Bioethics and Medicalization

Despite critique, medicalization continues unabated. One part of the explanation is that while many resources have been spent on developing the field of public bioethics as a “watchdog” of medicine and science, public bioethics as it has developed is largely incapable of offering an effective critique of medicalization. This is clear from the fact that while bioethics is capturing tasks from medical sociology one by one, one topic that remains the province of medical sociologists and not bioethicists is medicalization. Public bioethics has become a subordinate profession to science and medicine, and its dominant form of ethical argumentation is the same as that which would be used by science and medicine. Bioethics then cannot discourage medicalization. For bioethics to contribute to a critique of medicalization and reductionism, public bioethics must be severed from science and medicine.

After the Therapeutic Revolution

As nation states became concerned about disease in the later eighteenth century, government actors joined the age-old human fight against disease. Given the limitations of medicine’s curative powers before the 1890s, preventive models of disease control were prioritized, and constituted the first line of defense. This changed during the brief era from about 1945-1980, the age of the “therapeutic revolution.” Since then, new strategies of disease control and prevention have been constructed according to the economic and political pressures shaping state policies, and by a new cultural environment where health is linked to lifestyle and individual subjectivity. In the “new public health” environment, state intervention appears permissible only in the face of dire, external epidemic treat. Prevention efforts are limited to attempted manipulations of individual lifestyle choices.

Reductionism, Holism, and Consumerism

This chapter examines the historical shift from the welfarist provision of health care by collective action to a consumerist form of provision that treats health care as a matter of individual judgments. Reductionist medicine is a natural fit for a consumerist approach, given its apparent indifference to the moral causes or collective implications of individual problems. However, since the problems of dependency cannot be eliminated, only relocated, the moral and collective dimensions of medicine are inescapable. While any measure of burden sharing remains, so will the function of adjudicating claims. A socially sustainable health care system must incorporate an understanding of mutual obligation: both our responsibility for the physical and social conditions of the sick, and their commitment to change those things within their power.

The Problem of Suffering in the Age of Prozac

Personal stories about depression and anti-depressants have become a ubiquitous facet of American culture. Such depression memoirs represent a crucial forum for grappling with the problem of suffering; they also illuminate the narrative templates people utilize in the face of depression. An analysis of the literature shows both the increasing salience of the biomedical model for depression, and also the various ways it is co-opted into the project of recasting the self in light of mental illness. Much as biomedical language runs through the pages of these memoirs, so do broader narrative templates, such as spiritual discovery and therapeutic self-reconstruction. Collectively, these narratives represent an enduring effort to find sense in suffering: to work with and around the biomedical model in order to find a place for depression in a meaningful self-narrative.

Introduction Holism against Reductionism

The Introduction sets out the major themes of the book. These include medicine’s role in the moral and cultural agendas of contemporary society, challenges to the biomedical model represented by new regimes of disease and disorder, and the limitations of principlist bioethics for moving in a more holistic direction. In the working definition of the book, “reductionism” suggests a mechanistic and narrowly somatic understanding of disease, monocausal theories of disease, and an exclusive preoccupation with cure to the neglect of prevention. Meanwhile, “holism” refers to a contextual understanding of disease causation, intervention, or practice. A systemic concern with the whole organism, a focus on the interconnected effects of the larger environment, and ethical concerns with the clinical encounter, can all be characterized as holistic. The Introduction situates the struggle between these perspectives in historical context, and calls for a renewed focus on the social determinants of health and a more holistic ethical perspective.

Digitized Health Promotion

This chapter explores the use of digital health technologies in health promotion endeavors. This “digitized health promotion” is the latest stage in the trajectory of health promotion ideology and practice over the past four decades in wealthy Anglophone nations. Lupton argues that over this period the individualistic approach to good health commonly espoused in medicine and public health was challenged by advocates arguing for a greater focus on social justice and social epidemiology. The individualistic approach to health promotion never disappeared, however, and has gathered momentum in the current economic, political, and technological climate. While many health promotion workers still champion the ideals of “health for all,” public health policy in the context of digitized health promotion has begun to return to emphasizing personal responsibility for health.

After Medicine

Many laypersons already believe that neuroscience can now answer fundamental and age-old questions about our aesthetic, moral, religious, and other human experiences. But such reductionist claims are controversial, and rest on shaky empirical grounds. If taken seriously they lead to some disturbing conclusions, notably the loss of moral agency. This chapter argues that the popularity of neuroscientific explanations owes less to scientific progress than to sociomedical factors, including the increasing medicalization of everyday experience; the reduction in practice of “principlist” bioethical principles to patient autonomy; and the joining of medicine with cultural preoccupations of enhancement and cosmetic alteration. If neurocentric claims are rapidly becoming part of our social imagination, Echarte argues, it is because of new practices in the “therapeutic culture,” not new scientific discoveries.

Replacing the Official View of Addiction

This chapter critiques the “official view” of addiction: that addiction is a chronic, relapsing, but manageable disease wherein congenitally vulnerable individuals lose much of their free will after exposure to an intrinsically addictive chemical substance. Alexander argues this official view provides neither an adequate understanding of addiction nor a basis for effective intervention. He offers a radically different perspective, “dislocation theory,” which is holistic on both the personal and social levels. He also argues that the official view has maintained its status largely because its narrowed, reductionist biomedical understanding of addiction protects the modern status quo, by focusing on the need for individual correction rather than for societal reorganization, and by confining the global addiction problem to a relatively small group of “deviants.”

Conclusion Limits in the Interest of Healing

In the Conclusion, Davis summarizes the essays’ explorations of problematic reductionism. He then suggests practices that could have some countervailing holistic force in the three spheres of medicine, bioethics, and public health. In medicine, these might include distinguishing between “health” and professional health care, and mobilizing health professionals to defend their practice against the claims of consumerism. In bioethics, we must make medicine’s ethical values more transparent; rather than accepting a default set of stealth goods, we must deliberate in open recognition that the goods at stake are inescapably common and ethically charged. Finally, public health should reconnect with its social medicine roots, regaining a complementary (not subservient) relationship with medicine. This public health would again focus on life conditions and social inequities, not just on individual behaviors.

In Search of an Ethical Frame for the Provision of Health

The distinction between the healthy and the good, a major basis for ethical reflection, has become increasingly blurred in the past few decades. González seeks to reintroduce that distinction, and to explain the tendency to naturalize the good with reference to developments in nineteenth-century philosophy and science. She then argues that while this process of naturalization has been reinforced by the desire to avoid ethical controversies, it fails precisely in that effort. Ethical controversies always return in the end, and it is better to address them in explicitly ethical terms at the outset, before they erupt. Such controversies—such as the definition of proper care and the just distribution of health resources—can be resolved only to the extent that we develop a comprehensive notion of the human good, and its relation to the common (ethical) good.