Medicalization
Markku Myllykangas & Raimo Tuomainen
Science - the ruler of our health
Health is a determinant factor of the quality of human
life. It is a critical component of well-being. A weakness in health easily
leads to problems in any other components of well-being. We support ourselves
on science as we improve our living conditions, and science is
also the key word in maintaining or enhancing our own physical or mental
condition. The aim to cure or to be fit has inspired a great volume of
scientists' intensive work, creating truths and disproving truths. Science is
nowadays the highest authority and it produces changing facts and verities of
progressively shorter duration.
We want to know the right way to live - nowadays
religion cannot give adequate answers to a critical public. Because medical
science is connected with the problems of "how to
live" or "how to avoid suffering", it serves insecure people's
hopes. Actually, medicine is only one way of trying to
solve health problems, quite a new one: and the weaker the longer we look back
historically. The doctors with their medical science achieved their exceptional
status only in the last decades of 1800's.
Modern medicine can be seen
to originate at the end of the 1700ts. At the beginning of the 1800's clinical
doctors were able to describe something which had been unseen or outside the
observation. Autopsy had generated a basis for the development of an
anatomical-clinical system - as autopsies became a practice, clinical
observations could be correlated with findings in
tissues - and the concept of illness was fixed with the human body. Medicine
evolved, along with the general Western social development, into a clinical
science: instead of a patient doctors saw a sickbed of
a clinic - a field of scientific research. (Foucault 1975)
During the 20th century there
occurred a significant mental change: biomedicine became a central part of
medical science. First there was "medicine as an
art", then "medicine as a science" (Lyng
1990). Gordon (1988) has stated that clinical appraisal has
traditionally been classed under the term of 'art', but modern medicine
flows somewhere between 'art' and 'science'
Penicillin can be counted as one of the ten most
important inventions of mankind. According to Sontag
(1982) it was finally the success of antibiotics in conquering many malignant
diseases that made people accept the wisdom of medicine: many diseases
originated from micro-organisms and medicine was
sovereign in curing them. Foucault (1975) took the view that as our medicine
has developed, the conception of disease has also been distinguished
from metaphysical bad - and human illness has come under the rules of
positivistic science. The supernatural context in explaining human illness has
vanished; if not totally then, at least out of sight, is.
Now, the maturing of surgery to the age of transplant
technologies has built up the glamour of medicine and raised the human dream of
a self-regenerating organism to a concrete aim of science. (Tuomainen etc.
1995).
Medicalization
Zola (1972) is the father of concept 'medicalization'.
It means an expansion of the medical institution and reviewing deviance and the
processes of human life from a medical perspective. In the process of medicalization the power of medicine extends to areas which
were considered non-medical. For instance overweight,
certain use of stimulants or certain sexual behaviour
or difficulties in falling asleep have become diagnoses.
The concept 'medicalization' has been determined in
various ways. The central idea has been to talk about it considering the status
of medicine and the power of medical doctors: doctors control us more and more.
But, in a narrow sense, it means that human decisions
(both on a personal and a common level) increasingly rest on facts that
medicine has generated. People have begun to state the terms of medical science
and judge things more and more on the basis of medical
statements.
The process of medicalization also means that we
listen carefully what the agents of medical science tell us to do; and doctors
seem to have message about a widening range of human life. Medicine corners new
areas both on a greater and lesser scale.
It was indisputably McKeown (1976) who laid the
foundation for the rational critique of medicine by identifying its social
overvaluation. His thesis was that in fact medicine has had a quite marginal
effect on public health. The changes in environment explain the disappearance
of a major part of the various infections and the fall in mortality. Illich and Zola (e.g. Illich etc.
1977) have progressed far in radical medical critique, together and with their
own personal publications. Their books have reached a status of unquestioned
classics of medicalization theories. Conrad and Schneider (1980a, 1980b) have a
more neutral reputation among social scientists, but the valuation of their
works connects many kinds of medicalization theorists. In Finland
the public medicalization debate really began as late as during the 2000's, but
before that some researchers of the University of Kuopio especially attracted
attention with their articles, also causing indignation. (Tuomainen etc. 1999)
The doctor has a legitimate right to examine and cure
our bodies and minds. Any matter related to body or mind can
be treated as a medical problem. This tendency to detect medical
problems everywhere does not necessarily spring from a zealous medical
institution but is linked to a broader social context
and the common need to explain and control the course of life. One can speak
about "disease mongering": turning ordinary ailments into medical
problems, seeing mild symptoms as serious, treating personal problems as
medical ones, and seeing risks as diseases. Medical scientists find new
diseases and syndromes and try to categorize abnormalities and peculiarities.
