Medicalisation and Professional Power

Medicine holds authority over a domain, and the boundaries of that domain have moved enormously within living memory.

Conditions have entered it and conditions have left it — and the processes by which they did are not principally discoveries about bodies.

This lesson is about how a jurisdiction is claimed and defended, how the medical one expanded, what that has cost, and — the part usually omitted — what it has been worth.

One diagnosis removed by a vote, and one created by a campaign.

The first. In the diagnostic manual of American psychiatry, published in 1952, homosexuality appeared as a sociopathic personality disturbance. In the 1968 edition it was reclassified as a sexual deviation.

It was a diagnosis. It grounded involuntary treatment, aversion therapy, exclusion from employment and immigration, and the assessment of individuals as disordered.

Activists began disrupting psychiatric conferences in the late 1960s, and the argument they made was substantially an evidential one: that the clinical literature was built on patients and prisoners — a sample selected on being in trouble (see 7.3.2) — and that research on people not in either category found no evidence of psychopathology.

In 1973 the association's board voted to remove it.

And then, because the decision was challenged from within the profession, it was put to a ballot of the membership. Around ten thousand psychiatrists voted, and a clear majority upheld the removal.

A disease status was determined by a vote.

It did not disappear cleanly. A replacement category covering distress about one's own orientation was retained, renamed in the 1980 edition, and finally removed in 1987 — so the full process took nearly two decades and produced three successive compromises.

Read the episode carefully, because both available readings are too simple. It is not that psychiatry discovered it had been wrong. It is not that a scientific matter was settled politically. It is that the question — is this a disorder? — was never the kind of question a laboratory could answer, and the vote made that visible.

The second, running the other way.

In the late 1990s, a pharmaceutical company received approval to market an existing antidepressant for a condition that had been in the manual since 1980 and had attracted little attention.

A public awareness campaign followed. Advertising, media placement, patient advocacy materials, and prevalence figures suggesting the condition affected a large share of the population. The campaign's public message was that a familiar experience — intense, disabling anxiety in social situations — was a recognised medical condition with an available treatment.

Prescriptions and diagnoses rose substantially.

And here the honest reading is again the harder one. Severe social anxiety is real, disabling, and was under-treated. People who received effective treatment as a result of the campaign were helped.

And the campaign was a commercial operation whose object was to expand a market, whose prevalence claims were at the high end of the evidence, and whose effect was to shift the boundary between an ordinary human difficulty and a treatable disorder.

Both things.

One condition out by ballot, one in by campaign — and neither process was a discovery about bodies.

What makes something a disease?

Three candidate answers, and the third is the one that operates.

Biological dysfunction. Something is not working as it evolved or developed to. A necessary condition for many diseases and not a sufficient one — most bodily variation is not a disease, and some conditions with no identified dysfunction are unambiguously diseases.

Harm or distress. A condition that causes suffering or impairment. Necessary for most and not sufficient — grief, poverty and a bad marriage cause suffering and are not diseases.

And social recognition: a condition is a disease when it is recognised as one — by a diagnostic manual, a profession, an insurer, a court, an employer, a benefits system.

The third is what actually determines the consequences, and this is 7.1.3's point in its sharpest form. A condition's diagnostic status determines whether treatment is available, whether it is paid for, whether absence from work is legitimate, whether accommodations are required, whether a benefit can be claimed, and whether the sufferer is believed.

And "socially recognised" is not the same as "not real" (see 7.1.3, 8.4.1). The suffering is real. What is socially determined is the classification, and the classification determines what happens next — which is why the fights over it are not academic.

The profession

How a jurisdiction is held.

The classical account locates professional power in two things.

Autonomy — control over one's own work, and specifically over its evaluation. The distinctive feature of a profession is that only its members are competent to judge whether a member has done the work properly, which makes external assessment structurally difficult and internal discipline the only real check.

And a licensed monopoly: legal control over who may practise, secured from the state, with the profession controlling entry, training, certification and expulsion.

