Three months after starting at medical school in 1976, along with his revered copy of Gray’s Anatomy, Dr No bought another book that was most definitely not on the official list of recommended reading. Called Limits to Medicine1, by the theologian and philosopher Ivan Illich — an author said to be “extremely dangerous for people of moderate intelligence” — the book and the ideas it contains are better known as, and better described by, the first part of the subtitle, Medical Nemesis. The central premise is that, in the natural order of things, there are limits to what medicine can achieve, and should attempt; and if these hubristic limits are passed, then Nemesis will strike.

In the collection of papers and books that make up his thesis on medical nemesis — it had a protracted and somewhat confused birth over two years — Illich relies heavily on the concept of iatrogenic harm, harm to health caused by medical activity. He identifies three types of iatrogenesis. The first is clinical iatrogenesis, the direct  clinical harm done to a patient by medical interference. Adverse effects from drugs, operations that go wrong and hospital acquired infections are all examples of clinical iatrogenesis, with the common theme being that they are all clinical conditions for which, as Illich puts it, the remedy, doctor or hospital are the pathogens, or “sickening” agents.

The second type of iatrogenesis is social iatrogenesis, which we today recognise as the medicalization of ordinary life. The transformation of dyscopia into depression, treated with anti-depressants, and the screening for and treatment of high cholesterol in otherwise well people, treated with statins, are both examples. So too is the expectation of an antibiotic for a common cold caused by a virus, when whisky and lemon, honey and paracetamol are all that is needed. The common theme in social iatrogenesis is hubristic expropriation of normal, everyday life, and all that goes with it, by the medical establishment.

The third type of iatrogenesis identified by Illich, cultural iatrogenesis, is even more pervasive. It sets in when the zeitgeist shifts to allow the medical establishment to interfere with some of the most profound, yet still natural, ways of being human, from birth, through suffering, to death. Birth, itself a natural event, becomes an exclusively medical event, managed in hospital under the control of white coats. Death, once something that happened more often than not at home, gets a whole medical industry to itself, brimming with mechanical pathways and mechanised protocols. For Illich, a society’s prevailing image of death is, in particular, the ultimate window on its soul, that “reveals the level of independence of its people, their personal relatedness, self-reliance, and aliveness.” When the medical establishment has taken control of death, Illich says, then “health, or the autonomous power to cope, has been expropriated down to the last breath.”

Clinical iatrogenesis is an obvious harm. But in many ways, the second and third types of iatrogenesis, social and cultural, are both more insidious and, in the long run, more harmful. Both involve the unwarranted removal of autonomous control, or dominion, first over health and then over all life itself, from the cradle to the grave; and to the extent that individuals lose that control, that dominion, they become ever less resilient, and so weaker, and sicker. It is the very act of removing autonomous control — the expropriation — of health and life, that brings about the weakness and sickness. The individual, relieved of all personal responsibility for health, has but to submit to the will and ministrations of the medical establishment, and in this abdication, the individual’s capacity to suffer the slings and arrows of outrageous fortune at first atrophies, and then dies.         

Always controversial, Illich’s ideas are still nonetheless very relevant today. The rise in recent years of safetyism, the urgent and pressing desire to be kept safe, at all times, and at whatever the cost, creates a rich and fertile ground for an iatrogenic land grab on a continental scale. Small wonder, then, that when covid–19 came along, the politico-medical establishment made its grab. From the clinical iatrogenesis caused by the misappropriation of non-covid NHS services to manage covid–19, through to the social iatrogenesis of mass screening and indiscriminate masking, to the ultimate cultural iatrogenesis of interference in all aspects of our lives, through social controls and lockdowns, all harmonised under a narrative that says the only way to conquer covid is through top down politico-medical control — the cavalry narrative, of Moonshots and vaccines — we have lost, or in Illich’s terms, had expropriated, our individual ability to manage, and live with, covid–19. The greater the expropriation, the more we lose, again in Illich’s words, our independence, our personal relatedness, our self-reliance and our aliveness. In short, we lose much of what it is to be human.

If Illich is strong on diagnosis, he is less sure-footed on a cure. But for us, caught up in the biggest iatrogenic land grab ever seen, the remedy is clear. Just as Alex Paton, with the help of his brother-in-law, an orthopaedic surgeon, says in a review of an early version of Medical Nemesis, better to be the individual who takes up bicycling, than the patient who attends the physiotherapy department. We must reject the cavalry narrative, that some external medical solution, be it mass screening, mass vaccination or whatever mass fantasy next grabs the politico-medical establishment’s fancy, and take back our autonomy, our control of our lives, and so, ultimately, our human capacity to live with the pain, suffering and unavoidable deaths from what remains — Dr No is as sure as ever on this crucial point — just another seasonal flu like illness.

