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.

The stated aim of her paper is to address the neglect of social factors in dementia. In her application of the medicalization thesis, she adopts a historical social constructionist approach that focuses on the emergence of dementia as a medical category and explains how the problem entered the medical domain. She charts ideas about dementia from the Middle Ages to the present day. In the Middle Ages, for example, dementia was interpreted within the prevailing theological model that identified demented old women as witches.

She adds that only premature senility was considered an illness earlier in the twentieth century – senility in old age was considered normal. She uses this opportunity to point out parallels between Alzheimer’s and hyperkinesis. Until recently, hyperactivity in children, like senility in old age, was considered to be within the normal range of behaviour. Now there is biomedical ownership of these recently discovered ‘diseases’ which are attributed to biological causes and subject to treatment. Secondly, Lyman presents a critical analysis of the biomedical theory of dementia.

Her critique addresses three parts of the biomedical model – the definition of pathology, disease stage attributions, and the legitimisation of medical control over dementia sufferers. In terms of pathology, she argues that it is difficult to distinguish mild dementia from the stable condition of normal aging known as ‘benign senescent forgetfulness. ‘ She adds that even the neuropathological changes associated with Alzheimer’s disease do not neatly distinguish pathological from normal; Alzheimer’s-type brain lesions are found in many intellectually preserved individuals at post-mortem.

In her opinion, pathology must be framed within a socio-cultural as well as a biomedical definition. Lyman next argues that sociologists need to question the causal analysis of the biomedical model: that stages of progressive brain deterioration result in corresponding clinical stages of impairment. This often sets the stage for limited opportunities for sufferers based on expectations of increasing incompetence. However, there is considerable evidence from community studies contradicting the assumption of universal stages of progressive impairment.

She also discusses how medical practitioners and family caregivers exercise control over the demented person. Medicalization, through medical labels, disease typifications and medical authority, justifies control as appropriate treatment for the good of the patient. This encourages dependency; acts of independence by dementia sufferers are either ignored or punished. In the third part of her critique, Lyman examines the impact of the biomedical model on caregiver strain.

She provides a context: families provide much of the care for those diagnosed with dementia and their burnout or strain is a concern to policymakers faced with spiralling health costs. To cope with the uncertainty around dementia, these caregivers readily accept the biomedical model of dementia. It rationalises certain treatment strategies and gives the possibility of institutionalisation as a final care option. However, Lyman argues that the medicalization of dementia shifts attention from problems in the social situation of caregivers to locate problems in the pathology and misbehaviour of the demented person.

To summarize, it is Lyman’s belief that the biomedical model of dementia is narrow, limited, and distorted in its ignorance of social forces that affect the definition, production and progression of dementia. She argues that sociologists should offer a broader view of these social forces: these include cultural definitions of dementia, the socio-environmental context in which impaired people receive care, and the dynamics of the care-giving relationship. In 1983, Catherine Reissman pointed out that medicalization can be a two edged sword and Peter Conrad (1975) talked about the brighter and darker side of medicalization.

One of the strengths of Lyman’s paper is that it recognises the advantages of the medicalization process. She states that the biomedical model of dementia has countered the ageist assumption that senility is an inevitable condition of old age and has legitimised research that offers hope for a cure. Dementia is characterised by an uncertain trajectory. Medical labels and medical authority help to ease the stress of dementia care by increasing the sense of predictability and control for caregivers.

A model of stage-like disease progression can make more tolerable the difficult role of caring for and deciding future care for a demented love one. Another strength is that Lyman sketches the importance of dementing illnesses – approximately 20% of the population over 80 are affected. She also provides a good definition of dementia. Yet another strength is her use of a historical social constructionist analysis of the medicalization of dementia; this helps to underpin her argument.

Lastly, she provides an alternative to the view of medicalized deviance. The sociogenic model recognizes that “all human experience involves intentional social action and interaction, in socially constructed environments, in the context of taken-for-granted socially constructed knowledge about aging, development and disease. ” A limitation of the paper is that the title suggests that it will focus on dementia, but almost immediately it latches onto Alzheimer’s disease.

Lyman does not provide a broad definition of medicalization before she focuses on the medicalization of deviance. Only two sets of authors are referenced – Conrad & Schneider and Zola. The choice of Conrad & Schneider is natural because of their extensive work on the medicalization of deviance. Her choice of Zola at this point is more suspect – he has focussed largely on the idea of medical intervention as social control. She does not, however, discuss social control until later in her paper and she does not reference him at this point.

Lastly, it could be argued that Lyman’s paper is somewhat ambiguous – although she sets out to critique biomedicalization and to provide an alternative, she does write in the paper that dementing illnesses involve disease processes for which biomedical research may hold the key to an eventual cure. The second paper is by John Bond (1992) and is simply entitled ‘The medicalization of dementia. ‘ The stated aim of the paper is to describe the contribution of medicine to the social construction of dementia and to look at the impact of the medicalization of dementia on people with the condition and their informal caregivers.

