monopolistic professional empires. Medicine converges with education and law enforcement. The medicalization of all diagnosis denies the deviant the right to his own values: he who accepts the patient role implies by this submission that, once restored to health (which is just a different kind of patient role in our society), he will conform. The medicalization of his complaint results in the political castration of his suffering. For this see Jesse R. Pitts, "Social Control: The Concept," International Encyclopedia of the Social Sciences (1968), 14:391.

   262 H. Huebschmann, "La Notion d'une société malade," Présence, no. 94 (1966), pp. 25-40.

   263 Basaglia, La maggioranza deviante.

   264 Michel Foucault, Surveiller et punir: Naissance de la prison (Paris: Gallimard, 1975). On the rise of the pan-therapeutic society in which morality-charged roles are extinguished. English translation to be published by Pantheon Books, New York.