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Abstract

Medicalization designates a multidimensional social process whereby a growing array of conditions and experiences of human life become deﬁned, understood, and managed through medical and medically related expertise. Over the last 50 years, the multidisciplinary study of medicalization has been distinctly infused with moral concerns gravitating around issues of aspirations, freedom, power, and domination in society. In light of the accumulated scholarship, the medicalization of life and society is considered a development characteristic of modernity and late modernity with ample and disputed implications. Processes of medicalization are seen as constitutive of far-reaching transformations in contemporary societies, including globalization; the emergence of new forms of political and economic power; and the redeﬁnition of social, cultural, and moral practices.

Moral questions surrounding medicalization relate to a wide array of bioethical elaborations on topics like reproductive health, end of life care, genetics, or the conduct of medical research, to take only a few examples. However, bioethical analyses of medicalization qua medicalization, as comprehensive social phenomenon are yet to be fully developed. In this respect, social justice and human rights perspectives may be particularly suited to contribute normative frameworks for the ethical examination of medicalization. Such contributions would enrich the critical debate of moral aspects of medicalization and would further an ethically grounded local and global health governance.

Introduction

The medicalization of society was studied mainly in the social sciences and increasingly in other disciplines, including bioethics. Scholarly contributions were designated by different terms over time, such as the theory, thesis or critique of medicalization, and, more recently, as medicalization studies. The latter are deﬁned as the “interconnected yet diverse contributions that together give a picture of the process of medicalization, by focusing on the origins, content, conﬂicts, and consequences of medical deﬁnitions and treatments of human problems” (Conrad 2013, p. 200). The study of medicalization encompasses diverse theoretical perspectives and vocabularies and is distinguished by the multiplicity of sites and instances of medicalization being investigated with either narrower or broader lenses. Moreover, the medicalization debate has been traditionally underpinned by a preoccupation with issues of power and domination in society, and the worth and moral implications of medicalization have been a constant concern for scholars.

Reﬂecting a diverse and thematically complex literature, the purpose of this contribution is twofold: to offer the reader an overview of key propositions advanced in the study of medicalization over the last ﬁve decades and to emphasize critical moral and ethical concerns embedded in the problematic of medicalization, such as the creation of medicalized identities as part of new regimes of social control or the depolitization and obscuring of social suffering, along with speciﬁc bioethical elaborations on the concept of medicalization.

To achieve its purpose, the entry focuses on key contributions to the literature of medicalization published in English and favors the examination of medicalization as a broad social phenomenon over that of speciﬁc subareas such as, for instance, the medicalization of reproduction or of emotional states.

The ﬁrst part of the entry outlines important aspects in the emergence and development of the study of medicalization, brieﬂy reviewing the contexts that aided the crystallization of this area of study in the 1960s and early 1970s, and the major arguments formulated in the subsequent development of the medicalization critique. The second part of the entry presents commonly accepted deﬁnitions of medicalization and emphasizes critical conceptual distinctions useful in analyzing this phenomenon. Special attention is given to the conceptualization of medicalization from a bioethical perspective.

The third part of the paper highlights moral and ethical concerns related to the medicalization of society. A survey of moral “discontents” or “dark side” of medicalization repeatedly noted in the general medicalization critique is provided. Continuities between the treatment of moral concerns in the social sciences scholarship of medicalization and in the bioethical literature are emphasized, and a review of recent contributions to the ethical evaluation of processes of medicalization is presented. The multiplication of ethical dilemmas along recent globalizing trends in medicalization and the relevance of a bioethical human rights approach to furthering the ethical development of medicalization practices are also considered. A brief conclusion will emphasize the relevance of the problematic of medicalization for the contemporary moral and sociopolitical debate and will argue for an increased role of ethical assessments of broad dynamics of medicalization in guiding health governance measures that protect and strengthen fundamental human rights, including cultural, social, political, and economic rights.

