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Fall 2006
Volume 06, Number 1

Newsletter on Philosophy and Medicine

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Boxing with Shadows: Medicalization and Other Fetishes

James Lindemann Nelson
Michigan State University

For present purposes, I’m going to understand the charge that some problem, or some feature of life, has been medicalized as implying that ideas shaped by medicine’s technical powers and therapeutic practices, or its characteristic explanatory structures, or its common patterns of valuation, over-influence how people see and respond to that problem or feature. Medicalization, on this account, is a distinctive sort of distortion of social understanding: perhaps due to a kind of opportunism on the part of those who wield or want to wield social clout, or maybe resulting more directly from a kind of infatuation with medicine and its track record against disease and trauma, we cramp lots of disparate issues into a shape spuriously unified to look like the sort of thing with which medicine can deal.

"Medicalization" can, of course, be used without critical intent. Yet it is, I think, more commonly employed in the rather grumpy way I’ve suggested and, so used, carries the implication that we’d understand our problems better, and, at least often, respond to them more efficiently and effectively if we saw them free of the cognitive and affective static imposed by medicine and its trappings. I say "often" since at least some complaints filed under this head don’t really seem to hinge on whether medicalizing a problem retards its resolution. Imagine, for example, that there’s a pill in our future that will help those prostrated by grief over the death of a loved one—not by making their grief vanish but by moderating grief’s excesses, moving the bereaved through mourning’s "stages" with dispatch, while at the same time allowing mourning the chance it needs to do its necessary psychic and social work. Some still might regard the use of such a pill as an objectionable instance of medicalization, despite—or perhaps because of—its effectiveness. I think this is a telling feature of the medicalization complaint, for reasons to which I’ll return.

There is also a more political understanding of medicalization, which takes it as a process by which power is transferred from citizens to the state, or the medical profession, or both, without proper acknowledgment of individual liberties. I won’t discuss the political dimension here, except perhaps by implication.

There’s no doubt that medicalization has gone on, nor that it continues, and to our cost. Yet having granted that, I’m going to try to dig out some of the contrasts that seem often to fuel the charge of medicalization. In general terms, here’s the sort of thing I have in mind: it’s often said, with considerable plausibility, that we medicalize death, and aging, and childbirth, and classroom disruption, physical failings and declines, unhappiness, our experience of our sexed and gendered bodies, and on and on and on. If only we could exorcise medicine’s baneful over-influence we’d be—just what, exactly? More likely to see these phenomena and their attendant problems for precisely what they are? Alert to a much richer expanse of possible solutions? Less likely to manipulate people and more likely to treat them as if they were citizens of a Kingdom of Ends?

Well, possibly. But my worry is that the medicalization complaint sometimes—perhaps often—is prompted by other more or less unified habits of thought and assessment, and that these habits carry with them their own tendencies to cause distortion. I’ll try to explain why I think this is a point worth taking to heart, and to start to rough out how its implications might point to better ways to identify, assess, accommodate, or counter at least some of the kinds of charges that get expressed under medicalization’s umbrella. Here’s the suspicion: while, say, Big Pharma might well be doing some very nasty things to society, and while it may well be the case that lots of us die in ways that could be much improved, it may not turn out to be very helpful at all to see these problems as instances of a single phenomenon, "medicalization." Maybe our problems with Pharma have as much or more to do with capitalism than medicine, our problems with death more to do with religion than with healthcare. And so forth.

Sorting Out Medicalization

First, let me underscore a couple points that I may have made too quickly in the opening sketch.

