Medicalization of Aging
As a discipline and a "worldview," medicine has been one of the most important and powerful forces in the twentieth century. As a paradigm, the biomedical model focuses on individual organic pathology, physiological etiologies, and biomedical interventions.
Turner (1987) delineates the medical model as one in which disease is interpreted regarded as a direct result of malfunctions within the human body. The model "assumes that all human dysfunction might eventually be traced to such specific causal mechanisms within the organism," and it "presupposes a clear mind/body distinction where ultimately the causal agent of illness would be located in the human body" (Turner, p. 9). The sociological model, according to Turner, stands in contrast to the biochemical model of disease by allowing, if not demanding, attention to the cultural specificity of medical science. Brown (1996) and others (Estes and Binney, 1989; P. Fox, 1989) highlight the importance of looking at social causation and the way that the discovery of a disease affects its labeling and treatment. Naming a condition through diagnosis initiates the labeling process and locates the parameters of normality and abnormality. Thus, diagnosis is an integral aspect of the illness experience. Medicine may have emotional, political, and economic impacts.
Medicalization describes a process through which largely social issues may be redefined as medical problems, thus increasing the jurisdiction of medicine. Critics argue that medicalization is a strategy for extending professional dominance and/or institutionalized social control. Some suggest that medical social control ensures social cohesion by focusing on curing and containing diseases that could otherwise disrupt life. Bury (1991) discusses not only the inadequacy of the biomedical model but also of all one-dimensional sociological models of illness and disability labels. Broom and Woodward (1996) cite positive aspects of medicalization for individuals, such as validation, a sense of relief, and support. They explicate the utility of distinguishing between "over-medicalization," which is typically viewed as negative, and "constructive medicalization." A reversal, or process of demedicalization (R. Fox, 1994), can also occur—for example, the redefinition of homosexuality from a mental illness to a lifestyle choice.
In 1951, Talcott Parsons observed that medical diagnosis could legitimize a range of human troubles in cases where behavior could be understood and/or blame removed through a process of medical examination (such as chronic fatigue syndrome). A key goal of medicine, in Parsons's view, is assuring compliance with medical authority. Arguably, power is exerted in medical practice via the dominance and techniques of biomedical science. If medical authority is unstable, or the definition of illness is contested, issues of medical and social control are more likely to surface.
Medicine as an institution achieves social control over potentially deviant populations (e.g., violent offenders) by expanding medical categories. Zola (1972) suggests that medicine has become a form of social control comparable to religion and law. Medicalization, through disease typifications, medical authority, and the labeling of illness (or behaviors) as deviant from everyday life, has important political consequences: "The medical profession. . .has a virtual monopoly over anything that is defined as illness or a 'medical treatment"' (Conrad and Schneider, 1992, p. 36).
The medical model has assisted in the transformation of health and other human needs into commodities for specific economic markets in ways that have promoted a gargantuan and highly profitable (but not necessarily most efficacious) trillion-dollar medical-industrial complex. For example, the desire for a "silver bullet" to cure health problems reflects the tendency of doctors to medicate and of health care consumers to prefer to be medicated. One example is taking cholesterol medicine rather than changing behavior (e.g., eating less fats or exercising). Both tendencies are consistent with how medicine and society have constructed illness and how to treat it via pharmaceuticals. The result may be an over-medicated population. Clearly, not only are there financial costs to such approaches to health care, but emotional, physical, and social ones as well.
"Biomedicalization" is another term used to describe the medicalization process, through which an increasing number of human problems are classified under the rubric of bioscientific medicine and its corresponding technological interventions. Estes and Binney (1989) note that within aging, two dimensions of biomedicalization are essential: (1) the social construction of aging as a medical problem—that is, thinking of aging itself primarily as a disease and/or medical problem as defined by medical practitioners, and (2) the "praxis," or practice of seeing aging as a medical problem, and the subsequent behaviors and policies that grow out of the biomedical conceptualization of aging.
The biomedical model emphasizes the clinical treatment and management of diseases of older adults as defined and treated by medical practitioners—while giving marginal attention to the social and behavioral processes and problems of aging. Lock (2000) contends that conceptions of "normal" and "abnormal" health are intrinsically tied to cultural and political constructions of "moral order." She explores aging as a way to investigate how morality is articulated through a picture of decline and impairment. Accordingly, it is not possible to try to separate categories of health and illness—and here, aging—from the context in which they are embedded. Renée Fox (1994) also attests the importance of situating conceptions of medicalization in time and place: "What is defined as health and illness, normality and abnormality, sanity and insanity varies from one society, culture, and historical period to another" (p. 403).
As the primary way of viewing the world of aging, or "institutionalized thought structure" (Berger and Luckmann), the medical model influences everything else—research and the development of knowledge in the field, gerontological and geriatric practice, policymaking, public perceptions (Estes and Binney), and subjective experiences. The equation of old age with illness has encouraged society to think about aging as a pathological, abnormal, and undesirable state, a view that in turn shapes the attitudes of members of society toward elderly persons and of older adults toward themselves (Estes). "Sick role expectations" (Parsons, 1951) of appropriate behavior when ill may result in social withdrawal, reduction of activity, increased dependency, and the loss of self-esteem, efficacy, and personal sense of control—each of which increases the social control of elderly persons through medical definition and management (Estes and Binney). The critical perspective purports that "Casting persons in the sick role is regarded as a powerful, latent way for the society to exact conformity and maintain the status quo" (R. Fox, p. 404).
