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Acknowledgments
Nancy Tomes was supported in part by a Robert Wood Johnson Foundation
Investigtor Award in Health Policy Research. The views expressed imply no
endorsement by the Robert Wood Johnson Foundation.
References
1 Illich I. Medical nemesis. New York: Pantheon, 1975: 4, 35.
2 Mead N, Bower P. Patient-centeredness: a conceptual framework
and review of the empirical literature. Soc Sci Med 2000; 51:
1087–110.
3 Tomes N. Patients or health care consumers? Why the history of
contested terms matters. In Stevens R, Rosenberg C, Burns, LR,
eds. History and health policy. New Brunswick, NJ: Rutgers
University Press, 2006: 83–110.
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medicine and the lay populace in “late modernity.” Soc Sci Med
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5 Conrad P. The shifting engines of medicalization.
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modern age. Cambridge: Polity Press, 1991
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12 Metzl J, Riba M. Understanding the symbolic value of medications:
a brief review. Prim Psych 2003; 10: 45–48.
13 Epstein S. Impure science: AIDS, activism, and the politics of
knowledge. Berkeley: University of California Press, 1996.
14 Lerner BH. The breast cancer wars: hope, fear, and the pursuit of a
cure in twentieth-century America. New York: Oxford University
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15 Tomes N. The patient as a policy factor: a historical case study of the
consumer/survivor movement in mental health. Health Aff 2006;
25: 720–29.
Beyond medicalisation
Nikolas Rose
Medicalisation has become a cliché of critical social
analysis. It implies something suspect when a problem
is created or annexed, in whole or in part, by the apparatus
of medicine. Critiques of the ways in which doctors have
extended their empire have become part of everyday and
professional debate. Such critiques have contributed to
the part deprofessionalisation of medicine. Nowadays,
the power of doctors is constrained by the shadow of the
law, the apparatus of bioethics, evidence-based medicine,
and patients’ demands for autonomy to be respected,
their rights to health satisfied, their injuries compensated.
The focus of critique has turned to the methods used by
drug companies in search of markets and profits. There
is, no doubt, much to criticise. Yet medicalisation has
had an even more profound effect on our forms of life: it
has made us what we are.
Since at least the 18th century in developed countries,
medicine played a constitutive part in “making up people”.1
It was in part through medicine that the human being
became a possible object for positive knowledge—a living
individual whose body and mind could be understood by
scientific reason. Medicine was perhaps the first scientific
knowledge to become expertise, in which authority over
human beings derived from claims to scientificity.
Medicine was entwined with new ways of governing
people, individually and collectively, in which medical
experts in alliance with political authorities tried to manage
ways of living to minimise disease and promote individual
and collective health. Medicine was linked to the
secularisation of ethical regimes, as individuals came to
describe themselves in the languages of health and illness,
question themselves against criteria of normality and
pathology, take themselves and their mortal existence as
circumscribing their values. The history of medicine has
thus been bound up with the history of the different ways
in which human beings have tried to make ourselves better
than we are.2
Immediately two cautions must be entered. The we
needs unpacking by age, class, race, nationality, sex, and
more: some people are more medically made up than
others—women more than men, the wealthy differently
from the poor, children more than adults, and, of course,
differently in different countries and regions of the world.
Furthermore, medicine itself needs to be decomposed.
The technologies of the operating theatre are not those of
general practice, or epidemiology, or public health
medicine, or health promotion. Medicine has no essence,
be it epistemological (there is no single medical model),
political (the power of medicine cannot be reduced to
social control or the management of social problems), or
patriarchal (medicine and medics do not merely seek
control over women and their bodies). Medicine is not a
single entity: clinical medicine is only one component
among many ways in which individual and group life have
been problematised from the point of view of health. And
medical knowledge, medical experts, and medical practices
play very different parts in different locales and practices.
Here I distinguish three dimensions through which medicalisation
has made us the kinds of people that we are.