One concerns whether medicalization as a concept merely describes a recognizable complex of thoughts and attitudes, or whether it additionally explains, at least in some part, why people’s thoughts are prone to take that sort of shape, and why it assumes whatever influence it may have. Seeing medicalization as a descriptive concept—one that, as it were, denotes symptoms and not causes—prompts this sort of question: Are medical terms, metaphors, procedures, values, and so forth tempting for various reasons to those with antecedent interests in certain kinds of social control? Examples of such employment of medical terms are numerous, most infamously perhaps in the recruitment of medical language by the Nazis and their tame physicians as part of the Final Solution. Surely, anti-Semitic mania didn’t emerge because of medicine’s social influence and technical prowess. Rather, anti-Semitism predated scientific medicine and worked its way into expression through medical terms and via medical actions—in part, perhaps, because it was thought that a connection with concern about "hygiene" might provide anti-Jewish policies with a sort of patina of rational justifiability. The Nazis could have dropped all their medicalized language and kept doctors out of the camps, and their program would have been likely to emerge nonetheless, surely just as heinous as ever.1

Other uses of medicalization, though, suggest that there may be something within medicine itself that prompts a kind of imperialistic disposition on the part of some people (social theorists, policy makers, healthcare providers, business executives, and so forth)—this is the use with which I’m going to be particularly concerned. In such instances, medicine is taken to generate its own motivation for influencing social structures and practices. The notion here is that the success of medicine (perceived or real) in responding to a certain prominent class of the problems that human beings confront is itself a powerful goad to try to see other problems as amenable to the same kind of solution—in somewhat the way, perhaps, that rationalist ambitions were sparked by the power of mathematics, or various reductionist programs in philosophy by the power of the empirical sciences. In cases like this, as contrasted with the Nazi case, if we’re misdiagnosing problems by setting them under medicine’s spell—giving unruly kids Ritalin when we should be giving them spankings, or something of the sort—we presumably would be making progress if we became disenchanted.

I also want to underscore something already at least implicit in what I’ve already said about efficiency and appropriateness—namely, that the charge of medicalization is not solely an epistemic indictment. Medicalization is often portrayed as a tool to achieve, preserve, or extend social power—as well as to ameliorate social problems—not merely by importing a certain set of techniques, but also in part by imposing an over-simple or at least inaptly tailored regime of values on humans and human interactions. Rather than see people as, say, free and independent agents, whose problems should be solved in ways that take account of their rational agency and their distinct visions of the good, as we might think characteristic of liberal conceptions of politics—or, to take another example, as sinners whose problems require repentance and expiation, as we might think characteristic of some religious conceptions of life—medicalization tends to depict people not so much as agents but, rather, as patients, not so much as individuals as parts of a population with an expanding burden of illness, or as potential vectors of disease, or in some other way that attenuates individuality and responsibility. Looking out from that vantage, we’re inclined to seek for, engineer, and implement responses to people’s problems in ways that get their normative support from the powerful values we associate with health or, perhaps, with its metaphoric extensions. The visions of the good that support medicalized initiatives may seem more authoritative then they actually are, that is, because of the conception that health is a primary good, something that all rational agents needs to rank high on their lists of things to be pursued. Hence, the concern that other important human values—e.g., civil rights, pious resignation—are at risk from medicalization.2

Medicalization’s Underside

There’s hardly any denying that seeing things steadily and whole, being disposed to think outside boxes, and appreciating people in all their rich complexity, as responsible agents, as ends rather than means, are all on the side of the angels, while tendencies of thought that systematically undermine these virtues are bad. But examination suggests that it’s not only champions of the epistemically undistorted and the ethically well-defended who complain about medicalization; the complainers can themselves oftentimes embody habits of thought that reflect a substantive and controversial agenda. Behind charges of medicalization there can lurk ways of perceiving, structuring, and responding to problems that also constitute, or fuel, or otherwise lend themselves to distortion.

For example, what I’ll call (not altogether happily) "naturalization" appears to give rise to at least some charges of medicalization—a hankering, that is, for ways of understanding, resolving, dissolving, or living with problems that prizes a sort of quietism, a resignation born from a proper understanding of the limits we do and ought to have. People used to die, or age, or give birth, or settle classroom disputes, or seek for happiness, as Deus sive Natura intended—or such is the image that sparks the thought that we’ve done something wrong in approaching these features of life with weapons from the medical armory.

