Miah, A. (2009) Medicalization, Biomedicalization, or Biotechnologization? Biocultural Capital and a New Social Order, Salute e Società / Health and Society (Italian), special edition ‘The Medicalization of Life’, edited by Maturo A. & Conrad, 8(2), pp.248-251 [dual published in Italian, pp.264-267].
In May 2007, I witnessed five hours of a Deep Brain Stimulation (DBS) procedure at a hospital in France, as part of activities related to a European policy advisory group. The octogenarian patient had advanced Parkinson’s disease and was receiving his second electrode implant, which would help to alleviate his symptoms. We arrived mid-way through the procedure and the neurosurgeons, along with their assistants, were focused on a monitor display, which visually articulated the effectiveness of the precise location of the device. After watching for over an hour, it became clear that the miniature device being located deep in the patient’s brain was attached to a wire that passed through his head, down across his neck and into his chest, finally connecting with a battery device. While the patient was lucid throughout the procedure, we were there to talk with the neurosurgeons about the implications of remote nano-sized devices, as a possible extension of this science. In particular, we were tasked with identifying ethical and policy issues that could arise from the development of this science for the purposes of lifestyle medicine or human enhancement. How does this procedure fit within what Adel Clarke and Janet Shim describe as biomedicalization and how does their thesis differ from medicalization in this case?
In support of their characterization, we might draw attention to the technoscientific solution that is utilized to treat this condition and inquire into its legitimacy. We might also talk about the reliance on imaging technologies, which the authors emphasize. Even Nicholas Rose’s notion of the ‘molecular gaze’ is prominent, as the devices approach nanotechnological proportions. We might also broadly describe this procedure as part of the shift towards treating ageing as a disease, which inherently involves corrupting the traditional views on what aging entails and how we should accept it, rather than treat it.
Yet, it also seems mistaken to describe the treatment of Parkinson’s disease via such technology as a case of medicalization in the sense meant either by Peter Conrad or, I think, by Clarke and Shim. Rather, it is the possible extension of the therapeutic intervention to something else that coheres with biomedicalization. Moreover, it is the possible expansion of this technology to the non- or less-medical sphere that broadly describes biomedicalization. This expansion was a prominent feature of our debates about how the technology of DBS might progress. For instance, one of the initial findings from primate research involves DBS their being linked to eating patterns. It would appear that such technology – designed for therapeutic use – might also have the capacity to affect other behaviours, such as eating disorders. Indeed, this was one of the major concerns of researchers at the hospital. What if we discover applications that could assist in the treatment of health related disorders where there is much more disagreement about the legitimate course of treatment; where there are complex neurological, sociological and psychological dimensions to a condition?
Alternatively, what if the surgery was not at all invasive? This is suggested by current uses of transcranial magnetic stimulation to treat eating disorders. Conceivably, a nanosized device could be located in the brain without needing to open it. Would this lead to a greater willingness to use them for non-medical purposes? Alternatively, what if remote devices could also provide a way for societies to keep track of people, a kind of biochip passport? How else might such technologies be used and what interests would operate around such innovation which, in turn, spur its development? These latter questions are apparent within Clarke and Shim’s articulation of biomedicalization. Indeed, in noting that they wish to ‘identify and describe’, as well as ‘critique’ we might observe the development of such devices as part of a broader process of biosurveillance, where the increasing miniaturization of technology can lead to greater control over individuals by the state.
Yet, within this case, there are difficulties with Clarke and Shim’s separation of ‘difference’ and ‘enhancement’, as distinct groupings of biomedicalization. Clearly, such implants improve life, though this does not necessarily imply greater ‘safety’. However, this is also a technology of ‘difference’, insofar as it transforms an individual from being disabled to being able. Other examples of this difficulty are apparent in any number of emerging technologies. For instance, consider the use of genetic selection for sex, where there is no medical need for such choice – ie. there are no hereditary sex-linked conditions that parents seek to avoid passing on to their offspring (Miah 2007). How should we characterize such a use of a medically restricted technology? Does its use for non-medical purposes constitute a process of biomedicalization? Clearly, it is a case where the relevant context extends well beyond the patient-doctor relationship that characterized medicalization. Thus, in this new biomedicalized environment, a range of health care professionals and new expertises are brought to bear on this decision and have an opportunity to influence the conditions that permit such choices. However, it is harder to identify why genetic selection for non-disease traits should be categorized as either ‘enhancement’ or ‘difference’, as the authors would want. As a sex-determining technology, it is clearly an example of manufacturing ‘difference’, though we might also explain how it enhances our procreative capacity.
