In order to illustrate the predominance of medical explanations, a definition of the medicalisation thesis will be given and illustrated by the case of the treatment of terminally ill patients. The medicalisation of death and dying will be highlighted by a review of sociological literature from both feminist and non-feminist perspectives.
The limits of medicalisation will be provided as a rationale for the resistance of the medifcal model.Finally, the ways in which individuals negotiate and resist the medicalisation of death will be discussed including the rise of pro-euthanasia groups, increasing use of complementary medicine, and the popularity of the hospice movement. The main elements of the medical model of health are the search for objective, discernable signs of disease, its diagnosis and treatment Biswas, 1993. Therefore, by adhering to this reductionist view, the human body is seen as a biochemical machine Turner, 1995 and health merely as an absence of disease, a commodity to be bought and sold.
The rise of hospitals with their goal of curing and controlling disease has led to the marginalisation of lay medicine, and a focus upon the individual rather than society as a cause of ill health. Health education and promotion with their focus upon “victim blaming” and individualism have extended the remit of the medical profession from the hospital into the community. With medical imperialism the power of medicina has grown and medicine has all but replaced religion as an institution of social control. Illich 1976, p53 describes medicine as a: “moral enterprise.
….
which] gives content to good and evil….
. like law and religion [it] defines what is normal, proper or desirable”.Medicalisation is defined as:”a process of increased medical intervention into areas that hitherto would be outside he medical domain” Bilton et al, 1996 p422. Areas of life which could be considered “natural” such as pregnancy, childbirth, unhappiness, ageing and death have been brought within the medical remit Taylor & Field, 1997 and therefore are increasingly viewed under the principles of the medical model.
Indeed many of these “ailments” cannot be cured by medical intervention but are still subjected to the “medical gaze” Szasz 1964 believed that treatment of the mentally ill by drugs and electroconvulsiv therapy was not only unnecessary but a violation of human rights cited in Scambler, 1991. Social problems such as child abuse, violence and alcoholism have become redefined as medical problems as medicalisation is a more effective way of controlling deviance than legal punishment Scampbler, 1991.The medical profession have claimed victory over the eradication of many acute infectious diseases although critics would argue advances in social conditions and nutrition were more instrumental. People are now living longer and their expectations of health have changed.
Whatever the cause, the pattern of disease has altered with the acute killers of the past being replaced with chronic long-term, often degenerative diseases for which there are no cures. The effect of the medicalisation of increasing areas of life has increased the power of the medical profession and relatively decreased the power of their patients.Ther has been a: “stripping away from human culture of ways of coping with pain, birth and death and their replacemnet by a sanitised technological medical intervention against which individuals and society are unable to fight back” Jones, 1994 p456. Zola 1972 cited in Armstrong, 1989 maintains that this causes a loss of autonomy, creating passive patients who conform to whatever the medical profession dictate.
This is damaging because: “not only is the process masked as a technical, scientific, objective one, but one done for our own good” Jones, 1994 p456.Illich claims that this process has undermined our ability to cope with the normal human condition and that we can no longer accept suffering as inevitable: “every ache is an indication for a nedd for padding and pampering” Taylor and Field, 1997 p56> Victor 1993 describes death in Britain as a highly medicalised event. Due to the 1836 Births and Deaths Registration Act, a doctor is required to certify both death and the underlying causes. The majority of deaths now occur in a medical context be it a hospital ward, under General Practitioner supervision or in an accident and emmergency unit Bradbury, 1993.
Death has become a medical event studied by medical sociologists and even bereavement has become medicalised by its association with medically trained psychiatrists rather than academic psychologists Walter, 1993. In the United Kingdom a bereaved person is more likely to visit their family doctor for assistance than any other professionl Walter, 1999 and there is a tendency to prescribe pills rather than give supportive care to the grieving Fennell et al, 1988. It has become much less common to say that an elderly person has died of “old age” but rather a set of medically defined signs and symptoms Ahmedzai, 1993. Death has pale4d into a metamorphical figure and killer disease has taken his place” Illich, 1976 p199.