This is 8.2.1's social closure, applied to an occupation, and it is the most successful example of it in existence.

And a more useful development treats professions as a competing system rather than as individual achievements.

Jurisdiction is claimed over a problem, and claims are contested by other professions. Who owns childbirth — obstetricians or midwives? Who owns mental distress — psychiatrists, psychologists, therapists, social workers? Who owns dying? Who owns nutrition, addiction, learning difficulty, workplace stress?

The claims are fought in three arenas simultaneously: the workplace, where the actual division of labour is settled informally; public opinion, where the plausibility of a claim is established; and the legal and regulatory system, where it is codified.

Two implications.

A profession's power is relational. It expands where a rival's contracts, and jurisdictional boundaries move constantly.

And the outcome in the workplace frequently differs from the outcome in law. The formal jurisdiction may belong to one occupation while the work is done by another — which is 9.3.1's informal system, operating between professions rather than within an organisation.

Medicalisation

What the concept names, and how its drivers changed.

Medicalisation is the process by which a problem comes to be defined and treated as a medical problem — an illness or disorder, addressed by medical means.

It operates at three levels. Conceptually, when a medical vocabulary is used to describe something. Institutionally, when organisations adopt a medical approach to it. And interactionally, when it happens in a consultation between a doctor and a patient.

The classical account attributed the expansion to the profession — to medical imperialism, an occupational group extending its jurisdiction.

And the most important revision to the concept was made by its own leading proponent, who argued that this had ceased to describe the mechanism.

The engines have shifted, and doctors are now frequently gatekeepers rather than drivers.

Biotechnology and pharmaceutical companies have a direct commercial interest in the expansion of diagnostic categories, and — where permitted — market directly to potential patients.

Consumers and patient organisations demand recognition, diagnosis and treatment, sometimes for conditions the profession is reluctant to recognise (below).

And payers and managed care determine which categories attract reimbursement, which is frequently the decisive fact about whether a diagnosis exists in practice.

Which reverses the political valence of the original critique. The classical account described a profession imposing definitions on a public. The current situation more often involves a public and an industry pressing definitions on a profession that is rationing them.

The mechanisms of expansion, which are specifiable.

Lowering a threshold. A diagnostic cut-point is moved, and a population that was previously normal becomes a patient population overnight. The clearest documented case concerns bone density, where an international working group in the 1990s defined a range below normal but above disease, creating a named intermediate category — and with it a very large population of people with a condition, a risk, and an available treatment.

Adding subthreshold and prodromal categories — mild, early, at-risk — which extend a diagnosis to people who do not meet its criteria.

Converting risk factors into diseases. A raised measurement that predicts a future condition becomes a condition in itself, treatable now. "Pre-" categories are the visible form of this, and they enlarge patient populations by orders of magnitude.

Extending to new populations — to children, to the elderly, to women, to men — where a condition was previously recognised only in one group.

And awareness campaigns, which raise both genuine unmet need and diagnostic expansion at the same time, and which are frequently indistinguishable from marketing.

The case against, and the case for

The critique, at its strongest.

Medicine as social control. The argument that medicine has displaced law and religion as the principal institution defining deviance — and that this is more effective, because a medical judgement appears technical rather than moral, and is therefore harder to contest. Behaviour previously judged sinful or criminal becomes sick, which is more humane and no less controlling.

Iatrogenesis — harm caused by medicine itself. Clinical: the direct damage of treatment. Social: dependence on medical provision. And cultural: the erosion of a society's capacity to cope with pain, suffering and death without medical intervention.

And the empirical cost that is best documented: overdiagnosis.

The clearest case concerns thyroid cancer in a country that introduced widespread ultrasound screening. Detected incidence rose by an order of magnitude over two decades. Mortality did not change at all.

Read what that combination means. The screening was finding real cancers — the pathology was not wrong. It was finding cancers that would never have caused symptoms or death, in people who were then treated surgically, with lifelong consequences.

