Introduction
Medicalization is the development of medicine into a social institution. Medicine then became an institution of social control. (Scrambler, 2005) Medicalization moves the viewpoint from some moral failing of an individual to a medical diagnosis and quantifiable or qualifiable reason based in medicine. Medicalization influences the way that society perceives and reacts to physical characteristics and social behavior of an individual. Medicine as institution can be viewed in light of how and for what conditions human are treated. With medicine as a social institution it redefined social policy, resulting in therapeutic treatment, decriminalization, and decarceration of abhorrent social behavior because it is now classified as a medical problem rather than a social one. Examples include redefining alcoholism, drug addiction, obesity and the like as medical problems and diseases. In this way, medicine has become an institution of social control, and medicalization directs the resulting consequences of this social control for society in general. (Conrad & Schneider, 1992).
Many societal factor and forces fed and continue to feed into the process and trend of medicalization. One factor is when health insurance costs became reimbursable only if they were associated with a definable medical condition. A second factor that led to medicalization was the fact that death certificates required a cause of death. A third factor was that research funding for studying symptoms or behavior was often contingent upon problems that could be linked or defined as a disease. Additionally, for drug trials and approval the symptoms or condition the drug is treating needs to be defined as a particular disease. Finally, society desired then to explain all behavior and human conditions as a result of genetics or a disease so as to minimize personal responsibility for behavior and lifestyle. (On the Medicalization of Our Culture, 2009).
In the 1970s and early 1980s, biomedicine had taken a strong foothold in American medicine. Starting in about 1985, biomedicine underwent an even more dramatic change. Changes in the practice of biomedicine coalesced into the concept of biomedicalization. Biomedicalization then evolved out medicalization and became the second wave, evolution or transformation of this concept and definition as it began in 1985 and continues to develop into the present day. This transformation was facilitated by biomedicine and the integration of “technoscientfic” innovation. The demarcation of medicalization to biomedicalization is the shift from just control over biomedical phenomena to actual transformation of them. (Clarke, Mamo, Fishman, Shim & Fosket, 2003)
Then around 2010, the evolution of biomedicalization resulted in a further paradigm shift to what is now referred to as biomedicalization 2.0. Biomedicalization 2.0 is hallmarked by the immense power of the digital age intersecting with the post-human genome era, a world where privacy has become archaic and a postindustrial society that has either exported or automated most industries. Biomedicalization 2.0 is “emerging as recent technoscientific innovations converge with venture capitalism, technoutopian cyberculture, and the digital economy at sites outside of biomedicine’s jurisdiction.” (Boesel, 2012). Biomedicalization 2.0 challenges traditional medical authority via medical practices that fall outside of the control and oversight of institutional medicine. Instead of transforming medicine from the inside out, biomedicalization 2.0 is transforming and changing the institution of medicine from the outside in. (Boesel, 2012).
Thus, over the last sixty years, western medicine has undergone (1) medicalization, where medicine has exercised its control over areas previously outside of its realm, (2) biomedicalization, which in addition to control, actually transformed the way in which medicine is practiced, and now (3) biomedicalization 2.0 which extends the practice of medicine outside of the control and jurisdiction of institutional medicine that was originally established by medicalization. This paper examines the evolution of biomedicalization to boimedicalization 2.0 and analyzes the impact of biomedicalization 2.0 in extending the practice of medicine outside of the realm of the institution of medicine, termed here as “extra-institutional medicine.”
The social theory of biomedicalization can be broken down into five key interactive processes that define the evolution of biomedicalization or are produced as a result. The first is the political and economic reformation of biomedicine which has become a major player in today’s politics and economics. The second is the increased focus on healthcare and health itself combined with the increased focus on risk and the resulting increased scrutiny of biomedicine. The third is the increasing scientific and technological nature of biomedicine. (Clarke, Mamo, Fishman, Shim & Fosket, 2003). This has come to be known as the “technoscience” of biomedicine. “Technoscience is a conjunction of two words that refer to two streams of activity traditionally viewed as separated and separable into ‘(basic) science’ and ‘(applied)’ technology.” (Bell & Figert, 2015, p. 4)
Technoscience is followed by the fourth key process, the transformation of how biomedical knowledge and discoveries are produced, distributed and consumed. This transformation was made possible by the evolution of information technology and medical information management. The final and fifth process was taking this transformation and applying it to individuals on a sociological level. Biomedicalization resulted in encompassing and engulfing individual attributes previously relegated to the social sciences into the realm of biomedicine with the ability to be viewed and treated as a medical problem rather than a social issue. Thus, biomedicalization resulted in the production of new individual and collective technoscientific identities. (Clarke, Mamo, Fishman, Shim & Fosket, 2003).