History And Development Of Medicalization Studies

Medicalization emerged as a concept and as an area of study in the Western social sciences in the late 1960s and early 1970s. Rapid expansions in the knowledge base of medicine over several decades and changes in the organization of medicine as discipline and profession had led to an unparalleled growth in health services in the West. As a result, medicine was increasing its visibility in society and expanding its expertise over more and more conditions, life cycle events, and daily activities (Nye 2003; Lock 2004). The initial conceptualization of medicalization and the emerging public and scholarly debate responded to these developments of the institution of medicine. It built upon concerns that had been expressed repeatedly since the 1950s by cultural, medical, and social critics regarding the rising inﬂuence and impact of scientiﬁc medicine in society. At the same time, the emerging study of medicalization in the social sciences resonated with the dominant intellectual concerns of the time, particularly with liberal humanist and social justice ideals, freedom, human rights, and social change, and with the contestation of the sociopolitical status quo and of forms of professional authority (Lupton 1997). Among the direct inﬂuences on the crystallization of the study of medicalization frequently referenced are the inﬂuential anti-psychiatric critique and sociological critique of the profession of medicine of the 1960s (Conrad 1992). At the same time, important propositions in the early sociohistorical analyses of Michel Foucault were opening up new understandings about the interworking of psychiatry, medicine, and the state in the elaboration of forms of power speciﬁc to modern societies (Conrad 2013; Rose 1998). Foucault’s examination traced the historical development of medicalization in the West back to the eighteenth century (Lock 2004). Subsequent studies conﬁrmed this extended historical timeframe and established the commonly accepted view that the medicalization of society evolved over several centuries as an inherent dynamic to modernizing western capitalist societies prior to its recognition in the second part of the twentieth century (Nye 2003).

In the early 1970s, seminal studies published in the Anglo-American literature advanced the notion of medicalization and linked it to key themes of medical dominance and social control while also emphasizing its critical moral dimensions. American sociologist Irving Zola (1972) advanced a classical formulation of the thesis of medicalization as a form of social control:

(…) medicine is becoming a major institution of social control, nudging aside, or even incorporating the more traditional institutions of religion and law. It is becoming the repository of truth, the place where absolute and even ﬁnal judgments are made by supposedly neutral and objective experts. And these judgments are made, not in the name of virtue or legitimacy, but in the name of health. Moreover, this is not occurring through the political power physicians hold or can inﬂuence, but is largely an insidious and often undramatic phenomenon accomplished by ‘medicalizing’ much of daily living, by making medicine and the labels ‘healthy’ and ‘ill’ relevant to an ever increasing part of human existence. (.. .) If we search the ‘why’ of this phenomenon, we will see that it is rooted in our increasingly complex technological and bureaucratic system – a system which has led us down the path of a reluctant reliance on the expert. (Zola 1972, p. 487)

Another inﬂuential and widely circulated publication of the time was Ivan Illich’s “Medical Nemesis” (1976), a volume credited with bringing the issue of medicalization to the attention of the general public and of the medical profession (Lock 2004). According to Illich, characteristic to the West was a societal disease of medical hubris which he termed “iatrogenesis.” Imperialistic professional medical interests in association with capitalist power and modes of production create medicalization as an exploitative and selfserving enterprise. Iatrogenesis was systemically deployed at individual, social, and cultural levels; it was a political economy issue with severe moral and political consequences. Its consequences included the commodiﬁcation of health, illness, and death; the expropriation of health from the authority of the laity; the creation of medical dependencies for dealing with the unavoidable facts of life – pain, ailing, and death; and the erosion of freedom, human dignity, autonomy, and solidarity. Thus, the stronger the impetus of medicalizing forces, the more diminished was the health of individuals and communities.

The view that “a medical takeover of everyday life” was under way, encroaching upon the interests and liberties of the dupe and passive laity (Ballard and Elston 2005, p. 231) was common in the early critique of medicalization, and the quest of physicians for inﬂuence and money was regarded as the main force driving medicalization. Throughout the 1970s and the 1980s, medicalization was generally understood as over medicalization, an excessive and detrimental dynamic in society (Conrad 1992).

Subsequent contributions nuanced these positions while continuing documenting medicine’s role in creating forms of social control. Several lines of investigation acquired prominence, most notably the constructionist and labeling framework, and the Foucauldian framework. Conrad and Schneider (quoted in Conrad 1992) published in 1980 the inﬂuential study Deviance and Medicalization: From Badness to Sickness, which employed a labeling theory and constructionist approach to analyze the expansion of medical jurisdiction over the control of deviance in the cases of madness, alcoholism, opiate addiction, homosexuality, delinquency, and child abuse. Conrad and Schneider proposed a ﬁve-step sequence to the institutionalization of medical claims as a central mechanism leading to the medicalization of a given condition. They argued that medicalization operated the decriminalization of certain behaviors and, more broadly, a shift from construing “badness” as sickness. Concurrently, social control was instituted through medicine’s authority to deﬁne the normal and the pathological and to the extension of medicine’s jurisdiction over new medical diagnoses and therapeutic areas. Over the subsequent decades, Peter Conrad – the most prominent scholar of medicalization in the US context – continued to pursue the constructionist-deﬁnitional and empirical approach to medicalization and consolidated the view that the adoption of medical deﬁnitions was the key mechanism to medicalizing processes. This analytical strategy allowed Conrad to substantiate that rather than monolithic, processes of medicalization are multidimensional, ﬂuctuating, and reversible, with uneven progression, variable physician involvement form high to absent, and highly dependent upon the speciﬁc contexts and actors driving them (e.g., the medicalization and demedicalization of homosexuality) (Conrad 2013, p. 197).

