“Medicalisation is the process by which human conditions and problems come to be defined and treated as medical conditions, and thus become the subject of medical study, diagnosis, prevention, or treatment” (source http://en.wikipedia.org/wiki/Medicalization)
Our every day concerns, lifestyles, issues, bodily changes become the interest of medical and psychiatric practitioners who seek to identify, classify, diagnose and then sell a treatment or cure for conditions that actually arise within everyday social life. This becomes the “pill for every ill’ approach. It also of course involves surgery.
‘Pharmaceuticalisation’ is a related term whereby drug companies engage in research, development and marketing of drugs to deal with what might otherwise be social, personal or political problems.
Ben Goldacre (2008), has argued that medicalisation may be a:
“….reductionist, bio-medical explanations for problems that might more sensibly and constructively be thought of as social, political, or personal…..this medicalisation of everyday life isn’t done to us; in fact, we eat it up.”
So what does he mean by this phrase? The first word is ‘reductionist’. This means to reduce complex phenomena down to simpler parts. That is to say we break it down in an attempt to understand or explain it.
Take the phenomenon of depression. If we reduce it down and say it is something that occurs in the brain, to say that it results from imbalances in brain chemistry, and that is all it is, we have reduced it down to chemical reactions.
The second word he uses is ‘bio-medical’. This means that we understand a phenomenon by referring to biology, physiology, anatomy and the knowledge generated by medical science. Again take depression. I have already reduced it to a bio-medical explanation by referring to it brain chemistry. This is a reference to physiology and the anatomy of the brain to explain depression.
Medicalisation then, is to take the social, political or personal problems that people have and turn them into medical conditions. This then allows us to seek a medical explanation and or treatment for what otherwise might be social ‘problems’ requiring social solutions.
Obesity: is this a social or medical problem? Think about the root causes. Are the solutions surgical or social or political or a mixture of all? What might result if we only see it as medical/physiological issue? Orlistat as the solution?
Consider, Insomnia: the subjective experience of not getting enough sleep. A reductionist bio-medical view might seek answers in the imbalances in hormones, perhaps caused by stress, which releases corticosteroids. The medical answer may be the prescription of a sleeping pill. The word itself ‘Insomnia’ is a medical term, people talk about lack of sleep but because the word is so well known we have adopted a medical term for an experience that might not be medical in origin.
Goldacre talks of personal problems…what if long hours at work and money worries is the root cause? These are not medical problems, they are social, personal, and some would argue political in a culture that values long hours.
Consider hair loss. Male pattern baldness, is this a medical problem? Is it a problem at all? In so far as it is, it may be due to ideas about the ideal male body than any medical deficit. Yet baldness is discussed in terms of ‘cure’ in some magazines as if it were a disease.
So, are we taking normal human behaviour and normal stages in human development and making them into new medical conditions? Drug companies investigate and create products (antidepressants) to deal with ‘normal’ sadness, or childhood behaviours (e.g. Ritalin).
Health journalist John Naish asks if we are turning normal human behaviour and normal stages in human development into medical conditions. It is estimated that 10 per cent of British people take anti-depressants and 10 per cent of American children take Ritalin to control their behaviour. It seems that a new mental illness is invented every week, covering every potential quirk in the human condition, such as Restless Leg Syndrome, Social Anxiety Disorder, Female Sexual Dysfunction and Celebrity Worship Syndrome.
Medical Intervention and Counter productivity.
Ivan Illich: iatrogenesis and counterproductivity.
Iatrogenesis means ‘brought forth by the healer’ (greek: iatros = healer; genesis = brought forth by) and so an iatrogenic disease/injury is one caused by medics. Illich argued (1976, p 24):
‘the pain, dysfunction, disability and anguish resulting from technical medical intervention now rival the morbidity due to traffic and industrial accidents and even war related incidents and make the impact of medicine one of the most rapidly spreading epidemics of or time.’
Counterproductivity occurs when the institutions of advanced industrial society reach a certain threshold and cease to be useful; their activities begin to go against their stated aims. Consider the medicalisation in large hospitals of childbirth, of death and of mental distress, which often resulted in outcomes that were far from helpful for many people. The counterproductivity of dealing with these issues may have been recognised, as arguments began to be put forward in the late 20th century for death, childbirth and mental illness should be taken out of large institutional care.
A modern case may be care of the elderly. Many frail elderly people are now ‘cared for’ in larger and larger care homes as costs rise and families can no longer cope. The transformations in society that have required families to be mobile in search of work, now results in the isolation of many elderly people from mainstream society while society itself is struggling to come to terms with the costs of social care (Dilnot 2011). The ‘care industry’, as it is becoming, may soon become counterproductive in the sense that the aim of providing a home and social care occurs in a context which militates against providing those aims to acceptable standards.
Care home companies state that the care their residents receive is more than adequate and that the Care Quality Commision provides a measure of protection and quality for all residents. These companies would be unlikely to accept accusations of counterproductivity. However, it is the social institution and the social devaluation of care, which they are a part of, that could become counterproductive.
While developing the theory of counterproductivity, Illich collected statistics to support his case, so what is the evidence for this phenomenon today? The rise of evidence-based medicine (Sackett et al 1996), it could be argued, is in part (or primarily) a response to practices that had not only little in the way of evidence to support their efficacy but also as a result of a growing awareness of the damage some practices inflicted.
