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219 C H A P T E R N I N E T E E N T h e Q u e s t f o r P a s t S o m a t i c s Barbara Duden A gain and again, for two long decades, I was irritated when Ivan Illich answered inquiries about the route that led to Medical Nemesis.1 He argued that the book was one more contribution to a critique of the service economy ; that it was an attempt to say more about what he called “radical monopoly”; that he meant to analyze three different levels on which contemporary institutions become counterproductive; and that his reflections might just as well refer to the post office as to health care. To most of his listeners the story sounded either whimsical or arcane, but to me it was the source of a stubborn and persistent irritation. I was annoyed by the very idea that the sluggish delivery of letters could in any way be considered commensurable with sickening medical treatment. My request that Illich write a second volume, to be called “Nemesis-2,” grew out of this irritation. I urged him to go beyond the analogies between contemporary medical care and other modern institutions and finally to focus primarily and directly on the special, incomparable symbolic effects of our medical system. The cultural effect of late twentieth-century medicine, which he is competent to elucidate and stigmatize, still lay beyond the horizon of the symbolic functions he analyzed in the mid-1970s. I have been waiting for some time; I would like him to go beyond the paradigms of radical monopoly and symbolic counterproductivity to identify the role that medicine has played in the road to the late twentieth-century culture of disembodiment, of disincarnation. Through tracing the step-by-step progress toward disincarnation, the convergence of many intellectual, institutional, and symbolic characteristics of late modernity could be brought into view. Here and there in his writings, and much more in his conversations, he gives indications of being en route to such a synthesis. Disembodiment is obviously on his agenda. This can be seen in an article written ten years after the publication of Medical Nemesis, in the afterword for the 1995 German edition of Medical Nemesis, and most obviously in the keynote address to a conference in Bologna on “Health and Illness as Social Metaphors.”2 On these three occasions, Illich argued that it is impossible to understand modern health, and even more the postmodern self, without a historical perspective on the flesh and its cultural decomposition. For “Nemesis-2,” I have in mind an answer to three questions: (1) How do we reshape research on the historicity of the experienced, carnal self to encompass those transformations in self-perception that have become obvious since about 1980? (2) How do we speak about changes in the patient/physician relationship that go beyond those described by him in Medical Nemesis? (3) How do we recognize, analyze , and resist the rising social demand for services—for counseling, information, lifelong education, self-examination, risk-evaluation—that promote a new type of self-perception based entirely on technically mediated observation and a hermeneutical exegesis of the self? My argument thus has three points: (a) Only if Illich integrates his recent insights into the history of autoception will it be possible to progress from the analysis of the iatrogenesis of sickness, pain, and death, well described in the third part of Medical Nemesis, toward an understanding of the iatrogenesis of the body itself, that is, the appearance of the iatrogenic soma. (b) Only if he reflects on several high points of the transformation in the patient/physician relationship from the early eighteenth century to the present will he be able to render an account of the evolution in twentieth-century biocracy: from authoritarian to stochastic patient management . (c) Only by spelling out the recent shift in diagnosis from the visualization of physiological processes to the creation of actuarial profiles and the difference between the self-ascription, nay, interiorization, of these two modes of self-definition could Illich provide us with the guidance we seek on ways and means to avoid these forms of self-disincarnation. I find myself in a singular situation. I know that it is impossible to understand his thinking during the last twenty-five years without attention to the flesh. I could not imagine my own intellectual route during this period without his collaboration on...

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