Exchange of Letters on Medicalization
Between Leon R. Kass, M.D.
and Paul McHugh, M.D.

Dear Leon:

You asked me to summarize my thoughts about the progressive medicalization of human mental life—an issue that the Council has considered in discussing “therapeutics” versus “enhancements” at several of its meetings, and about which both you and Michael Sandel have written enlighteningly.

The prime concern from my point of view is the insidious transition of pharmacological and other bio-scientific discoveries for treating mental disorders such as depression, attention deficit, chronic fatigue into means of enhancing personal skills and faculties on demand. We are witnessing a kind of “off-label” usage of medications for cosmetic, commercially driven, even fashionable purposes, rather than for disorder-directed, reparative ones.

This is a vexed problem with regard to psychotropic agents in particular because psychotropic medications lack the biological specificities that inform most medical treatments—say in cardiology or infectious disease—and for the most part keep those treatments within bounds.

At the risk of being simple-minded, let me develop that point—placing it into a historic perspective. The major advance in modern medicine—occurring in the late 19th century—was the abandonment of “symptomatic” therapeutics (treating symptoms such as fever, rash and the like directly) for “rational” therapeutics (treating the causes of symptoms such as infections or vascular insufficiencies).

The treatment of gangrene exemplifies the issue. In mid-19th century, gangrene was separated into “wet” and “dry” forms. If wet, you dried it; if dry, you wet it. With both, you prayed. Now we differentiate gangrene into that due to infection, infarction, neoplasia and the like, and, accordingly, direct a rational treatment against it (antibiotics for infections, re-vascularization for infarction, chemotherapy/radiation for neoplasia).

We have not abandoned symptomatic treatments. We use aspirin for pain and fever relief today. But the rule does hold that symptomatic treatments are problematic if they are the mainstay of therapeutics. Their effects are unpredictable, and they tend to be overused.

Most psychotropic medicines are “symptomatic”—discovered by accident, indefinite in their mechanisms of action, and indeed titled by the symptoms they target as with antidepressants, anxiolytics, mood-stabilizers and the like. We psychiatrists are pleased to have these medications available as they have brought us great power. But an expanding usage against new targets was almost predictable because of their symptomatic character and because the present day classificatory approach to psychiatry—the DSM III and IV method—is a symptom-based nomenclature. Symptomatic treatments for symptom-defined conditions will expand and tend to push other treatment approaches and ways of looking at mental travails aside. Hence the medicalization of human mental life that is the concern for us today.

What's the answer? Obviously, if we could identify at their roots in the brain all aspects of mental travail, we might know just where a rational practice might find its targets and its limits as we do in other organ-based specialties in medicine such as cardiology. But we cannot translate mind events into brain events in either health or disease. Many psychiatrists hold that the symptom-criteria definitions of mental disorder employed by DSM-IV is the best we can expect until the mind/brain problem is solved and are prepared to accept the expansion of treatments without much limit, given that we need to learn more about what we can do for people.

I have been long dissatisfied with this stance because similar mental symptoms are not the same in either nature or cause and deserve careful thought over their therapies. Mourning and melancholia are not the same, although both are forms of depression. Youthful high spirits and attention deficit disorder are not the same, even though both bring about distraction from schoolwork. Stage fright and panic disorder are not the same, although both are anxieties and lead to conduct diffidence. Borderline personality and bipolar affective disorder are not the same, even though both display wide ranges of emotional expression and provoke interpersonal difficulties. The efforts to distinguish these conditions from one another in DSM-IV have not held back the expansion of psychotropic treatment of their common symptoms.

I always struggle against psychiatry's imperialist tendencies to bring more and more of ordinary human living under its jurisdiction and its control. Previously I fought against the assumptions about human nature that drove Freudians. Now I argue against the imperialism of psychopharmacology that would promote a pill for every vexation and justify the practice by calling the vexation a “mental disorder.”

Essentially my concerns over the Freudians and the psychopharmacologists are the same. I do not deny that with some patients a Freudian conflict might be the problem or that with some patients psychotropic medication is effective. I use both forms of therapy every day. What I object to is the assumption that, at root, all mental disorders are the same—either some sexual conflict open to psychoanalysis or some twisted neuron suitable for psychopharmacologic correction. With neither do I see a way of keeping practices within bounds once their assumptive premises are accepted.