Another major line in the investigation of medicalization adopted the Foucauldian view that institutional and conceptual changes in medicine shaped in profound ways typically modern “ideas about the body, health, and illness, not only among experts, but also among populations at large” (Lock 2004, para.10). Modern societies are thus constitutively medicalized, this “serving to monitor and administer the bodies of citizens in the effort to regulate and maintain social order as well as to promote good health and productivity” (Lupton 1997, p. 100). If for the early medicalization critique, medicalization was the result of an imposition from above, according to the Foucauldian view, medicalization rested largely on the embodiment of medical and health promotion precepts by the population at large who actively participates in assuming a regime of personal responsibility for health (Nye 2003; Rose 1998).

The Foucauldian critiques of medicalization focused on the study of discursive practices, on the creation of identities, and on techniques of monitoring and surveillance that achieve normalization at the individual and population level. The control of risk factors and the rising regimes of health and wellness were given special attention in Foucauldian-inspired analyses, and public health disciplines, such as epidemiology, health promotion, and disease prevention, were identiﬁed as inﬂuential vectors in expanding these areas of medicalization (Conrad 1992; Lupton 1997; Lock 2004).

The constructionist and labeling approach and the Foucauldian perspective converged in documenting how identities, bodies, and subjectivities are shaped through medicalization (Lock 2004) and consolidated the view that “medicine is a dominant institution which in Western societies has come to play an increasingly important role in everyday life, shaping the ways that we think about and live our bodies” (Lupton 1997, p. 106).

Gender and cross-cultural dimensions to medicalization were richly explored by social scientists. The gender dimension entered the study of medicalization in the late 1970s when feminist scholars argued that women’s bodies and lives were disproportionately medicalized as a result of the patriarchal medical control of reproductive functions. Subsequent contributions continued to document the increased medicalization of women’s lives, yet feminist scholars increasingly focused on women’s active and selective participation in medicalizing processes (Lupton 1997; Lock 2004). Recently, the gender perspective has also encompassed the increased medicalization of men’s bodies (Conrad 2013).

The important cross-cultural dimension of medicalization was traditionally explored by medical anthropologists who examined the multiple and contentious facets of the expansion of Western medicine into other cultural areas through colonial and modernizing processes or, more recently, as part of international development and global health initiatives, including international biomedical and pharmaceutical research activities (Lock 2004). Important asymmetries were noted between local knowledges, biologies, and cultural practices and the language and practices of western scientiﬁc medicine and institutionalized assistance to developing countries. Medicalization would thus be a vector in creating – at interactional, organizational, discursive, and structural levels – new hegemonies that have replaced the colonial order.

During the 1990s, medicalization was increasingly understood as a complex societal practice driven by multiple forces, including patient activism, rather than the result of evenly advancing medical domination (Ballard and Elston 2005). The view of a credulous laity indiscriminately giving in to exploitative and dominating medicalizing institutions was replaced by the recognition of complex strategies of acceptance, resistance, or active negotiation of medicalization dynamics on the part of the public, as well as by the emergence of an informed and discerning consumer. At the same time, criticisms were directed at marketization and commodiﬁcation trends whereby the citizenry was more and more understood as “consumers” of health goods. Generally, medicalization was increasingly accepted as a multidimensional concept, reﬂecting complex, contradictory, and at times ambiguous dynamics that involve multiple social actors and mediations, and complex negotiations of meanings and interests (Ballard and Elston 2005).

In the 2000s, scholars noted important shifts in the landscape of medicalization. It is considered that medicalization is intensifying in the West and globally along new and uneven technological and political lines (Conrad 2007; Clarke et al. 2010).

If medicalization had been regarded as the result of medical professional, organizational conﬂicts, and social movements, currently “shifting engines” determine sprawling dynamics of medicalization (Conrad 2007). These new “engines” currently driving medicalization include new technologies, including biotechnologies, genetics, and information technologies; pharmaceutical, marketing, and advertisement industries; and health insurance and managed care complexes, especially in the USA (Conrad 2007). These forces generate new trends in medicalization, such as biotechnologization, geneticization, rising enhancement therapies, and sprawling health markets and consumers in a neoliberal framework (Conrad 2007; Clarke et al. 2010). Additionally, it is considered that medicalization contributes to globalization and is itself globalized through such vectors like new information technologies and expertise, the global pharmaceutical industry, the increased diffusion of Western medicine, the integration of market and ﬂows of capital, or the globalization and medicalization of public health (Clarke et al. 2010). The medical profession, long regarded as a driving force of medicalization, is currently considered a “gatekeeper” to medicalizing dynamics (Conrad 2007).

