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MEDICINE AS AN INSTITUTION OF SOCIAL
CONTROL*
Irving Kenneth Zola
T
he theme of this essay is that medicine is becoming a major institution of social control, nudging aside, if not incorporating, the more traditional institutions of religion and law. It is be- coming the new repository of truth, the place where absolute and often final judgments are made by supposedly morally neutral and objective experts. And these judgments are made, not in the name of virtue or legitimacy, but in the name of health. Moreover, this is not occurring through the political power physicians hold or can influence, but is largely an insidious and often undramatic phenomenon accomplished by 'medicalizing' much of daMy living, by making medicine and the labels 'healthy' and 'ill' relevant to an ever increasing part of human existence. Although many have noted aspects of this process, by confining their concern to the field of psychiatry, these criticisms have been misplaced.^ For psychiatry has by no means distorted the mandate of medicine, but indeed, though perhaps at a pace faster than other medical specialities, is following instead some of the basic claims and directions of that profession. Nor is this extension into society the result of any professional 'imperialism', for this leads us to think of the issue in terms of misguided human efforts or motives, li we search for the 'why' of this phenomenon, we will see instead that it is rooted in our increasingly complex technological and bureaucratic system—a system which has led us down the path of the reluctant reliance on the expert.^ Quite frankly, what is presented in the following pages is not a *This paper was written while the author was a consultant in residence at the Netherlands Institute for Preventive Medicine, Leiden. For their general encouragement and the opponunity to pursue this topic I will always be grateful. It was presented at the Medical Sociology Conference of the British Socio- logical Association at Weston-Super-Mare in November 1971- My special thanks for their extensive editorial and substantive comments go to Egon Bittner, Mara Sanadi, Alwyn Smith, and Bruce Wheaton.
Irving Kenneth Zola definitive argument but rather a case in progress. As such it draws heavily on observations made in the United States, though similar murmurings have long been echoed elsewhere."*
An Historical Perspective The involvement of medicine in the management of society is not new. It did not appear full-blown one day in the mid-twentieth century. As Sigerist* has aptly claimed, medicine at base was always not only a social science but an occupation whose very practice was inextricably interwoven into society. This interdependence is perhaps best seen in two branches of medicine which have had a built-in social emphasis from the very start—psychiatry^ and public health/preventive medi- cine.*^ Public health was always committed to changing social aspects of life—^from sanitary to housing to working conditions—and often used the arm of the state (i.e. through laws and legal power) to gain its ends (e.g. quarantines, vaccinations). Psychiatry's involvement in society is a bit more difficult to trace, but taking the histories of psy- chiatry as data, then one notes the almost universal reference to one of the early pioneers, a physician named Johan Weyer. His, and thus psychiatry's involvement in social problems lay in the objection that witches ought not to be burned; for they were not possessed by the devil, but rather bedeviled by their problems—namely they were in- sane. From its early concern with the issue of insanity as a defence in criminal proceedings, psychiatry has grown to become the most domi- nant rehabilitative perspective in dealing with society's 'legal' deviants. Psychiatry, like public health, has also used the legal powers of the state in the accomplishment of its goals (i.e. the cure of the patient) through the legal proceedings of involuntary commitment and its con- commitant removal of certain rights and privileges. This is not to say, however, that the rest of medicine has been 'socially' uninvolved. For a rereading of history makes it seem a matter of degree. Medicine has long had both a de jure and a de facto relation to institutions of social control. The de jure relationship is seen in the idea of reportable diseases, wherein, if certain phenomena occur in his practice, the physician is required to report them to the appropriate authorities. While this seems somewhat straightforward and even functional where certain highly contagious diseases are con- cerned, it is less clear where the possible spread of infection is not the primary issue (e.g. with gunshot wounds, attempted suicide, drug use
