Medicalization Is Not Medicine or Science; It Is a Semantic-Social Strategy
OCTOBER 01, 2007 by THOMAS S. SZASZ
The Merriam-Webster Online Dictionary defines “medicalize” as “to view or treat as a medical concern, problem, or disorder” and offers this phrase as illustration: “those who seek to dispose of social problems by medicalizing them.” Accordingly, we speak of the medicalization of homosexuality and hostility, but do not speak of the medicalization of malaria or melanoma.
The concept of medicalization rests on the assumption that some phenomena belong in the domain of medicine and some do not.
However, where a thing “belongs” is the result of how we classify the “thing,” that is, the result of (more or less arbitrary) human action. Is an anencephalic baby a human being? Is smoking crack a crime, a disease, a right? Answering such questions is what religion, politics, and, today, medical ethics are all about. The point to keep in mind is that, unless we agree on clearly defined criteria that define membership in the class called “disease” or “medical problem,” it is fruitless to debate whether any particular act of medicalization is “valid” or not.
Everything that we do or happens to us affects or depends on the use of our body. In principle we could treat everything that people do or that happens to them as belonging in the domain of medicine. Conversely, we could maintain that nothing that we do or happens to us belongs in the domain of medicine because all is ordained by God and belongs in the domain of religion. Such, indeed, was the case in ancient times, before people distinguished between faith healing and medical healing. A similar view is held today by Christian Scientists, whose faith is based on a radical denial of the reality of the material world. For them, only the spiritual realm exists or is “real.” Nothing belongs in the domain of materialist medicine. Christian Science represents the most radical case of demedicalization possible.
Contemporary public health is the mirror image of Christian Science. Everything in our lives—housing, food, education, work, recreation, and procreation—affects our health. Hence, everything—not only health care narrowly defined—belongs in the domain of medicine as health care. Linda Landesman, a former president of the Public Health Association of New York City, states: “We expect and demand that government ensure that we breathe clean air, drink safe water, work with minimum danger . . . . Left on our own, we don’t always make the healthiest choices.” In this view, we are uninformed, undisciplined children whose health and well-being require the unremitting protection of the therapeutic state.
In practice we must draw a line between what counts as medical care and what does not. The question is where to draw that line. What is a disease and what is not? What should be treated medically, by physicians or medical personnel, and what should not? Because people in modern societies expect the state to defray all or most of the cost of what is deemed a “medical service,” where we draw the line between “health care” and “not health care” is informed more by economic and political considerations than by medical or scientific judgments.
Moreover, not only must we demarcate disease from nondisease, we must also distinguish between medicalization from above, by coercion, and medicalization from below, by choice. Not by coincidence, these strategies match psychiatry’s two paradigmatic legal-social functions, civil commitment and the insanity defense, social control and excuse-making.
Disease and the Patient Role
The difference between disease as objective physical condition and the patient role as social status is obvious, provided we are willing to recognize it. Having a disease and occupying the patient role are independent variables: not all sick persons are patients, and not all patients are sick. Physicians, politicians, the press, and the public nevertheless continue to confuse and conflate the two categories. This is a cultural setting conducive to the growth of medicalization.
Medicalization is a two-way street. Until recently, homosexuality was considered a disease. Today it no longer is. Has it been cured out of existence? No. It has been demedicalized. At the same time, hundreds of behaviors never before treated as medical problems are now diagnosed as diseases: for example, “gender disorder” and “substance abuse.” Have these new diseases been discovered? No. They have been invented; that is, they are the products of medicalization.
Ironically, technological advances in medicine, combined with the conflation of the concepts of disease and patient role, facilitate not only medicalization but also confusion between discovering diseases and creating diagnoses. As a result, when a behavior categorized as a disease is “declassified”—as happened with homosexuality—journalists, science writers, and the public are easily persuaded by the stakeholders in medicalization that demedicalization is also a product of scientific progress and moral enlightenment, and not the product of a power struggle between stigmatizers and stigmatized.
Neither medicalization nor demedicalization is a new phenomenon. Formerly, people spoke about imaginary diseases and persons who pretended to be ill. Molière (1622–1673), the great satirist of malingerers and of the quacks whose harmful ministrations they invite, titled one of his plays The Imaginary Invalid (Le malade imaginaire).
Although medicalization encompasses much more than psychiatry, we must be clear about one thing: Psychiatry is medicalization through and through. Whatever aspect of psychiatry psychiatrists claim is not medicalization can only be such if it deals with proven diseases of the central nervous system, which belong to neurology, not psychiatry. (Psychoanalysis and other forms of psychotherapy, qua medical practices, are of course also instances of medicalization.)
In short, medicalization is not medicine or science; it is a semantic-social strategy that benefits some persons and harms others. In the past the persons most clearly benefiting from medicalization were psychiatrists and the persons most obviously injured by it were mental patients. “[T]he medical treatment of [mental] patients began with the infringement of their personal freedom,” observed Karl Wernicke (1848–1905), the pioneer German neuropathologist. Today the situation is more complex, more “democratic.” Anyone may, at some time, be helped or harmed by medicalization; the only consistent gainers from it are the agents of the therapeutic state.
Formerly the priest was both protector and punisher. Today the physician plays both roles. Formerly people could not imagine living in a society unguided and uncontrolled by God: church and state formed a holy union called “theocracy.” Today people (in the West, but not in the East) cannot imagine living in a society unguided and uncontrolled by science, especially medical science: medicine and the state form a “healthy union” called “pharmacracy.”