In his contributions to a discussion of medicalization held by the President’s Council for Bioethics, Leon Kass provided a nice statement of something in the neighborhood of what I have in mind here. In an open letter to a Council colleague he wrote,

The push for medicalization…is [thus] only partly driven by new technologies, though the availability of effective drugs and other instruments lends much support to a medical conception of the problem, and contributes to creating demand for medical services as treatment. It is also driven by deep cultural and intellectual currents: for example, to see more and more things in life not as natural givens to be coped with, but as objects rightly subject to our mastery and control; to have compassion for victims more than to blame perpetrators, even when the victims are victimized by their own perpetrations; to see the human person in non-spiritual and non-moral terms, but as a highly complex and successful product of blind evolutionary forces (which still perturb him through no fault of his own). It is also driven by commerce and the love of technique, the nflation of human desires to remove all obstacles to our happiness.3

This view splits the difference a bit between my "description/explanation" distinction, although the brunt of Kass’s concern seems to be that it isn’t primarily the power of specifically medical modalities that cause medicalization. Rather, recruitment of such technologies is promoted by other features of a pragmatic culture. It is tempting to see those "deep cultural and intellectual currents" as just the ones which contemporary medicine both swims in and stimulates. I, however, want to focus attention on a different point.

Kass’s words bespeak something other than a contrast between medicalization as a kind of motivated distortion of reality, on the one hand, and a kind of flexible, alert readiness to see problems for what they are and to follow the best paths to solutions wherever they may lead, on the other. What stands as medicalization’s alternative, as Kass sees it, is a much more definite nexus of ideas and assessments. It counsels resignation in the face of difficulties that are obdurate because there is some normative authority that mandates their obduracy; it insists that there are some objects not "rightly subject to our mastery and control." If objects of that sort are causing us problems, they are not, to use a distinction of T. S. Eliot’s, the kind of problem that ought to be solved—even if they can be—but, rather, the kind of problem that ought to be lived with, drawing on humility, patience, and grace rather than technology—or so I understand Kass’s imagined contrast.

In fairness, I must note that Kass’s approach to medicalization is intended, so he avers, to leave completely open the question of whether medicalization is a good thing or not. ("I intend a descriptive account, not a moralizing one."4) But I find it hard not to see some grumpiness in his characterization of the notion, and a corresponding enthusiasm for the counter-ideology. If I’m right about that, and right as well about the rather substantial moral commitments that nourish what I understand to be a critique, then medicalization, at least as Kass deploys the idea, needs to be seen not as a distortion to be unmasked and discarded but as a distinctive and substantial position, opposed not by Reason but by specific kinds of reasons that themselves might be contestable and confused.

If, for example, medicalization is open to criticism for portraying people too readily as patients and, thus, is too blithe about excusing them from responsibility, Kass’s (apparently supernaturally tinged version of) naturalization seems prey to a penchant for moralizing—and not very attractive moralizing, either. At some level, it seems to be a kind of ethics of taboo. Taboo, however, isn’t even a likely starter for reasoned assessment, so a fair critic should look for another reading. Perhaps Kass is concerned about hubris. Yet that idea can’t do much on its own, either—we need a good account of what makes a certain ambition overweening.

A more interesting line of moral thought that might be operating here connects to the "fragility of goodness" slogan—which I take to express the idea that much of what is most deeply characteristic and most valuable about human life is conditioned by its evanescence, its insufficiency, its enormous vulnerability.5 Here we have a serious position, one I’m not inclined to deny. However, I don’t see any realistic prospect for medicine’s rendering human lives systematically invulnerable any time soon—indeed, quite the contrary—so neither am I inclined to join those who want to warn us about the worrisome growth of our power over nature. In my view, we can stand to develop a good bit more power before we need to be concerned about whether we’ve got too much.