For instance, some social and mental problems have already
long been labelled medical.
The clearer the deviance can be seen
as a biomedical phenomenon, the stronger is its medical stigma. Explanations which are bound to soma are more emphatic than
definitions resting on observable behaviour. There
are attempts to connect mental deviance to physical response. In the classic trialism 'biological - mental - social'
particularly the biological realities have been perceived as most decidedly the
substance of medicine. Now, the critics of biomedicine especially have claimed
that it is unnatural to view a man as a biological entity, out of his mental,
social or natural settings. If we take the holistic health theories seriously
enough, we just cannot find any specific section for medicine; it is like Tao,
in everything. And if we go further with this line of
thought, medicine can legitimately interfere in every aspect of life.
Ever stronger
medicine
In the West we have no
difficulties in detecting the process of medicalization. Its concrete
expression is the expansion of industries and financial flows connected to
health (Conrad and Schneider 1980a). And more
abstractly, it can be seen as a sharpening awareness of health risks and as a
broadening concept of health. In politics and administration
medicalization also emerges: health wisdom and health hazards have a great
effect on the results of the policy-making; in practice the status of medicine
and health care is determined.
In the Western world health
care has become one of the main institutions. The number of doctors, nurses and
other health care staff has increased everywhere during the last decades. The
growing significance of medicine can also be noticed
when we view the capital flow of scientific research: medical projects absorb a
large part of them. In many countries the pharmaceuticals industry has evolved
into a vital and profitable business, in the wake of the growth of medicine.
Health care has long been a significant business
activity. It gives jobs, money and power to many well-educated,
to nonaltruistic people, too. Chronic competition is
a characteristic of health care: in addition to material benefits
many people are interested in having authority or gaining status in the
academic community. This all has an impact on the actions, orientation,
routines and image of health care. (Myllykangas 2001)
Conrad and Schneider (1980a) point out of the
exceptionally secure position that medicine has: it can largely create its own
demand. Trying to convince essentially well people that they are sick, or slightly sick people that they are very ill is big
business. Illich (1976) has claimed that in health
care there are perpetually more jobs due to actions of doctors. The treatment
often has sideeffects or causes insecurity or
suspense, which must be cured. And
sometimes, of course, real malpractice occurs.
As women perceive their symptoms and use health
services more actively than men, it can be said that
medicalization has broken out above all among the fair sex. Women make up the
majority of both health care staff and patients, but the leaders are generally
male. Many feminists have argued that medicine is not primarily a science but a
sexist ideology bolstered by male doctors. The tradition of women's studies has
specifically proclaimed the threats of medicalization and warned that
reproduction and psycho-social problems should be
spared the manipulation of medicine. (Rauhala 1985).
More and more drugs are used
for many other aims than the primary treatment of a disease. They are seen as a remedy when we want to constrain our heartbroken
mind, to slow loss of hair, to slim down or to harden erection. These are just
a few concrete examples of the triumph of medicalization. (Klaukka
1999)
The new medical science is substantially profiled by
the visions the medical top disciplines share, especially representatives of
molecular genetics. According to them we shall soon
witness a revolution of medicine and health care: widespread illnesses as well
as severe and uncommon diseases can be cured and eliminated with methods we
have not seen ever before. Such excessive optimism has recurred frequently in
the history of modem medicine. (Helén 2002)
The health industry pumps out new cures at an accelerating
pace. These are not even thought to be used as a
treatment of a disease but as a cosmetic aim or to serve narcissistic, foppish
interests. Once upon a time there were sick people,
who undoubtedly needed new methods of treatment - now we have sophisticated
methods, for which we should find users. (Myllykangas
2001)
Healthy life of the citizen
One essential goal and achievement in medicine is the
liberation of human beings as a race, as a community and as individuals from
the vicious circles of biological necessities. A very essential part of the
medical power is the promise to put the limits of life as far as possible and
thus allow all to live, if not yet an eternal but a better life. To fulfill
this promise people have to accept the actions of medical authorities and they
have to change their behaviour, too, and yield to
medical subjects. (Helén 2002)
The continuing monitoring of health hazards is a very
good example of the relationship between the experts and lay people of the
modem world. Medical experts constantly create new knowledge on different kinds
of risks, and try to disseminate this knowledge to lay people. And the new awareness has an impact: lay people change their
behaviour and way of life because of those new
findings — the impact is usually greater among highly educated people. The
scientific truths and behavioral guidelines last only some time and are soon replaced by new ones. Some time ago
smoking was advisable for recreation. Secondly, we have to remember that in
medicine there are always opposing opinions about health risks. (Giddens 1991)
A model citizen takes the most recent health advice
seriously and avoids known risks. As nowadays the
scientific truths are abolished and risks are changed sooner and sooner, life
is full of refreshing alternation. It can be anxious that the general advice is
not necessarily suitable for the individual, but fortunately
many people do not doubt anything - and if they understand, they can repress
it.