To conclude this brief review of the development of concerns with the medicalization of society, a set of key general observations that have been repeatedly put forward in the literature should be emphasized. First, in the light of the accumulated scholarship, the medicalization of society is a salient feature of contemporary societies, and it presents complex social, economic, technological, political, cultural, symbolic, and moral dimensions. Secondly, there appears to be a relentless expansion of aspects of life being medicalized. A recent categorization identiﬁes four classes of such aspects: deviant behaviors (alcoholism, other addictions) and an ever-increasing list of mental disorders; the entire natural life cycle events, from preconception to death; issues of everyday living, such as anxiety, sadness, or overweight; and biomedical enhancements aimed to improve the performance of otherwise healthy individuals, such as cosmetic surgery, performance enhancements, and, potentially, genetic enhancements (Conrad 2013). This classiﬁcation can be expanded to include the category of proto-diseases and lifestyles as medicalized concerns, e.g., eating, sleeping, or exercising.

Finally, medicalization is intensifying and/or transforming in a complex and uneven fashion at the global scale. In this process, new forms of power, societal controls, and resistance are shaped, and ethical and moral dilemmas related to health, illness, and death, and to life itself are proliferating (Conrad 2007; Clarke et al. 2010).

Definition And Conceptual Clarification

“The concept of medicalisation has been put forward in order to name, analyse and criticize the changing role of medicine in modern society” (Verweij 1999, p. 90). Despite the fact that deﬁnitions of medicalization have not always been explicit and the meaning of the concept has varied across disciplinary traditions and temporal phases in the critique of medicalization (Conrad 1992, 2013), a number of formulations have been widely circulated and proved particularly inﬂuential over time.

A frequently referenced deﬁnition is that advanced by Zola: medicalization is a “process whereby more and more of everyday life has come under the medical dominion, inﬂuence and supervision” (Conrad 1992, p. 210). This deﬁnition has a broad scope and emphasizes the processual nature of medicalization; it establishes two main domains engaged in the process of medicalization, i.e., everyday life and medical establishment, and suggests the asymmetry of power between them.

Peter Conrad advanced a widely used, broad deﬁnition of medicalization: the “process by which previously nonmedical problems become deﬁned and treated as medical problems, usually in terms of illness or disorders” (Conrad 2007, p. 4). According to this deﬁnition, medicalization fundamentally rests in deﬁning a problem as a medical one “and involves the creation, promotion, or the implementation of medical categories (usually diagnoses) to that problem” (Conrad 2013, p. 200). This formulation emphasizes the processual nature of medicalization and underlines the centrality of jurisdictional and deﬁnitional mechanism. Related to this view, it was also proposed that medicalization can be analyzed separately at three independent levels: conceptual, institutional, and in interactions between doctors and patients (Conrad 1992). This analytical separation proved useful in reﬁning the understanding of dimensions and dynamics of medicalization.

Understood as a broad analytical category, the concept of medicalization has facilitated the study of complex and often ambiguous medicalizing dynamics with differing scope, levels, actors, content, degrees, or location. It is generally accepted that a broad conceptualization facilitates situating phenomena of medicalization in their multiple contexts of occurrence – symbolic, moral, social, cultural, institutional, economic, and political. Contextualization, in turn, is critical to adequately understanding and evaluating processes of medicalization and their outcomes (Ballard and Elston 2005; Conrad 2013).

This view is consonant with that advanced by Sadler et al. (2009) in their endeavor of situating medicalization within the ﬁeld of bioethical reﬂection. Taking as point of departure Conrad’s deﬁnition noted above, these scholars advance an even broader and more simpliﬁed version: “medicalization describes a process by which human problems come to be deﬁned and treated as medical problems” (Sadler et al. 2009, p. 412). According to Sadler and colleagues, this broad and process-centered deﬁnition provides several important advantages: it offers a wide enough scope for the normative assessment of different aspects of medicalization; it eliminates the need to dwell on what constitutes “truly” or “really” a medical versus a nonmedical problem; it can accommodate the analysis of many cases of medicalization that do not involve categories of illnesses or disorders as is increasingly the case in the medicalization of risk, lifestyle, or health promotion; it offers equal room for the investigation of either individual or group/social dynamics of medicalization; and ﬁnally, it can accommodate the analysis of both controversial and noncontroversial issues.

