Twice a month, The duty challenges enthusiasts of philosophy and the history of ideas to decipher a question news based on the theses of an outstanding thinker.
The last two years have highlighted the major problems and difficulties of the Quebec health network. Thousands of patients are waiting for surgery or treatment. The crowds in the emergency room are plethoric, when they are not closed due to the lack of nursing staff. Nurses are overworked and exhausted after working excessive hours or on sick leave. Hundreds of thousands of people do not have a family doctor. Faced with the lack of health professionals, the government is becoming proactive and intends to recruit at least 3,500 nurses abroad. This is the very poor picture of the state of the Quebec health network. What would Ivan Illich say? What reform would he propose?
Philosopher and historian, Ivan Illich was born in Austria in 1926 and died in Germany in 2002. In 1961, he co-founded the Intercultural Documentation Center of Cuernavaca (CIDOC), in Mexico, a meeting place for many intellectuals in the years 1960s and 1970s, which reflected on the problems of advanced industrial societies and on alternatives. An iconoclastic thinker, Illich is one of the harshest critics of their great institutions: education in A society without school, the energy in Energy and equity, industrialization in Friendliness, the professional system in Creative unemployment, as well as medicine in Medical nemesis, the expropriation of health. Illich’s notoriety was great in the 1970s and 1980s. Its popularity then declined in the decades that followed. But his thinking can help us interpret the current crisis in the health network.
The institutionalization of needs
According to Illich, mankind has experienced two modes of production. The first is the “autonomous mode of production”, which generates goods with use value. The second is the “heteronomy mode of production”, where the individual cedes to industry his power to create for himself. Industry is now an “equipped activity”, that is to say, having science and ever more efficient technologies that have only one goal: to produce as many goods as possible in order to consume as much as possible thanks to the institutionalization of needs.
If one can do without the object of desire, it is otherwise with the object of need. The superindustrial societies have given themselves institutions to train specialists, whose diplomas are sanctioned and legitimized by the State in order to satisfy the ever-growing needs of the population. These specialists exercise “mutilating professions” whose members, in particular doctors, benefit from a “radical” monopoly. These professionals are “untouchable” despite their “dominant and counter-productive functions” which lead to the overproduction and overconsumption of care.
If medicine has become a dominant profession, it is because doctors are invested with three fundamental authorities: sapiential authority to advise, instruct and lead, moral authority to make their services mandatory and charismatic authority to associate their services with the defense of patients’ interests. Now mainstream medicine determines which diseases society should not tolerate; it labels the patients who must be treated; it has the power of correction; she decides what to do with the sick and how to dispose of them. Its “mutilating effects” annihilate the autonomy of individuals by forcing them, through the institutionalization of the health system, to become consumers of care.
Exceed the limit threshold
According to Illich, when an institution becomes bureaucratic and crosses a “threshold limit”, it becomes harmful and dysfunctional in relation to its own objectives and ends. In illichist vocabulary, the institution thus becomes “counterproductive” and generates perverse effects. The mode of “heteronomous production”, in which the doctor has the “radical monopoly” of his profession, gives him the power to proceed with the medicalization of his patient. These “medical acts” become a source of iatrogenic diseases (from the Greek word iatros which means doctor). This disease is fueled by clinical conditions, drugs and hospitals, which can be pathogens. It is thanks to the “mutilating professionals” that the “counterproductive” medical institution is maintained.
To improve the medical system, it must be “reversed”. Illich uses the word ” dis-establish “, in the sense of making it lose its “massive” aspect to make it “friendly”. Conviviality, according to Illich’s conception, means that “the modern tool”, that is to say in this case the health system, is placed at the service of the person and not at the service of specialists. It relies on beings who are free, autonomous and capable of taking care of themselves. Because, for the philosopher, the primary responsible for health are individuals and their community, illness being the consequence of biological factors, of course, but also of the physical and social environment.
Deciphering the health network
With regard to our health and social services network, exceeding the threshold began in the 1980s to reach its climax with the reform of Minister of Health Gaétan Barrette during the years 2014-2018, a reform characterized by a optimal centralization and merging of devices into megastructures such as integrated health and social services centers (CISSS) and integrated university health and social services centers (CIUSS).
The “mutilating” effects on the delivery of care are evident. The number of Quebecers registered with the counter for access to a family doctor has doubled since 2018: from 430,000, it rose to nearly 870,000 on 1er October 2021, as reported The duty last December. According to the admission even of the minister of health Christian Dubé, there are 1.5 million Quebecers in total who do not have a family doctor. Despite this “counter-productivity”, the budget associated with the heteronomous mode of production of doctors continues to increase from year to year, without the health of the population as a whole improving. Other perverse effects appear. Instead of devoting all their time to their primary duties, nurses are forced to write administrative reports, while being subjected to a grueling regime of “compulsory overtime”.
Facing a crisis
How to improve the health network? According to Illich’s thinking, it is neither by asking the 10,000 general practitioners to do more, nor by authorizing the Régie de l’assurance maladie du Québec (RAMQ) to communicate to network managers the time slots of availability general practitioners, or by increasing the number of patients cared for by family physicians, or by offering bonuses to nurses, that Quebec’s medical institution will succeed in fulfilling its mission. We would only be exceeding even further the limit threshold reached by the network. Illich would rather propose to the government to debureaucratize the health system, to divide it into micro-networks by decentralizing for the benefit of local communities.
Conviviality in medicine is also based on multidisciplinarity, interdisciplinarity and, more generally, the “deprofessionalization” of nursing staff, beneficiary attendants and family caregivers being confused. In favor of a necessary reform, health professionals must themselves use the “user-friendly tool”, following the example of the pilot experiment in which nurses from Baie-Saint-Paul are participating. By arranging their own schedules, they managed to keep the emergency department threatened with closure open. But the friendly health network will really emerge when we understand that our society is facing a crisis, when we arrive at “the moment of choice, this wonderful moment when people suddenly become aware of the cage in which they are locked themselves, and the possibility of living differently,” writes Illich.
His critics consider him a utopian. May be. But Illich’s theses, in particular those that the philosopher elaborated in his works Medical nemesis. The expropriation of the health and Friendliness, first of all make us aware that our health network is in crisis. Subsequently, this thought could serve as a source of inspiration for the “refoundation” of the Quebec health system which Minister Christian Dubé promises to tackle.
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