I have been arguing that recognizing a structure of psychiatry that divides patients and their problems into four distinct “reference classes” will help limit the medicalization of mental life. Each class is made up of several different mental disorders that share a common identifiable basic nature. These reference classes are (1) the class of conditions encompassing the diseases of the brain such as dementia, manic-depression, schizophrenia; (2) the class of conditions encompassing destructive behaviors where choices play a role such as sexual paraphilias and drug addictions; (3) the class of conditions encompassing the problematic dispositions such as the mentally subnormal, the histrionic, and the immature who face emotional problems because of their dispositional vulnerabilities; and (4) the class of conditions derived from troubled life experiences, social maladjustments, and disruptive assumptions such as grief, jealousy, homesickness and demoralization.

These four reference classes (Diseases, Behaviors, Dimensions, and Life Stories) embrace all the conditions psychiatrists encounter and are described by symptoms alone in DSM-IV. These classes define how psychiatrists develop their opinions and identify what they can say with confidence.

But the concept of reference classes (along with their natural distinctions from one another) keeps us from floundering over symptoms and complaints that all psychiatric patients share. With each reference class the assumptions about appropriate treatments can be analyzed and the expansion of treatments beyond the class identified and debated. This permits an honest conversation with patients as to what are truly beneficial treatments and what may cheat them. The aim is to identify both the place and the limits of psychiatric expertise and restrict the medical treatment of human mental life to those limits.

Psychiatrists, after all, work with a selected sample of mankind—patients. Therefore, they are not expert on every aspect of human nature. And, they should be the first to make that clear by defining just what they mean by disorders and do so in ways that are more explicit than simply composing a dictionary that lists symptoms and complaints. Treatments that act on people without disorders, but with distinctions in their nature, may well impoverish our world and distract us from appreciating the diversities in it.

Leon, as I said, though, this is just a beginning of a conversation that needs to continue.

To be continued,

Paul


II. Leon Kass to Paul McHugh—May 29, 2003

Dear Paul:

I have read your letter several times. I appreciate its contents and the effort that produced it. Here is my not fully considered response, to keep the ball rolling.

First, let me set down the context for this exchange and discussion. The “beyond therapy” project has several times touched on the matter of the creeping “medicalization” of life—not only of mental life through the offices of psychiatry, but also of procreation in screening of fetuses and embryos, of the life cycle in dealing with aging or memory, or of athletic and other performances through enhancement technologies. We have so far not made this subject thematic. To do so, we should ask: what IS medicalization—as an idea, as a practice, as social/institutional attitudes and arrangements? Is it really on the rise? If so, what is responsible for it? What are its consequences? Why should we care? What, if anything, could/should be done about it—or some aspects of it? Formulated this way, it is a very big topic, certainly too big for the Council right now, and certainly too big for one session at one meeting. But it is one of the big themes of what ought to concern us.

Second, your letter stays (both for better and for worse) narrowly within the confines of psychiatry and its contributions to the medicalization of mental life. And within that delimited domain, the main emphasis is on diagnostic uncertainty and confusion. Given the overall and somewhat grandiose view of the topic, I find what you have done good and useful, but limited. Even keeping within the context you choose, you do not indicate what the consequences of medicalization are or why we should be bothered by it (not that you had to take this up).

More important—and some substantive points now—you treat the drugs as the driving force in the new medicalization of mental life, rather than the reconceptualization of all behavior on the biological model (a change of thinking about the mind that, to be sure, the drugs contribute to, but so does it contribute to the turn to drugs). As my next point will try to make clear, a fuller look at what medicalization IS might fruitfully enrich your presentation, even staying within the confines of psychiatry (which after all helped—or tried—to medicalize alcoholism, stress, anxiety, guilt, narcissism, sexual orientation, etc., even in the absence of psychotropic drugs). Moreover, and more serious, it is not YET clear to me from what you have said how your wonderful new scheme with reference classes (which, as I have told you, I like greatly) will address the problem at hand. After all, people in all four classes will still come to the DOCTOR rather than to their priest, and they will expect cures— not absolution or encouragement for reform or education. One might even suggest that your vastly improved scheme could even encourage more people to look to medical psychiatry for remedies, given that behaviors, dispositions, and life experiences are now put in DIAGNOSTIC (i.e., medical) categories. Now I suspect that I am missing something here, and that it is I and not you who is confused. But the letter as written does not give help on this point.