He states that dementia is a disease category that has been used by psychiatrists to describe a variety of clinical conditions that appear to result in a loss of intellectual power. He adds that dementia is not a single entity but is applied by the medical profession to a number of conditions including Alzheimer’s disease, Multi-Infarct dementia, Creutzfeld-Jacob disease, Pick’s disease, Neurosyphilis, Korakoff’s psychosis, Huntington’s disease and Parkinson’s disease. Bond applies the concept of medicalization to explain why the biomedical model in the study of dementia is so dominant.

He provides a definition of medicalization: it means defining behaviour as a medical problem and mandating the medical profession to provide some form of treatment for it. He references Friedson, Zola, Conrad and Illich, all contributors to the medicalization debate. His definition of medicalization is almost identical to Conrad’s definition in the latter’s seminal paper on the discovery of hyperkinesis (1975). This is not a coincidence as Bond applies the concept of medicalization by linking dementia to deviance, a topic well covered by Conrad.

Bond states that the loss of intellectual power in dementia is perceived by professionals and lay people as being problematic because it leads to difficulties in remembering, making decisions, thinking through complex ideas, carrying out practical tasks, retaining information and acquiring new skills. He adds that behaviour which has been defined as a problem is deviant behaviour. This allows him to link dementia with deviance. Bond’s central argument is that social processes are excluded from the biomedical model, which is therefore incomplete as an explanation of dementia.

He criticises the biomedical model of dementia which is, in his estimation, inherently weak. Society has little understanding of the causes of dementia and there is no known cure. Diagnosis is an imperfect science – estimates of moderate to severe dementia range from 20 to 78 per 1000 people aged 65, but part of this variation is due to the different methods of categorising and assessing symptoms of dementia. In addition, since epidemiological surveys have shown that age is the most important risk factor for dementia, there is an indication that deterioration in cognitive function might be part of the normal aging process.

Bond admits that in some conditions such as Multi-Infarct Dementia, the neuropathological relationship appears well understood with damage to blood supply leading to cell death. But he singles out Alzheimer’s disease as a form of dementia where the biomedical model is especially tenuous. Bond applies the medicalization thesis to highlight four areas where the process has had unfavourable implications for dementia sufferers and their caregivers. He adds that these are all reasons for de-medicalizing dementia.

The first is expert control – the medical profession has a monopoly over knowledge relating to dementia. It might be appropriately diagnosed and treated by the medical profession but care-giving is very much a social state of affairs. However, as the medical profession has the authority to define dementia, it controls research grants in this area. Secondly, in its role as arbiter of social values, medicine acts as an institution of social control. Psychiatrists decide whether an individual is demented or not.

These judgments occur independently of the beliefs of caregivers or an individual’s own beliefs. Thirdly, the biomedical model focuses on the individual, the diagnosis and treatment of the illness rather than seeing the illness in the context of the social system. In the same way, the effect of dementia on the caregiver is individualised and not related to the social structure of the caring unit and caring relationship. A last reason for applying the medicalization model is de-politicisation of behaviour.

By defining the behaviour and cognitive problems of dementia, the biomedical model ignores the meaning of the individual’s behaviour in the context of the social system. The perspective of the person with dementia and their caregiver is thus ignored. Bond argues that the medicalization thesis should be used to change the social environment in which people with dementia live and de-medicalize the issue. By challenging the biomedical model of dementia, society will help generate new social relationships between people with dementia and their fellow human beings.

One of the strengths of Bond’s paper is that he begins by proclaiming that dementia is one of the most feared of all modern diseases, emphasising the importance of studying how the condition has been medicalized. He provides a definition of dementia in his paper and describes the diversity of the category well. He also provides a good definition of medicalization as it applies to deviance and shows how dementia is a type of deviant behaviour. In his definition of deviance, he references a broad range of authors who have contributed to the medicalization debate and this is to his credit.

Bond describes the unfavourable aspects of medicalization well. However, he also delineates some benefits of medicalization and critiques these. The medical label of dementia legitimates an individual’s bizarre behaviour. Medical labels and authority also ease the stress of dementia care by increasing the sense of predictability and control for caregivers. However, a disadvantage is that once the label of dementia has been applied, even normal behaviour is interpreted in terms of disease stages.

The biomedical model medicalizes the role of caregivers, offering solutions to policy issues such as reducing the effect of strain or burnout on both family and formal caregivers. However, if dementia is viewed only as a medical condition, the behaviour of the person with dementia is individualised and the relationships between people with dementia and their caregivers are considered unimportant. Bond’s paper also has some limitations. While it starts powerfully and attracts the reader’s attention, it is not until half way through the paper that he describes the medicalization concept.

He fails to use a historical social constructionist analysis and this may be a weakness. Bond states in his paper that the different types of dementia are socially constructed, the difference between normal and abnormal being quite arbitrary but later admits that in Multi-Infarct Dementia and Parkinson’s disease, the neuropathological relationship appears clearly understood; this seems contradictory. Lastly, Bond argues that there is an urgent need to provide alternative theories to the biomedical model of dementia but does not set out what these might be.

