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The Medicalization of Everyday Life is a collection of sixteen essays written by Thomas Szasz between 1972 and 2006. Although each of the essays has been published elsewhere, there is substantial value attained by viewing them together in a single volume. The collection is unified by the idea there have been, and continue to be, powerful trends toward the "medicalization" of many aspects of life -- indeed, too many aspects of life. Its aim is to clarify what medicalization is, how it is manifested in different medical institutions and practices, what is wrong with it, why it occurs, and what should be done about it. The focus of the discussion is, of course, psychiatric practices and institutions, although other medical practices also receive close scrutiny. The collection is divided into two parts. The first, Demarcating Disease from Nondisease, consists of seven essays addressing questions of the definition of 'disease' and 'mental disease' and clarifying the history and significance of such definitions. The second, Disturbing Behavior and Medicine's Responses to It, consists of nine essays surveying numerous putative examples of medicalization and providing detailed discussion of each (e.g., coercive psychiatric practices, hysteria, routine neonatal circumcision, suicide, pedophilia, criminal responsibility, euthanasia, medical ethics, relations between medicine and the state.)
Those familiar with Szasz's writings over the past fifty years, will recognize many of the themes found in this collection: the importance of history for understanding current medical and psychiatric practices, the importance of language in structuring medical practices and institutions, the coercive potential of language, the "myth" of mental illness, the importance of individual autonomy, the threat to individual autonomy and responsibility posed by psychiatric diagnosis, the tensions between individual autonomy and the state, and the recruitment of medicine and psychiatry as extensions of the police powers of the state. Those who are new to Szasz's writings will quickly be brought up to speed on Szasz's critical stance toward contemporary psychiatry and the deeper trends in medicine and society that underlie psychiatric practices and institutions.
The basic conceptual framework underwriting Szasz's analysis is as follows. Assuming that the distinction between medical and non-medical practice is of critical importance because it influences medical care, law and social policy, and hence the lives people live, it is of paramount importance to delineate legitimate medical practice. Simply put, 'medicalization' refers to an illegitimate practice of introducing medical terms, concepts, and practices into an area of social or personal life when it is inappropriate to do so (e.g., viewing racism or homosexuality as diseases.) As Szasz understands it, medicalization is a semantic and attributional strategy that shapes forms of social and professional practice and forms of individual consciousness and behavior. The thrust of this strategy is that, when someone is viewed as sick (ill, diseased) or their behavior is viewed as the product of sickness (illness, disease), then the behavior is viewed as not under the person's rational control (i.e., not reason-based, not motivated), the individual is viewed as not fully a moral agent, and his/her moral and social status is diminished. As a consequence, medicalized individuals are viewed as less responsible for their behavior and as more fitting candidates for being the object of coercive treatment by others. Furthermore, such individuals are classified in a way that enlists various social institutions and practices erected for the purpose of dealing with them (e.g., sick individuals fall within the domain of medical practice.)
There are two general forms of medicalization. First, there is "medicalization from below" (i.e., from powerlessness) which takes the form of malingering or self-medicalization, wherein the individual (falsely) assumes the role of patient to be treated in certain ways and excused from certain responsibilities. In this sort of case, the individual adopts the medicalizing strategy to pursue certain interests (e.g., avoid punishment, avoid having to confront difficult situations, receive benefits), at the expense of others. Second, there is "medicalization from above" (i.e., from power) which takes the form of "medicalization of the other to control or punish", wherein individuals who are disruptive, deviant, dangerous, troublesome, etc are placed in the patient role which then legitimates various forms of "treatment" or other (coercive) measures with or without the person's consent. In this sort of case, an individual (or group) viewed as detrimental in some way to other people, society or the state, is identified as diseased and controlled in ways that harm them (via dehumanization and deprivations of liberty). In both sorts of case, the interests of some are served while those of others are harmed as a consequence of a powerful linguistic-social strategy.