Third, turning from your letter back to the broader subject, a few words on medicalization itself, written now off the top of my head, and done mainly to force me to clarify my own mind here. What do I think I mean when I use this bit of unfortunate jargon? Something like this: Medicalization is, in the first instance, a way of thinking and conceiving, that then guides ways of acting and organizing social institutions. Medicalization is the tendency to CONCEIVE an activity, phenomenon, condition, behavior, etc., as a disease or disorder or an affliction that should be regarded as a disease or disorder, to wit: (1) people SUFFER it (the essence of patient-hood) or it befalls them; they are victims of it, not causes, neither are they responsible for it; (2) the causes are PHYSICAL or SOMATIC, not “mental” or “spiritual” or “psychic”; (3) it requires (needs) and demands (has a claim to) TREATMENT, aimed at CURE or at least relief and abatement of symptoms; (4) at the hands of persons trained in the healing arts and licensed as HEALERS; and (5) this conception of the condition will be supported by the society, which will also support efforts at treatment out of its interest in the HEALTH (as opposed to the morals or the education) of its people.

Fourth, look at the many aspects of human life that have increasingly been brought under the medical gaze and paradigm: ordinary childbirth, infertility, sexual mores and “perversion,” certain aspects of criminal behavior, alcoholism, anxiety, stress, dementia and old age more generally, grief and mourning. This is meant to be said without passing judgment; I intend a descriptive account, not a moralizing one.

Fifth, the push toward medicalization is thus only partly driven by new technologies, though the availability of effective drugs and other instruments lends much support to a medical conception of the problem, and contributes to creating demand for medical services as treatment. It is also driven by deep cultural and intellectual currents: for example, to see more and more things in life not as natural givens to be coped with, but as objects rightly subject to our mastery and control; to have compassion for victims more than to blame perpetrators, even when the victims are victimized by their own perpetrations; to see the human person in non-spiritual and non-moral terms, but as a highly complex and successful product of blind evolutionary forces (which still perturb him through no fault of his own). It is also driven by commerce and the love of technique, the inflation of human desires to remove all obstacles to our happiness, etc.

Finally, to return to your letter, here are some suggestions for how it could be developed to be somewhat broader as a jumping-off point for Council conversation, and without taxing you too much in a short space of time. The following thoughts occur to me, all of them merely suggestive.

First, we should make explicit what we of course implicitly agree upon: that we are NOT trying to cast doubt on the existence, blamelessness, and need for treatment of people with mental illness.

Second, perhaps some initial material could indicate that you do indeed understand that the matter of medicalization is more than a problem of off-label uses of these drugs or of a faulty symptom-based system of diagnosis. Having presented the broader context, your own reflections on a part of the problem will be taken for exactly that.

Third, you could spell out in brief why it might matter that this medicalization takes place, and why it may be worrisome in its consequences and outcomes. Finally, and perhaps most important from the point of view of what it is that you are emphasizing, you could expand the last part on the new and better classification, to show how it might indeed help to improve the medical treatments of medical problems and avoid medicalizing those which should not be. This means showing, as you did for the staff, the differences in the types of interventions that the four categories call for.

As you told us, there is no way to keep all four types of conditions from being brought to the doctor's door—people present with their own troubles, and where the shingle is out, one takes them in. But the additional and perhaps pernicious medicalization of their travails could be prevented if physicians themselves were better versed in the distinctions among the kinds of sufferings and their cause, and better able to sort out what is pathological and what is just part of the pain and sorrow of life.

Time does not allow for refinements or improvements in what I have only hastily put together here. But I hope that this will serve as the basis of a conversation, and, if you are willing, for a response and an enlargement of your letter so that we could send it to Council members in the briefing book.

Best,

Leon


III. Paul McHugh to Leon Kass—June 3, 2003

Dear Leon:

As always in our exchanges you raise the level of discourse from the mundane level of my practice to the implications hidden within it. I noted the ethical incoherence of some psychiatric matters, and then you replied by noting the more deeply problematic issue of the contemporary “medicalization” of all human travails.

You define “medicalization” as that view reducing all forms of human distress and disorder to aspects of “sickness”, expressions of “patient-hood” and thus expressly open to technical, mostly bio-medical, correction at the hands of experts for whom ideas of good and evil, freedom and responsibility, sanctity and sin, approval and reprobation are meaningless. Medicalization is a materialist ethos with roots in both biological sciences and contemporary medicine. You want us to think about its emergence, its authority, its hubristic potential, and how to speak to it. I'm certainly happy to try.

We must, though, begin with an emphatic assertion. You and I celebrate the technical and conceptual advances of medicine (including psychiatry) that have occurred in the last century. Antibiotics, antihypertensives, antiarhythmics in medicine and antidepressants, antipsychotics, anxiolytics in psychiatry have been life-preserving, life-enhancing, welcome. These achievements rest upon knowledge of the body and brain that is continuing happily to advance with even better treatments (more specific, less disruptive etc.) in the offing.

