A Critical Appraisal of the Concept of Medicalization for Understanding Dementia
The aim of this paper is to critically appraise the use of the concept of medicalization, as used by sociologists to examine dementia. It will examine medicalization and dementia and the association between the two. Three papers that have used medicalization to understand and explain dementia will be examined. The papers will be critically appraised on the strengths and limitations of the author’s application of the concept. The study will use the arguments raised in the three papers to conclude whether the concept of medicalization can be used to understand dementia.
Sociologists have been concerned with medicalization for over three decades. The earliest mention focused on the medicalization of deviance (Pitts 1968). However, sociologists soon saw the concept’s applicability to a wide range of human problems that had entered into medical jurisdiction (Friedson 1970; Zola 1972; Illich 1976). Medicalization simply describes a process by which non-medical problems become defined and treated as medical problems, usually in terms of illnesses or disorders. Although the literal meaning of the phrase is ‘to make medical’, it has most frequently been used in the context of a critique of medicalization. While sociologists have mostly concurred that medicalization refers to the process of problems entering the medical jurisdiction, they have offered different definitions. Friedson (1970) emphasised the jurisdictional mandate the medical profession has over anything that has been labelled an illness, regardless of its ability to deal with it effectively. Zola (1972: 495) defined medicalization as a “process whereby more and more areas of everyday life had come under medical supervision.” He also drew attention to the fact that medicine operates as a powerful institution of social control. Conrad (1975) stated that medicalization consists of defining behaviour as a medical problem and mandating the medical profession to provide some treatment for it. Illich (1976) termed medicalization ‘social iatrogenesis’ and said that it resulted from medical imperialism; he expressed particular concern at the increasing ‘medicalization of life.’ Mechanic (1978) wrote that medicalization involved professionals widening their domain to include areas where they have little special knowledge or competence. Lastly, Navarro (1976) has argued that medicalization is a means of social control that serves the interest of powerful groups in society such as the ruling capitalist class.
Therefore, medicalization consists of defining a problem in medical terms, using medical language to describe a problem, adopting a medical framework to understand a problem or using a medical intervention to treat it. Within our society, medicalization of human problems has occurred primarily with deviance and natural life processes. Medicalization of deviance includes alcoholism and mental disorders for example. Examples of common life processes which have been medicalized include childbirth and menopause. Conrad (2000) argues that there are degrees of medicalization. Certain conditions are almost fully medicalized (e.g. childbirth), others are partly medicalized (e.g. menopause) and others are minimally medicalized (e.g. sexual addiction). Factors that affect the degree of medicalization include availability of medical treatments, coverage of medical insurance and the presence of individuals or groups promoting or challenging medical definitions.
Even though there is not complete agreement within the medical community concerning the nature of dementia as a disease, a biomedical paradigm is generally used as a framework for explaining the nature of the disorder (Gubrium 1986; Lyman 1993). When people are officially diagnosed with the condition, it is presented as an organic disease ‘said to be caused’ by the degeneration of cells in the brain (Gubrium 1986). If dementia is viewed as an organic disease, then inappropriate behaviour which otherwise would be considered deviant, can be interpreted as merely a symptom or sign of the disease. Deviant behaviour is medicalized and the demented individual is absolved of the responsibility for their actions. Within the dementia literature, in particular within the caregiver handbooks (e.g. Mace and Rabins 1981), those who look after dementia sufferers are told that they must always remember that the person with the disease is not responsible for their actions. Furthermore, whatever the individual does out of character is a result of the disease. An alternative to the reductionist and disease orientated biomedical model is a holistic and contextual social model where ill health is caused by social factors (Gillespie & Gerhardt 1998).
Most analysts of medicalization write in a critical mode, either emphasising the problems of over-medicalization or its consequences. Karen Lyman’s 1989 paper ‘Bringing the social back in: a critique of the biomedicalization of dementia’ is of this ilk. The central argument of the paper is that reliance upon the biomedical model to explain the experience of dementing illness overlooks the social construction of dementia and the impact of treatment contexts and care-giving relationships on disease progression.
Lyman gives a definition of dementia early in her paper: it consists of a group of progressive brain disorders characterised by gradual deterioration of memory, language, other intellectual abilities, and general competence over a 7 to 15-year period until death. She views dementia as an example of the medicalization of deviance, which she defines as “explaining and treating personal and social troubles as medical problems.” She references Conrad and Schneider and Zola for this definition.