In the past, the typical death bed scenario was a family concern where loved ones gathered around the dying individuals to make their peace in the final hours Hoefler and Kamoie, 1994. However, in recent times the death bed is typically found in a hospital or long-term medical facility. Over 70% of deaths today in urban areas take place in hospitals Fennell et al, 1988 whereas in 1900, 80% of all deaths occurred in the home Hoefler and Kamoie, 1994.Whilst most people are pushed into institutions, the home becomes increasingly inhospitable to those who elect to hang on, only the very rich and vert independant can avoid the medicalisation of the end of life Illich, 1976.
There is a popular misconception that by giving in to hospitalisation pain will be reduced and chanbes of longevity increased, Illich 1976 p112 denies that this is so: “of those admitted with a fatal condition to the average British clinic 10% died on the day of arrival, 30% within a week, 75% within a month and 97% within three months….
.In terminal cancer there is no difference in life expectancy between those who end their days in a home and those who die in the hospital”. The Voluntary Euthanasia Society 1999 state that at least 5% of terminal pain cannot be fully controlled and Kearl 1999 reveals that one half of conscious patients who died in hospitals reported moderate to severe pain at least one half of the time. Religious interest in the process of dying has been undermined as medicine replaced its presence at the death bed Walter, 1999.
This destruction of the typical scenario has resulted in terminally ill patients being physically and emotionally removed from their families. By denying the community the opportunity to care for their dying, the medical profession have successfully medicalised death. When death took place within the home, the sick and the dying were the responsibility of the family, this responsibility has now been transferred to intermediaries in the form of medical professionals, funeral directors and solicitors Clark, 1993.Feminist writers argue that this transferral has removed the responsibility of death from the largely feminine sphere of lay caring in the hom to the largely masculine sphere of professionals 9Littlewood, 1994.
Oakly 1979 reiterates this de-feminisation of death and adds that it is women who still do the: “bulk of the often dirty and demanding care of the dying” in their roles as nurses and lay carers cited in Walter, 1993. Of those fortunate enough to remain in the home, approximately 75% are cared for by a female relative Abbott and Wallace, 1990.However, the alternative argument suggests it is changes in wider society itself that have resulted in the hospitalisation of many dying individuals rather than the process of medicalisation. Changes in the structure of families along with geographical and social mobility have resulted in many people living alone or with their spouses.
The eradication of the extended family has reduced the likelihood that their will be a carer available within the home when the elderly become sick Seala, 1993. he increasing number of women in the workforce also me4ans that many women do not have the time, energy or financial resources to care for their ailing relatives in the demanding terminal phase Field and James, 1993.It is also argued that due to falling death rates because of medical advances, and improvements in social conditions and nutrition, people are less accustomed to dealing weith death. Death is becoming an increasingly elderly concern as two thirds of deaths are now associated with diseases of old age Illich, 1976 and many people therefore feel removed from its presence.
Thus by seeking ways to avoid the distress associated with death we attempt to compartmentalise it, shut it away from view. The increasing trend of hospitalisation for the dying may be merely a symptom of medical success rather then a deliberate attempt to exert power over all areas of life: “death is characterised by fear and shame,people who are dying to provoke unease and embarrassment therefore it is seen to be appropriate that they are removed from the community to die in isolation” Littlewood, 1993 p70.Crowther 1993 p113 alikens hospitals to top security prisons as: “both institutions are looking after a section of the community which society as a whole does not wish to be involved with”. Other sociologists argue that the process of medicalisation has resulted in a change in the way death is perceived.
Once a natural event, death is now seen as a failure of technology and science: “something that ought not to have happened and which people find more difficult to accept and come to terms with” Taylor and Field, 1997 p56.It is seen as the end of an individual life rather than, as in traditional societies, a process of renewal of the generations Gidens, 1997. The apparent obsession with death prevention stems from the medical profession viewing death, even when it is by no means premature, as a failure of their science and skill in what Kearl 1999 describes as the: “stone age ethics of space age medicine”. As a result new invasive sophisticated procedures have been developed in order to maintain life.