At the root of this analysis is a conception of what is a genuine medical disease and, hence, what is an appropriate use of the terms 'disease', 'diagnosis', 'treatment', "physician", and "patient". Without such an analysis, the distinction between "medicalization" and legitimate medical practice cannot be made. According to Szasz, a genuine disease involves an objectively identifiable physical lesion of the body, where a lesion is a disturbance in the structure or function of cells, tissues, and organs. (22) In legitimate medical practice, such diseases are discovered and classified by research pathologists, and they are diagnosed and treated by physicians, always with the consent of the individual patient. In medicalization, there are departures from this standard in which "diseases" are constructed and projected onto "patients" for the purposes of justifying "treatment" by "physicians", with or without consent. The deep significance of this latter practice is at least twofold. First, medicalization leads to increased dehumanization (viewing someone as less than a moral agent) and loss of freedom (depriving someone of their rights) for individuals in a wide range of contexts. Second, it is a driving force in the emergence of the "therapeutic state": as individuals, the public, the government, and various special interest groups promote medicalization of more and more areas of personal or social life, the prestige and power of science and medicine are recruited into legitimizing medical practices in the service of the economic, political, ideological, and social interests of the state, thereby increasing its sphere of influence. The various papers in the volume aim, in one way or another, to clarify and justify these two points of significance. A few examples will have to suffice.
As explained by most of the essays in the volume, the paradigmatic example of medicalization, according to Szasz, is the use in psychiatry and related "mental health" professions of such terms as 'disease', 'diagnosis', 'treatment', 'patient', and other terms designating medical conditions, practices, and roles. Though literally applicable in genuine medicine contexts, such terms are used at best "metaphorically" when applied to disturbing behavior and life problems that become the objects of psychiatric practice. One argument for this claim proceeds as follows: a genuine disease involves a physical lesion of the body, and, hence, only bodily parts or processes can be diseased; the mind and all things mental are either thoughts or behaviors or dispositions to think or behave, none of which are substances or parts of bodies and, hence, none of them can be diseased. To attribute 'disease' to the mind is to commit a "category mistake" or to engage in a metaphor (as in a "sick" joke), perhaps for rhetorical and strategic purposes. Buttressing this argument are two further points: 1) rejection of naïve materialist reductionism and determinism (i.e., the mind is not reducible to or otherwise determined by the brain); and 2) assertion that the standards by which bodies and minds are judged are different (e.g., while bodies can be diseased, minds can only be irrational or vicious.) To bring home the point, Szasz uses the following analogy: physical disease is to "mental disease" as a broken television is to a bad television show.
Szasz famously concludes that mental illness is a harmful myth, psychiatry is not a bona fide medical specialty, and psychiatrists are not medical experts. The deep harms that result from these practices include: dehumanization of individuals by not viewing them as the authors of their behavior and as responsible for it (e.g., the Church's initial internal response to child-abusing priests), loss of freedom by coercive intervention (e.g., involuntary commitment, involuntary treatment, suicide prevention), undermining of legal and social justice by influence on legal proceedings and social policy (e.g., the insanity defense, the Americans with Disabilities Act), and creation of a broad culture of pathologizing and control in contexts where other approaches are called for. Of medical classification in general, but especially psychiatric classification, he charges that its purpose is not to objectively identify conditions that are diseases but to prescribe what conditions should be viewed as diseases for the purposes of prescribing social policy regarding what is appropriate treatment for what conditions and paid for by whom; he links such classification to monetary gain and the politicization of medicine.
Past or present categories of mental disorder that come under critical scrutiny in this volume include homosexuality, masturbation, hysteria, depression, schizophrenia, pedophilia, sexual perversions, and drug addiction: in all cases medical, disease-oriented interpretations of the behavior associated with these categories are disputed; if there were a brain disease associated with any of them (which Szasz deems most improbable), then they would be brain diseases, not mental diseases.