As noted above, biomedicalization 2.0 is the transformation of institutional medicine from the outside in. Biomedicalization 2.0 is defined by three key phenomena: extramedicality (the extra-institutional practice of medicine), digitality (the evolution of the information age), and chiasmi (the convergence of medicine with outside disciplines). Chiasmi occurred when innovations in medical and information technology converged with “network culture, venture capital, and techoutopianism at sites outside institutional biomedicine’s authority.” (Boesel, 2012). It has evolved to incorporate the application of consumer demand, biotechnology, managed care, law and politics. (On the Medicalization of Our Culture, 2009).
Biomedicalization 2.0 comprises activities previously under the exclusively jurisdiction of institutional medicine occurring outside of that jurisdiction. Biomedicalization 2.0 can trace its roots to the patient advocacy groups that initially began formation in the 1970s. However, it was the arrival of the Internet that gave individuals the power to access a plethora of medical knowledge previously restricted to the medical institution. It also allowed individuals to communicate and network with each other, exchanging information about healthcare, doctors, disease and treatments. Since the advent of Internet, patient support and advocacy groups have grown exponentially. The large number of these groups is now powerful enough to affect changes in federal policy as well as to fund and direct scientific and medical research. (Boesel, 2012).
The outside force then began to internally transform medicine as an institution. Players within institutional medicine such as pharmaceutical companies, physician organizations, and research entities began to form their own “grassroots patients’ movements – which are sometimes called ‘Astroturf movements’ by critics – in order to capitalize on a new avenue of influence.” (Boesel, 2012). Biomedicalization 2.0 is further marked by an increase in patients desiring more collaborative and equal relationships with their doctors. Additionally, biomedicalization 2.0 resulted in the devolution of healthcare, in that the responsibility shifted to the patients and their families for much of the monitoring of the patient’s health as well as the medical care itself. Thus, this extra-institutional “practice” of medicine became the hallmark of the evolution to biomedicalization 2.0.
Specific examples of biomedicalization 2.0 include personalized medicine, direct-to-consumer genetic testing, and state laws which permit patients to order their own laboratory tests without having to consult a doctor or have a doctor provide a lab order. Personalized care is the identification of individual organic pathology and diagnosis followed by individualized intervention and treatments. It shifts the concept of medicine from a one size fits all treatment mentality to treating each patient as a separate diagnosis. This has a profound effect on the definition and treatment of aging, consequently resulting in the “biomedicalization of aging.” The biomedicalization of aging has allowed the prior social constructs of “old age” (decremental physical decline) to be replaced with aging as a construct that is under the control of biomedicine, and thus subject to its domain and not that of conventional social perception. This has further prompted reevaluation of what constitutes aging, the profession of gerontology, aging policy and public perception of aging. (Estes & Binney, 1989).
Direct-to-consumer genetic testing is another example. Individuals can order their own genetic tests, primarily over the Internet. These tests can range from paternity, to infant genetic testing for over one hundred possible genetic diseases or disorders, to heritage (e.g. through Ancestery.com). (What is Direct to Consumer Genetic Testing? 2016). States (e.g. Arizona) are also beginning to pass laws that allow individuals to order their own laboratory tests without any order or oversight by a physician. The individual can fill out a lab order, have the labs drawn and receive the results without ever involving any inside the institution of medicine. (Della Cava, 2015) These two examples are true examples of the evolution of extra-institutional medicine in biomedicalization 2.0.
Now other institutions are also experiencing these transformations. The pharmaceutical industry is experiencing pharmaceuticalization. Genetics is experiencing geneticization. (Maturo, 2012). It foreseeable in the future to actually see a merger of biomedicalization, geneticization and biomedicalization where individuals take an even more active role in directing their own healthcare and become their own diagnosticians, requesting a consult with a physician only as needed. No one spends more time identifying, tracking and monitoring his symptoms than the individual himself. Patients are beginning to realize that ten minutes or less with a doctor is often insufficient to truly address their healthcare needs, and that responsibility for their health is theirs. An individual’s health affects everything he does. Thus, it is only natural that medicine will continue to evolve and converge with all other social forces in the world, as well as with pharmaceuticalization and geneticization. This combined with the rapid expanse of the Internet and information technology, providing massive amount of information at one’s fingertips through smart phones and tablets, will certainly result in a further evolution to biomedicalizaton 3.0.
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