The Healing View and Medicalization
The values involved in defining health and disease
Here’s an easy game you can play the next time you run into a physician. Ask them “So what do you think this medicine thing is all about, anyway? What’s the ultimate point?” Most likely, they’ll respond with something about healing. Medicine is about making people better, bringing them to a better state of health, etc. (I say ‘physician’ above because they’re particularly dedicated to the healing view. Other health professionals tend to be more expansive.)
To be sure, the healing view captures a good chunk of what medicine does. If you break your arm, you go to the doctor to get it fixed. They’ll also try to keep you alive if you have a heart attack and prevent you from having another one, they’ll treat your cancer so it doesn’t kill you, and so on.
The healing view goes back a long way. The Hippocratic Oath begins with the words “I swear by Apollo healer” and then refers to itself as “the Healer’s oath”. More recently, in an essay from 1975, Leon Kass famously defends the healing view, saying “I trust it will shock no one if I say that I am rather inclined to the old-fashioned view that health—or if you prefer, the healthy human being—is the end of the physician’s art.”
The biggest problem with the healing view is that it is false. There are two main problems. First, it’s easy to come up with examples of medicine that don’t involve healing, such as tubal ligation (getting your ‘tubes tied’) and vasectomy. Neither involves healing—if anything, they are damaging a healthy reproductive system—but it is uncontroversial that they are within the proper boundaries of medicine.
The same is true of other cases, such as Tommy John surgery, which only improves baseball pitching; elective cosmetic surgeries such as breast augmentation; and ‘elective’ abortion (i.e., where health isn’t the driving factor). Of course, abortion is controversial, but the abortion debate isn’t about whether abortion promotes a proper aim of medicine. Defenders of the healing view either have to make exceptions for these examples, in which case their approach is ad hoc, or they have to define ‘healing’ or ‘health’ so broad that it can capture pretty much everything (this is the misguided approach of the World Health Organization).
The second reason the healing view is false is that there’s no justification for why medicine should be so restrictive. Tubal ligation and vasectomy are valuable interventions, so why should medicine leave them out? Since medicine has focused on healing for a long time, some people, like Kass, argue that it should stick to that. Another reason is that throwing out the healing view opens the door for other interventions that some providers would rather exclude, such as assisted dying, so a retreat to healing becomes a way to avoid such unwelcome forms of expansion. These aren’t convincing.
Since the healing view doesn’t work, you might be wondering what the other options are. My preference, which I’ve argued for with my colleague Jeremy Davis, is that medicine is about promoting patient values. Since we should only fix your broken arm if you want us to fix it, this indicates that what’s really doing the explanatory work is that you value having your arm fixed. And having your arm fixed will allow you to pursue the things you care about. The fact that promoting your value involves healing is an effect of value promotion, not the cause.
Instead of digging into value promotion, I’m going to focus on another effect of the healing view. Since the healing view is so common in health care, it shapes how decision-makers define diseases, disorders, and conditions. If providers think that medical interventions are only justified if they lead to healing, then this will likely have the effect of causing them to view more behaviors and states as part of health and healing.
The WHO’s capacious definition of health is in this spirit. If you’re the World Health Organization and you want to expand your scope, it’s easier to expand the definition of health than to rebrand as, say, the World Physical, Mental, and Social Well-Being Organization.
A similar pattern occurs with defining diseases. For example, consider the American Medical Association’s 2013 decision to recognize obesity as a disease, even though the AMA’s own Council on Science and Public Health recommended against it. The council’s view was that using body mass index (BMI), the main way to identify obesity, is a poor metric for determining health. Someone can be obese according to their BMI yet have no metabolic or other indicators of poor health. And, while obesity is associated with health conditions such as diabetes, the causal arrow is difficult to pin down. So perhaps obesity isn’t a disease itself.
But others thought that the ‘disease’ designator would be useful. Here’s an illustrative remark from an article at the time:
“I think you will probably see from this physicians taking obesity more seriously, counseling their patients about it,” said Morgan Downey, an advocate for obese people and publisher of the online Downey Obesity Report. “Companies marketing the products will be able to take this to physicians and point to it and say, ‘Look, the mother ship has now recognized obesity as a disease.’”
Downey doesn’t explicitly connect the point that physicians will take obesity more seriously with the healing view, but it’s a natural fit: i.e., now that obesity is a disease, it falls within their scope.
Determining what constitutes a disease will be difficult in any theory. There are going to be hard cases. But obesity is telling in that, even with recommendations to the contrary, the case for defining it as a disease ruled the day. This kind of ‘capture’ is what we’d expect from the healing view.
Other examples aren’t difficult to produce, especially in psychiatry. Since physicians, including psychiatrists, are primarily aiming at healing people, we should expect that there will be a higher rate of capture than some other approaches. But then the path from normative judgment to defining the trait as a disorder to proposed medical treatments becomes more common.
This is represented most infamously by the categorization of homosexuality as a mental disorder. After years of pushback from the gay rights community, the American Psychiatric Association dropped homosexuality from the DSM, not because of any empirical or scientific change, but because the normative landscape shifted.
The rise of neurodiversity advocacy, which pushes back on the traditional approach of seeing all disability as pathology, is similar in that the debate is about values—when should we try to ‘fix’ people? What constitutes a pathology?—and not the result of any new science (though better understanding of autism and other conditions is valuable). Accepting this doesn’t entail that there are no disorders or pathological traits. Instead, it challenges psychiatry’s normative framing about the badness of particular traits and disorders.
Another example is drug use. Carl Hart, a psychologist, neuroscientist and chair of Columbia University’s psychology department, challenges the standard view that addiction is a mental disorder:
The notion that drug addiction is a brain disease is catchy but empty: there are virtually no data in humans indicating that addiction is a disease of the brain, in the way that, for instance, Huntington's or Parkinson's are diseases of the brain. With these illnesses, one can look at the brains of affected individuals and make accurate predictions about the disease involved and their symptoms.
The importance of facts is crucial—Hart is objecting on scientific grounds to the framing of addiction as brain disease. Still, the song remains the same from the healing view: drug use is bad, so drug use is a disorder, therefore we can treat it. To use Hart’s term, the healing view causes ‘neuro-exaggerations’.
Abandoning the healing view reframes the purpose of medicine. It’s no longer about curing what ails you, where ‘ails’ is mainly defined by physicians and their value judgments. Instead, the goal of medicine is to help people to pursue their values using the specific expertise possessed by physicians and other healthcare providers. No healing, no problem.