The dominance of the medical model in aging obscures the extent to which illness and other problems of older adults are influenced by potentially modifiable social factors, such as income and education, safe and supportive housing environments that promote healthy behaviors, opportunities for meaningful human connections, the lack of public policy emphasis on (or financing for) rehabilitation, and a better understanding of subjective experiences and quality of life. Biomedical thinking diverts attention, and subsequently solutions, away from research to understand sociological "root causes" of health, including social, economic, and environmental elements (Estes et al.).
Despite the reality that the greatest burden of disease in old age now stems from chronic, rather than acute, conditions, public policy regarding medical care for seniors clings to a medical-engineering model, which constructs health and illness on the basis of a rational system of causes within the context of the body's cellular and biochemical systems. This model implies a reliance on an "expert" to fix problems (typically after they occur), while also supporting society's growing investment in medical care and technology as the primary determinant of good health, in spite of the expanding body of research that substantiates the significant effect on health in old age of behavior, environment, social inequalities, and myriad other factors.
Clarke and colleagues (2000) depict "a new biomedicalization" within health and illness, which involves a shift from the past medicalization of deviant behavior to a contemporary biomedicalization of normalcy. Medicalization occurs not only on conceptual, organizational, and interactional levels that characterize the past, but also on the new social, cultural, economic, and institutional forms of biomedicine. All of this transpires within the increasingly corporatized, privatized, and multinational context of early twenty-first-century society.
With illness viewed as "deviance" under medicaliztion (Parsons, 1951; Zola, 1972; Conrad and Schneider, 1992), Clarke et al. critique dominant conceptions that equate health with what is defined as "normal" or normatively acceptable (the "gold standard" within biomedicine). Conrad and Schneider observe that the process of biomedicalization transfers definitions of badness to sickness. With medicalization there is a parallel unification of health (defined as free from "disease") and rectitude in contemporary society.
Viewing old age and the life course through a lens of disease and its surrounding rhetoric only accentuates the increasing trend toward seeing the process of aging as something to be fended off and controlled. Such tendencies create a conundrum for gerontologists, policymakers for health and aging matters, society overall, and all persons as individuals. This serves to reinforce the already pervasive stigma of aging and of older adults. A biomedical model of aging precludes an understanding of relevant social and biological dynamics that profoundly shape old age and aging both as experienced by individuals and as "treated" by society through social policy (Estes and Binney).
The biomedicalization of specific conditions, such as dementia, is also debated—for example, whether senility is the site of pathology or an acceleration of essentially normal aging. Gubrium (1986) critically reviews of evidence for the "discovery" of AD as a disease category, suggesting it is not possible to differentiate dementing illness from normal aging. Therefore, attempts to do so are mechanisms to create order in the complex world of dementia.
Patrick Fox (1989; P. Fox et al., 1999) discusses the historical shift in the biomedical conceptualization of AD. Labeling AD as a specific disease category reversed the notion of cognitive decline as an inevitable part of old age and brought aging into the purview of medicine. Specifically, the definition of AD as the primary cause of senile dementia reflects biomedical claims to the diagnosis and management of old age. Cutler (1986) also analyzes the politics of AD as a process whereby those who have interest in creating new disease categories construct "facts." This has greatly increased the number of cases of what we now call Alzheimer's disease and has led to its being perceived as a significant social and health problem.
Patrick Fox et al. purport that conceptions of the relationship between health and aging permeate social, cultural, and political images of old age. Identification of AD indicates that cognitive changes associated with aging result from specific disease processes that can be classified, understood, and, ideally, prevented. Therefore, the biomedicalization of senility is implicit in the designation of "Alzheimer's disease" as a health and societal problem that insinuates social, economic, and biomedical imperatives to avoid disability in old age.
Thus, both contemporary and historical contestation over the definition of conditions like AD is both inevitable and chronic in times of medical dominance. The primacy of directing attention to the disease rather than to the person is done in the interest of a profession to enforce the necessity, if not the urgency, of the power granted to scientific medicine.
Although dementing illnesses involve a disease process for which biomedical research may hold the key to an eventual cure, the reliance on a biomedical model to explain experiences of dementing illness overlooks the social construction of dementia and the impact of treatment and care contexts on disease progression (Lyman), as well as firsthand accounts of subjective experiences. Lyman observes: "[The] biomedical view of dementia is narrow, limited, and sometimes distorted in its ignorance of social forces that affect the definition, production, and progression of dementia" (p. 600). Few examples highlight the biomedicalization of aging more concretely than AD.
The power of the medical model has suppressed resources that might be applied to pursue promising alternative social, behavioral, and environmental approaches while instead encouraging the "magic-bullet" mentality of Americans seeking the "nirvana" of a happy and eternal life, according to Estes et al. Although biomedicine merits a respected place for its contributions to aging, its extension to and control over all aspects of life diminish its effectiveness, diverting priority away from essential and critical research needed to understand the complex social and environmental factors that significantly shape and structure, and may modify, old age and aging.
Lock warns that notions of normality imply a dichotomy and suggest a need, and potential, for correcting the "mistakes" of natural development (p. 273). The dangers, as well as the benefits, of the current medical model need continual reevaluation. The flourishing medical ideology both poses dilemmas and offers alternatives. Neither is without consequence.
RENÉE L. BEARD CARROLL L. ESTES
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