Szasz's alternative view of individuals who are classified as "mentally ill" is as follows: the individual is a moral agent who is the author of his or her actions and hence is responsible for them. Since life is fundamentally tragic, involving free will, responsibility, and human weakness, some people are unhappy, failures, in conflict with others, liars, manipulative, violent, or criminals or have bad habits; but none of these things are appropriately called "illness." For example:
· -Of individuals expressing "delusional ideas" he contends that, on a par with actors and criminals, such individuals should be viewed as acting on "the desire to gain existential rather than economic advantage" and "we ought to view such behavior as a type of "existential identity theft..." (39)
· -With respect to "hysteria" he insists that "hysterical symptoms" are a form of communication used in the context of "game-playing" and that "hysterics act disabled and sick; their illness is not real but an imitation of a bodily illness. By means of body language, hysterics communicate with themselves and others, especially those willing, perhaps even eager, to assume the role of protecting and controlling them." (76)
· -And, finally, commenting on a defendant pursuing a verdict of not guilty by reason of insanity, Szasz writes that the defendant was "suffering from the consequences of having lived a life very badly, very stupidly. Very evilly; that from the time of her teens, for reasons which I don't know, she had, whatever she had done, she has done very badly. She was a bad student. There is no evidence that she was a particularly good daughter, sister. She was a bad wife. She was a bad mother. She was a bad employee insofar as she was employable. Then she started to engage [in taking] illegal drugs, then she escalated to illegal assault, and finally she committed this murder...Life is a task. You either cope with it or it gets you...If you do not know how to build, you can always destroy. These are the people that destroy us in society, our society, and other people." (110-111)
In addition to psychiatry, Szasz discusses several other examples of medicalizing trends and practices. In "The Fatal Temptation: Drug Control and Suicide", Szasz attempts to draw out latent contradictions in orthodox talk about suicide, drugs, autonomy, and rights involving life and death. Associating the "right to die" with "our skittishness about suicide and our longing for good doctors to kill us at just the right time and in just the right way but, more fundamentally, ... [with] our repudiation of bodily self ownership and the responsibilities that go with it", Szasz argues that suicide is a basic human right and that it implies a right to free access to drugs. He suggests that it is the dual fears of dying a protracted, pointless, and painful death and of living with a free market in drugs that undermine "pharmacological autonomy" and that inappropriately vest power in medical agents, institutions, and practices.
In "Routine Neonatal Circumcision: A Medical Ritual", Szasz argues that routine neonatal circumcision (RNC) is a practice that demonstrates how contemporary culture has bought into medicalizing practices. According to Szasz, RNC is not justifiable on health grounds (e.g., prevention of cancer or infection), is ethically and medically on a par with female genital mutilation, and, hence, is an essentially religious ritual that is legitimized as a medical practice to serve ideological, political, and religious interests.
"Killing as Therapy: The Case of Terri Schiavo" is presented as a study of hypocrisies concerning euthanasia, physician-assisted suicide, the medicalization of death and dying, and access to drugs. Szasz observes that "The Schiavo drama was a classic battle of words: he who controlled the vocabulary controlled the debate and was assured of victory," (118) and he details how the language of ethics (e.g., 'rights', 'persons', 'autonomy') and medicine (e.g., 'coma', 'permanent vegetative state', 'irreversible brain damage', 'patient', 'physician', 'treatment', 'physician assisted suicide') shaped the unfolding of the case which, on his view, was badly handled by all parties involved: the husband, the parents, the media, medical ethicists, religious groups, physicians, the courts, and the state. He concludes that "Terri Schiavo was killed ... [b]ecause no one --not her husband, not her parents, not any philanthropist, not the American taxpayer- was willing to pay to keep her alive ... If we believe that executing innocent people is wrong, then the Schiavo case presents no ethical problem. It presents economic, political, and social problems." (129-130) And the deeper moral is supposed to be that practices concerning death, dying, and dependency, matters that previously have been problems for the family and the church, are now becoming problems for the state and are increasingly being framed in medical terms (e.g., 'physician-assisted suicide"). But, again, such medicalization comes with a cost: "In short, the legal definition of PAS as a procedure that only a physician can perform expands the medicalization of everyday life, extends medical control over personal conduct, especially at the end of life, and diminishes patient autonomy." (129)
"Peter Singer's Ethics of Medicalization", is a study of the views of Peter Singer, a medical ethicist. Szasz writes as follows: "Why do I consider his views --which I think are mistaken and wicked- in this volume? I do so because he is a prominent figure in contemporary bioethics and because his "preference utilitarian perspective" is a striking example of the contemporary debauchment of morality and politics by means of the medicalization of ethics." (134) Szasz sees in Singer a prime example of how processes of medicalization and the therapeutic state, with their objectionable consequences for personal responsibility and freedom, are buttressed by medical ethicists.