Overdiagnosis is not misdiagnosis. It is the correct identification of a condition that would not have harmed the person, and it is a structural consequence of looking harder — which is why it accompanies almost every screening expansion, and why "earlier detection" is not automatically a benefit.

And the political cost, which this course has met before. Medicalising a social problem relocates it into an individual body and removes the political question (see 8.6.2 on individualisation). Distress produced by insecure work, unpayable rent or isolation is real distress, and treating it as a disorder of the person treats the symptom while leaving the cause unexamined — and does so in a way that appears helpful and is cheaper than the alternative.

And the case for, which the critique underweighted and this course will not.

Legitimation of suffering. A diagnosis converts you are lazy, weak, imagining it, difficult, or making a fuss into you have a condition. For people whose suffering has been disbelieved, this is not a minor benefit; it is frequently the difference between a life and a ruin.

Access. Treatment, medication, workplace accommodations, educational support, benefits and insurance coverage are all gated by diagnosis. A person without a recognised category has no route to any of them, however severe their impairment.

Removal of moral blame. The reclassification of addiction, of epilepsy, of learning difficulty and of mental illness from moral or supernatural failings into conditions has been, on the whole, an enormous improvement in the treatment of the people concerned — and the historical record of what preceded it is not a golden age.

And the point the classical critique got most wrong: much medicalisation has been demanded from below.

There is a whole class of contested conditions in which patients campaign for medical recognition against professional resistance — chronic fatigue syndromes, fibromyalgia, environmental sensitivities, long-lasting post-viral conditions, and, historically, a number of conditions now uncontroversially accepted.

Patients in these cases organise, collate their own evidence, commission research, and press the profession to recognise them. The literature describes this as the position of having an illness you have to fight to get, and it inverts the standard story completely: the profession is the gatekeeper refusing a diagnosis, and the demand for medicalisation comes from the people who are ill.

A framework that treats medicalisation as something done to people cannot see this, and it is common.

The proportionate position, then. Medicalisation is a process with real costs and real benefits, its direction of causation runs both ways, and the useful question is never "is this medicalisation?" but "who gains and loses from this particular classification, and what would happen to these people without it?"

And where the process has moved next.

The character of medical attention has shifted from treating illness to managing risk in the healthy.

Screening, monitoring, risk scores, threshold medications, genetic risk estimates and continuous measurement extend medical attention to people who are not ill and may never be — an extension from control over disease towards optimisation, enhancement and surveillance.

Its effects are genuinely double-edged. Real conditions are caught early and prevented. And a population of the not-yet-ill is created, for whom the appropriate relationship to their own body is permanent vigilance.

And the newest driver is 9.3.3's, arriving in medicine. Risk stratification by algorithm, on continuously collected data, allocating attention and access — with the same features: granularity, automation, information asymmetry, and no one to argue with (see 8.4.1 on what happens when social categories enter clinical models).

Which makes the question of who sets the threshold, and on what data, the central question of the next phase of this literature.

Because the classification determines the consequences, and the classification is decided by processes that are not clinical.

Four questions for any diagnostic category.

Who benefits from this classification existing, and who from its not existing? Patients, professions, manufacturers, insurers and employers frequently want different answers.

Where is the threshold, who set it, and when did it last move? A large share of diagnostic expansion is a number changing.

Is the demand coming from above or below? Both happen, and the political reading is opposite in each case.

And what would happen to these people without the diagnosis? This is the question that keeps the analysis honest, because the answer is frequently: nothing, from anybody.

Two things to hold together, which is again the difficult part.

Medicine's jurisdiction has expanded into territory where it is a poor instrument, converting political and social problems into individual conditions, and generating overdiagnosis wherever it looks harder. That critique is sound and the evidence for it is good.

And a diagnosis is, for a great many people, the only key to being believed, treated, accommodated and supported — and the people campaigning hardest for medicalisation are frequently the ones with the most to gain and the least power.

A critique of medicalisation written from the position of someone whose suffering has never been doubted will get this wrong, and much of the classical literature was written from exactly there.

One closing observation about the vote.