It is important to distinguish between illness and injury caused by negligence and incompetence (e.g. surgical swabs left in situ after surgical closure), and that caused by the very practice of medicine itself when undertaken by its own rules and procedures. In addition a distinction could be made between harm to individuals and harm to society. The latter may result in focusing on medical answers to (social) problems, which deflect attention away from social answers.
An indication of the scale and types of harm caused to patients can be seen on the National Patient Safety Agency (NPSA) website: http://www.npsa.nhs.uk/. Consider two areas that feature in the literature: medication errors and nutrition in hospital.
The first type of iatrogenesis is clinical, and involves physicians, surgeons and other healthcare professionals causing harm by negligence, incompetence and the application of techniques with questionable efficacy.
Illich also argued for the existence of social iatrogenesis, which:
“obtains when medical bureaucracy creates ill health by increasing stress, by multiplying disabling dependence, by generating new painful needs, by lowering the levels of tolerance of discomfort or pain, by reducing the leeway that people are wont to concede to an individual when he suffers, and by abolishing even the right to self-care. Social iatrogenesis is at work when healthcare is turned into a standardised item, a staple; when all suffering is hospitalised and homes become inhospitable to birth, sickness and death; when the language in which people could experience their bodies is turned into bureaucratic gobbledygook; or when suffering, mourning, and healing outside the patient role are labelled a form of deviance.” (1976 p49.)
Social iatrogenesis refers to the process by which ‘medical practice sponsors sickness by reinforcing a morbid society that encourages people to become consumers of curative, preventive, industrial and environmental medicine’. It makes people hypochondriac and too willing to place themselves at the mercy of medical experts—a dependence on the medical profession that allegedly undermines individual capacities. The way society deals with death and dying are topics which may fall into this category and we will return to this later.
Cultural iatrogenesis implies that societies weaken the will of their members, by paralysing ‘healthy responses to suffering, impairment and death’. Here, the whole culture becomes ‘overmedicalised’, with doctors assuming the role of priest, and political and social problems entering the medical domain.
Palmieri et al (2007), outline technological iatrogenesis (in addition to Illich’s clinical, social and cultural iatrogenesis) in which modern healthcare has been characterised by a plethora of technologies including information technology. These technologies of course enhance healthcare practice but, they argue, have introduced new ways of causing harm which needs addressing by risk management.
Doctors themselves are aware of the process (Moynihan et al 2002)
An editorial in the British Medical Journal warned of inappropriate medicalization leading to disease mongering, where the boundaries of the definition of illnesses are expanded to include personal problems as medical problems or risks of diseases are emphasized to broaden the market for medications. The authors noted:
”Inappropriate medicalisation carries the dangers of unnecessary labelling, poor treatment decisions, iatrogenic illness, and economic waste, as well as the opportunity costs that result when resources are diverted away from treating or preventing more serious disease. At a deeper level it may help to feed unhealthy obsessions with health, obscure or mystify sociological or political explanations for health problems, and focus undue attention on pharmacological, individualised, or privatised solutions.”
Citing anecdotal case studies they were familiar with, the authors suggested further systematic research into this field to better understand the extent of influence this inappropriate medicalization has on public perception and the medical field.
The patient as willing consumer
However, as Goldacre suggested above “we eat it up”. We, the public, often demand medical interventions to ease our social problems. Illich’s work might overplay medical dominance and underplay our modern connivance as consumers of health services and practices.
Ballard, K. and Elston, M. (2005) Medicalisation: A multi dimensional concept. Social theory and Health 3: 228-241
Originally, the concept of medicalisation was strongly associated with medical dominance, involving the extension of medicine’s jurisdiction over erstwhile ‘normal’ life events and experiences.
More recently, however, this view of a docile lay populace, in thrall to expansionist medicine, has been challenged. Thus, as we enter a new era with increased concerns over risk and a decline in the trust of expert authority, many sociologists argue that the modern day ‘consumer’ of healthcare plays an active role in bringing about or resisting medicalisation.
Earlier accounts of medicalisation over-emphasized the medical profession’s dominating (imperialistic) tendencies and often underplayed the benefits of medicine.
With a consideration of the social context in which medicalisation arises, we argue that medicalisation is a much more complex, ambiguous, and contested process than the ‘medicalisation thesis’ of the 1970s implied.
As we enter the 21st century where expertise is being challenged and health is being seen as commodity to be bought and sold, where patients are customers, understanding medicalisation as a one way process (doctor to society) as the result of medical dominance alone is clearly insufficient.
Goldacre, B. (2008) The Medicalisation of Everyday life. Bad Science. [online] http://www.badscience.net/2008/09/the-medicalisation-of-everyday-life/
Illich, I (1976) Limits to medicine; medical nemesis, the expropriation of health. Marion Boyars. London
Moynihan, R., Heath, I., Henry, D. (2002). “Selling sickness: the pharmaceutical industry and disease mongering”. BMJ 324 (7342): 886-891.
Palmieri, P., Peterson, L., and ford, E. (2007) Technological iatrogenesis: new risks force heightened management awareness. Journal of Healthcare Risk Management, 27 (4) pp 19-24