If deﬁning medicalization broadly presents important advantages, difﬁculties are also inherent to this situation, especially in relation to establishing the optimal scope of the concept. For some scholars, the boundaries of the concept should be traced as narrowly as, for instance, an exclusive focus on what physicians do. At the opposite end, it has been recently proposed that medicalization is currently transformed into bio medicalization. This is deﬁned by Clarke and colleagues as “the increasingly complex, multisited, multidirectional processes of medicalization that today are being both extended and reconstituted through the emergent social forms and practices of a highly and increasingly technoscientiﬁc medicine”(2010, p. 46). Conrad argues that the optimal scope of the concept cannot be restricted to a single cause or angle of the process of medicalization, e.g., medical or pharmaceutical domination, yet cannot be as broad as that deﬁned by the concept of bio medicalization that threatens to dissolve the speciﬁcity of medicalization (Conrad 2007, 2013).

Controversies typically elicited by the concept of medicalization refer to the ontological status of medical conditions – are they “truly” medical or not – and also to the worth of medicalization, with many formulations conveying a pejorative valuation. Both issues have received attention in the work of bioethicists and of social scientists. The latter often emphasized that their primary interest was in understanding how phenomena of medicalization take shape and attempted to separate the descriptive from the normative content of the concept. Verweij used the concept of medicalization to analyze the moral intuitions embedded in the practice of preventive medicine and noted two key aspects. First, attempts at separating the descriptive from the normative sides of the concept inadvertedly “remove the sting from medicalization arguments. They do so not just by divorcing fact and value statement; but by oversimplifying the content of the concept” (Verweij 1999, p. 94). This undermines the analytical effort “because in moral debates about preventive medicine people do use the term ‘medicalization’ to express moral intuitions which criticize this increasing importance of health, illness and medicine in daily life. These moral intuitions are simpliﬁed if they are reduced to the question whether the growth in supply and demand for medical care is justiﬁed and, if so, whether the effects of that emerging market’ are acceptable” (Verweij 1999, p. 94). Secondly, the comprehensiveness of the concept of medicalization is particularly attractive for moral critiques of medicine but also limiting the “clarity and tenability of moral arguments in which the concept is employed” (Verweij 1999, p. 113).

The concept of medicalization presents afﬁnities with a number of related concepts. For instance, the critique of medicalization has drawn important inspiration from Foucauldian concepts like the clinical gaze, docile bodies, panopticism, governmentality, biopower, biopolitics, and normalization (Nye 2003; Lupton 1997; Lock 2004), and, more recently, from such concepts as biocapital or global assemblages (Clarke et al. 2010). Another set of concepts related to medicalization is represented by those notions describing new developments in medical and health disciplines and markets, such as pharmaceuticalization, marketization, or geneticization. For some authors, the processes reﬂected in these notions are subcategories of medicalization, while other scholars maintain that it is only under speciﬁc circumstances that these can lead to medicalization. Additionally, biomedicalization, the concept proposed by Clarke and colleagues (2010) to emphasize the technoscientifc transformation of contemporary medicine, is linked to new concepts of molecularization, digitization, or globalization.

Finally, the concept of “healthism” proposed by Crawford in 1980 (quoted by Ballard and Elston 2005) to characterize the rise of the pervasive preoccupation with the “problem” and the pursuit of health in society was initially regarded as an extension of medicalization. More recently, healthism was also interpreted as the broader ideological and cultural conﬁguration within which medicalization forces are effectively deployed (Ballard and Elston 2005).

Returning to the concept of medicalization, it can be concluded that since its emergence in the early 1970s, it has functioned as a fertile analytical category that facilitated the description and interpretation of causes, forms, mechanisms, and impacts of phenomena related to the rising role played by scientiﬁc medicine in society. Centering on a conceptual framework rather than on a theory (Conrad 2013), medicalization is understood today as a broad concept that subsumes and relates to other concepts and allows for the deﬁnition and examination of overall dynamics as well as of particular cases and dimensions of medicalization.