If one probes other examples used to describe the authors’ categorization of difference and enhancement, further questions arise. For instance, how can ‘drugs for preventing cancer’ be characterized as ‘enhancing’, when they are traditionally described as therapeutic? In the field of bioethics, this distinction hs been the critical issues arising from processes of biomedicalization in recent years (see Elliott 2003). In short, there is a lot more within the category of ‘enhancing’ than the authors specify, though I would expect that – like medicalization - biomedicalization is not so concerned with the traditional treatment of ailments. Rather, it is more interested in the expansion of such treatment to cases where there is no consensus on how best to treat. In any case, the enhancement category would be better characterised by the use of, say, nanodevices as DNA passports, or indeed, the use of elective surgery for aesthetic alterations, rather than drug delivery.
In the early 1990s cyborgology was heavily criticized for overlooking the way in which the dual processes of repair and enhancements occur concurrently in an era of biological modifications. What also seems absent from the biomedicalization thesis is how the biocapital of science and technology – their conflation to technoscience needs greater scrutiny, since they are remarkably different – becomes biocultural capital for individuals who access them outside of the traditional medical environment. Biocultural capital describes the lived experience of biomedicalization as a mode of conspicuous consumption. It is understandable that the authors focus on biocapital, but within this should be a greater recognition of how biocapital transforms the cultural sphere. Additionally, it should encompass the transformation of knowledge economies around funding trends within the life and biosciences. For instance, it involves understanding how biochemistry is rallying around the language and terminology of nanotechnology – some would say re-branding itself – to remain competitive. The same kind of processes occurred around genetics towards the end of the 20th century. Such an understanding also helps to explain how far medicalization ‘bleeds’ into biomedicalization.
When coining new terms, there is always a process of struggle over the legitimacy of what is expressed by the new concept. We discuss whether it is sufficiently distinct, too broad or narrow, and whether it will stand the test of time. Many of the processes and transformations that are occurring around health care and medicine that the authors describe are essential to highlight and what they describe is the transformation of medicalization into something else (even though a large part of medicalization remains evident).
What concerns me most about the term biomedicalization is that both ‘bio’ and ‘medical’ might be too narrow to adequately capture these transformations. It is difficult for me to conceive of the 21st century as the ‘century of biology’, at a moment when Darwin’s 200-year birthday anniversary has just occurred. The last two centuries might make similar claims in different ways. Regardless, it is more the infiltration of biology by technology and the shift towards a nanotechnological view of biology that characterizes our times (and here physics still matters). Moreover, it is the departure from medicine that these processes imply, which most adequately describes the kinds of concerns these authors have. By proposing biotechnologization as a further concept to consider, I intend to pursue further the struggle of ideas. The concept allows medicalization to retain its core grounding, while taking into account the central, distinct shifts that the authors describe in their beautiful analysis of our contemporary biosphere. It also places at the centre of this debate the pivotal and expansive role of biotechnology, as a particular view on the relationship between biology and technology.
Professor Andy Miah is Chair in Ethics and Emerging Technologies in the School of Media, Language & Music at the University of the West of Scotland. He is Fellow at FACT, the Foundation for Creative Technology and Fellow at the Institute for Ethics and Emerging Technologies. He is Editor of ‘Human Futures: Art in an Age of Uncertainty’ (2008, Liverpool University Press) and co-author with Emma Rich of ‘The Medicalization of Cyberspace’ (2008, Routledge). Contact: email@example.com
Elliott, Carl. Better Than Well: American Medicine Meets the American Dream. New York and London: W.W. Norton & Company, 2003.
Miah, A. "Genetic Selection for Enhanced Health Characteristics." Journal of International Biotechnology Law 4, no. 6 (2007): 239-64