Irving Kenneth Zola anguish on one another does not seem similarly on the wane. The most effective forms of brain-washing deny any physical contaa and the concept of relativism tells much about the psychological costs of even relative deprivation of tangible and intangible wants. Thus, when an individual because of his 'disease' and its treatment is forbidden to have intercourse with fellow himian beings, is confined until cured, is forced to undergo certain medical procedures for his own good, per- haps deprived forever of the right to have sexual relations and/or pro- duce children, then it is difficult for that patient not to view what is happening to him as punishment. This does not mean that medicine is the latest form of twentieth century torture, but merely that pain and suffering take many forms, and that the removal of a despicable in- humane procedure by current standards does not necessarily mean that its replacement will be all that beneficial. In part, the satisfaction in seeing the chains cast off by Pinel may have allowed us for far too long to neglect examining with what they had been replaced. It is the second issue, that of responsibility, which requires more elaboration, for it is argued here that the medical model has had its greatest impact in the lifting of moral condemnation from the indiv- idual. While some sceptics note that while the individual is no longer condemned his disease still is, they do not go far enough. Most analysts have tried to make a distinction between illness and crime on the issue of personal responsibility.* The criminal is thought to be responsible and therefore accountable (or punishable) for his aa, while the sick person is not. While the distinction does exist, it seems to be more a quantitative one rather than a qualitative one, with moral judgments but a pinprick below the surface. For instance, while it is probably true that individuals are no longer directly condemned for being sick, it does seem that much of this condemnation is merely displaced. Though his immoral character is not demonstrated in his having a disease, it becomes evident in what he does about it. Without seeming ludicrous, if one listed the traits of people who break appointments, fail to follow treatment regimen, or even delay in seeking medical aid, one finds a long list of 'personal flaws'. Such people seem to be ever ignorant of the consequences of certain diseases, inaccurate as to symp- tomatology, unable to plan ahead or find time, burdened with shame, guilt, neurotic tendencies, haunted with traumatic medical experiences or members of some lower status minority group—religious, ethnic, or socio-economic. In short, they appear to be a sorely troubled if
Medicine as an Institution of Social Control
not disreputable group of people. The argument need not rest at this level of analysis, for it is not clear that the issues of morality and individual responsibility have been fully banished from the etiological scene itself. At the same time as the label 'illness' is being used to attribute 'diminished responsibility' to a whole host of phenomena, the issue of 'personal responsibility' seems to be re-emerging within medicine itself. Regardless of the truth and insights of the concepts of stress and the perspective of psycho- somatics, whatever else they do, they bring man, not bacteria to the centre of the stage and lead thereby to a re-examination of the indiv- idual's role in his own demise, disability and even recovery. The case, however, need not be confined to professional concepts and their degree of acceptance, for we can look at the beliefs of the man in the street. As most surveys have reported, when an individual is asked what caused his diabetes, heart disease, upper respiratory infection, etc., we may be comforted by the scientific terminology if not the accuracy of his answers. Yet if we follow this questioning with the probe: 'Why did you get X now?', or 'Of all the people in your community, family etc. who were exposed to X, why did you g e t... ?', then the rational scientific veneer is pierced and the concern with per- sonal and moral responsibility emerges quite strikingly. Indeed the issue 'why me?' becomes of great concern and is generally expressed in quite moral terms of what they did wrong. It is possible to argue that here we are seeing a residue and that it will surely be different in the new generation. A recent experiment I conducted should cast some doubt on this. I asked a class of forty undergraduates, mostly aged seventeen, eighteen and nineteen, to recall the last time they were sick, disabled, or hurt and then to record how they did or would have com- municated this experience to a child under the age of five. The pur- pose of the assignment had nothing to do with the issue of respons- ibility and it is worth noting that there was no difference in the nature of the response between those who had or had not actually encountered children during their 'illness'. The responses speak for themselves. The opening words of the sick, injured person to the query of the child were: 1 feel bad' 'I feel bad all over' 'I have a bad leg' 'I have a bad eye' 'I have a bad stomach ache' 'I have a bad pain' 'I have a bad cold'
Medicine as an Institution of Social Control
the retention of absolute control over certain technical procedures; thirdly, through the retention of near absolute access to certain 'taboo' areas; and finally, through the expansion of what in medicine is deemed relevant to the good practice of life.
