Abstract
Many critics of medicalization (the process by which phenomena become candidates for medical definition, explanation and treatment) express concern that the process privileges individualised, biologically grounded interpretations of medicalized phenomena, inhibiting understanding and communication of aspects of those phenomena that are less relevant to their biomedical modelling. I suggest that this line of critique views medicalization as a hermeneutical injustice—a form of epistemic injustice that prevents people having the hermeneutical resources available to interpret and communicate significant areas of their experience. Interpreting the critiques in this fashion shows they frequently fail because they: neglect the ways in which medicalization may not obscure, but rather illuminate, individuals’ experiences; and neglect the testimony of those experiencing first-hand medicalized problems, thus may be guilty of perpetrating testimonial injustice. However, I suggest that such arguments are valuable insofar as they highlight the unwarranted epistemic privilege frequently afforded to medical institutions and medicalized models of phenomena, and a consequent need for greater epistemic humility on the part of health workers and researchers.
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Notes
I am grateful to an anonymous reviewer for highlighting Davis’ definition of medicalization. Although I shall focus on ‘medicalization’ per se in this essay, several critiques focus on more specific aspects of biomedical constructions of phenomena, and refine their terminology appropriately. ‘Biomedicalization’, for instance, has been used to describe particularly technoscientific and individualistic forms of medicalization (Clarke et al. 2003), while ‘pharmaceuticalization’ (Abraham 2010; Bell and Figert 2012) and ‘geneticization’ (Lippman 1998) concern the particular forms of medicalization that concentrate on drug-based interventions for, or genetic explanations of, phenomena, respectively.
One reviewer raised the question of whether it is appropriate to consider this an injustice, rather than merely a harm; since I am following Fricker’s terminology, I am not necessarily concerned with adjudicating on this either way, but the close association Fricker draws between the social processes producing hermeneutical injustice (i.e. inequitable hermeneutical participation), and those responsible for different forms of social injustice, goes some way to motivate her choice; it also serves a heuristic advantage in highlighting these similarities.
It is important to note here that Fricker uses (and I shall follow her) the term ‘power’ in a way that (a) does not necessarily entail that its exertion is unjust, and (b) is always to some extent dependent upon structural concerns (a coordinating and enabling social context). It may operate “purely structurally”—not exerted by any given agent or agent(s), but rather as the cumulative result of the lives and actions of everyone living within a given community, acting as enabled and constrained by their social environment (Fricker 2007, 10–13). Fricker (2007, 159) suggests that hermeneutical injustice is always purely structural, though others suggest that at times it may arise as ‘wilful’ or ‘culpable’ ignorance, implying additionally some exertion of agential power (Pohlhaus 2011; Mason 2011).
As one reviewer highlighted, the idea of a ‘proportionate’ epistemic privilege perhaps requires some further development. As I shall use the term, it is proportionate to epistemic warrant, which I take roughly to concern both the empirical success of a discipline in accounting for certain phenomena, and the objectives against which the empirical success of a field’s work is measured. Thus, for instance, medical authorities have a proportionate epistemic privilege in the field of acute treatment of bacterial pneumonias, both because biomedical models of pneumonia and its treatment are highly successful in explaining the pathogenesis, pathophysiology, and mechanism of action of various therapies, and because the ‘pragmatic’ goal of curative treatment is one of the main measures of medicine’s empirical success.
Indeed, it is less the question of medicalization’s misdescription that worries Elliott, so much as the exclusivity of its description; he accepts that the medical standpoint may be valuable, but is concerned about the possibility of its becoming the only one available. As he puts it:
On Prozac, Sisyphus might well push the boulder back up the mountain with more enthusiasm and creativity. I do not want to deny the benefits of psychoactive medication. I just want to point out that to see him as a patient with a mental health problem is to ignore certain larger aspects of his predicament connected to boulders, mountains, and eternity (Elliott 2004, 160).
I am grateful to an anonymous reviewer for this last example.
It is worth noting here that, of the critics of medicalization discussed above, Carl Elliott notably does not ignore the kinds of testimony regarding depression discussed here; rather, it is precisely the nature of this testimony that worries him, in relation to its causal origins. One may question, however, the level of credibility Elliott attributes to the evaluative judgments in such testimony; much of his critique may be read as concerning the ‘adaptive’ nature of those preferences (Elliott 1998, 2004).
Kraemer provides an extensive reading of the testimony of such patients in terms of enhanced authenticity (Kraemer 2010).
The patients interviewed by Karp portray a range of reactions to medical management, from the unambiguously positive [“Instead of thinking I was becoming inauthentic by taking medication, I realised that I was totally inauthentic when I wasn’t taking medication because I was doing things that made me somebody that I didn’t want to be” (2007, p. 124)] to the deeply suspicious [“the pills take me away from me, they do something else. The lithium sort of organises me, the Wellbutrin lifts me up, the Benadryl puts me down. But it’s not me” (p. 113)]. The majority, however, display some degree of ambivalence: acceptance through desperation [“I have nothing else to put my faith in” (p. 89)]; viewing the medical lens as offering an accurate, but partial, picture [“[I]t’s kind of like there’s two me’s. There’s the depressed me and there’s the happy me. So the depressed me is me, but the nondepressed me is also me. So it’s not really changing me” (pp. 124–125)]; or embracing the benefits of medicalization but regretting the consequent dependence [“I think I’ll always regret having started medication even for any of the good that it did in my life. To not know what I could do on my own without it is very difficult” (p. 89)].
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Wardrope, A. Medicalization and epistemic injustice. Med Health Care and Philos 18, 341–352 (2015). https://doi.org/10.1007/s11019-014-9608-3
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DOI: https://doi.org/10.1007/s11019-014-9608-3