Transcript The questions of medicalisation, priotisation and ageing

The questions of medicalisation,
prioritisation and ageing society
in Finnish health care system
Kirsi Vainionpää
Dep. Of Soc. Studies
University of Lapland
Medicalisation
 By
medicalisation it is referred to the ways
in which medicine expands to new arenas
that were previously not defined to be part
of the field of medicine (Zola 1972)
 Medicine has, according to Zola, become
the major institution of social control and
has replaced the traditional controlling
institutions of religion and law.
Medicalisation
 Medicalising
everyday living is
accomplished hidiously by making
medicine and the labels “healthy” and “ill”
relevant to the human existence.
 By the acceptance of a specific behaviour
as an ‘illness’ and the definition of illness
an undesirable state the issue becomes
not whether to deal with a particular
problem but how and when.
Medicalisation

Some people have claimed that nowadays,
instead of clergymen, doctors are acting as the
mediators of the truth, and people accept
regulations that are supposed to help them
guarantee their health. (Conrad 1992,Turner
1992)

The extension of medicine and the extent of
health adoring are described as “the tyranny of
health” by Michael Fitzpatrick (2001).
Medicalisation
Medicalisation happens at three levels
1)
2)
3)
conceptual
institutional and
interactional levels.
Can you give me examples?
Medicalisation
 On
the conceptual level, medical
terminology is used to define the
problem and also, that the medical
definition becomes general

Can you name examples of conceptual
medicalisation?
Medicalisation
 Conceptual
medicalisation:
Alcoholism
ADHD
Ageing
Erectile disorders
FSD
Medicalisation
 On
the institutional level, organizations
may adopt a medical approach to
treating a particular problem in which
the organization specializes.
 Can
you name examples of institutional
medicalisation?
Medicalisation
 Specialists
inside medicine
This is what I study: male menopause
and thus, male clinics. Women have
had gynaecologists and now men have
their andrologists
Medicalisation
 On
the interactional level,
medicalisation occurs as part of doctor
– patient interaction, when a physician
defines a problem as medical or treats
a social problem with a medical form of
treatment
 Can
you name examples?
Medicalisation
 This
should be easy…. Let’s think
about drunk husbands and beaten
wifes for example.
 Another
example: fear for
unemployment and cannot sleep >
doctor prescribes sleeping pills and
ignores the social situation
Medicalisation – why now?

the diminution of religion i.e. secularization
 a abiding faith in science, rationality and
progress
 the increasing prestige and power of
medical profession
 the penchant of technological solutions for
problems
(Conrad & Schneider 1980b, Conrad 1992)
Many conditions have become
medicalised


giving birth
dying
 a continuing medicalisation of madness
 alcoholism, opiate addiction
 homosexuality
 child abuse and family violence (Conrad & Schneider
1992, 280–286)
 the medicalisation of compulsive buying (Lee & Mysyk
2004)
 finding the diagnosis Attention Deficit/Hyperactivity
Disorder (ADHD)
 the use of the drug Ritalin® among school age
population to control the ADHD children (Singh 2004).
Medical social control

Medical social control means the ways in
which medicine functions to secure adherence
to social norms by using medical means to
minimise, eliminate, or normalise deviant
behaviour
 Largely understood, medical social control is
the acceptance of a medical perspective as the
dominant definition of certain phenomenon
(Conrad & Schneider 1980, 242)
Medical social control

