Medicalising everyday life

The British Medical Journal (BMJ) has published a special issue on ‘medicalisation’ – the growing tendency to treat all kinds of personal and social issues as medical conditions or diseases (1).

Many have welcomed this as a sign that the medical profession is waking up to the problems resulting from the spread of medical influence over wider and wider areas of life. A closer look reveals that the leading journal of British medicine is in a state of confused introspection rather than engaged in serious questioning of current trends in practice.

The feature that won wide attention was the BMJ‘s list of the Top 20 ‘non-diseases’ – everyday problems that GPs are increasingly expected to deal with in their surgeries today. In fact, this feature reveals the journal’s difficulty with the subject of medicalisation.

The list includes boredom, bags under the eyes, big ears, grey hair, ugliness, freckles (indeed these are all in the Top 10). Now in my 20 years as a doctor, nobody has ever presented any of these as symptoms, never mind believing them to be diseases. The list does not seem to work as a joke – it also includes problems such as loneliness and unhappiness, which though not very amusing, do commonly bring people into doctors’ surgeries. Number 18 is pregnancy, which is perhaps the only condition in the list which could be considered a normal human experience that doctors have a tendency to treat as a disease. The Top 20 feature manages both to trivialise medicalisation while also avoiding the real issues at stake.

The BMJ‘s Top 20 leaves out a wide range of conditions that in recent years have come under the medical umbrella, yet many would consider to be ‘non-diseases’. These include ME/chronic fatigue syndrome, irritable bowel syndrome, fibromyalgia, whiplash, repetitive strain injury; syndromes such as attention deficit hyperactivity disorder, post-traumatic stress disorder or social phobias; addictions to alcohol and drugs, and also to nicotine and gambling; teenage pregnancy, domestic violence, bullying. It is perhaps not surprising that the BMJ doesn’t consider these conditions within the framework of medicalisation: many have been promoted in recent issues of the BMJ.

A curious feature of the BMJ‘s special issue is the prominence it gives to Ivan Illich and his 1975 book Medical Nemesis. Illich is cited or quoted in several articles and, more than a quarter of a century after its publication, his book is honoured with an enthusiastic review by the BMJ editor himself. Richard Smith confesses that listening to Illich was the closest he ever came to a religious experience. After attending a lecture given to medical students in Edinburgh in 1974 by this ‘charismatic and passionate man’, who argued that ‘the major threat to health in the world is modern medicine’, Smith dropped out of medical school (only to drop back in again three days later).

I attended a similar lecture by Illich in London in the same period, but perhaps because of my earlier experience of clerical oratory (Illich was a former Jesuit priest), I was less susceptible to his evangelical charisma. His peculiar glorification of pain and suffering suggested an incomplete rupture from the doctrines of Catholicism. Though I was impressed by aspects of his critique of medical professionalism, I was repelled by his ‘repent-the-end-is-nigh’ apocalyptic environmentalism. It seemed to me that the positive aspects of Illich’s polemic against medicalisation were negated by his backward-looking hostility to science and technology (and to all forms of industry), and his sentimental affinity for primitive or traditional societies.

In the 1970s, Illich was briefly fashionable among environmentalists and disaffected medical students, but he made little impact on the medical mainstream. Though he was comprehensively repudiated from the left in David Horobin’s Medical Hubris, his rugged individualism proved congenial to the consumerist, self-help and alternative health fads of the Thatcher era.

Some of his anti-professional themes were taken up by law lecturer Ian Kennedy in his Reith Lectures in 1980 (they reappeared in the 2001 report of the inquiry into the Bristol children’s heart surgery unit, which Kennedy chaired). Illich himself disappeared without trace. Yet now, more than 25 years later, he’s back and being feted by the medical establishment he once excoriated (and of which Richard Smith has, by his own admission, become ‘a pillar’). What’s going on?

In a thoughtful contribution on the subject of the medicalisation of dying, palliative care consultant David Clark notes that ‘at the time when Illich was writing, the mid-1970s, a much more unitary and optimistic view of medicine was in evidence than exists today’. By contrast, ‘the modern medical system is pervaded with doubt, scepticism and a mistrust of expert claims’.

When the world of medicine retained some confidence in its scientific methods and professional achievements, it could reject Illich’s misanthropic critique. In today’s demoralised climate, doctors are ready to embrace it. Though Clark concludes, ‘in a sense he has won the argument’, it might be more accurate to say that the nihilistic outlook that was confined to a fringe in the 1970s has now become mainstream.

Readers of the BMJ, who voted in a poll for a special theme issue on the subject of medicalisation, are likely to be bemused by the result. There are some useful discussions of important aspects of medicalisation in the spheres of obstetrics and gynaecology (pregnancy, childbirth, the menopause), psychiatry, geriatrics and palliative care, the role of the drug companies, screening and prevention. But the whole is gravely compromised by the facetious tone of the leading feature and by the lack of overall coherence or perspective.

One example illustrates the BMJ‘s capacity to miss the point about medicalisation. The special issue includes a lengthy article entitled ‘Sexual behaviour and its medicalisation: in sickness and in health’. This eye-catching feature is illustrated by nineteenth-century depictions of the ‘facial effects of masturbation’ and a device for discouraging such self-abuse. It reproduces an advertisement from the ‘Laser Vaginal Rejuvenation Institute of Los Angeles’ and a detailed account of genital enhancement procedures now available in the USA.

Readers will no doubt find all this enlightening, amusing and even titillating. Yet this comprehensive survey of medical intervention in sexual behaviour past, present and future entirely ignores the key initiatives in this area over the past decade: the safe sex campaign (which exploited fears about HIV/AIDS to foster sexual restraint), the crusade against teenage pregnancy (which pruriently demonises adolescent sexuality), and the current anti-chlamydia campaign (which hypes fears of infertility to deter sexual experimentation).

While I have yet to see a single patient influenced by the promotion of the ‘designer vagina’, the impact of these campaigns is unmistakable. Given that the authors have been actively engaged in promoting these forms of medicalisation, it is not surprising that they seem incapable of recognising them as such.

In his opening editorial paean to Illich, Richard Smith recommends the ‘de-medicalisation’ and ‘de-professionalisation’ of primary care (though the rest of the issue includes little discussion of issues of medicalisation in general practice). He reassures readers that ‘this is no longer a radical agenda’. In truth, de-medicalisation Illich-style always had a reactionary character. The new popularity of Illich among the medical elite in the new millennium indicates its evasion of the real issues of medicalisation in favour of a despairing return to the manifestos of the past.

Dr Michael Fitzpatrick is the author of MMR and Autism, Routledge, 2004 (buy this book from Amazon (UK) or Amazon (USA)); and The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA). He is also a contributor to Alternative Medicine: Should We Swallow It? Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)).

Read on:

After Bristol: the humbling of the medical profession, by Dr Michael Fitzpatrick

Doctors on the defensive, by Dr Michael Fitzpatrick

(1) ‘Too Much Medicine’, BMJ, 13 April 2002