1. Illich, I. (1976) Limits to Medicine. Medical Nemesis: The Expropriation of Health. Marion Boyars Publishers Ltd, London. ISBN 0714525138. This late version (which is the one Dr No has) describes itself as the ‘definitive version of Medical Nemesis – The Expropriation of Health’. 


  1. Tish Farrell Reply

    Thank you for this excellent piece, Dr. No – giving a frame (and vocabulary) for some of the thoughts and conclusions that I (as patient) have come to over the years. In fact the more one thinks of this, the more obvious it is that for many decades we have been systematically brainwashed (from every quarter) into the expectation of illness being the norm.

    Once you start thinking like this, there’s a tendency to abandon responsibility for the state of oneself (well or unwell). If things have gone wrong someone else must fix them. Also when the emphasis of industrialized medicine becomes much about firefighting conditions and symptoms, it forgets about healing (from the bottom up as it were), i.e. harnessing the individual’s own capacities to the wellness cause. The current Government solutions to SARS CoV2 are banking on our surrendered response. They have stoked the conflagration by every means to the point of convincing us there is only one way to put it out. Superstition dressed up as science?

  2. Devonshire Dozer Reply

    Thank you. This is a wonderful post, but probably too late. Perhaps it could be summarised as the old ‘primum non nocere’ line.

    Your words here should be required reading for every windbag in Westminster & every Sir Humphreys/Chris/Pat etc.. A follow up test question such as “Summarise the post in up to five words” might be revealing.

    How many students today read anything of substance more than a paragraph or tweet beyond their immediate course requirements?

  3. Tom Welsh Reply

    Thanks for reminding us of Illich’s ideas. Like “Deschooling Society”, they seem outrageous but, on further thought, make more and more sense – the mark of truth.

    “If Illich is strong on diagnosis, he is less sure-footed on a cure”.

    We should never reject or suppress the description of a problem just because there is no solution in sight. Identifying the problem is the first step; and once it has been made plain for all to see, sure enough someone will come up with a solution in due course.

  4. Annie Davenport Turner Reply

    Absolutely brilliant, Dr No. Thank you. And I agree wholeheartedly with Tish – so much so I actually checked my own website for the exact words I’ve had systematically ignored for the ten years they’ve sat there, ready as they were to entice huge number into a happy and anticipatory state as they pick up the phone to call and book in….not. Over 41 years I’ve watched the world get ever more used to ‘believing their body is fragile, broken, and a hopeless piece of kit… In 2013 I wrote, I thought encouragingly, ‘We’ve been subtly led to believe that the body is a disaster, a failure of design that, at best, we have to beat into submission in order for us to live in it. But it’s really not so. (…) The truth has been masked; the body is actually remarkable, extraordinary, incredible, and certainly wonder-full.‘ I was thought deluded by most.
    Whatever anyone else thinks I will be doing everything in my power to not be punctured and filled with whatever is in those phials. Whatever it is, it isn’t, imho, good medicine,.

  5. dr-no Reply

    Thank you all for your comments. Social and cultural iatrogenesis, safetyism, abdication of autonomy and blameism are certainly all parts of a hideous jigsaw waiting to fall into place, with each part, once in place, feeding off its neighbours. It is hard to see how it has all come about. For example, when Dr No was young, taking a risk — the opposite of safetyism — was part of being alive. Nothing ventured, nothing gained, and all that. Somewhere along the way Dr No came across ‘go where it feels most risky, because that is where the learning is’. Perhaps that is another idea ‘extremely dangerous for people of moderate intelligence’, but as a principle applied prudently eg don’t climb onto the wing of a 747 in flight to learn about aerodynamics, because in practice you will shortly learn more about terminal velocity than aerodynamics, it has much to commend it. Dr No has done a lot of sailing over the years, something no one has to do theses days, yet it is a perfect example of taking a measured but real risk, to both gain something spiritual, and get somewhere physical. Today’s youngsters learning to sail, cocooned in their lifejackets and hard hats and watched over by the safety boat, are no doubt safer than ever before, but they have lost some the elemental thrill of sailing alone on the sea, salt in the air and wind in the hair.

    Dr No has always been in awe of both the human body and mind, and their joint and powerful urges and abilities to heal themselves. When a young medical student takes a step back, it is those urges and abilities he sees and learns about. For much of medicine’s long history, a sizeable part of good medical practice involved nothing more than a subtle distraction of the patient while the body and mind healed themselves. Even the most apparently aggressive branch of medical practice, surgery, is in fact nothing more than an exercise in rearranging anatomy so that the body can heal itself. Of course there are exceptions, but these things still remain general truths.