Indeed, other people who complain about medicalization seem to be concerned about matters that are quite different from—perhaps even inconsistent with—Kass’s worries. For instance, there are those who think that the problem with medicalization is that it tends to laden people with more moral obligations, holding them to a higher standard of accountability for their health, with the anxieties and burdens attendant on having one’s moral agency (over)extended.
More generally, we can here see again the fault line between worries about medicalization that are more or less pragmatic in their character (where the concern is that throwing drugs at a problem might just make it worse, or that intensified monitoring of normal deliveries causes more harm than good, and so forth), and those that are ideological in character (where whether an instance of medicalization works or not is beside the point—unless, indeed, working well is precisely the problem). Pragmatic concern with medicalization should focus on whether we’re in effect encouraging bad medicine, turning too many things into nails just because we’ve got a hammer.

The proper response to pragmatic worries may be equally pragmatic—for example, more and better medicine—and that doesn’t seem quite to capture what’s at the bottom of the worry about medicalization, as I hoped to suggest with my earlier reference to the pill that regularizes and moderates mourning. A critic of medicalization in psychiatry might point out that, although melancholia and mourning can both be called depression, there’s a lot that’s different about them.6 Just so, and the related concern about harming patients by misdiagnosis and poorly targeted therapy is a serious and straightforward one. But if the resistance to the medicalization of mourning survives the development of the pill I’ve described—as I suspect it might—then we’ve got something other than either a concern for health or for clear thinking—we’ve got a substantive and controversial counterposition.

Such counterpositions may be more than merely an alternative to medicalization: they may be contributors to what medicalization is taken to be. It’s against a particular set of commitments concerning the nature of human beings, human problems, and the limits of human agency that a different collection of activities and attitudes assumes a particular character—becomes "medicalization," as opposed to medicine—and, as I’m understanding the matter, poses a particular set of worries. For example, the medicalization about which Kass speaks is, at least in part, that set of practices that keeps us from fidelity to preferred views of human origins (Creationism, perhaps? Intelligent Design?), as such infidelity is effected by people who wear white coats. But lots of us who tend to wear black jackets instead are also—perhaps in a rather more focused way—doing what we can to promote faithlessness to those views. Insofar as it is of paramount importance to a person to keep non-Darwinian conceptions in working order, the social penchant for looking to medicine for responses to problems might seem to take on a kind of cultural significance and threat it might not otherwise present. What’s more, beguilement by medicine can take on lots of forms—if opponents of the cultural currents identified by Kass were to spend too much of their time railing at medicine for how it turns those currents into entrenched practices, they might miss other features of the social world that were actually doing more "mischief" than medicine.

I want to discuss another possible contrast to medicalization, one I’ll label "socialization." What I have in mind is the objection that "medical models" of disability are across the board harmful because disabilities are not fundamentally due to bodies that don’t work as they ought but, rather, to societies that don’t work as they ought. This is perhaps less discussed under an explicit medicalization heading, possibly because there’s less of a sense that a class of human problems dealt with in nonmedical ways has been progressively colonized by medicine. If there’s movement in prevailing understandings of disability, it seems to be going more in the social direction. But the complaint that a medical model of disability is inappropriate seems substantially a medicalization charge, so I’ll consider it here.

As a number of commentators have noted, the "most basic cooperative framework" in a given society will determine who is and who is not "disabled"7; being disabled, then, is not a monadic property, but a relational one. If we combine this highly plausible idea with another notion—that many features of human lives that are poorly suited to the prevailing cooperative frameworks emerge not from anything that can easily be regarded as a pathology or a trauma but, rather, are a matter of being at the tail end of a normal distribution of properties—we come up with a view that may look with suspicion on a conception of disabilities as diseases or traumas and, therefore, as problems.

I say may advisedly here, of course, because there seems nothing in this nexus of ideas that implies that medical approaches need not be useful for people facing these problems: conditions may be part of normal species variation, and, yet, distinctly problematic. Their problematic status may reflect something like an ill fit between physical powers and social requirements, but it may be much more efficient (and not otherwise objectionable) to alter a person’s body than it is to change her society so as to relieve the problem.