The last paper is by Baila Miller, Michael Glasser and Susan Rubin (1996) and is entitled: ‘A paradox of medicalization: physicians, families and Alzheimer’s disease. ‘ The aim of their paper is to provide evidence that the medicalization of Alzheimer’s and related disorders remains incomplete. The authors state that a diagnosis of Alzheimer’s disease implies a progressive decline, irreplaceable loss of personality and eventual death. They define medicalization as the process in which social problems become defined as the domain of medical professionals.

They focus their analysis on two aspects of the medicalization process – defining behaviour as deviant and identifying claims in diagnosis and treatment. Mechanic’s and Conrad & Schneider’s work is referenced. They add that medicalization has been applied to the aging process and to various deviant states. For example, Estes and Binney (1989) have argued that aging is now socially constructed as a medical problem, reflecting a biomedicalization of the aging process. In terms of deviant states, the researchers give the example of alcoholism, which was once considered as a social problem to be handled by individuals and their social networks.

However, increasingly the treatment and management of the disease has come under the purview of the medical community. They argue that the medicalization of dementia has followed a similar evolution. Memory loss and associated behaviours are no longer seen as normal features of aging but as symptoms of organic disease. A lack of historical precedent and societal norms associated with family care-giving of older persons with dementia creates another force for the process of medicalization. The person with dementia is viewed as afflicted with something outside his control.

As a result, the role of the family caregiver of the Alzheimer patient takes on special importance and raises new role expectations for the physician and for the family. It is the authors’ assertion that Alzheimer’s disease is incompletely medicalized. Assignment of the responsibility for researching the cause or cure of dementia is given to the medical profession. However, as a progressively chronic incurable disease, responsibility for management of the disease remains with the family and community.

This, they argue, is a paradox of medicalization. They attempt to prove this by using interview data obtained from physicians in the medical community and family caregivers in the lay community who have been asked in previous studies about their experiences of Alzheimer’s disease. The authors then apply Conrad & Schneider’s model of medicalized deviance by asking; how are behaviours defined and interpreted as disease symptoms by physicians and families and what are the claims and counter-claims to expertise in the management of the illness?

The results suggest to them that physicians and families resolve the paradox between physician capability and family expectations by accepting the definition Alzheimer’s disease as a unique, highly variable, currently incurable illness. They argue that this definition seems to inhibit the medicalization process by emphasizing individual rather than professional solutions. Their findings also seem to confirm an observation by Mechanic (1978): that the breakdown in supports in everyday life may contribute as much to the medicalization process as the professional imperialism of medicine.

It is the author’s contention that the medicalization of Alzheimer’s disease may never become complete while the knowledge base is so weak. One strength of this paper is, I feel, that the authors concentrate on Alzheimer’s disease (where the biomedical model is particularly weak) rather than complicating matters by looking at the broad category of dementia. Another strength is its consideration of the degree of medicalization, rather than simply stating that Alzheimer’s disease is medicalized. This is also something that has concerned Conrad.

They use qualitative data to prove that the medicalization of Alzheimer’s is incomplete. However, they admit that this information was not originally collected for the purpose for which it was put to use and so it must be treated with caution. There is also recognition of advantages of medicalization such as reducing societal stigma and increasing resources for disease-based research. One important limitation of the paper is that the authors do not provide a specific definition of Alzheimer’s disease. In addition, they do not discuss the broad concept of medicalization, but only how it is applied to deviance.

They reference only Conrad & Schneider and Mechanic’s work in this area. Lastly, they do not provide an alternative social model of Alzheimer’s disease as the previous two authors have attempted. It can be seen from these papers that medicalization is a useful concept for understanding dementia. Through studying medicalization, we come to understand the social processes involved in the cultural production of medical categories such as dementia and the extension of medical control over the disease. It helps us also to understand the ever-increasing demands for more healthcare provision (Armstrong 2000).

However, the concept of medicalization has limitations in its examination of dementia. It focuses its critique on the weakness of the biomedical model, which is very strong in some types of dementia, for example Neurosyphilis. The medicalization thesis also perhaps focuses too much on the medical profession – one of the greatest recent drives to medicalization of dementia has been the pharmaceutical industry which has developed new drugs to treat it. In addition, the medicalization thesis is guilty of neglecting some of the changes that have been occurring in the relationship between medicine and the lay public in recent times.

Williams and Calnan (1996) state that most medicalization studies view the general public as largely passive or uncritical of medicine’s expansion and this is largely true of the papers above. They point out that lay perspectives on medicine have become much more critical in recent years. Lupton (1997) notes that our post-modern society is characterised by people’s increasing disillusionment with scientific medicine. The media has, in particular, played a de-mystifying role in relation to modern medicine. There is also a paradox within the medicalization thesis.

While it suggests that the wider social context of illness such as dementia must be taken into account by health professionals, if they do take them into account they are then accused of medicalizing more aspects of social life (Doyal & Pennel, 1979). Thus, a more humane medicine may, at the same time, be one that involves more extensive social regulation. Lastly, Strong (1979) has suggested that sociologists, in drawing attention to the expansionist tendencies of modern medicine and hyping alternative social models of health and illness, may be just as guilty as their medical counterparts of empire building.