Ethical Dimensions Of Medicalization

General Considerations

The medicalization of society and life was initially perceived as a disquieting phenomenon and was frequently associated with a sense of personal and collective loss. It was treated by many authors as a contested development and seen as an excessive and detrimental phenomenon in democratic societies, undermining fundamental rights and freedoms. Medicine turning into a moral arbiter in society and exerting a moralizing function was recognized early on as an intrinsic mechanism of medicalization. Thus, acute moral concerns were at the core of the emerging medicalization debate in the 1960s, and important moral intuitions have continued to be part of the examination of increasingly complex medicalizing dynamics. Scholars with different disciplinary afﬁliations could not avoid the fundamental question embedded in the problematic under study: is the medicalization of society good or bad, or beneﬁcial or detrimental for people? While the answers varied, it is generally accepted that, notwithstanding the merits and effectiveness of expanding medical interventions, there are numerous moral “discontents” inherent to medicalization and a “dark side” of its impact in society.

In what concerns the relation between the topic of medicalization of society and the ﬁeld of bioethical reﬂection, several observations can be made. While aspects of medicalization can be seen as relating to virtually all areas of health care and public health treated by bioethicists, the speciﬁc problematic of medicalization has only recently received attention in the ﬁeld of bioethics (Sadler et al. 2009). Moral concerns formulated within the general medicalization critique and the propositions advanced in the work of social scientists informed to a large extent the bioethical discussion of medicalization. Thus, important continuities characterize the study of medicalization in the social sciences and in bioethics. Additionally, recent speciﬁc bioethical efforts attempted to offer a normative framework for assessing medicalization and to advance a social justice approach to distinguishing legitimate medical interventions in society.

It can also be observed that as the engines driving medicalization multiply beyond the traditional sphere of medicine and health care, the concept of medicalization becomes relevant for ethical elaborations beyond the ﬁeld of bioethics, such as, for instance, in marketing and business ethics. Key contributions by social scientists serve as a bridge to the exploration of medicalization from these new ethical vantage points.

In the pages to follow, key moral concerns expressed in the general medicalization critique are brieﬂy surveyed, followed by a review of bioethical contributions to the literature of medicalization.

The “Discontents” Of Medicalization: Key Moral Concerns In The Medicalization Critique

Interrelated concerns about the moral character of medicalization and about its morally problematic consequences have been repeatedly raised by scholars. These include, in no particular order:

As part of medicalization, health and illness become moralized through the discourses and practices of medicine, which acquires the role of moral arbiter in society. This situation goes unnoticed due to the common assumption that medical and allied disciplines are scientiﬁc – thus, morally neutral, or due to the naive assumption of moral and ethical probity on the part of medicalizing agents.
By deﬁning normality, medicine serves to legitimize desirable versus undesirable qualities in groups and individuals and instills divisive practices of marginalization or stigmatization usually applied to people and groups of lower social status.
Medicalization shapes and reinforces the valorization of health as a supreme value and turns the achievement of health into a crucial goal in life. As a consequence, higher human aspirations – including ideals of freedom, solidarity, autonomy, and dignity – are shunned.
Due to medicalization, social problems are regarded as individual pathologies and treated with medical interventions at the individual level. This serves the undue depolitization and individualization of social problems.
Concurrently, the dominating notion of an individualized responsibility for one’s health de-emphasizes sociopolitical determinants of health and the political responsibility for strategies that ensure the premises of good health for all people. This situation serves market driven neoliberal power and leads to de-emphasizing the quest for collective wellbeing in the public domain of life.
Related, through medicalization, a “regime of obligation” replaces a “regime of rights” for health.
The medicalization of virtually all aspects of life trumps experiential knowledge and diminishes the autonomy and freedom of the citizenry.
Medicalization serves the institutionalization of the virtually limitless panoptical monitoring and surveillance of the biology, behaviors, emotions, and distresses of individuals and populations.
Sprawling strategies for identifying “risks to health,” including genetic risks, lead to discriminatory practices at the work place and in providing health insurance.
The medicalization of deviance leads to the erosion of traditional notions of “bad,” “evil,” and “sin” and to disconnecting responsibility from evil intent and wrong doing.
Medicalization creates “subjugated knowledges,” reinforces old, and creates new asymmetries of power that lead to the domination and exploitation of the less powerful in society – locally and globally – by power elites, as well as to subverting ideals of fair and just societies.
Related, medicalization in a global neoliberal framework challenges and restricts fundamental human rights and liberties, including social and economic rights. The global commodiﬁcation, privatization, and marketization of health lead to deepening social, economic, and health inequalities.
In the global arena, pockets of medicalization or over medicalization coexist with the under provision or lack of access to basic medical care, a situation which rises a set of speciﬁc ethical dilemmas.
Medicalization practices linked to technologies of enhancement and genetic intervention lead to the redeﬁnition of health and, potentially, to a “laissez-faire eugenics” on grounds of economic access to genetic procedures.
Overall, medicalization contributes to fundamentally transforming humanity and life in the name of ameliorating health.