One source of suspicion here is provided by people who think that medicine needs to be kept in bounds by a combination of (a certain understanding of) its tradition and by features of the natural world. It’s permissible—even laudable—when medicine responds to pathologies or traumas—and particularly okay when those conditions can be identified without our having to deploy values, or at least values that anyone would contest. But, the thought continues, we should be very wary, or flat-out outraged, if medicine tries to meddle with conditions other than diseases and traumas. (Admittedly, a good deal of present day medicine goes on in precisely these ways, but we should, on this view, try to roll that back, and certainly not encourage it—otherwise, we’re "medicalizing.")

Yet the motivation for this kind of restriction isn’t clear at all. One thought might be that medical responses to such problems eviscerate agency, distract from political dimensions of problems, leave people discontented, even ashamed of themselves, send invidious messages to those who have the conditions that medicine targets, interfere with the formation and transmission of individual identities and broader subcultures centered around certain conditions. But if this is what’s at issue, the connection to whether we’ve got the right analysis of "disease" doesn’t really seem much to the point.8 Here, one wants to say that the problem doesn’t lie so much with strategies and tactics as with the evaluative understandings we allow to track them, and that we ought to be able to make some judicious distinctions here. If it happens that pain, discomfort, restricted abilities, shortened life-spans, etc., can be avoided or ameliorated with heathcare techniques, we ought to be able to figure out ways to take advantage of those benefits while reducing or eliminating the problems concerning agency, shame, identity, and so forth. Indeed, we sometimes may find that the problems are more in the perception of the critic than in the actual social effects emerging from medicine, even as now constituted. Yet even when this is not so, the concern that needs to be sorted out is not in any determinative way a matter of reining in medicine, but of freeing it from a set of ideas about its "proper" place, about what it is to be a patient, and so forth.

Bioethics and the philosophy of medicine have, I think, a role to play here. Recently, another member of the President’s Council involved in their discussion of medicalization, Paul McHugh, has acknowledged that mental health providers often are called to respond to people whose problems are not traceable to some lesion in their brains. Despite his concern that medicine in general and psychiatry in particular has "imperialist tendencies to bring more and more of ordinary human living under its jurisdiction and control,"9 McHugh does not think that physicians should turn all the ordinary humans away. Rather, in a working paper prepared for the Council, he calls for an improved psychiatric nosology that would identify four reference classes of complaint: (1) the class of conditions encompassing the diseases of the brain (e.g., dementia, bipolar disease); (2) the class of conditions encompassing destructive behaviors where choices play a role (e.g., drug addiction); (3) the class of conditions encompassing "problematic dispositions" (such as mental subnormality, and histrionic tendencies); and (4) the class of conditions derived from troubled life experiences, social maladjustments, and such things as grief and jealousy. In cases that fall in classes (2)-(4), McHughs writes, physicians qua physicians should attempt to respond to patient need, but in a way that is clear about the limits of their expertise, and that will alert patients to the fact that there are other sources of help for their problem. In his view, this allows medicine to provide what it can to those whom it might help, without claiming in some imperious way that it has a defining stake in all problems.

I think this view particularly laudable in that it renounces the idea that medicine goes wrong if it tries to help people whose problem is neither disease nor trauma. What’s less laudable is that it sees the obligation to warn about limitations and inform about alternatives as pertinent only to categories (2)-(4), and not to medical conditions themselves. Although some critics who profess concern about medicalization or medical models have portrayed bioethicists as part of the problem, it seems to me, on the contrary, that it is something very similar to these warnings about limitations and openness to alternatives that prominent currents in bioethics have been trying to effect on medicine generally, by encouraging physicians to honor the individuality, the schedules of value, the self-conceptions, and practical identities that emerge out of their patients’ personal and cultural surrounds—in short, to see their patients as agents.

The moral here is that the kind of response to medicine that comes from those making the medicalization charge from the perspective of socialization can be seen, when appropriately deflated, as akin to what bioethics has tried to do, without (typically) the same kind of frontal assault. Concerns that something has been medicalized can be eased by the kind of work that bioethics ought to do—e.g., making healthcare safe (or safer, at least) for people who are not only patients, and who have problems other than those to which medicine can effectively respond.