I. The expansion of what in life is deemed relevant to the good practice of medicine The change of medicine's commitment from a specific etiological model of disease to a multi-causal one and the greater acceptance of the concepts of comprehensive medicine, psychosomatics, etc., have enormously expanded that which is or can be relevant to the under- standing, treatment and even prevention of disease. Thus it is no longer necessary for the patient merely to divulge the symptoms of his body, but also the symptoms of daily living, his habits and his worries. Part of this is greatly facilitated in the 'age of the computer', for what might be too embarassing, or take too long, or be inefficient in a face- to-face encounter can now be asked and analyzed impersonally by the machine, and moreover be done before the patient ever sees the physician. With the advent of the computer a certain guarantee of privacy is necessarily lost, for while many physicians might have probed similar issues, the only place where the data were stored was in the mind of the doctor, and only rarely in the medical record. The computer, on the other hand, has a retrievable, transmittable and al- most inexhaustible memory. It is not merely, however, the nature of the data needed to make more accurate diagnoses and treatments, but the perspective which accom- panies it—a perspective which pushes the physician far beyond his office and the exercise of technical skills. To rehabilitate or at least alleviate many of the ravages of chronic disease, it has become increas- ingly necessary to intervene to change permanently the habits of a patient's lifetime—be it of working, sleeping, playing or eating. In prevention the 'extension into life' becomes even deeper, since the very idea of primary prevention means getting there before the disease process starts. The physician must not only seek out his clientele but once found must often convince them that they must do something now and perhaps at a time when the potential patient feels well or not especially troubled. If this in itself does not get the prevention-oriented physician involved in the workings of society, then the nature of 'effec- tive' mechanisms for intervention surely does, as illustrated by the
Irving Kenneth Zola statement of a physician trying to deal with health problems in the ghetto: 'Any effort to improve the health of ghetto residents cannot be separated from equal and simultaneous efforts to remove the multiple social, political and economic restraints currently imposed on inner city residents.''" Ortain forms of social intervention and control emerge even when medicine comes to grips with some of its more traditional problems like heart disease and cancer. An increasing number of physicians feel that a change in diet may be the most effective deterrent to a number of cardio-vascular complications. They are, however, so perplexed as to how to get the general population to follow their recomendations that a leading article in a national magazine was entitled 'To Save the Heart: Diet by Decree?'" It is obvious that there is an increasing pressure for more explicit sanctions against the tobacco companies and against high users to force twth to desist. And what will be the im- plications of even stronger evidence which links age at parity, fre- quency of sexual intercourse, or the lack of male circumcision to the incidence of cervical cancer, can be left to our imagination!
- Through the retention of absolute control over certain technical procedures In particular this refers to skills which in certain jurisdictions are the very operational and legal definition of the practice of medicine— the right to do surgery and prescribe drugs. Both of these take medicine far beyond concern with ordinary organic disease. In surgery this is seen in several different sub-specialities. The plastic surgeon has at least participated in, if not helped perpetuate, certain aesthetic standards. What once was a practice confined to rest- oration has now expanded beyond the correction of certain traumatic or even congenital deformities to the creation of new physical pro- perties, from size of nose to size of breast, as well as dealing with certain phenomena—wrinkles, sagging, etc.—formerly associated with the 'natural' process of ageing. Alterations in sexual and reproductive functioning have long been a medical concern. Yet today the frequency of hystereaomies seems not so highly correlated as one might think with the presence of organic disease. (What avenues the very possibility of sex change will open is anyone's guess.) Transplantations, despite their still relative infrequency, have had a tremendous effect on our very notions of death and dying. And at the other end of life's continuum,
