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How to Distinguish Medicalization from Over-Medicalization?

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How to Distinguish Medicalization from Over-Medicalization? Medicine, Health Care and Philosophy https://doi.org/10.1007/s11019-018-9850-1 SCIENTIFIC CONTRIBUTION How to distinguish medicalization from over-medicalization? Emilia Kaczmarek1 © The Author(s) 2018 Abstract Is medicalization always harmful? When does medicine overstep its proper boundaries? The aim of this article is to outline the pragmatic criteria for distinguishing between medicalization and over-medicalization. The consequences of considering a phenomenon to be a medical problem may take radically different forms depending on whether the problem in question is correctly or incorrectly perceived as a medical issue. Neither indiscriminate acceptance of medicalization of subsequent areas of human existence, nor criticizing new medicalization cases just because they are medicalization can be justified. The article: (i) identifies various consequences of both well-founded medicalization and over-medicalization; (ii) demonstrates that the issue of defining appropriate limits of medicine cannot be solved by creating an optimum model of health; (iii) proposes four guiding questions to help distinguish medicalization from over-medicalization. The article should foster a normative analysis of the phenomenon of medicalization and contribute to the bioethical reflection on the boundaries of medicine. Keywords Medicalization · Over-medicalization · Boundaries of medicine · Moral evaluation of medicalization · Guiding questions · Pragmatic approach Introduction 1996; Parens 2013) started to appreciate positive aspects of medicalization as well. Therefore, how should we For the purposes of this article, I use the following socio- assess this phenomenon? logical definition of medicalization, according to which The aim of this paper is to outline the pragmatic criteria X is medicalized when it “is defined in medical terms, for distinguishing between medicalization and over-medi- described using medical language, understood through the calization. The article: (i) identifies various consequences adoption of a medical framework, or ‘treated’ with medi- of both well-founded medicalization and over-medicali- cal intervention” (Conrad 2007, p. 5). Thus, medicaliza- zation (Table 1); (ii) demonstrates that the issue of defin- tion consists in interpreting newer and newer aspects of ing appropriate limits of medicine cannot be solved by reality,1 including human behaviour, in medical terms, creating an optimum model of health; (iii) proposes four and treating them as medical problems rather than e.g. guiding questions to help distinguish medicalization from social, political or existential ones. The history of the over-medicalization and to analyse specific examples of notion of medicalization clearly indicates that from its medicalization (Table 2). The article should foster a nor- very beginning it has been associated with the criticism mative analysis of the phenomenon of medicalization and of expansion of medicine and perceiving it as an instru- contribute to the bioethical reflection on the boundaries ment of social control (Zola 1972; Szasz 1970, 2007; of medicine. Illich 1976, 2010; Busfield 2017). Over time, however, some sociologists and bioethicists (Broom and Woodward * Emilia Kaczmarek [email protected] 1 Although there is no room in the article for in-depth ontological or epistemic considerations, it should be noted that whenever I use 1 Ethics Department, Center for Bioethics and Biolaw, such words as “reality”, “causes”, “objective factors”, “undoubtedly” Institute of Philosophy, University of Warsaw, ul. or “in fact”—they should be interpreted in the context of pragmatic Krakowskie Przedmieście 3, 00-097 Warsaw, Poland theory of truth. Vol.:(0123456789)1 3 E. Kaczmarek - Various effects of medicalization - and over‑medicalization According to Erik Parens, medicalization is wrong “when the institution of medicine oversteps its proper limits” (Parens 2013). In order to discuss over-medicalization of a phenomenon, the latter must be demonstrated to have been wrongly recognised as a medical problem, whereas in fact it is e.g. a political or a cultural one—or it has been simply misinterpreted as a problem in the first place. Furthermore, inadequate identification of the underlying cause of a phe- nomenon results in taking inadequate measures aimed to eliminate it. As Parens wrote: … as medicine focuses on changing individuals’ bod- ies to reduce suffering, its increasing influence steals attention and resources away from changing the social structures and expectations that can produce such suf- fering in the first place. The idea is that, for example, rather than changing the bodies of shy people with drugs, we could change our