A Closing Caution

Considering these contrasts suggests to me that there is a peculiar kind of caution we ought to observe before we label a pattern of social response to some problem as an instance of medicalization. The concern is that at least some of our charges of medicalization may be self-indicting. The notion that we are confronting, at the object level, a pattern of action or policy that has enough, and the right kind of, unity to be usefully characterized as "medicalized" is itself an indication of a problem. Our critical thinking would seem to be disordered by an overly simple grasp of the social role medicine plays, as well as by the "shadows" medicine casts. By "shadows" I mean medicine’s "rivals": the natural and the social, and also perhaps the commercial, the traditional, the "non-hubristic," the religious, and so forth, also over-generally imagined as rather tightly unified ways of understanding and responding to the world. What we’re thinking about—social life, and the ways people try to cope with it—is nicely variegated. It’s how we think about social life when we’re keen to see in it instances of medicalization that may well be the very problem against which we inveigh.

This kind of thought doesn’t exclude the possibility that medicalization, in the "classic" sense, does indeed go on. There are too many examples of people’s lives being smashed in the name of racial hygiene and its like, too many instances of vulnerable people being manipulated into accepting forms of healthcare they don’t want as they give birth, live, and die to doubt that. However, a little more skepticism about medicalization as an explanatory concept may lead us to wonder whether the recruitment of medical nosologies, practices, and value patterns to understand and resolve social problems may not itself be a variegated phenomenon with multiple causes, expressions, and degrees of depth and tenacity.10

Endnotes

1. It’s also common to see medicalization explained in part as a function of physicians’ desire to extend their own influence and feather their financial nests. Robert Nye’s useful "The Evolution of the Concept of Medicalization in the Late Twentieth Century," Journal of History of the Behavioral Sciences, 39 (2003): 115-29, which focuses on the political dimensions of medicalization, argues that the picture is more complicated. I’m grateful to Mary Rorty for the reference.

2. A last comment by way of set-up: it’s clear from my examples that I’m not inclined to restrict medicalization to problem-gobbling imperialism as practiced by doctors. In his contributions to a President’s Council on Bioethics (PCB) discussion of the concept in 2003, Leon Kass seemed to think that such a restriction was appropriate. He requires medicalization to involve conceiving of an "activity, phenomenon, condition, behavior, etc." as a disease or disorder, or as an affliction that should be so understood, and that therefore is to be transferred to "physicians or others trained in the healing arts" to be cured (www.bioethics.gov/background/kass_mchugh.html, accessed June 21, 2006). It seems to me, on the other hand, that medicalization’s metaphoric surge can run both ways, transforming problems not previously seen as medical into ills in search of therapies, but also pressing social agents not previously seen as healers into the posture of faux doctors.

3. From Leon Kass’s contribution to an exchange with Paul McHugh, discussed at a meeting of the President’s Council on Bioethics, June 12, 2003, available at www.bioethics.gov/background/kass_mchugh.html, accessed June 21, 2006.

4. Ibid.

5. I’m thinking here of Martha Nussbaum’s work, of course, but also of Erik Parens’s article, "The Goodness of Fragility," Kennedy Institute of Ethics Journal, 5, no. 2 (1995).

6. Indeed, as one did. See Paul McHugh’s contribution to the epistolary exchange with Leon Kass, cited in note 3.

7. As discussed in Allen Buchanan, Dan W. Brock, Norman Daniels, and Daniel Wickler, From Chance to Choice: Genetics and Justice (Cambridge, 2000: 20).

8. Another concern might be economic: if we don’t rein in medicine according to some reasonable concept of its proper sphere, there will be no controlling it, and healthcare spending will ruin us. Again, though, that’s what might be called an external criticism of medicalization. The problem with medicalization, on this view, is simply that we can’t afford to do it as much as otherwise seems attractive.

9. See the link cited in note 3.

10. I’m grateful to Mary Varney Rorty for spearheading the panel for which an earlier version of these remarks were drafted, to my co-panelists for their own good thoughts and their comments on these ideas, to Rosamond Rhodes for a perceptive edit, and to Hilde Lindemann for her valuable philosophical and editorial suggestions.

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