I recently had the pleasure of listening to an eponymous lecture at Hopkins given by our Council colleague and friend Janet Rowley. She described her discoveries of the fundamental, molecule-based mechanism of one of the leukemias, along with the cure to which this mechanism succumbs. Like some Champollion at the Rosetta Stone, she transformed the hieroglyphs of genes, molecules, and protein structures into the coherent language of pathogenesis, pathophysiology, and rational therapeutics. It was breathtaking.

I have also witnessed over the last decades great advances in conception and treatment in psychiatry. We can celebrate together the progress in knowledge and understanding of Alzheimer's disease, Huntington's disease, schizophrenia, bipolar disorder etc. These mental disorders are diseases in every sense of the word and the patients who suffer from them deserve all the supports—protective, fiscal, empathic—we offer the sick everywhere.

I should remind you that the discovery of specific treatments often confirmed the idea that these conditions are diseases and the patients victims. The most telling of such discoveries was that of lithium for manic-depression. Here was an ELEMENT that relieved a complex and persistent affective condition indicating that the problem was not derived from personal mismanagement of life's conflicts, but a brain dysfunction affecting a vital psychological faculty. The idea that manic-depression, schizophrenia, and several other psychiatric conditions were brain diseases—in that sense like epilepsy—is now secure, and investigations to study them at the genetic, molecular, and structural level of the brain are advancing apace.

If we can agree about all this, then what are our concerns? I think I can speak for both of us in saying that one of the concerns is how to keep the power of these new techniques from spreading out in unintended ways. If we can cure manic-depression, should we then eliminate grief? If we can treat attention-deficit disorder, should we then scrub boyish high jinks from the classrooms?

In these dubious proposals one senses the medicalizing assumption that is our main concern here. They follow from the idea that all our vexations are due to some twisted molecule or protein that may, for better or worse, be fixable in time.

Since these two concerns intertwine, let's untangle them at first with nomenclature calling the first concern (keeping a treatment or practice within professionally befitting bounds) the ETHICAL PROBLEM and the second concern (the disposition or viewpoint about humankind that spurs thoughts, customs, and practices which you have called medicalization) the ETHOS PROBLEM. For all that they are entangled, they do have slightly different sources and implications and are addressed in slightly different ways.

Both have been around for as long as there have been doctors thinking about what they are doing. Doctors with powers to act on the body quickly realize that these powers can be misused. Much of the Hippocratic canon revolves around the injunction “first do no harm” and the Hippocratic Oath around the expressed intention “I come for the benefit of the sick.” The Oath demonstrates how professional ethics emerges from a coherent ethos. What you are specifically striving for (the professional ethos you support) determines what you will and won’t do (the professional ethics).

Within the Oath one finds several explicit ethical injunctions on treatment: “I will neither give a deadly drug to anybody if asked for it nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy.” Although these ethical injunctions against physician-assisted suicide and abortion are still debated, they at least derive from the expressed intention to “benefit the sick.” Likewise, matters of ethical decorum—keeping secrets, and refraining from sexual relations with patients—are spelled out in the Oath as further expressions of doctoring as a humane practice.

You expand usefully on the passage about “the benefit of the sick” in your chapter on the Hippocratic Oath in Toward a More Natural Science. Here you point out that in the Hippocratic conception, people qualify for a physician's services “because they are sick, not because they have claims, desires, wishes, demands or rights. The healer works with and for those...who are not whole.” (p.232) This important idea challenges the “medicalization” ethos because it demands that we describe what we mean by “sick” and think about whether we are expanding our treatments too far.

We offer some medical/surgical treatments to people who are “whole” but would like help to “fit in.” We see no ethical concern in such practices as orthodontia because both dental function and appearance are enhanced. Face-lifts and “tummy-tucks” begin to provoke concern that we are going beyond the sick, but we accept them—sometimes with an embarrassed laugh over our vanities. Finally, sex change operations and limb amputations for sexual desirability we sometimes see as abominations.

Where are we in psychiatry, though? People come to us because they are troubled or are troubling others. We recognize the ones with diseases and treat them. But the claim that alcoholism, narcissistic personality, and stage-fright are “sicknesses” of the same kind as schizophrenia cannot be sustained just because these people walk into our office and we help them. I hold that such a medicalized claim is foolish at its root and disruptive to any coherent view of the way we help these patients.

Hence my call for reference classes that specify the nature of the disorders that psychiatrists manage, the therapeutic approaches these natures imply, and the distinctive character of our success with these patients. Without such a structure we can neither decide on the ethical sense in psychiatric practice nor explain why we are not succumbing to a medicalizing ethos where it is most pernicious—in its appreciation of human mental life—when we are working to help these folk.