When medical perspectives of certain problems
and their solutions become dominant, they
diminish other possible ways of understanding
that problem
 Medical social control is enacted through
professional medical intervention, via medical
treatment
 These interventions aim at returning ‘sick’
individuals to their conventional social roles or
adjusting them to new roles, or making
individuals more comfortable with their
conditions (Conrad & Schneider 1980, 242)
Medical social control
 Medical
social control is carried about by
medical profession and assisted by
different forms of medical technology.
 Without
medicalisation in a definitional
sense, medical social control loses its
legitimacy and is more difficult to
accomplish
Medical social control
 The
development of a technique of
medical social control (e.g.
pharmaceutical interventions) may
precede the medicalisation of a
problem, but for implementation some
type of medical definition is necessary
 More typically medicalisation precedes
medical social control. (Conrad 1992)
Medical social control
There are four forms of medical social control:
 medical technology (including pharmacy),
 medical collaboration meaning doctors assist
as information providers, gatekeepers,
 medical ideology that imposes a medical model
primarily because of accrued social and
ideological benefits and
 medical surveillance
Prioritisation of health care
 Setting
priorities (also a term ‘rationing’
is used) means ranking things in order
of importance.
 Medicalisation
and the prioritisation of
health care are related to each other
being mainly juxtapositional, i.e. they
mostly draw to opposite directions
Prioritisation of health care
 In
health care prioritisation is usually a
question of choices in conflicts between
service needs and financial resources.

The aim should be a balance between
individual and common good, and the
guiding principle helping the greatest
possible number of people within the limits
set by the available resources.
Prioritisation of health care
 Finnish
health policy discussion is
today mostly about prioritisation:
we have to make hard choices in
allocating scarce resources.
 There
is no doubt about the need of our
society to prioritise our health care
Prioritisation of health care

Priority setting in Scandinavia has gone through two
phases

The first phase in discussions and reports was
characterised by a search for priority setting
systems, which could tell the decision-maker directly
how a given service should be prioritized in relation
to other services.

The second phase has followed the realization that
the idea of devising a simple set of rules is flawed
(Holm 1998, 1000)
Prioritisation of health care

The Finnish Medical Society Duodecim
published in June 2000 its comment on
prioritization called Priorisointi–
terveydenhuollon valinnat [Prioritisation–the
choices in health care].
 In the booklet there were not concrete advice
on how to prioritize or make choices
 According to the Committee, the most
equitable and the most costs-saving basis to
prioritization is the requirement of the
efficiency of the treatments (Finnish Medical
Society Duodecim 2000, 31). (Saarni 2001)
Prioritisation of health care

The aim of prioritisation should be a balance
between individual and common good, and
the guiding principle helping the greatest
possible number of people within the limits
set by the available resources.
 Choices should be based on ethical criteria,
such as the effectiveness of the treatment,
justice and equality, and respect for human
dignity and the rights of the patient.
Prioritisation of health care
 Without
discussion on values and clear
ground rules, such choices tend to be
based on chance, the status of the
individual, the ability of the service
claimant to plead his/her cause or other
grounds that do not stand up to critical
assessment. (National Advisory Board
on Health Care Ethics (ETENE) 2001)
Prioritisation of health care
 As
a basis of rationing can be many
different normative principles which can be
and often are juxtapositional when making
individual prioritisation choices
 these principles can be divided into two
goals:
i) the efficacy of health care as what
comes to public health and
ii) justice/equality
FINNISH POPULATION IS
AGEING FASTEST OUT OF
ALL THE EU POPULATIONS
Finnish population by age groups
between 1900–2050,
millions (Räty et. al. 2003)
Prioritisation of health care

In the next fifty years, the fastest growing population
group in Finland is people over 80 years

It is much cheaper for the society to keep ageing
people living at their own homes than to situate them in
nursing homes

Governments may even welcome some of society’s
problems being redefined as medical with the
possibility of new solutions (Moynihan & Smith 2002)
Prioritisation of health care

In a British Medical Journal recent vote on bmj.com for
“When is a disease a non-disease’, ageing was voted
for number one

The growing population of affluent older people has
great expectations of medical care, fuelled by greater
consumerism

Medications are promoted for personal and social
problems
Prioritisation of health care
New technologies in the care of the elderly are
recommended because they support self-care
 It is much cheaper for the society to keep eldering
people living at their own homes than to situate them in
nursing homes
 Pharmaceutical companies sponsor diseases and
promote them to prescribers and consumers in order
to extend the boundaries of treatable disease to
expand markets for new products

 Would
it be too wild to say that
people are socially controlled by
medicines and pharmaceutical
industry?
Ageing: Social or personal
problem?

