There is little doubt that the medicalisation of society, the framing of normality as a medical issue, has resulted in harmful violations of medicine’s first principle: ‘to do no harm.’ In his analysis of this, Justman draws from both medical and non-medical professionals to critique inappropriate labelling of problems, concerns, complaints, symptoms and assorted conditions into categories of discrete disorders. ‘Medicine has extended its writ not only over the less sick but many not sick at all, such as patients suffering from normal distress,’ explains the author (p. 12). To build his arguments, Justman uses a myriad of sources, from Dostoevsky and Tolstoy, to Montaigne, Shakespeare, Thomas Kuhn, Christopher Lasch and a wealth of medical clinicians.
The book addresses the world of the nocebo – the opposite side of the placebo coin and the side least studied – arguing that it is troubling because of the ethical and long-term implications to both the individual patient and public health in general. The author has taken the subject of medicalisation to a whole new level by demonstrating how a distorted judgment and overzealous diagnosis, such as found in the American Psychological Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) – the recognised coin of the realm – not only distorts the calculation of harms and benefits but negatively affects a patient’s health and well-being through the power of suggestion.
The author explains that the nocebo effect works much like the placebo through the power of expectation. While the placebo refers to a therapeutic effect that rises from the expectation of a benefit – real or imagined – the nocebo effect works through the expectation that something might produce an adverse result, which it often does. While the placebo in clinical trials tests the claims of the pharmaceutical industry for innovative new products and is therefore seen as an obstacle to overcome, the nocebo, by contrast, has become the industry’s marketing engine which it uses through artful advertising to stuff heads with threats, inferences and complications. In our generation, western medicine and pharmacy enjoy a high degree of prestige. Together, they claim expertise in diagnosing and repairing the body to pre-existing conditions. Aided by imprecise language enabled by the United States Food and Drug Modernization Act of 1997, they benefit from an industry-to-consumer advertising market, magnifying symptoms into diseases and epidemics and, in the process, staggering the magnitude of those suffering from Big Pharma’s creative disorders.
The book is an indictment of the pharmaceutical industry and its plethora of television advertisements on everything from irritable bowel syndrome, erectile dysfunction, chronic fatigue syndrome, and fibromyalgia, to more troubling matters involving the premature and overzealous misdiagnosis of post-traumatic stress disorder (PTSD) and attention deficit hyperactivity disorder (ADHD). Although the categories found in the DSM were presumably not ghostwritten by the pharmaceutical industry (but who knows?), they were nonetheless aimed at selling drugs to the widest possible market. Capitalising on the word ‘or’ in the DSM, the industry created an expansive eligibility of potential sufferers – an enlarged diagnostic net that gathered in a host of unassuming but needy patients. To further complicate matters, manufacturers have increased the cost of these essential pharmaceuticals to whatever level of greed they think society might tolerate.
The book is also an indictment of psycho-therapeutics in general and of the DSM becoming the final arbiter of mental disorders; of physicians who misread clinical signs by engaging in diagnostic inflation; of patients who have learned to ‘game’ the system by living up to the diagnostic labels and are themselves ‘gamed’ in the process; and of Big Pharma, which has stoked the coals of professional and non-professional medicalisation by inflating the interpretation of common symptoms, overselling disorders, mislabelling symptoms common in a healthy population, and making ethically harmful business decisions that overshadow the medical imperative of doing no harm. What the author identifies as the ambiguity of normality helps to explain the depth to which the health professions have built an industry of greed out of the exploitation of uncertainty.
The author’s vocabulary and sentence structure are excellent and some of his sentences are worth placing on billboards. Moreover, he has brilliantly demonstrated how the over-prescription of psychoactive drugs has taken place under the auspices of the DSM, distorted the calculation of risks and benefits, and associated certain behavioural traits into a highly suggestive ADHD diagnosis.
Overall, I am impressed with the author’s use of sources which speak to the breadth of his knowledge base. I had almost as much enjoyment reading the endnotes as I did the narrative. Aside from a poorly developed index and an absent bibliography which are negatives, the book represents an important challenge to ethical and public policy issues imbedded in its content.