Irving Kenneth Zola span of human existence, but it opens the possibility of medicine's services to millions if not billions of people. In the United States at least, the implication of declaring alcoholism a disease (the possible import of a pending Supreme Court decision as well as laws currently being introduced into several state legislatures) would reduce arrests in many jurisdictions by ten to fifty per cent, and transfer such 'offenders' when 'discovered' directly to a medical facility. It is preg- nancy, however, which produces the most illuminating illustration. For, again in the United States, it was barely seventy years ago that virtually all births and the concomitants of birth occurred outside the hospital as well as outside medical supervision. I do not frankly have a docu- mentary history, but as this medical claim was solidified, so too was medicine's claim to a whole host of related processes: not only to birth but to prenatal, postnatal, and pediatric care; not only to conception but to infertility; not only to the process of reproduction but to the process and problems of sexual activity itself; not only when life be- gins (in the issue of abortion) but whether it should be allowed to be- gin at all (e.g. in genetic counselling). Partly through this foothold in the 'taboo' areas and partly through the simple reduction of other resources, the physician is increasingly becoming the choice for help for many with personal and social problems. Thus a recent British study reported that within a five year period there had been a notable increase (from twenty-five to forty-one per cent.) in the proportion of the population willing to consult the physician with a personal problem.^-'
- Through the expansion of what in medicine is deemed relevant to the good practice of life Though in some ways this is the most powerful of all 'the medical- izing of society' processes, the point can be made simply. Here we refer to the use of medical rhetoric and evidence in the arguments to advance any cause. For what Wootton attributed to psychiatry is no less true of medicine. To paraphrase her, today the prestige of any proposal is immensely enhanced, if not justified, when it is expressed in the idiom of medical science. To say that many who use such labels are not professionals only begs the issue, for the public is only taking its cues from professionals who increasingly have been extending their expertise into the social sphere or have called for such an extension.''* In politics one hears of the healthy or unhealthy economy or state.
Medicine as an Institution of Social Control
More concretely, the physical and mental health of American presid- ential candidates has been an issue in the last four elections and a recent book claimed to hnk faulty political decisions with faulty health.'-^ For years ys^'e knew that the environment was unattrac- tive, polluted, noisy and in certain ways dying, but now we learn that its death may not be unrelated to our own demise. To end with a rather mundane if depressing example, there has always been a constant battle between school authorities and their charges on the basis of dress and such habits as smoking, but recently the issue was happily resolved for a local school administration when they declared that such restrictions were necessary for reasons of health.
The Potential and Consequences of Medical Control The list of daily activities to which health can be related is ever growing and with the current operating perspective of medicine it seems infinitely expandable. The reasons are manifold. It is not merely that medicine has extended its jurisdiction to cover new problems,"^ or that doctors are professionally committed to finding disease," nor even that society keeps creating disease. "* For if none of these obtained today we would still find medicine exerting an enormous influence on society. The most powerful empirical stimulus for this is the realization of how much everyone has or believes he has something organically wrong with him, or put more positively, how much can be done to make one feel, look or function letter. The rates of 'clinical entities' found on surveys or by periodic health examinations range upwards from fifty to eighty per cent, of the popu- lation studied.'® The Peckham study found that only nine per cent, of their study group were free from clinical disorder. Moreover, they were even wary of this figure and noted in a footnote that, first, some of these nine per cent, had subsequently died of a heart attack, and, secondly, that the majority of those without disorder were under the age of five.^" We used to rationalize that this high level of prevalence did not, however, translate itself into action since not only are rates of medical utilization not astonishingly high but they also have not gone up appreciably. Some recent studies, however, indicate that we may have been looking in the wrong place for this medical action. It has been noted in the United States and the United Kingdom that within a given twenty-four to thirty-six hour period, from fifty to eighty per cent, of the adult population have taken one or more 'medical'
Medicine as an Institution of Social Control