Could we end up with blaming the victim ie.
do we rather see the causes of the problem
in individuals rather than endemic to the
society (William Ryan 1971)?
 C. Wright Mills explored the connections
between private problems and public issues
and pointed out that the troubles a person
experiences arise in the context of broader
social problems (Mills 1959)
MALE MENOPAUSE AND MALE HORMONE
THERAPY IN THE
CONTEXT OF MEDICALISATION AND
PRIORITISATION OF HEALTH CARE
 Kiinnitä
huomiota vointiisi Tunnetko
usein itsesi väsyneeksi? Onko
seksuaalinen halusi vähentynyt viime
vuosina? Onko lihasvoimasi heikentynyt?
Kärsitkö väsymyksestä?
Tämä voi johtua testosteronin puutteesta.
 www.testosteroni.fi testi : )))
A PhD Thesis
There are four parts in this PhD Thesis study:

Male menopause and male hormone therapy in Finnish lay journals

A disease and a drug as a solution for aging society? The development of
male menopause and its treatments in Finnish physicians’ information

Male menopause on the Internet

The diffusion of male hormone therapy in Finland compared to the female
hormone therapy
SOME FINDINGS OF THE FIRST PART
Male menopause and male hormone therapy in Finnish lay journals


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

The amount of Finnish lay magazine articles concerning male
menopause and its treatment grew significantly from the early
1980s to the early 2000s
Male menopause was initially presented as a social problem
related to men’s working careers
During the study period writers increasingly presented it as an
illness managed by medical experts and treated with hormones
Often a woman was rereffed to as a ’lay expert’, guiding her
partner to see the doctor
The most quoted professional experts in the material
researched were associated with the pharmaceutical industry
SOME FINDINGS OF THE SECOND PART
Male menopause in Finnish physicians’ information
 The
aim of this study was to investigate
conceptions of the male menopause
(also known as andropause) in the
educational and professional literature
of Finnish physicians from 1982 to 2002
 The main point of interest was how the
presentation of the male menopause
and its treatments have changed
SOME FINDINGS OF THE SECOND PART
Male menopause in Finnish physicians’ information
 Material
for analysis was retrieved from
the two main Finnish medical journals
and from introductory gynaecology and
urology textbooks using keywords for
male ageing and hormones
SOME FINDINGS OF THE SECOND PART
Male menopause in Finnish physicians’ information
 The
ambivalence surrounding the
phenomenon of male menopause was
noticeable:
 some authors described it as a
consequence of the decline in gonad
functioning that comes with
increased age
 some argued that we are making a
disease out of normal ageing
SOME FINDINGS OF THE THIRD PART
Commercial web-based information on male menopause
and male hormone therapy

Objective was to study ‘male menopause’ by asking
what kind of themes the Internet provided about
‘male menopause’ and its treatments; to evaluate the
quality of the commercially available web-based
information by comparing it to the best available
scientific information

The data were selected on the basis of its
accessibility in web sites available to Finnish men.
SOME FINDINGS OF THE THIRD PART
Commercial web-based information on male menopause
and male hormone therapy
 The
content was qualitatively analysed
by searching for the themes that were
used to construct the meaning of male
menopause.
 The
WWW pages’ information was also
compared to the best available medical
scientific information
SOME FINDINGS OF THE THIRD PART
Commercial web-based information on male menopause
and male hormone therapy
 Six
different thematic formations were
found in the material: healthism, a takecare-of-yourself theme, a quasiprofessional theme, an uncertainty theme,
a risk theme, a good sex theme and a
similar-to-women theme.
 The web-based information did not
correspond to the best available medical
scientific information.
SOME FINDINGS OF THE THIRD PART
Commercial web-based information on male menopause
and male hormone therapy
 These
themes produce societal
phenomena that can be briefly detailed
according to the themes and can be seen
to constitute a new form of treatable
illness, ‘male menopause’ and ‘male
hormone therapy’.
SOME FINDINGS OF THE FOURTH PART
The first steps of testosterone therapy
dissemination in Finland