Medical forms of life
The practices of medicine have modified the very life form
that is the contemporary human being. Sewage systems,
regulated cemeteries, purified water and food, dietary
advice, and the general sanitisation of human existence,
domestic life, public space, working environments, all in
part under the aegis of medical authority, have altered
physicalappearance—height,weight,posture,capacities—
longevity, morbidity, and much more. These practices
have changed the relations that human beings have with
Lancet 2007; 369: 700–01
Prof N Rose PhD,
Centre for the Study of
Bioscience, Biomedicine,
Biotechnology and Society,
London School of Economics,
LondonWC2A 2AE, UK
N.Rose@lse.ac.uk
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www.thelancet.com Vol 369 February 24, 2007 701
their companion species of bacteria, viruses, parasites,
scavengers etc. The practice of vaccination—hybridising
human beings with dead or deactivated bacteria—has
transformed human sociality; saved millions of lives; and
contributed to the growth of the population, the possibility
of living in towns, and hence urban sociality. The school
and the home, transformed by medicine into hygienic
machines, have inculcated habits and manners that have
become automatic, from table manners to toothbrush
drill. Practices for defecation, urination, menstruation etc
have produced bodies that are disciplined in relation to
health in unprecedented ways. Medical management of
sexuality has reshaped regimes of pleasure, practices of
intercourse, continence, and incontinence. And so on. We
relate to ourselves and others, individually and collectively,
through an ethic and in a form of life that is inextricably
associated with medicine in all its incarnations. In this
sense, medicine has done much more than define,
diagnose, and treat disease—it has helped make us the
kinds of living creatures that we have become at the start
of the 21st century.
Medical meaning
Medicine is inextricably intertwined with the ways in
which we experience and give meaning to our world.
Whether through medical themes in literature, medical
images in art, medical heroes and villains in movies or
on TV, medical narratives of patienthood, the
imagination of those of us who live in developed
countries has become permeated with medicine. This is
true for systematic knowledge as much as for popular
culture. Many of the theories of society that emerged at
the end of the 19th century and through much of the
20th century—from Durkheim to Parsons—understood
societies themselves in medical terms, as organic
systems whose institutions and processes performed
vital functions for the health of the whole. Still today,
economies are sick and can be cured, the UK was “the
sick man of Europe”, racism infects the body politic, etc.
The relation between the metaphor and its referent is
bidirectional: cancer partakes of the malign character of
racism at the same moment that racism is described as
cancerous. As lay systems of meaning have become
bound up with medical thought, medical languages, no
matter how technical, have become infused with cultural
meanings. Medicine thus makes us what we are by
reshaping the relations of meaning through which we
experience our worlds.
Medical expertise
Medicine also makes us what we are through the role of
medical expertise in governing the ways we conduct our
lives. We might believe that the limits of medicine should
be circumscribed by illness, disease, or pathology; that
medical authority properly applies where the natural
norms of the body have been disturbed by infection,
injury, or some other insult; that the proper role of the
doctor is to seek to restore that lost normativity of the
body. We might think that if medical authority goes
beyond these limits it runs the risk of illegitimacy. But
this belief would be mistaken. Doctors have long engaged
with collective as well as individual bodies. Since the start
of the 19th century, perhaps earlier, doctors were involved
in the mapping of disease in social space, collection of
statistics on the illnesses of the population, design of
sewers, town planning, regulation of foodstuffs and
cemeteries and much more—indeed doctors have a good
claim to be the first social scientists. From at least the
mid 19th century, medical concerns embraced not just
illness, but health and all that was thought to be conducive
to it. And doctors have long been called on to exercise
authority beyond therapy; to childbirth, infertility, sexual
mores and practices, aspects of criminal behaviour,
alcoholism, abnormal behaviour, anxiety, stress,
dementia, old age, death, grief, and mourning.3
Nowadays, there are many examples of such extension of
medical expertise to the management of life itself, from
new reproductive technologies, through hormone
replacement therapy and treatment for age-related sexual
dysfunction, to psychopharmaceutical attempts to modify
mood, emotion, and volition. The division of the natural
and the cultural has ceased to do useful analytical work.
Medicine has helped make us thoroughly artificial.
Beyond medicalisation
The theme of medicalisation, implying the extension of
medical authority beyond a legitimate boundary, is not
much help in understanding how, why, or with what
consequences these mutations have occurred. Medicalisation
might be a useful neutral term to designate
issues that were not at one time but have become part
of the province of medicine. It might be a useful slogan
for those who wish to dispute the legitimacy of that
medical remit. But the term itself should not be taken
as a description or an explanation, let alone a critique.
Not an explanation for there is no dynamic of
medicalisation, no implacable logic of medical entrepreneurship,
no single motive of medical interests, that
lies behind these various boundary renegotiations; not
a description, for there are many important distinctions
to be made here. The term medicalisation obscures the
differences between placing something under the sign
of public health (as in the contemporary concern with
childhood obesity), placing something under the
authority of doctors to prescribe, even though not
treating a disease (as in the dispensing of contraceptive
pills to regulate normal fertility) and placing something
within the field of molecular psychopharmacology (as
in the prescription of drugs to alleviate feelings that
would once have been aspects of everyday unhappiness).
Nor does medicalisation help as critique, for why should
it seem ethically or politically preferably to live one
aspect or department of life under one description
rather than another? The term medicalisation might be
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702 www.thelancet.com Vol 369 February 24, 2007
the starting point of an analysis, a sign of the need for
an analysis, but it should not be the conclusion of an
analysis.
