Normal Physiology or Pathology? It’s Not as Simple as You Might Think
When I first started working in healthcare as a scribe, charting for doctors and filling out superbills, I quickly became familiar with the International Classification of Diseases (ICD). Some ICD-9 codes were straightforward, but others less so. If I typed “urinary tract infection,” the appropriate code would quickly come up: 599.0. But if I typed “low back pain,” I couldn’t find what I was looking for. Fortunately, the person who was training me helped me navigate the system. “Yeah, that’s a weird one,” he said. “You have to search for ‘lumbago.’” Sure enough, I found the right code: 724.2.
The origins of the International Classification of Diseases can be traced back to 1893 when French statistician and demographer Jacques Bertillon published the International List of Causes of Death. Eventually, hospitals and insurance companies wanted to start using the list for billing purposes, and as a result, it expanded significantly from the original 161 causes of death. Journalist Kathryn Schulz notes, "it now contains entries for every imaginable health-care interaction, from well visits to warts.” Therefore, ICD-10 codes (now on the tenth revision) also serve as a record of medicalization — the process by which human conditions that were previously not considered to be pathological come to be defined as medical conditions and treated as such.
Medicalization isn’t inherently good or bad. Rather, it’s a complex phenomenon that has potential for good and potential for harm. On the one hand, medicalization has led to dramatic improvements in terms of both quality and quantity of life. Defining something as a new medical condition opens the door to research funding, which opens the door to potentially discovering a safe and effective treatment. Medicine has come a long way, and there have been some truly revolutionary breakthroughs. In the United States, life expectancy for women and men respectively has increased from 71.1 and 65.6 years in 1950 to 81.1 and 76.1 years in 2016. However, the unequivocal benefits of medicalization exist alongside significant controversy.
Critics argue that medicalization has quickly turned into overmedicalization. The concern is that the threshold for what constitutes a medical condition (and therefore necessitates medical treatment) has continuously been lowered. For example, impotence, once considered a normal part of aging, is now known as erectile dysfunction. Bad breath is diagnosed as halitosis. Natural postpartum drooping of the breasts is officially labeled mammary ptosis. Forgetfulness is identified as dementia. The list goes on. Conditions including “obesity, smoking cigarettes, draft malingering, bachelorhood, divorce, unwanted pregnancy, kleptomania, and grief, have [all] been declared a disease by medical and psychiatric authorities.” Others have added to this list “menopause, alcoholism, attention deficit hyperactivity disorder (ADHD), posttraumatic stress disorder (PTSD), anorexia, infertility, [and] sleep disorders.”
This isn’t to say that those examples should or shouldn’t be considered medical conditions. The point is, defining something as a medical condition is often contentious. Where’s the line between human behavior and disease? Between physiology and pathology? Who gets to decide where to draw these lines? Who benefits from these decisions?