On the Medicalization of Our Culture
There are perhaps few academic topics of equal interest to scholars of history, law, anthropology, neuroscience, and literature. But this was part of the point when scholars of these disciplines gathered on April 22 for a symposium on medicalization—a phenomenon, they argued, that has infiltrated nearly every facet of modern life.
This explains how Christopher Lane, a professor of literature at Northwestern University, came to write a book about social anxiety disorder and commercial interests' role in the condition's definition and in the approval of drugs to treat it.
In the introduction to his talk, Lane offered these general comments:
Medicalization isn’t the most elegant noun…but it’s the best one we have for describing how common emotions and traits are turned into treatable conditions. Bad breath becomes halitosis, for example, and impotence erectile dysfunction. Even overdoing plastic surgery gets a brand-new name: body dysmorphic disorder. To put it bluntly, this process of pathologizing has gotten out of control. It’s become a juggernaut that no one seems able to stop.
Lane outlined the history of social anxiety disorder, as presented in his book: a name change from “social phobia”; the 1997 action by the Food and Drug Administration (FDA) to relax restrictions and allow direct-to-consumer advertising (which only one other country, New Zealand, allows); a subsequent ad campaign that likened the disorder to being "allergic to people," created by an advertising agency that also served such major corporations as Visa.
Jennifer Fishman, assistant professor in the department of social studies of medicine at McGill University, divined a similar conspiracy in the definition of erectile dysfunction and the development and approval of Viagra. Until the 1960s, she said, impotence was regarded as a natural part of aging. With the sexual revolution, impotence was reenvisioned as a psychological condition treatable with psychotherapy; in the 1980s, she said, Western society began to move toward its current view, actively encouraged by the field of urology. With too little business for the number of practicing urologists, Fishman asserted, a group of doctors founded the International Society for Impotence Research in 1982 and, in 1989, a journal for the study of impotence. The development of penile injections and implants in the 1980s, also by urologists, shifted the view of arousal from a process governed by the mind to something more physical, she said.
But the discovery of Viagra itself came about by accident, Fishman said: the drug was originally tested as a treatment for hypertension and coronary artery disease, and it was only when a suspiciously high number of subjects refused to return their leftover supplies at the study's conclusion that Pfizer realized the drug had a different effect that could also be marketed. Fishman displayed a selection of ads showing how Viagra's marketing campaigns have evolved since it received FDA approval in 1998. The earliest ads featured elderly couples, but more recent examples feature younger models and hint at recreational use rather than disease treatment.
In analyzing ads for statins—cholesterol-lowering drugs such as Pfizer's Lipitor—Jeremy Greene, a physician and historian of science at Harvard, argued that pharmaceutical companies have looked to "the suburbs of disease" for new customers. That is, Greene contends that because most people with very high cholesterol are already taking medication, drug companies are targeting people with moderately high cholesterol—levels within what some would define as the healthy range. Displaying a Merck ad that read "Stop! Do you know your cholesterol number?" and showed a stoplight with numerical values assigned to the red, yellow, and green lights, Greene said that such messages helped to enshrine the cholesterol level as a relevant measurement every American should know.
Nearly 60 percent of Americans age 50 or older meet the current specifications for being prescribed statins, although only 400,000 people have cholesterol high enough "to clearly constitute a disease," Greene said. He displayed a 1960s illustration of "hypercholesterolemic xanthomatosis," in which people had cholesterol levels so high that the substance collected in growths on their eyelids, elbows, knees, and buttocks. At that time, the cutoff for this condition was defined as 400 milligrams per deciliter—the extreme right tail of the bell curve for the American population. Standards today deem anything greater than 240 mg/dL as "high risk," and the range from 200 to 240 mg/dL as "borderline high risk." Greene noted that, at an FDA hearing on Merck's bid to sell a statin drug over the counter, the company argued that anyone with cholesterol over 150 should take a statin daily. Using this standard, he said, 90 percent of Americans would qualify.