Assembling forms of life
Medicalisation implies passivity on the part of the
medicalised. One example is when people claim that
disease-awareness campaigns persuade potential customers
to “recode” their unease and dissatisfaction in the
form of a diagnostic category to extend the market for
pharmaceutical products and the remit of medical practitioners.
With notable exceptions (children, prisoners,
people deemed mentally ill and admitted to hospital
under compulsion), doctors do not force diagnostic
labels on resistant individuals. And although drug
companies use techniques of modern marketing, they
do not seek to dupe an essentially submissive audience.
Marketing techniques, since the 1950s, have not regarded
the consumer as a passive object to be manipulated by
advertisers, but as someone to be known in detail, whose
needs are to be charted, for whom consumption was an
activity bound into a form of life that must be understood.4
Marketing does not so much invent false needs, as
suggested by cultural critics, but rather seeks to
understand the desires of potential consumers, to
affiliate those with their products, and to link these with
the habits needed to use those products. It is this process
of mutual construction, the intertwining of products,
expectations, ethics and forms of life, that we observe in
the development and spread of psychiatric drugs such as
those for depression. This process is not a brute attempt
to impose a way of recoding miseries, but the creation of
delicate affiliations between subjective hopes and
dissatisfactions and the alleged capacities of the drug.
Such a medicalisation of sadness can occur only within a
political economy of subjectification, a public habitat of
images of the good life for identification, a plurality of
pedagogies of everyday existence, which display, in
meticulous if banal detail, the ways of conducting oneself
that make possible a life that is personally pleasurable
and socially acceptable. In engaging with these formulae
in inventive ways, individuals play their own part in the
spread of the diagnosis of depression and shaping new
conceptions of the self.
Thus, beyond medicalisation, medicine has shaped
our ethical regimes, our relations with ourselves, our
judgments of the kinds of people we want to be, and the
lives we want to lead. But if medicine has been fully
engaged in making us the kinds of people we have
become, this is not in itself grounds for critique. Critical
evaluation of these heterogeneous developments is
essential. But we need more refined conceptual methods
and criteria of judgment to assess the costs and benefits
of our thoroughly medical form of life—and of those
that offer themselves as alternatives.
Conflict of interest statement
I declare that I have no conflict of interest.
References
1 Hacking I. Making up people. In Heller TC, Sosna M, Wellbery DE,
eds. Reconstructing individualism: autonomy, individuality and the
self in Western thought. Stanford: Stanford University Press, 1986:
222–36.
2 Rose N. Medicine, history and the present. In Jones C, Porter R,
eds. Reassessing Foucault: power, medicine and the body.
Routledge: London, 1994: 48–72.
3 US President’s Council on Bioethics, Kass L. Beyond therapy:
biotechnology and the pursuit of happiness. Washington:
President’s Council on Bioethics, 2004: xxi, 328.
4 Miller P, Rose N. Mobilising the consumer: assembling the subject
of consumption. Theor Cult Soc 1997; 14: 1–36.
Medicalisation of race
Troy Duster
“Illnesses that seem identical in terms of symptoms may
actually be a group of diseases with distinct genetic
pathways. This would help explain blacks’ far higher
mortality rates for a host of conditions, including
diabetes, cancer and stroke.”
“Until now, these gaps have been attributed largely to
racism in the healthcare sector and widespread poverty
among African-Americans.”1
Biotechnology firms have found an unusual and effective
way around the problem of confronting the issue of race
as a biological category. The strategy does not deal with
the notion in a systematic full-scale case-control design,
but uses a clinical study that was not intended to test
whether race plays any part–only to discover later that the
race of the clinical population, however defined, bears
some unknown relation to drug efficacy. The reinterLancet
2007; 369: 702–04
ProfTroy Duster
NewYork University, NewYork,
NY 10003, USA
troy.duster@nyu.edu
pretation of already obtained data sets by racial categories
thereby conveniently circumnavigates the problem of
having to define what is meant by race. By sharp contrast,
a case-control study that categorised participants
according to race would require the researcher to specify
the boundaries of the relevant populations. The story of
how the first racial drug was approved by the US Food
and Drug Administration (FDA) is a remarkable tale of
the racialisation of medicine. BiDil (NitroMed, Lexington,
MA, USA) is a combination drug (isosorbide dinatrate
and hydralazine) designed to restore low or depleted
blood nitric oxide concentrations to treat or prevent
congestive heart failure. The drug was originally designed
without racial specification. But early clinical studies
showed no compelling efficacy,2
and a US Food and Drug
Administration advisory panel voted 9 to 3 against
approval.3