Although to some these technological advances are invaluable, to others they are potentially destructive. This: “therapeutical relentlessness in its commitment to the preservation of life…
.. has come to symbolise a prototypically modern form of torture combining benevolence, indifference and technological wizardry” Hoefler and Kamoie, 1994 p82. Illich 1976, p106 states: ‘the line separating the physician from the mortician has been blurred.
Beds are filled with bodies neither dead nor alive’.The aggressive overtreatment of the terminally ill is something of a new phenomena. Pneumonia, the ‘old man’s friend’ was often the cause of many frail patients’ demise, however with use of antibiotics this condition can now be remedied with the result of, in some cases, denying the patient a quiet and speedy death Kennedy, 1990. More sophisticated technology has led to the power to: ‘keep almost anybody alive indefinitely.
.. without thought of feeling, or hope of recovery’ Rachels, 1986 p106. Doctors have a tendency to strive or longevity rather than quality’ Kennedy, 1990 p26.
Robert Blank 1988 cited in Hoefler ; Kamoie, 1994 has devised a title for this: ‘the technological imperative’. The power of the medical profession and dominance of hospital medicine have resulted in the concentration of death within the hospital where the form of care previously described is often inappropriate for terminal patients Victor, 1993. More sophisticated and invasive medical procedures persistently alienate the patient from the physician.New diagnostic techniques have distanced the doctors from their patients and their felt experiences thus: ‘medical training produces a collection of caretakers that are best described as strangers and mechanics rather than friends and humanists’ Hoefler ; Kamoie, 1994 p79.
It is alleged that medical technological progress has left behind the necessary skills of communication and that: ‘understanding attitudes have not advanced or even kept pace….
they have been sacrificed in the name of progress’ Crowther, 1993 p115.This inadequate training coupled with a strict allegiance to the ‘technological imperative’ has led to the breakdown of the patient-doctor relationship. Thompson 1993 p111 describes the situation as ‘paternalistic benevolence’ where the doctor’s: ‘superior professional knowledge and altruistic intentions..
.. warrant acting for a patient’s best interest without fully informing the patient of the nature of the diagnosis or treatment’. Perhaps this has resulted in an increasing number of individuals opting to resist the medical model in ways to be described later.
Feminist sociologists would argue this breakdown in the doctor-patient relationship is far more pronounced for female than for male patients. Physicians, more frequently male, are trained by a: ‘medical culture which emphasises and highlights the health problems of women, thereby constituting women as patients…
. women’s disorders are characteristically conceived to be psychogenic in character relating to women’s neurotic behaviour Turner, 1995. As women have a longer life expectancy than men Mulkay, 1993 they often outlive their partners thus are statistically more likely to require more medical support in later life.Thus women are increasingly the victims of the drawbacks of medicalisation already mentioned.
In addition, it has been discovered that adult men of working age receive more attention from hospital staff and are more likely to be told their terminal diagnosis than women Field et al, 1997. An elderly woman’s chances of being institutionalised are also far higher than that of men and the differential increases with age see appendix 1. Elderly women in Britain have a 55% higher chance of ending their days in an institutional home Arber ; Ginn, 1991.Men are much more likely to die in their homes with comfort from a female lay carer and as a result are less likely to lose their independence and feelings of self-identity.
Illich 1976 advocates a resistance to the medical dominance over all areas of life, and encourages people to take responsibility for their own health care. It is important to view death as a natural process rather than a pathological condition in order to avoid the ‘social death’ that results in the alienation and ostracision of the terminally ill Taylor ; Field, 1997.As a reaction to medicalisation a number of groups have developed which actively reject medical lifesaving interventions in their terminal phase: ‘for them a good death is one where the only medical intervention that takes place is that of pain relief’ Bradbury, 1993 p70. This is an example of individuals attempting to wrestle back control from the medical system.