The scholars outlined the multiple societal forces that feed into the trend of medicalization:
- the very existence of health insurance (costs are only reimbursable when associated with a definable medical condition
- death certificates (the need to give a name to what caused a person's death)
- research funding (funding is more likely for problems defined as diseases)
- drug trials and approval
- and even a desire to wash one's hands of blame for one's condition (for instance, by considering obesity a disease that assails people rather than the result, at least in part, of one’s own actions and lifestyle).
In the domain of criminal law, Harvard Law School professor Martha Field said, there has been a move away from medicalization, at least with regard to one concept: insanity. Use of the insanity defense tapered off, she says, after states made their laws stricter in the wake of John Hinckley Jr.'s acquittal, by reason of insanity, in the shooting of President Ronald Reagan in 1981.
The area of disability law, on the other hand, "has been medicalized for a long time," Field said, although people with disabilities have mixed feelings about the phenomenon. In general, they would like to be regarded as part of a normal range of life circumstances, she said, but in order to gain protections, they have had to envision their disabilities as medical problems, at least for some purposes. Physicians, she said, serve as "gatekeepers," determining whether a given individual qualifies for a handicapped parking permit; deciding whether a patient qualifies for disability insurance; testifying that a patient is able to perform a particular kind of job with specific accommodations for his or her disability.
In the realm of reproductive rights, Field argued that medicalization has at times reached too far, encroaching on decisions that should properly remain moral and personal. She recalled the "120 Rule" that was common in hospitals before being struck down in a 1973 suit against a Worcester hospital: the hospital refused to perform sterilization on any woman for whom age, multiplied by the number of children already born, did not equal at least 120.
As genetic analysis capabilities have developed, Field added, she hears many complaints from expectant parents who feel pressured by their physicians to have amniocentesis done—even if the parents don't intend to abort their fetus under any circumstances—and then, if the test does reveal a disability, who report further medical pressure to abort. In cases involving conjoined twins, Field said that national laws and practices vary widely, though they all claim to be based in sound medicine. Where the American system favors keeping the twins conjoined, Field noted, a British court required separation in a recent case, even though the twins' parents opposed it. "The question," she said, "is not a medical one. The question is a personal one."
Offering an ecosocial perspective, Harvard School of Public Health professor Nancy Krieger highlighted some benefits of medicalization. Child abuse was not defined as a phenomenon until 1962, she pointed out; it surely existed before then, she noted, but its naming led to the ability to prosecute cases, as well as a cultural shift toward disapproval. She also cautioned against throwing the baby out with the bathwater. Although in some cases medicalization's reach does extend too far, she allowed, "we cannot ignore the fact that injustice has biological effects and causes health problems." (For more on Krieger's work, see this article from the Harvard Magazine archives.)
The presenters devoted much discussion to the DSM-IV (that is, the current, fourth edition of the Diagnostic and Statistical Manual for mental disorders). For Lane, the manual was the object of scathing criticism: : "The DSM criteria grow longer and more commonplace with each edition of the diagnostic manual, and the prevalence rates are revised upward so many times that more and more adults and children are defined every year as mentally ill."
University provost Steven E. Hyman, noting that he serves on the committee for the DSM-V (the forthcoming revised edition of the DSM-IV), said that he agrees with "almost everything" in Lane's critical view of medicalization—“and yet," he added, "I have shamelessly used medicalization to achieve what I believe are very good ends in other parts of my life."
Hyman, a neuroscientist who directed the National Institute of Mental Health from 1996 until 2001, agreed that the manual is flawed, but cautioned his colleagues not to discredit it entirely. By systematizing the definitions of various mental illnesses, the manual has enabled research—without it, there would be no way to evaluate grant applications and allocate funding fairly, he said. "We needed to have a shared nomenclature if we were going to make any research progress, if clinicians were going to be able to communicate with each other, if we were going to be able to prescribe drugs."