Ten thousand psychiatrists voted on whether a condition was a disorder, and the removal has been vindicated by everything since. The episode is usually told as an embarrassment — a scientific question decided by ballot.

It is better read as an admission. The question of what counts as a disorder was never answerable by evidence alone; it requires a judgement about what a life may be like without something being wrong with it. The profession discovered that it had been making that judgement all along, and voted only when it was forced to notice.

A diagnosis was removed by a ballot of ten thousand psychiatrists in the 1970s, after activists argued that the clinical literature rested on samples selected on being in trouble — and the process took nearly two decades and three compromises. And a barely used diagnostic category was expanded in the 1990s through a commercial awareness campaign that helped genuinely ill people and moved the boundary between ordinary difficulty and disorder. Neither process was a discovery about bodies.

Three candidate criteria for disease — biological dysfunction, harm, and social recognition — and the third determines the consequences: treatment, payment, legitimate absence, accommodation, benefit and being believed. Socially recognised is not the same as unreal.

Professional power rests on autonomy — only members judge members — and a licensed monopoly, which is social closure at its most successful. And jurisdiction is contested between professions in three arenas at once — workplace, public opinion, and law — with the workplace outcome frequently differing from the legal one.

Medicalisation operates conceptually, institutionally and interactionally — and its engines have shifted: from the profession to biotechnology, consumers and payers, so doctors are now frequently gatekeepers rather than drivers, which reverses the original critique's political valence.

The mechanisms of expansion are specifiable: lowering a threshold, adding subthreshold categories, converting risk factors into diseases, extending to new populations, and awareness campaigns indistinguishable from marketing.

The critique: medicine as social control, more effective for appearing technical; iatrogenesis in three forms; overdiagnosis, demonstrated where screening raised detected thyroid cancer incidence by an order of magnitude with no change in mortality — the correct identification of conditions that would never have harmed anyone; and the relocation of political problems into individual bodies.

The case for: legitimation of suffering; access to treatment, accommodation and benefits; removal of moral blame; and the class of contested conditions where patients campaign for recognition against professional resistance — which inverts the standard story and which a framework treating medicalisation as done to people cannot see.

And the process has moved from treating illness to managing risk in the healthy, with algorithmic risk stratification arriving with the same features as 9.3.3's control form.

Professional autonomy — control over one's own work and over who may evaluate it.

Licensed monopoly — legal control over practice, secured from the state; social closure at its most successful.

Jurisdiction — a profession's claim over a problem, contested in the workplace, in public opinion and in law.

Medicalisation — the process by which a problem is defined and treated as medical; conceptual, institutional and interactional.

Shifting engines — the movement of the drivers from the profession to biotechnology, consumers and payers.

Threshold change — expansion of a patient population by moving a diagnostic cut-point.

Risk factor as disease — the conversion of a predictor into a treatable condition.

Iatrogenesis — clinical, social and cultural harm caused by medical intervention.

Overdiagnosis — correct detection of conditions that would never have caused harm; a structural consequence of looking harder.

Demedicalisation — the removal of a condition from medical jurisdiction.

Contested illness — a condition for which patients campaign for recognition against professional resistance.

Biomedicalisation — the extension of medical attention from illness to risk, optimisation and surveillance in the healthy.

One — find a threshold. Take one common diagnosis defined by a number — blood pressure, blood sugar, bone density, cholesterol. Find out when the threshold last changed and how many people that moved into the category.

Two — ask the access question. For any condition you think is over-diagnosed, find out what a person with it can obtain that they could not without the diagnosis. Then decide whether you would remove it.

Three — trace a jurisdiction. Take one problem — childbirth, dying, addiction, learning difficulty — and list every occupation that claims competence over it. Then work out who has the legal jurisdiction and who does the work.

Four — look for demand from below. Find one condition whose sufferers are campaigning for recognition. Note who is resisting, and on what grounds.

Five — check for overdiagnosis. For any screening programme, find out whether detected incidence and mortality moved together. If incidence rose and mortality did not, you have found it.