The objective was to investigate the use of male
hormone therapy (HT), i.e. testosterone in
Finland from 1993–2004
 Three statistical sources were used:
i) drug sales statistics taken from Finnish
Pharmaceutical Data Ltd.,
ii) statistics from the Social Insurance Institution
and
iii) statistics from the Health 2000 Survey
undertaken by the National Public Health
Institute
SOME FINDINGS OF THE FOURTH PART
The first steps of testosterone therapy
dissemination in Finland
 Results:
The wholesale turnover for
testosterone in 1993 was €472 900. In
2004, the final year of the study, it was
€913 400. The value of retail sales of
testosterone in 2004 was €1 461 440.
 The value per testosterone package sold
rose from €12.67 to €14.74 between 1993
and 2004.
SOME FINDINGS OF THE FOURTH PART
The first steps of testosterone therapy
dissemination in Finland
 The
proportion of men using testosterone
was largest in the Helsinki Region where
€440 was spent per 1000 men on
testosterone drugs in 2004
 The growth of the use of male HT was
most vigorous in the capital area, as would
be expected considering theories about
the diffusion of medical innovations.
SOME FINDINGS OF THE FOURTH PART
The first steps of testosterone therapy
dissemination in Finland
 The
Health 2000 data reveals the pioneers
of male hormone use were highly
educated men living in the metropolitan
area.
 The
results indicate that men’s midlife and
ageing are becoming medicalised.
References
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Conrad, Peter & Schneider, Joseph, W. 1980a: Deviance and medicalization. From badness
to sickness. C.V. Mosby Company. St.Louis.
Conrad, Peter & Schneider, Joseph, W. 1980b: Looking at levels of medicalization: a
comment on Strong’s critique of the thesis of medical imperialism. Social Science and
Medicine 14A, 75–79.
Conrad, Peter 1992: Medicalization and Social Control. Annual Review of Sociology 18:
209–232.
Conrad, P. & Schneider, J.W. 1992: Deviance and medicalization. From badness to
sickness. Expanded edition. Temple University Press. Philadelphia.
Fitzpatrick, Michael 2001: The Tyranny of Health. Doctors and the regulation of lifestyle.
Routledge. London and New York.
Holm, Soren 1998: Goodbye to the simple solutions: the second phase of priority setting in
health care, British Medical Journal 317, 1000–2.
Lee, S. & Mysyk, A. 2004: The medicalisation of compulsive buying, Social Science &
Medicine 58, 1709– 718.
Singh, I. 2004: Doing their jobs: mothering with Ritalin in a culture of mother-blame, Social
Science & Medicine 59, 1193–1205
Turner, Bryan S. 1992: Regulating bodies: Essays in medical sociology. Routledge. London
and New York.
Zola, Irving Kenneth 1972: Medicine as an institution of social control. Sociological Review
20, 487–504.
References
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Finnish Medical Society Duodecim 2000: Priorisointi: terveydenhuollon valinnat. [Prioritisation – the
choices in health care.] Helsinki.
Saarni, S. 2001: Priorisointi – mahdoton yhtälö? [Prioritisation – an impossible equation?] Suomen
Lääkärilehti [Finnish Medical Journal] 56(12), 1417–1420.
National Advisory Board on Health Care Ethics (ETENE) 2001: Shared values in health care, common
goals and principles. ETENE publications 3. Available online at:
< http://www.etene.org/dokumentit/EteneENG.pdf >
[Accessed 5th August 2005]
Moynihan, Ray & Smith, Richard 2002: Too much medicine? Almost certainly. British Medical Journal 324,
859–860.