Peter Conrad (2007) noted that while iatrogenic risks to individuals’ health as a result of medical interventions are not insigniﬁcant – i.e., iatrogenic illness, screening with false-positive results – medicalization studies in the twenty-ﬁrst century will have to give priority to assessing the important social consequences of medicalization. These refer to (a) the pathologization of everything and the turning of human difference and uniqueness into targets for medical intervention; (b) the medical deﬁnition of normality through which medicine creates norms that become “proper” social norms; (c) the expansion of medical and social control, especially through pharmaceuticals and new technologies, but also through the increasing surveillance of behavior and body functions; (d) the individualization of social problems. Medicalization turns complex social problems into clinical categories (e.g., alcoholism, obesity) and offers individual solutions that ignore the social causes for the problems at hand; it makes social or environmental interventions ignored and marginal, reinforcing the preference for technological ﬁxes for complex human issues; (e) the rise of medical markets and consumers, whereby medical services become increasingly goods subjected to the logic of markets; and (f) the issue of pockets of resistance and of limits to medicalization (Conrad 2007, pp. 147–164).

Bioethical Approaches To Medicalization

Continuities With The General Medicalization Critique

Positions expressed by bioethicists generally resonated with the claims of the general medicalization critique. The following excerpt from a debate about the ethical implications of the medicalization of mental health that was organized by the President’s Council on Bioethics in the USA illustrates this point:

You deﬁne “medicalization” as that view reducing all forms of human distress and disorder to aspects of “sickness”, expressions of “patient-hood” and thus expressly open to technical, mostly bio-medical, correction at the hands of experts for whom ideas of good and evil, freedom and responsibility, sanctity and sin, approval and reprobation are meaningless. Medicalization is a materialist ethos with roots in both biological sciences and contemporary medicine. You want us to think about its emergence, its authority, its hubristic potential, and how to speak to it. (President’s Council on Bioethics 2003, section III, para. 2)

McHugh argues for nuancing these views and advocates the distinction between what he calls the “ethical problem” and the “ethos problem” of medicalization. The former focuses on assessing whether treatments and practices respect “professionally beﬁtting grounds,” while the latter refers to the “viewpoint about humankind that spurs thoughts, customs, and practices” known as medicalization. While these problems are entangled, they would beneﬁt from separate bioethical analyses (President’s Council on Bioethics 2003, section III, para. 9).

Another exempliﬁcation of the validity of the concept of medicalization for bioethical analysis is Verweij’s (1999) study “Medicalization as a moral problem for preventive medicine.” Here Verweij analyzed the ethical implications of preventive medicine as an important agent in the medicalization of normal life. He advanced that the notion of medicalization applied to preventive medicine conveys moral intuitions that cannot be framed satisfactorily in conventional bioethical categories, such as respect for autonomy or principles of nomaleﬁcence. These intuitions refer speciﬁcally to the accumulation of uncertainty about health, to the misallocation of responsibility for health and victim blaming, to the loss of autonomy and independence of people, to the rising valuation of health in the lives of persons, and to the obligation to participate in prevention. All these represent ethically controversial aspects. Verweij noted that it is precisely the summative effect of preventive interventions and their associated discourses that make preventive care ethically problematic; this becomes visible only when looking beyond practices of preventive medicine taken individually. According to Verweij’s analysis, in the case of both preventive medicine and health promotion, particularly problematic are their effects on (a) the accumulation of uncertainties and fears and the weakening of feelings of security and conﬁdence that people have on their health that is detrimental to a sense of wellbeing, and on (b) shaping ideals of a good life that overemphasize the role of health and encourage moral beliefs that are not warranted.

