The Therapeutic State
Medicalizing Quackery
BY THOMAS SZASZ
T
he Merriam-Webster Online Dictionary defines spiritual realm exists or is real. Nothing belongs in
medicalize as to view or treat as a medical the domain of materialist medicine. Christian Science
concern, problem, or disorder and offers this represents the most radical case of demedicalization
phrase as illustration: those who seek to dispose of possible.
social problems by medicalizing them. Accordingly, we Contemporary public health is the mirror image of
speak of the medicalization of homosexuality and hos- Christian Science. Everything in our liveshousing,
tility, but do not speak of the medicalization of malaria food, education, work, recreation, and procreation
or melanoma. affects our health. Hence, everythingnot only health
The concept of medicalization rests on the assump- care narrowly definedbelongs in the domain of med-
tion that some phenomena belong in the domain of icine as health care. Linda Landesman, a former presi-
medicine and some do not. dent of the Public Health Association of New York City,
However, where a thing belongs is the result of states: We expect and demand that government ensure
how we classify the thing, that is, the result of (more that we breathe clean air, drink safe water, work with
or less arbitrary) human action. Is an minimum danger . . . . Left on our
anencephalic baby a human being? Is own, we dont always make the health-
smoking crack a crime, a disease, a We must draw a line iest choices. In this view, we are
right? Answering such questions is uninformed, undisciplined children
what religion, politics, and, today,
between what counts whose health and well-being require
medical ethics is all about. The point as medical care and the unremitting protection of the
to keep in mind is that, unless we therapeutic state.
agree on clearly defined criteria that
what does not. The In practice we must draw a line
define membership in the class called question is where to between what counts as medical care
disease or medical problem, it is and what does not. The question is
fruitless to debate whether any par- draw that line. where to draw that line. What is a dis-
ticular act of medicalization is ease and what is not? What should be
valid or not. treated medically, by physicians or medical personnel,
Everything that we do or happens to us affects or and what should not? Because people in modern soci-
depends on the use of our body. In principle we could eties expect the state to defray all or most of the cost of
treat everything that people do or that happens to them what is deemed a medical service, where we draw the
as belonging in the domain of medicine. Conversely, line between health care and not health care is
we could maintain that nothing that we do or happens informed more by economic and political considera-
to us belongs in the domain of medicine because all is tions than by medical or scientific judgments.
ordained by God and belongs in the domain of reli-
gion. Such, indeed, was the case in ancient times, before
people distinguished between faith healing and medical Thomas Szasz ([email protected]) is professor of psychiatry emeritus at
SUNY Upstate Medical University in Syracuse. His forthcoming books are
healing. A similar view is held today by Christian Coercion as Cure: A Critical History of Psychiatry (Transaction) and
Scientists, whose faith is based on a radical denial of The Medicalization of Everyday Life: Selected Essays (Syracuse
the reality of the material world. For them, only the University Press).
THE FREEMAN: Ideas on Liberty 22
Medicalizing Quackery
Moreover, not only must we demarcate disease from Neither medicalization nor demedicalization is a
nondisease, we must also distinguish between medical- new phenomenon. Formerly, people spoke about imag-
ization from above, by coercion, and medicalization inary diseases and persons who pretended to be ill.
from below, by choice. Not by coincidence, these strate- Molire (16221673), the great satirist of malingerers
gies match psychiatrys two paradigmatic legal-social and of the quacks whose harmful ministrations they
functions, civil commitment and the insanity defense, invite, titled one of his plays The Imaginary Invalid (Le
social control and excuse-making. malade imaginaire).
Although medicalization encompasses much more
Disease and the Patient Role than psychiatry, we must be clear about one thing: Psy-
T he difference between disease as objective physical
condition and the patient role as social status is
obvious, provided we are willing to recognize it. Having
chiatry is medicalization through and through.Whatev-
er aspect of psychiatry psychiatrists claim is not
medicalization can only be such if it deals with proven
a disease and occupying the patient role diseases of the central nervous system,
are independent variables: not all sick which belong to neurology, not psychia-
persons are patients, and not all patients try. (Psychoanalysis and other forms of
are sick. Physicians, politicians, the press, psychotherapy, qua medical practices, are
and the public nevertheless continue to of course also instances of medicalization.)
confuse and conflate the two categories.
This is a cultural setting conducive to the Semantic-Social Strategy
growth of medicalization.
Medicalization is a two-way street.
Until recently, homosexuality was consid-
I n short, medicalization is not medicine
or science; it is a semantic-social strate-
gy that benefits some persons and harms
ered a disease.Today it no longer is. Has it others. In the past the persons most clear-
been cured out of existence? No. It has ly benefiting from medicalization were
been demedicalized. At the same time, psychiatrists and the persons most obvi-
The Imaginary Invalid
hundreds of behaviors never before treat- ously injured by it were mental patients.
ed as medical problems are now diag- [T]he medical treatment of [mental]
nosed as diseases: for example, gender disorder and patients began with the infringement of their personal
substance abuse. Have these new diseases been discov- freedom, observed Karl Wernicke (18481905), the
ered? No.They have been invented; that is, they are the pioneer German neuropathologist.Today the situation is
products of medicalization. more complex, more democratic. Anyone may, at
Ironically, technological advances in medicine, com- some time, be helped or harmed by medicalization;
bined with the conflation of the concepts of disease the only consistent gainers from it are the agents of the
and patient role, facilitate not only medicalization but therapeutic state.
also confusion between discovering diseases and creat- Formerly the priest was both protector and punisher.
ing diagnoses. As a result, when a behavior categorized Today the physician plays both roles. Formerly people
as a disease is declassifiedas happened with homo- could not imagine living in a society unguided and
sexualityjournalists, science writers, and the public uncontrolled by God: church and state formed a holy
are easily persuaded by the stakeholders in medicaliza- union called theocracy. Today people (in the West,
tion that demedicalization is also a product of scientific but not in the East) cannot imagine living in a society
progress and moral enlightenment, and not the product unguided and uncontrolled by science, especially med-
of a power struggle between stigmatizers and stigma- ical science: medicine and the state form a healthy
tized. union called pharmacracy.
23 OCTOBER 2007