The rise of the ‘right to die’ movement is indicative of people’s willingness to: ‘challenge the neglect and poor quality of service available in many traditional hospital settings’ Fennell et al 1988 p168.In recent years this attitude has developed with the emergence of many pro-euthanasia groups including: Euthanasia Research and Guidance Organisation ERGO; Voluntary Euthanasia Society VES-UK; Choice in Dying, Hemlock Society USA and Dying with Dignity Canada all advocating the rights of the terminally ill to have control over their death. In a study concerning reasons why patients requested euthanasia, dependency and loss of autonomy were mentioned in 33% of cases Dunlop & Hockley, 1998.The Voluntary Euthanasia Society 1999 states that: ‘requests for euthanasia may indicate not that the patients are giving up in the face of suffering but that they are positively asserting their desire to control events’.
It would appear that the medical professions obsession with hiding the true nature of a patient’s condition ‘for the patient’s own good’ is prompting patients to take matters into their own hands. Hoefler & Kamoie 1994 p95 found that: ’60 – 90% of physicians would still rather withhold information about the condition of terminally ill patients’.Women in particular are attempting to regain control from the medical profession of the formerly feminine tasks of caring for the dying. ‘The de-feminisation of the power to define and control the management of death is being challenged and alternatives to male, hospital based technological approaches to terminal illness are being sought’ Littlewood, 1994.
The advent of hospice care as an alternative to traditional hospitalisation has been led by powerful women figures such as Dame Cicely Saunders.The emphasis on palliative rather than terminal care can be construed as a battle against the medical establishment Walter, 1999 in its preference for an holistic approach. The World Health Organisation 1990 has defined palliative care as: ‘the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems is paramount.
The goal is achievement of the best possible quality of life for patients and their families’ WHO, 1990 cited in Dunlop & Hockley, 1998 p2.This definition appears to be more centred around emotional support for the dying and their family, an area sadly lacking in the typical hospital environment with its emphasis on the physical aspects of disease fenell et al, 1988. ‘The authority of male clergy to define post-death care in a time when the concern with the spiritual destination of the deceased wanes, is being supplanted by that of female bereavement counsellors and befrienders. A re-feminisation of death is under way, led by women’ Walter, 1993 p277.
Cruse bereavement care is battling against the increasing medicalisation of bereavement and was founded by Margaret Torrie, herself a widow Field et al, 1997. It would appear that the re-feminisation of dying and death is well-under way prompted by a dissatisfaction in the medicalisation of these areas. However, although challenging the medicalisation of death in many respects, the hospice organisation has been criticised as offering only a limited number of places, and mainly concentrating on terminal cancer patients Seale, 1993 although deaths from cancer only account for 26% of all deaths Victor, 1993.Biswas 1993 p132 maintains that: ‘the recent expansion of the hospice movement has seen the increasing medicalisation of hospice care’ and that palliative care has become a part of general medicine and thus it is at the mercy of medical professionals rather than being a patient-led service.
There is no denying the success of hospice care for many terminal patients but it would appear that ‘creeping medicalisation’ is having an effect on the quality of care these institutions provide. The rising popularity of complementary medicine for the terminally ill may also be seen as a reaction to dissatisfaction with medicalisation.Techniques such as breathing exercises, muscular relaxation, meditation, visualisation, massage, aromatherapy, acupuncture and spiritual healing are more often practised in hospices than within mainstream curative medicine establishments Pietroni, 1993. Once displaced by medical science, lay medicine is experiencing a re-emergence to provide hope and comfort for those the medics have failed.
In conclusion it appears that the medical profession have successfully monopolised the process of dying and death.Society is becoming increasingly dependent upon the tenets of the medical model although in many areas its contribution to well-being is refuted. With advancements in medical technology and new sophisticated invasive procedures a number of terminal individuals are being kept alive long after all meaning and quality of life have diminished. The inability to cure and control all ailments coupled with a therapeutical relentlessness which refuses to admit to failure has led to dissatisfaction with medical care of the dying.
Feminist sociologists particularly are involved with wrestling back control over the process of dying from the medical professionals and seeking alternatives in the re-feminisation of death. The increasing use of complementary medicine would appear to be a response to this dissatisfaction as is the rising popularity of the hospice movement. Euthanasia would seem to be a topic that, as time goes on, is becoming increasing difficult to ignore, although vehemently opposed by the British Medical Association.