Because of the expansion of medicalization, diagnostic
tests and visits to physicians are increasing. Thus
false positive results will also inevitably increase because the tests are
carried out with low predictive value. People are
groundlessly diagnosed with disease, further unnecessary tests are
needed and unnecessary treatments are initiated. Thus
the prevalence of diseases is increasing, at least as a subjective feeling and
stigmatization, even if people's health status remains the same. The
cost-effectiveness of health services is plummeting.
There are very good conditions in our society for the
expansion of medicalization. Tuomainen et al. (1999) have claimed that
medicalization gets its power by answering to six needs, the first three work
on the individual level and the next three help to keep the social order:
1.
the need for a truth authority
2.
the need to get rid of guilt and to
externalize problems
3.
the need to indulge narcissism
4.
the need to restrict deviance
5.
the need to support
market
6.
the
need to maintain power structure.
Threats
Industrial societies have built well-functioning
security systems for their citizens. Health care systems and organizations practising health promotion are a part of those systems.
But we can ask if the awareness of health and health ideology have in a way
undermined security by making people worried about maintaining their health
status and by presenting new, endless threats and everyday risks.
Medicalization has opposite effects. On the one hand
it creates guilt (the awareness of risks) and on the other hand it exonerates
from guilt (it is not my fault, it
is that disease).
In a medicalized culture
people have learned to cure their symptoms. Tiredness is one of the basic
symptoms of the modern, working human being. It has been made
into a disease, although usually the human psyche and the body are not sick
when they resist their destiny. The situation in which the people have to live
may be sick. Especially if people at least sometimes do not have liberating
experiences to fulfill themselves and be part of a net of human relationships,
where one can be weak, too, sickness is health: life has to be changed. (Tuomainen
2002)
If social values are hard, medicalization can lead to
even harsher control: deviance can easily be stigmatized as a disease which needs to be treated. New cultural phenomenon could be destroyed in this way. And:
can the meaning of life be readjustment to the tough competition and avoiding
risks? If the responsibility of the people is to stay healthy and if the
quality of babies is strictly controlled, we shall be approaching the ideals of
a certain German dictator. (Tuomainen 2001)
The most important mission of medicine is to help
people who are suffering. It has been a way to make society more
equal: sick people have come closer to normal people. If the wildest
scenarios of genetics come true, medicine is going to create a more obviously
unequal society. People can be improved even before
birth — we can choose those who deserve the miracle of birth. The children of the rich will get their blessing and be born
consonant with their rank. Is the lowest class then those who have to
live without genetic conditioning or those who because of that caring are saved
gently and austerely from life?
Postscript
Medicalization can give promises to people that many
diseases will be cured, but not only good news. It
brings high costs, feeling of guilt, dissatisfaction with oneself, irresolution
to deal with symptoms, that were once nothing but normal.
It creates a new kind of polarization, divides people
into two groups — people who behave right or wrong.
Medicalization is expanding because of the development
of medicine and technology. New treatments to cure disease
which were formerly incurable are developed continuously - also for
illnesses, which formerly were trivial. New techniques are
fast insisted on as routines, for all the people without any question. (Niiniluoto 2003)
The uncontrolled expansion of medicalization should be prevented using different methods (Mustajoki 2003):
-
medicalization has to be discussed
during medical studies
-
physicians have to lean on mainly
independent research reports, not the information produced by sponsors
-
patients' own health actions have to
be supported by practising physicians - it must be
discussed, how far it is reasonable to go in treating risks and in doing
screenings
-
in medical informing the illusion of
the omnipotence of medicine must be dispelled
-
a
national medical council should be established to critically assess medical
events and give guidelines concerning "dubious" diagnoses, screenings
etc.
We can justifiably take a sceptical
attitude towards the theorizing of medicalization. We may think that it
overemphasizes one social institution, one profession, one value orientation of
people and one social policy orientation. Social trends are vague, and
especially concerning single trends the outlining of
general development is disturbed by many opposite trends. However, seeing the
development of Western cultures and Finland, too, the twentieth century can be remembered as the century of medicalization. That
period made the health care system a mighty exerciser of power, raised the
health awareness of people and made the state to minister to the health of its
citizens. Medicine and medical truths live persistently in our minds. We feel
sick more consciously.
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Raimo Tuomainen