In Search Of A Systematic Normative Approach To Medicalization

If the concept of medicalization reﬂects important ethical intuitions and concerns that people have, it has also been noted that issues of medicalization are less than adequately covered by common bioethical categories and tend to “overgrow” conventional bioethical approaches (Verweij 1999). From a bioethical perspective, the fundamental concern is to determine the moral worth of medicalization under general and speciﬁc circumstances or, as Parens (2011) phrased it, how to distinguish good forms from bad forms of medicalization. Toward this end, Sadler and colleagues proposed a systematic approach for assessing the ethical dimension of phenomena of medicalization and exempliﬁed its application to the analysis of several “evaluative and metaphysical characteristics and contexts, right up to the eudemonic endpoints of human ﬂourishing” (Sadler et al. p. 424). Considered by its authors as adequate for policy deliberations and public debate, this approach consists of a sequential procedure. It starts with establishing a clear working deﬁnition of what constitutes medicalization, followed by establishing if a certain phenomenon represents a valid claim of medicalization and, subsequently, by uncovering and weighing the values and functions of medicalization in a speciﬁc instance. Regarding this latter point, multiple and at times conﬂicting values, interests, and social functions may be concomitantly at play in a given case of medicalization including interests for care, cure, and control of illness; proﬁt, power, and wealth; economical efﬁciency; and differing ideals of a good life and a good society – e.g., eudaimonia versus utilitarian and individualistic versus communalistic ideals. A careful consideration of these aspects is the task of the bioethicist. In addition to aligning one’s analysis to, for instance, a principlist approach that considers aspects of autonomy, beneﬁcence, nomaleﬁcence, and justice, a consideration of underlying epistemological and ontological assumptions (“metaphysical assumptions”) and of politicalphilosophical accounts is also necessary. The authors exemplify in their analysis of attention deﬁcit and hyperactivity disorder in children that “metaphysically parallel analyses” can lead to identifying common ground conclusions about the social worth of cases of medicalization (Sadler et al. 2009, p. 423).

Sadler and colleagues also insist that in order to make sense of processes of medicalization and of their ethical merit, carefully contextualized and “thick” sociocultural assessments are needed; this is because “at root, medicalisation is a complex phenomenon that interacts with other social structures, purposes, and intentions. As a social meaning, it is embedded in other meanings as a graded phenomenon, not an either/or absolute.” Thus, substantiating and weighing “medicalization claims” can only be advanced through their contextualization “within particular rationales, worldviews and belief systems” (Sadler et al. 2009, p. 414).

Social Justice: The Definition Of Health And Human Rights Perspectives

A recent contribution by Kukla distinguishes between scientistic and social justice projects of health. While the former are grounded in a natural science paradigm, are supported by scientistic deﬁnitions of health, and lead to sprawling medicalization, a social justice project of health is a normative endeavor aimed at establishing what the place of health should be in just society (Kukla 2014, p. 516). Kukla’s contention is that a “normative project of deciding what just health institutions and policies would look like” (Kukla 2014, p. 525) requires an adequate deﬁnition of health. Neither the social constructionist nor the scientistic conceptualizations of health are suited for this task. Instead, she advances an “institutional” deﬁnition of health:

A condition or state counts as health condition if and only if, given our resources and situation, it would be best for our collective well-being if it were medicalized – that is, if health professionals and institutions played a substantial role in understanding, identifying, managing and/or mitigating it. In turn, health is a relative absence of health conditions and concomitantly a relative lack of dependence upon the institutions of medicine. (Kukla 2014, p. 526)

Kukla considers that “health and its absence” can be used as “stable normative notions for the purposes of building an account of just social arrangements” (Kukla 2014, p. 527). Reviewed among the main concerns raised in the medicalization critique was precisely the observation that, under current sprawling medicalizing regimes, the relative absence of health conditions is constantly eroded by expanding medical and health expertises.

Whether a deﬁnition of health leading to socially just arrangements can be institutionalized is an open question at this point. Open to elaboration is also determining if the potentially fruitful application of the human rights perspective (ten Have and Jean 2009) can successfully advance the ethical examination of health governance, especially of practices and policies leading to medicalization in the global context. Nevertheless, “the demand for the normative assessments of medicalisation will only increase over the coming decades” (Sadler et al. 2009, p. 424) The ethical critique of medicalization has to overcome important challenges such as the broad and uneven character of processes of medicalization and the multiplicity of contexts in which these processes evolve, including contested, ﬂuid, and uneven global dynamics characterized by contradictory developments, by rapid changes, as well as by a complicated health governance historically resulting in only partially successful policies. An effective ethical approach to medicalization will likely have to rest on an encompassing framework that can be globally applied and can inﬂuence public debate and policy formulation, and that would couple the “thick” contextualization of medicalization practices and meanings with clear philosophical and ethical propositions.

Conclusion

The medicalization of society is a salient feature of contemporary life. It has important consequences ranging from personal to collective and global. It is a complex issue cutting through fundamental human and social concerns and through myriad moral questions. Does medicalization improve the human condition and does it decrease pain? What kind of conceptions for a good life and society does it impart? As commentators noted, medicalization touches on important intuitions about how society functions and about what constitutes legitimate moral, social, and political concerns in society. Acute questions of what life is, who we are, how should we live our lives, and what is a good life are currently linked to practices and experiences of medicalization. Paraphrasing Rose, it is the role of the ethicist “to open the possibility of posing certain questions about the costs of organizing our experience of ourselves” (Rose 1998, p. 69) in a medicalized way.

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