    So part of the way to dismantle that hideous jigsaw it to recognise these general truths. We can put aside the absurd notion that the body and mind were born flawed, and always need outside help to get fixed. Sometimes, of course, that is the case — Dr No is not for heaven’s sake suggesting for a moment that a woman in obstructed labour be left to fix herself — but oftentimes it is not. Dr No has long been an admirer of and advocate for the Swedish way of dealing with covid, believing that the iatrogenic interventionist hell of some governments’ responses appear in a harsh light compared to the measured gentler and ultimately healthier Swedish response, which recognises and relies on both the individual and society’s abilities to adjust and recover from biological assault. Let’s not forget that in by far the largest proportion, perhaps over 95% and in the non-elderly getting on for 99%, of patients with covid, external intervention does nothing; instead, as is the way of the body, it heals itself.

  6. Tom Welsh Reply

    A propos the joys of sailing – which I have tasted only briefly, a couple of times – I am reminded of Arthur Ransome’s brilliant telegram (from “Swallows and Amazons”, I think:

    “Better drowned than duffers. If not duffers won’t drown”.

  7. Mike S Reply

    Thank you Dr. No. Thank you Tish and Annie, for framing my thoughts as well. You all have a gift of expression that I envy.

  8. dearieme Reply

    “the body is actually remarkable, extraordinary, incredible, and certainly wonder-full.”

    Except the back, a woeful example of unintelligent design.

  9. Shawn Gibson Reply

    I agree entirely. I particularly like the term ‘safetyism’. I came across a book written just a few years ago by an Australian Psychologist – Brock Bastian (stick with me here) – entitled “The Other Side of Happiness – Embracing a more fearless approach to living”. In it he lists numerous studies which neatly illustrate the harms of avoiding all risk, both to people’s mental as well as physical health. Ultimately he makes a strong case for the fact that safetyism not only blunts people’s emotional response but in many cases causes more harms than it seeks to protects.

  10. Annie Davenport Turner Reply

    Oh, Dearieme, nooo! I understand how it seems that way, but 40 years-and-counting of introducing people to the discovery that there is no part of us which isn’t back, and thus our back is always being supported by, and in turn supporting, the whole. How I’d love to shine a light for you on just how brilliant a design it actually is – yes, when integrated and working as part of the whole, for I do remember the pain from when it wasn’t, and which brought me to my work so long ago now. But the joy of discovering ‘the back’ isn’t a ‘divine mistake’ and that when I let it work as designed, ‘my back’ was my friend; well, yes, it was life changing. I’m never-endingly grateful!

  11. dr-no Reply

    Shawn – thanks for the tip off about Brock Bastian, looks like a worthwhile read once you have got past the title! As it happens Dr No was a Yachtmaster Instructor for a dozen or so years and he well remembers a talk at one of the annual RYA YMI conferences from the early noughties, so getting on for twenty years ago, in which the speaker made the point that the couch potato staying safe at home watching TV was in fact insidiously harming him or her self; instead, far better to get out and about, and challenge oneself (aka go on a RYA practical sailing course), since it is by challenging ourselves that we get fitter and stronger, both physically and mentally.

    The early noughties were also the years in which the HSE over-reached itself, and told us that the working at height regs applied to going up the mast at sea, until we told them that scaffolding towers were not an option on a small yacht at sea, and nor was not retrieving that vital halyard that had gone aloft, so up the mast we would go, and that, as we were in effect small commercial catering premises, as most meals are prepared and eaten on board, we had to go on four day food hygiene courses, despite the fact that food poisoning, and that despite the fact that on a small yacht, the galley is usually also all but the front door step, was extremely rare (Dr No never came across a case, let alone an outbreak, on a course), to which we showed them a copy of our SOPs, and said phooo-eee.

    The point is — Tom, you are right, though whether there is any punctuation is a moot point, since it is a telegram, Dr No’s copy of Swallows and Amazons has it both with and without a terminal full stop — we are not duffers, and don’t, except very rarely, get drowned, but if we were, we would be better off drowned! And the best way to avoid being duffers is to get out there and learn.

    Dearieme and Annie – agree most definitely with both of you. We should perhaps remember that Homo erectus is an unusual mammal, bearing a spinal column that evolved in quadrupeds, and furthermore, our modern all to sedentary life style, including particularly driving, asks of our spines much that it was not evolved to do; but at the same time we are adaptive, and can learn and adapt. Even so, chronic back pain can be an intractable problem, not particularly well managed by the medical profession, and often much better dealt with instead by others trained in complementary methods.

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