The Expansion of Health Needs: Pathologisation, Medicalisation, Healthisation
"Today, the value attached to individual and population health is very high."
For the longest time in human history, medicine and health care were services that people purchased out of their own pockets. Health was, therefore, up to a point, a consumer good. With the introduction of welfare-state institutions in many countries across the globe, health has become a good that requires collective efforts to be safeguarded and maintained; health risks have become collectivized. There are different systems in place to protect all citizens against those risks – funded by compulsory insurances or taxes – but the main purpose has been to disconnect ability to pay from access to medical treatment as well as to other types of health promotion. Today, the value attached to individual and population health is very high. Accordingly, demand for the use of relevant institutions has constantly increased and caused higher costs than ever before. It is no wonder, then, that issues of justice in health care are high on the political agenda.
There are numerous processes that increase the demand for health care resources, which can be distinguished and analysed from a philosophical point of view. First, there is conceptual expansion: More and more health conditions are categorised under the umbrella term of disease. This process can be called pathologisation. Second, health-care measures can be expanded to address harms and disadvantages that used to be treated by other than medical means. This is medicalisation. Third, the value of health can be inflated. Call this healthisation.
The very fact that the presence of disease usually allows the use of publicly funded health-care resources makes the concept of disease a likely target for expansion. There are numerous powerful groups that have an interest in such conceptual expansion: medical personnel, the pharmaceutical industry and patients themselves. Since there are both significant confusion and disagreement about the definition of disease as well, it is difficult to keep pertinent expansive interests at bay.
Pathologisation does not need to be a bad thing. It can help affected people to overcome stigmatization and sometimes even moral contempt by others. Obviously, it can also help those patients to receive desperately needed support by public funds. There are numerous historical examples of such beneficial pathologisation – most importantly in the case of psychopathology. It should be stressed, however, that the beneficial aspects are mainly to do with the benefits of the social role of a patient. There are numerous other problems that come with labelling something a disease. Most importantly, because so many people identify disease with an impairment of well-being, there are possible misperceptions of the quality of life of people with chronic disease or disabilities.
Medicine does not speak with one voice, and there are many different theories of disease. It is therefore impossible to merely refer to medical parlance if we want to find out whether a specific condition is a disease. A sensible way to deal with the mentioned pluralism of disease theories is to find out whether any theory suffers from logical flaws and can, therefore, be rejected. After weeding out flawed theories there may still be a couple of plausible approaches left, and a further criterion to choose might be which theory best serves specific purposes. A pertinent social interest in connection with the concept of disease is its potential gate-keeping function. Usually we believe that diseases, but not healthy conditions, ought to be treated by publicly funded resources. Indeed, many real societies combine acknowledgement of disease with a prima facie claim to the use of publicly funded health-care resources. To prevent unnecessary costs for welfare-state institutions, it would be wise to endorse a theory of disease that prevents pathologisation of normal health conditions by offering clear-cut conceptual criteria.
To be sure, it does not seem right to choose theories on the basis of external interests. The best theory ought to be chosen on grounds of its scientific merits – that is, because it provides the most convincing explanation of the relevant phenomena. If the best available theory of disease maintains that a specific condition is a disease, then so be it. However, there are different reasonable ways to explain and define the phenomena. Hence, societies cannot merely leave to the best scientific evidence and theoretical worth the decision as to which health conditions should be acknowledged as disease and accordingly as implying claims for treatment. Curtailing pathologisation requires political decisions as well.
Medicalisation is the most frequently used term when discussing the expansion of medicine into new territory. According to my suggestion, the notion is used to cover the expansion of the practice of health care. A common example is the treatment of disruptive behaviour of children by prescribing drugs. Because such use of medication is usually connected to having a diagnosis, medicalisation and pathologisation tend to be connected phenomena. After all, a disease label – in our example, it is Attention Deficit Hyperactive Disorder – might be needed to apply medical treatment. Still, there are examples of medicalisation that do not go along with pathologisation. Certain public-health measures, such as fluoridation of water and treatment of malnutrition, could be seen as examples of expanding a medical perspective to social issues that used to be dealt with by nonmedical means. Many risk factors for disease, which are not themselves diseases – for instance high blood pressure – are these days considered worthy of immediate medical attention. Finally, medical practices have been used to enhance athlete performances, which can also be understood as an expansion into the territory of the non-pathological.
"Diseases ought to be treated by the medical profession, and people who suffer from diseases should have access to health-care resources."