Food and Drug Administration's 'Blue Ribbon' Committee Report on the safety, quality and efficaqr of all medical drugs commercially and legally on the market since 1938.^'' Though appalled at the lack and quality of evidence of any sort, few recommendations were made for the withdrawal of drugs from the market. Moreover there are no recorded cases of anyone dying from an overdose or of extensive ad- verse side effects from marihuana use, but the literature on the adverse effects of a whole host of 'medical drugs' on the market today is legion. It would seem that the value positions of those on both sides of the abortion issue needs little documenting, but let us pause briefly at a field where 'harder' scientists are at work—genetics. The issue of genetic counselling, or whether life should be allowed to begin at all, can only be an ever increasing one. As we learn more and more about congenital, inherited disorders or predispositions, and as the population size for whatever reason becomes more limited, then, inevitably, there will follow an attempt to improve the quality of the population which shall be produced. At a conference on the more limited concern of what to do when there is a documented probability of the offspring of certain unions being damaged, a position was taken that it was not necessary to pass laws or bar marriages that might produce such off- spring. Recognizing the power and influence of medicine and the doctor, one of those present argued: 'There is no reason why sensible people could not be dissuaded from marrying if they know that one out of four of their children is likely to inherit a disease.'^* There are in this statement certain values on marriage and what it is or could be that, while they may be popular, are not necessarily shared by aU. Thus, in addition to presenting the argument against marriage, it would seem that the doctor should—if he were to engage in the issue at all—present at the same time some of the other alternatives: Some 'parents' could be willing to live with the risk that out of four children, three may tuim out fine. Depending on the diagnostic procedures available they could take the risk and if indications were negative abort. If this risk were too great but the desire to bear children was there, and depending on the type of problem, artificial insemination might be a possibility. Barring all these and not wanting to take any risk, they could adopt children. Finally, there is the option of being married without having any children. It is perhaps appropriate to end with a seemingly innocuous and technical advance in medicine, automatic multiphasic testing. It has
Irving Kenneth Zola been a procedure hailed as a boon to aid the doctor if not replace him. While some have questioned the validity of all those test-results and still others fear that it will lead to second class medicine for already underprivileged populations, it is apparent that its major use to date and in the future may not be in promoting health or detecting disease to prevent it. Thus three large institutions are now or are planning to make use of this method, not to treat people, but to 'deselect' them. The armed services use it to weed out the physically and mentally unfit, insurance companies to reject 'uninsurables' and large industrial firms to point out 'high risks'. At a recent conference representatives of these same institutions were asked what responsibility they did or would recognize to those whom they have just informed that they have been 'rejected' because of some physical or mental anomaly. They calmly and universally stated: none—neither to provide them with any appropriate aid nor even to ensure that they get or be put in touch with any help.
Conclusion C. S. Lewis warned us more than a quarter of a century ago that 'man's power over Nature is really the power of some men over other men, with Nature as their instrument.' The same could be said regard- ing man's power over health and illness, for the labels health and ill- ness are remarkable 'depoliticizers' of an issue. By locating the source and the treatment of problems in an individual, other levels of inter- vention are effectively closed. By the very acceptance of a specific behaviour as an 'iUness' and the definition of illness as an undesirable state, the issue becomes not whether to deal with a particular problem, but how and when.^^ Thus the debate over homosexuality, drugs or abortion becomes focused on the degree of sickness attached to the phenomenon in question or the extent of the health risk involved. And the more principled, more perplexing, or even moral issue, of what freedom should an individual have over his or her own body is shunted aside. As stated in the very beginning this 'medicalizing of society' is as much a result of medicine's potential as it is of society's wish for medicine to use that potential. Why then has the focus been more on the medical potential than on the social desire? In part it is a function of space, but also of political expediency. For the time rapidly may be approaching when recourse to the populace's wishes may be impossible.
Irving Kenneth Zola The second example removes certain infonnation even further from public view. The issue of fluoridation in the U.S. has been for many years a hot political one. It was in the political arena because, in order to fluoridate local water supplies, the decision in many jurisdictions had to be put to a popular referenduni. And when it was, it was often defeated. A solution was found and a series of state laws were passed to make fluoridation a public health decision and to be treated, as all other public health decisions, by the medical officers best qualified to decide questions of such a technical, scientific and medical nature.
