It is hard to read a controversy in healthcare these days without coming across the concept of ‘medicalisation’. The new classification of mental disorders medicalises us1. Des Spence, writing in last weekend’s BMJ, says that prescribing antidepressants encourages medicalisation (and is reductionist to boot)2. This week, the idea comes up again in Ray Moynihan’s article3. Everywhere you look, this term ‘medicalisation’.
The idea of medicalisation has become too cheap – an excuse for lazy thinking. It is a portmanteau term designed to discredit the opposing argument in a summary way. Using the idea of medicalisation to discredit a practice is an example of what I think is called a petitio principii argument4 – one where the conclusion and argument used to reach that conclusion embody the same idea. Harmful consequences of medical care cannot be deduced from the use of that medical care alone. It is like saying that medicalisation is harmful because it leads to medicalisation. The question is not whether, but when, medical care should be used. The answer to that question is not self-evident, nor resolved by deploying the term ‘medicalisation’.
In the case of appendicitis, the use of medicine is good. So medicalisation is not bad just because medicine has been deployed. “But that is not what I mean by medicalisation”, do I hear you say? Fine, but then you must argue in the particular – you must say why a particular practice/diagnostic category is a bad thing, without recourse to the very fact that they were used.
This takes us to my real objection to the term. Medicalisation can mean lots of effects, and not all of them are bad:
1. Drug companies and doctors will make profits by selling an effective treatment (good thing);
2. Drug companies/doctors will make a profit by selling a useless/harmful product (bad thing);
3. People who are struggling will be helped (good thing);
4. People who, without the ‘medicine’, would manage just fine will now become dependent on it (moderately bad);
5. As in (4) but actually be harmed by it (very bad);
6. The effect of medication will spill over from the index condition to prompting a more general dependency, either in that particular individual or other people in broader society (could be good or bad – see below).
I think the early sociological writings on the subject were particularly concerned with the last issue above – creating a general dependency on medicines/doctors. The original idea of medicalisation was often tied up with the idea that medicine was not much use anyway – this was the time of McKeown and Illich’s ‘Medical Nemesis’5. The ideas of a ‘dependency culture’ and ‘the medical model’ took hold amongst a fair degree of ‘doctor bashing’ and, arguably, at a time when the successes of modern medicine in preventing or treating disease was less self-evident than it is now. Somewhat overlooked in this argument was the anthropological and paleontological evidence that seeking help in warding off or treating disease (real or imaginary) is just part of the human condition which, even in a scientific age, is only partially requited by ‘scientific’ medicine.
My take on all this is that an appeal to medicalisation is an overworked form of argument which can never, by itself, constitute a convincing case against any particular form of medical intervention. It is a lazy (and if I may say, rather pretentious) cop out. It is not useful shorthand, because what it is representing is too vague. No, a far better way to proceed is to consider the effects of the intervention, one by one, considering such evidence as may exist and calibrating the various harms and benefits as best one can.
Whenever the term ‘medicalisation’ is used, it should be qualified. There are many frameworks that could be used here, but I offer one:
1. Is there a strong ethical obligation, such that the practice may be excluded on ethical grounds – questions such as euthanasia or cloning may not turn on just benefits, harms and costs. However, the majority of issues will not be ruled out on ethical grounds alone, and will require further consideration (indeed, few, if any, ideas will be ruled out a priori on ethical grounds, without a utilitarian calculus in the case of ‘rule’ ulitarians such as myself).
2. At whom is the intervention targeted, and what is the counterfactual (i.e. with what is it being compared)? If more than one group, then the following issues should be considered for each in turn.
3. Who may be affected – patients/carers/family/others in society? If more than one group, then the following issues should be considered for each in turn.
4. What are the putative benefits and harms, physical, psychological – short term, long term?
5. For each benefit and harm proceed as follows:
1. Is it material?
2. If material, what is the evidence and hence what is my best estimate of the magnitude of the benefit/harm?
3. How serious is the harm if it materialises?
4. What are the costs to society?
6. Synthesis – putting it all together, either informally (intuitively) or using some sort of Decision Analytic model.
Of course, all this requires some deep thought and data collection. Slogans, such as ‘medicalisation’, are so much easier!
1. Wittchen HU, Jacobi F, Rehm J, Gustavsson A, Svensson M, Jonsson B, Olesen J, Allgulander C, Alonso J, Faravelli C, Fratiglioni L, Jennum P, Lieb R, Maercker A, van Os J, Preisig M, Salvador-Carulla L, Simon R, Steinhausen H-C. The size and burden of mental disorders and other disorders of the brain in Europe 2010. European Neuropsychopharmacology.2011;21:655-679
2. Spence D. BMJ 2013;346:f191
3. Moynihan, R. BMJ 2013;346:f2789
4. Davies AE. Fallacies. In: A text-book of logic. 1st ed. Ohio: RG Adams and Company; 1915. p508-588
5. Illich I. Medical Nemesis. J Epidemiol Community Health.2003;57(12):919-922