Like pathologisation, medicalisation is not necessarily bad. Diseases ought to be treated by the medical profession, and people who suffer from diseases should have access to health-care resources. For instance, medicalising clinical depression helped patients win necessary treatment. As we have seen before, the actual status of some conditions – whether they are really types of diseases – is not always firmly determined. In such cases, it might be better to enable medical treatment, to give it the benefit of the doubt, as it were. There might also be situations where medical means are especially effective, or even the only available options. For example, in emergencies quick fixes like ready-to-use foods might be advisable for the time being so that lives can be saved, although most people would probably prefer to see malnutrition eradicated by a more long-term political strategy.
On the other hand, if social ills are treated by medical means, possible social solutions might be forgotten or deemed inadequate. Important examples in this respect are to do with disadvantages – real or perceived – that come along with disability and medical impairment. People with disabilities rightly maintain that disadvantages they encounter are often related to poor consideration in planning environments, not their physical or mental conditions. To attempt to 'fix' the person by medical means instead of rearranging the environment is often a wrong and possibly insulting strategy – although it is also important to acknowledge that some people with disabilities indeed want medical 'fixes'. Where medical means become monopolised, we can identify one of the downsides of medicalization.
To be in good health is good for the person in this condition. That is why health is often discussed in relation to well-being and advantage. Considered in this way, health is what is usually called a prudential value. It is prudent to pursue health or to deem it valuable. How valuable health is for a person seems to be based on personal ideas as to what a good life consists of. Some people like to be fit and healthy and might invest a lot of effort and time in achieving this goal. Others might be less interested, perhaps because they balance the effort against other valuable pursuits. Healthisation is a process that inflates health as a personal value. It might result in a situation where people are criticised or deemed irrational if they attach a relatively lower value to health.
Healthisation can also result in moralising health. Given that treatment of ill health requires resources, to be inconsiderate of one's own health might be deemed a form of indirect harm to others, because it leads to an increase in the consumption of health-care resource. When individual health becomes an object of individual responsibility, it can easily be moralised.
"In competitive scenarios, to reach a basic threshold of enablement is not enough."
Finally, health can also be interpreted as a public asset. In a global economy, where domestic economies compete for international investments, the relative level of the work force's health is of vital collective importance. Here health promotion may become a governmental duty. It is important to see that this duty may go way beyond the duty to enable citizens to live a healthy life. In competitive scenarios, to reach a basic threshold of enablement is not enough. Relative considerations regarding the improvement of the citizenry's collective health will be on the political agenda. Accordingly, health will again be moralised, in a social sense, which is another aspect of healthisation.
Healthisation leads to an interpretation of organismic conditions in terms of social standing. Imperfect health is considered to be a disadvantage and accordingly to be a potential moral scandal. Undeserved health-related disadvantages are then assumed to be unfair and to require political efforts to level the playing field. Deserved disadvantages, however, are regarded as failures of individual responsibility. In consequence, every health-related disadvantage potentially manifests an individual moral failure or a social injustice when seen from this perspective. Since almost every social aspect can be a social determinant of health, health-related disadvantages are everywhere. Altogether, healthisation turns health conditions into moral conditions. Health improvements over and above the absence of disease are turned into a prescription – in both senses of the word.
Again, healthisation does not have to be a bad thing altogether. Indeed, it might be regarded beneficial to the pursuit of a just society, because social ills can be linked to health, which comes with its own normative significance. High levels of unemployment, for example, do not seem to morally engage many people these days. Redescribing unemployment as health risk can open up new avenues of moral engagement. However, the constant confusion of health and social norms seems to me to undermine reasonable political deliberation. First, social conditions that go along with certain statistical health risks, such as unemployment or low social status, are morally scandalised via their health impact and not via their direct impact on individual people, what seems to be more adequate – for instance, the harm of lacking meaningful occupation itself. Second, the value of health is mainly considered in competitive terms. In consequence, every physical or mental condition of human beings poses a potentially bad or unjust state, because it might be worse than other possible conditions. Such a constant overassessment and moralization of health conditions can lead to further developments, which I personally find worrisome as well. Put briefly, turning health into an asset easily leads to health care as a service for the worried well, who want to remain in an advantageous position. Eventually, it will undermine solidarity within societies and globally, because ill health is then mainly considered a product of moral fault, either of the individual or of the government. Health promotion is then not seen as a joint effort anymore.
We have examined several processes that lead to an expansion of the demand of health care in real societies. We have distinguished pathologisation, medicalisation and healthisation. Mainly, these processes are due to confusion regarding the boundaries of social ills as opposed to medical problems. The relevant developments should be viewed with a certain amount of scepticism, because they can lead to moral and political misjudgement. Curtailing health promotion is a political task that requires practical deliberation. Philosophical considerations can support such deliberation, but they cannot solve the issues for us.
Theories of Health Justice
Just Enough Health
Thomas Schramme is Professor of Philosophy at the University of Liverpool, UK.
Theories of Health Justice is available now.