"Pharmacracy: The New Despotism" (2001), focuses on issues related to practices informed by medicalizing ideology and the use of force "by physicians acting --explicitly or implicitly, wittingly or unwittingly- as agents of the state." (151) In particular, Szasz argues that, although certain coercive public health measures can be legitimate instruments of state control (e.g., quarantine during an epidemic), this sort of justification does not legitimately extend the role of the state to matters of private health. Just as it is important to maintain a separation between the church and the state, so, Szasz contends, it is important to maintain a separation between medicine and the coercive apparatus of the state: such a separation "is necessary for the protection of our traditional rights to life, liberty, and property." (154) Thus, "the answer to the question of whether a person has a "right to be ill" --physically or mentally- comes down to whether he is viewed as a private person or as public property: the former has no obligation to the community to be or stay healthy; the latter does have such an obligation. In proportion as medical care is provided by the state, doctors and patients alike cease to be private persons and forfeit their "rights" against the opposing interests of the state." (161)
Szasz's diagnosis for why America is drifting toward pharmacracy and the therapeutic state is that "Americans want a therapist-in-chief who is both physician and priest, an authority that will protect them from having to assume responsibility not only for their own health but also for their behaviors that make them ill, literally or figuratively. Pandering to this passion, politicians assure people that they have a "right to health" and that their maladies are "no-fault diseases"; promise them a "patient's bill of rights" and an America "free of cancer" and "free of drugs"; and stupefy them with an inexhaustible torrent of mind-altering prescription drugs and mind-numbing anti-disease and anti-drug propaganda --as if anyone could be for illness or drug abuse." (167-8) But, Szasz warns, as people rush to embrace the therapeutic state, "by the time they discover that the therapeutic state is about tyranny, not therapy, it will be too late." (168)
Strengths and Weaknesses
In addition to being quite readable and often entertaining, this collection of papers has several strengths. First, Szasz provides a critical perspective that demonstrates the sorts of analysis (e.g., unmasking influential ideologies and vested interests; identifying flawed inferences) that ought to be pursued if contemporary medical and psychiatric practices and institutions are to be understood, improved, or (if necessary) replaced. His is a perspective that all interested parties should understand and know how to respond to. Second, Szasz pursues attempts to clarify the historical roots and, hence, the contingency of contemporary practices: i.e., the world is not the way it is necessarily and understanding how it came to be the way it is is essential for progress. Third, more specifically, he provides a valuable clarification of the nature of medicalization practices and how they operate to shape consciousness, practices, and institutions. Fourth, he identifies important dimensions of medical and psychiatric practice that are often obscured from view: e.g., the psychosocial structure of mental health contexts and the risks to individuals inherent in such contexts (e.g., dehumanization, stigma, discrimination, and coercion.) Finally, he clarifies the importance of understanding the grades and types of criticism that might be pursued: some critical stances, while addressing recognizable problems, may (in so doing) reinforce problematic underlying assumptions that sustain the very practices being criticized (e.g., criticizing a specific category of mental disorder while implicitly affirming the concept of mental disorder).
Weaknesses of the volume are of three sorts. Szasz often depends on questionable assumptions and flawed argumentation, he is frequently silent on critical matters, and he makes limited recommendations for constructive change. First, Szasz relies upon a 19th century conception of disease that has been variously criticized as being unclear (what precisely is a "lesion"), as harboring normative assumptions, as failing to provide necessary and sufficient conditions, and as being too narrow if it precludes mental processes and functions from the domain of possible disease. Further, along with the definition of 'disease', Szasz relies on a quite dated philosophy of mind and an overly simplistic conception of "reduction" in the sciences to buttress his arguments for the mythical or metaphorical nature of "mental illness". As a consequence the arguments are not very compelling. Similar flaws undercut arguments for other claims made in the book (e.g., arguments about the right to suicide entailing an unrestricted right to drugs); although interesting and suggestive, the arguments are often not persuasive.