I have spelled these reference classes out in my first letter and will not repeat them here. Rather I want to draw from them their distinct principles of treatment and what ethical matters they imply.

With those mental disorders that we mentioned above as brain diseases, the prime responsibility for care lies with the doctor in both discovering and applying the proper treatments. Doctors here are healers and are dominant and irreplaceable. The ethical principles that apply encompass the expectations of the patient that the treatments offered are truly beneficial and that they are treatments with which the physician is fully familiar. Standard medical ethics is in order in the treatment of such medical conditions.

With the other reference classes that we psychiatrists manage and help (patients with behaviors that we strive to interrupt, patients with problematic dimensional characteristics such as subnormal IQ or neuroticism whom we try to guide, patients with difficult life stories that we try to reframe) we act less as medical healers and more as thoughtful counselors and coaches bringing mastery of situations to demoralized people, rather than “cures” for diseases. With these patients, our treatments are not aimed at interrupting an autonomous biologic process playing itself out along some fixed and determined course. They are efforts to help a person choose to live more successfully in the present and confront the future more effectively. Some biological measures help in these matters—methadone for heroin dependence, etc. But primarily one combats these mental conditions by promoting other attitudes and modes of life—persuading the patient that they are better than the ones in which the patient is embedded—activities that go beyond traditional medical matters. DSM-IV with its categorical diagnostic approach, however, defines itself as a “medical nomenclature” (p xviii) and thus may promote the medicalization of mental life.

I should, though, stop and say that the medicalized ethos embedded in psychiatry with DSM-IV is not the first—or the worst—problematic conception I have witnessed in psychiatry. Freudianism and Skinnerian Behaviorism are both conceptions of the human mind that have justified very strange practices. DSM-III was, in fact, an attempt to free psychiatrists from these earlier theories of human mental life and get them to concentrate on patient presentations—hence its oft-noted and self-proclaimed “a-theoretical” stance. In combating these original conceptions and moving the psychiatric conversation in a more pragmatic and empirical direction, we can all be grateful to the authors of DSM -III.

But DSM-III was composed 25 years ago and psychiatrists are now stuck in a medicalized stance that provides a gravely limited view of human assets and vulnerabilities. The oft-expressed view that such issues as crime, marital disruptions, poverty, discrimination, terrorism and the like will succumb to medical thought and practice misunderstands both what people are and doctors can do.

I hold that we need to promote a much more complete description of humankind than that promoted either by DSM-III, IV, or by evolutionary psychologists like Stephen Pinker. They both promote far too mechanical and deterministic a view of people—a view that not only flies in the face of psychiatrists’ experience helping patients,but represents an ideology derived from special pleadings about biological science and human mental life. No one—not even the Pope of Rome—is denying that human beings are biological creatures who have evolved from lower forms of animal life. But this is not all they are nor does this information grasp the most proximal formative factors affecting people.

We have evolved into a unique and special form of life where matters of our personal developmental history, our families of origin, the socio-cultural world with its authoritative “metanarratives” into which we emerged, and the technico-industrial capacities now available to us have as much and often far more influence on our mental life—its happiness and distress—than our biological nature and evolutionary history. Indeed the major achievement of our evolutionary history (regardless of how it came about) has been that we are free to bring new meanings into life in ways that make our futures—as individuals and as builders of societies—radically unpredictable. Our nature is one that permits us to create our world—for good or ill, for better or for worse.

From that position, one can reconsider our medical and psychiatric powers and reach far better conclusions about what we are doing to help people and why. That we are biological creatures with all the frailties of a material foundation means that we can break down and need repair. But that we are these special biological creatures called humans means that we are free and can build for good or for ill depending upon how we think, feel, and behave and occasionally need help in these matters to succeed.

How to deal with the medicalization ethos then devolves into a form of reply to the biblical question of whether we should “give tribute unto Caesar.” Because we are biological creatures carrying as it were the stamp of the biological imperium we must “render unto Caesar the things that are Caesar's.” That is: knowing that our bodies have dominion over us,we call for medical treatment for their preservation and medical research to relax the tyranny of their expression in disease (an enterprise our friend, Janet, has so nobly advanced). But we also must and should “render unto God the things that are God's.” That is: knowing our human capacity to build the life we have inherited in a meaningful way within a society that we help make more worthy, but also our capacity to go awry in these enterprises and suffer accordingly, we need help from others who see our confusions, judge them appropriately, and act with us to relieve them. Because today (for reasons we might discuss), so many of these others are doctors, we may have forgotten that this help is not strictly medical in character.

To be continued,

Paul