expectations of how peo- ple behave in novel situations; again, doing so, would exemplify the virtue of learning to affirm natural vari- behaviours and starting of punishing the instead patient, e.g. limited treatment behaviours criminal handicapped persons liability of the mentally stand the causes of their condition and see that they are not the only ones to suffer ones to stand the the causes of their not only are condition and see that they it from been recognised as a disease, e.g. through granting insurance coverage, reimburse as a disease, e.g. through been recognised granting coverage, insurance leave a sick take ment of medicines, entitlement to disorders at a psychiatric hospital instead of undergoing an exorcism hospital of undergoing instead at a psychiatric disorders Raising health awareness of the public, recognising medical grounds for particular of the medical grounds public, recognising for healthRaising awareness De-tabooisation of disease, explanatory value: patients gain the under possibility to patients gain De-tabooisation value: of disease, explanatory Improvement in the financial situation of individuals whose condition has officially in the financial situation of individuals whose condition has officially Improvement Possibility of using tools of evidence-based medicine, e.g. treating acute mental medicine, e.g. treating of evidence-based of using tools Possibility ation. Further, changing social expectations would be medicalization—opportunities Well-founded - fairer to individuals, who, instead of changing their - - bodies to better fit dominant norms, could, again, be affirmed in their norm challenging variation (Parens 2013, p. 30). Then, in the context of over-medicalization, inadequate response to a problem means, first and foremost, unnec- essary clinical interventions, which always entail certain health risks. However, medicalization also affects other aspects of life of individuals and communities that are not directly related to health. The table below illustrates selected opportunities and risks that may be produced by medicali- zation processes in various domains of individual and col- lective life: As shown in the Table, the consequences of consid- ering a phenomenon to be a medical problem may take radically different forms depending on whether the prob- lem in question is correctly or incorrectly perceived as a medical issue. Neither indiscriminate acceptance of medi- calization of subsequent areas of human existence, nor criticising new medicalization cases just because they are medicalization can be then justified. Based on what crite- inadequate reactions stemming therefrom, such as treating victim’s masochistic masochistic victim’s as treating therefrom, such stemming reactions inadequate as theviolence personality disorder cause behind domestic personal freedom; pressure to adjust one’s own needs and behaviour to fit to the pre needs and behaviour own one’s adjust to pressure personal freedom; women desire in sexual standards, e.g. pharmacological of low vailing treatment ment of iatrogenic diseases and consequences of medication errors diseases and consequences ment of iatrogenic ria, however, can we establish when medicine oversteps diseases, health risk side effects genic undesirable medical procedures, to related of the medication administered Ignoring of certain social, political and interpersonal background phenomena and Stigmatising certain conditions, individuals or their behaviour as sick; restriction of certain as sick; Stigmatising conditions, individuals or their behaviour Suboptimal expenditure and waste of public or private money, e.g. costs of treat e.g. costs of public or private money, and waste Suboptimal expenditure Harm to health caused by undue treatment (overdiagnosis, overprescription), iatro overprescription), Harm (overdiagnosis, undue treatment health to caused by its boundaries? Over-medicalization-risks Medicalization impact assessment—own elaboration assessment—own Medicalization impact 1 Social effects Psychological effects Psychological Economic effects Health effects Table 1 3 ?How to distinguish medicalization from over-medicalization Medicalization and models of health 1948 the World Health Organization defined health as ‘a state of complete physical, mental and social well- As many authors (Parens 2013; Vogt et al. 2016; Saracci being, and not merely the absence of disease or infir- 1997) have rightly pointed out, the broad, holistic definition mity’, and this is generally held to epitomize the social of health makes it more difficult to criticise over-medical- model of health. There are obvious problems about this ization. If, as defined by the World Health Organization, definition, which seems to incorporate the whole of health is “a state of complete, physical, mental, and social human existence (Blaxter 2010,
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