Thus the issue at base here is the question of what factors are actually of a solely technical, scientific and medical nature! To return to our opening caution, this paper is not an attack on medicine so much as on a situation in which we find ourselves in the latter part of the twentieth century; for the medical area is the arena or the example par excellence of today's identity crisis—^what is or will become of man. It is the battleground, not because there are visible threats and oppressors, but because they are almost invisible; not because the perspective, tools and practitioners of medicine and the other helping professions are evil, but because they are not. It is so frightening because there are elements here of the banality of evil so uncomfortably written about by Hannah Arendt.^*^ But here the danger is greater, for not only is the process masked as a technical, scientific, objective one, but one done for our own good. A few years ago a physician speculated on what, based on current knowledge, would be the composite picture of an individual with a low risk of developing atherosclerosis or coronary-artery disease. He would be: '... an effeminate municipal worker or embalmer completely lacking in physical or mental alertness and without drive, ambition, or competitive spirit; who has never attenipted to meet a deadline of any kind; a man with poor appetite, subsisting on fruits and vegetables laced with corn and whale oil, detesting tobacco, spuming ownership of radio, television, or motorcar, with full head of hair but scrawny and unathletic appearance, yet constantly straining his puny muscles by exercise. Low in income, blood pressure, blood sugar, uric acid and cholesterol, he has been taking nicotinic acid, pyridoxine, and long term anto-coagulant therapy ever since his prophylactic castration.'^^ Thus I fear with Freidson: 'A profession and a society which are so concerned with physical and functional wellbeing as to sacrifice civil liberty and moral integrity must inevitably press for a 'scientific' environment similar to that provided laying hens on progressive chicken farms—hens who produce eggs industriously and have no disease or other cares.'^" Nor does it really matter that if, instead of the above depressing picture, we were guaranteed six more inches in height, thirty more
Medicine as an Institution of Social Control
years of life, or drugs to expand our potentialities and potencies; we should still be able to ask: what do six more inches matter, in what kind of environment will the thirty additional years be spent, or who will decide what potentialities and potencies will be expanded and what curbed. I must confess that given the road down which so much expertise has taken us, I am willing to live with some of the frustrations and even mistakes that will follow when the authority for many decisions be- comes shared with those whose lives and activities are involved. For I am convinced that patients have so much to teach to their doctors as do students their professors and children their parents. Brandeis University.
1 T. Szasz: The Myth of Mental Illness, Harper and Row, New York, 1961; and R. Leifer: In the Name of Mental Health, Science House, New York, 1969- ^ E.g. A. Toffler: Future Shock, Random House, New York, 1970; and P. E. Slater: The Pursuit of Loneliness, Beacon Press, Boston, 1970. •' Such as B. Wootton: Social Science and Social Pathology, Allen and Unwin, London, 1959.
- H. Sigerist: Civilization and Disease, Cornell University Press, New York, 1943. ^ M. Foucault: Madness and Civilization, Pantheon, New York, 1965; and Szasz: op. dt. ^ G. Rosen: A History of Public Health, MD Publications, New York, 1955; and G. Rosen: 'The Evolution of Social Medicine', in H. E. Freenian, S. Levine and L. G. Reeder (eds.): Handbook of Medical Sociology, Prentice- Hall, Englewood Cliffs, N.J., 1963, pp. 17-61. " Wootton: op. dt., p. 206. ** Two excellent discussions are found in V. Aubert and S. Messinger: 'The Criminal and the Sick', Inquiry, Vol. i, 1958, pp. 137-160; and E. Freid- son: Profession of Medicine, Dodd-Mead, New York, 1970, pp. 205-277. ^ Freidson: op. ctr., p. 251. " J. C. Norman: 'Medicine in the Ghetto', New Engl. J. Med., Vol. 281, 1969, p. 1271. " 'To Save the Heart; Diet by Decree?', Time Magazine, ioth January, 1968, p. 42. ^2 J. L, Goddard quoted in the Boston Globe, August 7th, 1966. '••' K. Dunnell and A. Cartwright: Medidne Takers, Prescribers and Hoarders, in press.