Second, there are several matters, the clarification of which would both strengthen his arguments and promote a more effective agenda of change. For example, in recent years the so-called "harmful dysfunction" analysis of mental disorder has led many to (incorrectly) believe that the central organizing concept of psychiatry has been sufficiently clarified to render Szasz's critique otiose. Szasz's case would be strengthened by showing why such an analysis falls short; simplistic claims about category mistakes and minds not being substances do not suffice for this. And again, his case would be strengthened by explaining in technical detail why contemporary genetic and neuroscience research programs are not producing findings that support a disease model of "depression", "schizophrenia", and other psychiatric categories. For this, a more sophisticated philosophy of science than the crude anti-reductionism Szasz embraces, one which clarifies the nature of scientific evidence, inference, and explanation, is required. Further, although alert to the problem of dehumanization and stigma, Szasz does not adequately emphasize and explain why contemporary "anti-stigma" programs, currently pursued by defenders of psychiatric practice, are so wrong-headed. Performing these tasks would help arm the public for coping with the rhetoric of defenders of psychiatric practice who "educate" us about the disease status of these categories. The key limitation is that of not providing more effective tools for those who are confronted with the pressures of medicalization and the therapeutic state.
Finally, Szasz's constructive proposals for change are limited. In the first essay, he makes three such proposals as follows. First, since "mental health problems" are "not medical but human (that is, moral, social, political) problems, we cannot solve them by therapeutic means; hence we must stop continuing and even intensifying our efforts to solve them by such means." (8) Second, "since the vocabulary of psychiatry serves to systematically redefine moral and political problems as diseases, we must repudiate and stop this abuse of our language." (9) Third, "as psychiatric "treatments" are chiefly overtly or covertly involuntary, such interventions must be disavowed; we must reject the use of psychiatrists as policemen, judges and jailers; and we must seriously dedicate ourselves to the proposition that "mental health" workers should help only those who want to be helped, that they should do so only in ways acceptable to their clients, and they should stop doing everything else." (9) And, in the Introduction he makes yet a fourth proposal in the context of discussing "education" about mental illness: "It is also obvious that the self-styled psychiatric "educators" never mention two major risks inherent in every professional contact between an individual and a psychiatrist, namely, stigmatization by diagnosis and loss of liberty by forced psychiatric "hospitalization."" (xxvi) The proposal, of course, is that such risks should be regularly disclosed. Finally, Szasz's alternative conceptualizations of the behavior of those identified as "mentally ill" (e.g., the hysteric, the delusional person, the defendant pleading insanity) repudiates a disease interpretation in favor of using non-disease descriptions heavily freighted with moral terms of evaluation.
Unfortunately, for the most part, the above recommendations are negative, far too abstract to be of much use, and not terribly responsive to the demands of the context in which change might be pursued. In the case of alternatives to a disease conceptualization of behavior, Szasz seems to promote the false dichotomy, "brain disease or moral failing" that is relied upon by many defenders of psychiatry. In general, more detailed and constructive proposals are called for: e.g., proposals which clarify not only what viable alternative forms of discourse, institutions, and practices might be like, but also how change might be realistically implemented with alternatives that do not reinforce problematic dichotomies and assumptions that inform current practices.
Despite the critical points just rehearsed, this is a valuable collection of papers. In a culture of rampant medicalization with many apparent crises brewing (e.g., widespread psychiatric diagnosis and drug treatment of increasingly younger children; deep confusion in the development of the DSM system of classification), most of us are quite ill-equipped for recognizing and resisting the powerful social and linguistic influences that promote such practices and breed such crises. Szasz's writing stimulates thought, motivates a desire for change, and demonstrates forms of criticism in which everyone (especially those in the mental health professions) should be well versed.
© 2008 Jeffrey Poland
Jeffrey Poland, Rhode Island School of Design & Brown University