The manual—and the medicalization of mental illness—have helped put mental disorders on par (or at least closer to equal treatment) with other diseases, and to give psychiatrists the same dignity as cardiologists, Hyman said. As a major victory he cited the federal law barring health insurers from imposing lower coverage limits on mental-health services than they do on other medical treatments. (Congress passed the so-called mental-health parity law in 1996, but allowed it to expire; a permanent version passed in 2008 as part of the TARP financial bailout bill.)
Hyman noted, for example, historical differences in the way the healthcare system treated schizophrenia and Parkinson's disease. That one is considered a mental illness and one physical is seemingly random, he said, given that both diseases are, at a basic level, disorders of dopamine. Still, he said, much of the manual is based on a faulty assumption—rather than a clear boundary of "ill" or "not ill," mental disorders are, like elevated cholesterol, "quantitatively continuous with what is normal." Hyman was skeptical that the revision committee could make such a fundamental change; that, he said, would be akin to "repairing the airplane while it's flying."
But he did voice hopes that the committee could make the manual's descriptions of mental disorders better and more accurate in ways that ease the path for research. For example, he said, the current definition of schizophrenia carries no mention of one of the condition's most disabling symptoms: the inability to hold information in one's mind long enough to form a plan and execute it. Until that symptom becomes part of the definition, he asserted, it will be impossible to get funding to research the impact, if any, of drugs' effect on it.
While acknowledging a general impulse to name ever more disorders, Hyman argued that people with mental illness would actually be better served by reducing the proliferation of distinct disorders into "families" of related conditions that (though different in some details) might share some aspects of treatment. “The only way to get some chance of modeling nature better is to get back to a far smaller number of disorders," he said—and there is strength in numbers in the sense that clinical trials are more accurate (and more easily funded) when they involve a larger sample size.
no matter how far medicalization goes, Monrad professor of the social sciences Charles Rosenberg reminded his listeners, we remain stubbornly human and flawed:
Sickness, pain, and disability remain ultimately individual and idiosyncratic. We can choose, for example, to avoid the behavioral admonitions built into the guidelines for chronic-disease management. Some of us employ alternative healing practices; others opt out through what is euphemistically termed noncompliance or non-adherence. We choose, that is, not to take our prescribed pills and have our regular blood tests, mammograms, and colonoscopies. We may eat the guilt-inducing cheeseburger or smoke the ever more guilt-inducing cigarette. A woman may opt for a bilateral mastectomy or simply choose to live with what is, after all, a heightened statistical risk and not a disease.
So strong is our impulse toward the individual and idiosyncratic, toward viewing ourselves as agents capable of choice, toward viewing our lives as stories, Rosenberg said, that we keep reintroducing value judgments into the bland, emotionless world of medical terminology:
Health and illness cannot be reduced to morally neutral terms. We are commended for fighting cancer, for mastering impulse, for adhering to medical discipline. We can also blame ourselves and judge others for actions that seem, in retrospect, to have invited sickness. There is, for instance, a comforting order in the link between cigarette smoking and lung cancer. Disease trajectories are narratives, and thus stages on which we perform as individuals and moral actors. In the West’s bureaucratic and technology-dependent environment, it is ironic that, in some ways, pain, sickness, and incapacity remain a final and ultimately inaccessible citadel of human idiosyncrasy. We are shaped by our diagnoses. We are not reduced to them.
In the opening remarks, Humanities Center director Homi Bhabha had noted the stark distinction between American attitudes and those he observed growing up in Bombay:
I remember seeing friends and relatives tyrannized by medically treatable conditions that the family or the community couldn’t bear to recognize for fear of public shame. Serious disorders were absorbed into the realm of spiritual life and normalized by religious custom or ritual, to the relief of all, until suddenly the illness ripped apart both the individual and supportive institutions—family, temple, community. A sense of moral failure haunts and humiliates those who must endure their illnesses as a failure of will because society cannot face up to its responsibilities.
Bhabha's point spoke to an observation, by Graduate School of Arts and Sciences dean Allan Brandt (a historian of science with appointments in the faculties of arts and sciences and of medicine), that medicalization is not inherently, or simply, good or bad, but—like most phenomena that cut such a wide cultural swath—complex.